    [Senate Hearing 117-497]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-497

                                                            Senate Hearings

                                     Before the Committee on Appropriations

    _______________________________________________________________________

                                                      Departments of Labor,

                                                 Health and Human Services,

                                                 and Education, and Related

                                                    Agencies Appropriations

                                                           Fiscal Year 2022

                                              117th Congress, First Session

                                                                  H.R. 4502

            DEPARTMENT OF EDUCATION
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
            DEPARTMENT OF LABOR
            NONDEPARTMENTAL WITNESSES

                                                            S. Hrg. 117-497

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

    =======================================================================

                                    HEARINGS

                                    before a

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 FIRST SESSION

                                       ON

                                   H.R. 4502

     AN ACT MAKING APPROPRIATIONS FOR THE DEPARTMENTS OF LABOR, HEALTH AND
    HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES FOR THE FISCAL YEAR
               ENDING SEPTEMBER 30, 2022, AND FOR OTHER PURPOSES

                                   __________

                              Department of Education
                    Department of Health and Human Services
                              Department of Labor
                           Nondepartmental Witnesses

                                   __________

             Printed for the use of the Committee on Appropriations

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

     Available via the World Wide Web: http://www.govinfo.gov
                                 _________

                     U.S. GOVERNMENT PUBLISHING OFFICE

    44-181 PDF               WASHINGTON : 2023

                          COMMITTEE ON APPROPRIATIONS

                        PATRICK LEAHY, Vermont, Chairman
    PATTY MURRAY, Washington             RICHARD C. SHELBY, Alabama, Vice
    DIANNE FEINSTEIN, California             Chairman
    RICHARD J. DURBIN, Illinois          MITCH McCONNELL, Kentucky
    JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
    JON TESTER, Montana                  LISA MURKOWSKI, Alaska
    JEANNE SHAHEEN, New Hampshire        LINDSEY GRAHAM, South Carolina
    JEFF MERKLEY, Oregon                 ROY BLUNT, Missouri
    CHRISTOPHER A. COONS, Delaware       JERRY MORAN, Kansas
    BRIAN SCHATZ, Hawaii                 JOHN HOEVEN, North Dakota
    TAMMY BALDWIN, Wisconsin             JOHN BOOZMAN, Arkansas
    CHRISTOPHER MURPHY, Connecticut      SHELLEY MOORE CAPITO, West
    JOE MANCHIN, III, West Virginia          Virginia
    CHRIS VAN HOLLEN, Maryland           JOHN KENNEDY, Louisiana
    MARTIN HEINRICH, New Mexico          CINDY HYDE-SMITH, Mississippi
                                         MIKE BRAUN, Indiana
                                         BILL HAGERTY, Tennessee
                                         MARCO RUBIO, Florida

                       Charles E. Kieffer, Staff Director
               Shannon Hutcherson Hines, Minority Staff Director
                                     ------

     Subcommittee on Departments of Labor, Health and Human Services, and
                        Education, and Related Agencies

                       PATTY MURRAY, Washington, Chairman
    RICHARD J. DURBIN, Illinois          ROY BLUNT, Missouri, Ranking
    JACK REED, Rhode Island              RICHARD C. SHELBY, Alabama
    JEANNE SHAHEEN, New Hampshire        LINDSEY GRAHAM, South Carolina
    JEFF MERKLEY, Oregon                 JERRY MORAN, Kansas
    BRIAN SCHATZ, Hawaii                 SHELLEY MOORE CAPITO, West
    TAMMY BALDWIN, Wisconsin                 Virginia
    CHRISTOPHER MURPHY, Connecticut      JOHN KENNEDY, Louisiana
    JOE MANCHIN, III, West Virginia      CINDY HYDE-SMITH, Mississippi
    PATRICK J. LEAHY, Vermont, (ex       MIKE BRAUN, Indiana
        officio)                         MARCO RUBIO, Florida

                               Professional Staff

                                  Alex Keenan
                                  Kelly Brown
                                Michael Gentile
                                  Mark Laisch
                                   Megan Mott
                               Kathryn Toomajian
                          Laura A. Friedel (Minority)
                         Anna Lanier Fischer (Minority)
                            Ashley Palmer (Minority)
                             Emily Slack (Minority)

                             Administrative Support

                                 Fiona O'Brien
                           Sydney Crawford (Minority)

                                C O N T E N T S

                                  ----------

                                    HEARINGS
                            Wednesday, May 19, 2021

                                                                       Page

    Review of the Fiscal Year 2022 Budget Blueprint for the Centers
      for Disease Control and Prevention.............................     1

                            Wednesday, May 26, 2021

    Department of Health and Human Services: National Institutes of
      Health.........................................................    69

                            Wednesday, June 9, 2021

    Department of Health and Human Services: Office of the Secretary.   155

                            Wednesday, June 16, 2021

    Department of Education: Office of the Secretary.................   247

                            Wednesday, July 14, 2021

    Department of Labor: Office of the Secretary.....................   365

                                  ----------

                                  BACK MATTER

    Departmental Witnesses...........................................   435
        America's Public Television Stations and the Public
          Broadcasting Service.......................................   435
        National Public Radio........................................   440

    List of Witnesses, Communications, and Prepared Statements.......   857

    Nondepartmental Witnesses........................................   443

    Subject Index....................................................   863
        America's Public Television Stations and the Public
          Broadcasting Service.......................................   863
        Department of Education: Office of the Secretary.............   863
        Department of Health and Human Services......................   864
            National Institutes of Health............................   864
            Office of the Secretary..................................   865
        Department of Labor: Office of the Secretary.................   866
        Review of the Fiscal Year 2022 Budget Blueprint for the
          Centers for Disease Control and Prevention.................   867

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

                                  ----------

                            WEDNESDAY, MAY 19, 2021

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10 a.m. in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Durbin, Reed, Shaheen, Merkley,
    Schatz, Baldwin, Murphy, Manchin, Blunt, Shelby, Graham, Moran,
    Capito, Kennedy, Hyde-Smith, Braun, and Rubio.

      REVIEW OF THE FISCAL YEAR 2022 BUDGET BLUEPRINT FOR THE CENTERS FOR
                         DISEASE CONTROL AND PREVENTION

                   opening statement of senator patty murray

        Senator Murray. Good morning. The Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies will come to order.
        Today we are having a hearing on the Biden administration's
    fiscal year 2022 Budget request for the Centers for Disease
    Control and Prevention. It is our first subcommittee hearing
    this Congress, and our first hearing on the CDC's annual
    funding request since 2014.
        Senator Blunt and I look forward to continuing to work with
    you and our colleagues on both sides of the aisle, to build on
    the progress we have made previously, and help families in
    Washington State, Missouri, and across the country.
        And I intend to follow the example you set when it came to
    chairing hearings, Senator Blunt, and making sure that every
    member has an opportunity to ask a question.
        Senator Blunt and I will each have an opening statement.
    And then I will introduce our witnesses, Director Walensky, and
    Principal Deputy Director Schuchat. And after the witness'
    testimony, Senators will each have 5 minutes for a round of
    questions.
        Before we begin, I do want to walk through the COVID-19
    safety protocols in place. We are all very grateful to our
    clerks, and everyone who has worked hard to get this set up and
    help everyone stay safe and healthy.
        Given the new guidance from the Centers for Disease Control
    and Prevention and the Office of the Attending Physician, I
    will be working with Senator Blunt, committee members and
    staff, going forward, to follow the new guidance.
        For today, we will be conducting this hearing following
    similar COVID protocols to what we have used in the past.
    Committee members are seated at least 6 feet apart. Some
    Senators are participating by video conference, and while we
    are unable to have the hearing fully open to the public, or
    media for in-person attendance, live video is available on our
    committee website.
        And if you are in need of accommodations, including closed
    captioning, you can reach out to the committee or the office of
    Congressional Accessibility Services.
        I always say a budget is a reflection of your values and
    your priorities. And I think Americans can breathe a sigh of
    relief knowing this budget shows they have a President who
    values science and public health. COVID-19 has offered a stark
    reminder of why we must make and maintain robust investments in
    public health.
        Experts at CDC (Centers for Disease Control and Prevention)
    have been on the frontlines of this crisis from day one, and
    every day since. We have seen first-hand how critical it is CDC
    be equipped to effectively collect and analyze data in real
    time, communicate science-based public health guidance, help
    communities across the country get tests, and vaccines, and
    clear, reliable information to people, and address inequities
    that undermine the health of people of color, people with
    disabilities, rural communities, and others.
        That is why I have pushed for more funding for public
    health throughout this crisis. The tens of billions of dollars
    we have provided through six COVID bills so far, are supporting
    invaluable public health work at every level so we can finally
    end this pandemic.
        It has helped update and modernize data systems needed to
    track infections, variants, tests, vaccines, and inequities
    among demographic groups. It has helped fight misinformation
    and promote simple protective measures that have saved
    countless lives, like wearing masks and social distancing.
        It has helped expand our testing efforts, get vaccines into
    arms, and build partnerships with trusted voices in hard-to-
    reach communities. And I was pleased to hear the Biden
    administration announced last week, it was investing over $7
    billion from the American Rescue Plan, through CDC, to create
    tens of thousands of jobs in public health at the State and
    local level to fight COVID-19, and to help transition some of
    those workers to permanent careers as public health
    professionals.
        With new cases and deaths both down over 80 percent from
    their winter peaks, nearly three in five Americans vaccinated
    with their first dose, and over a third of Americans fully
    vaccinated, we can see the light at the end of the tunnel. But
    even as we get closer to ending this crisis, we know we are not
    there yet, and we cannot afford to come up short. That is why
    after years of underinvestment in CDC and attempted cuts to CDC
    by President Trump, this budget request is such a breath of
    fresh air.
        President Biden's request of $8.7 billion would increase
    CDC's budget authority by nearly a quarter. I have been pushing
    for more public health funding for years now. And I am excited
    to say this would be the largest budget authority increase for
    CDC in nearly two decades. These investments will help us
    finish strong when it comes to this pandemic, prepare for the
    next one, and make progress on other public health challenges.
        Investments in CDC, as well as requested increases for the
    Substance Abuse and Mental Health Services Administration will
    help address the record number of drug overdose deaths, and the
    spike in mental health issues, we have seen as a result of this
    pandemic. COVID-19 has also put a painful spotlight on how
    racism, sexism, ableism and bigotry hurt so many people in this
    country.
        CDC's recent announcement of a 2-year plan to invest more
    than $2 billion to work on COVID-19-related health disparities
    was an important step towards addressing this reality, and the
    administration's request to dramatically increase the social
    determinants of health program, Congress established at CDC
    last year from 3 million to 153 million will help make sure our
    response to health inequities is truly comprehensive, because
    there are so many challenges we need to tackle head-on.
        For example, Black, American Indian, and Alaska Native
    women are two to three times more likely to die from pregnancy-
    related causes than White women. And our overall maternal
    mortality rate is the worst in a developed country, so I am
    glad the administration budget request includes $200 million to
    reduce maternal mortality nationwide, and address disparities,
    an increase of 140 million.
        It also invests in other public health threats that have
    gone too long with too little attention. It doubles funding for
    gun violence prevention research, and establishes a new 100
    million community-based violence intervention program between
    CDC and the Department of Justice. And it increases funding for
    CDC's climate and health program by $100 million dollars.
        Of course, the challenges we face are bigger than any one
    budget. Before this pandemic hit, only half of Americans were
    served by a comprehensive public health system. Our public
    health workforce has lost 56,000 people, and State health
    officials estimated a quarter of their workforce was eligible
    to retire.
        So we have a lot of work ahead, not just to end this
    pandemic, but to build and maintain a public health system
    capable of addressing other pressing public health challenges
    and, of course, preparing for future ones.
        That is why earlier this year I reintroduced the Public
    Health Infrastructure Saves Lives Act, which would finally end
    the dangerous cycle of crisis and complacency in public health
    funding by providing dedicated annual investments in public
    health.
        Director Walensky, Principal Deputy Director Schuchat, I
    look forward to hearing from both of you about how investments
    like this, and like those put forward in the administration's
    budget request, can help families and States across the
    country. And I look forward to working with my colleagues to
    make the investments we need a reality.
        Finally, Dr. Schuchat, I understand you are leaving CDC
    this summer after 30 years with the agency. And I know I speak
    for absolutely everyone on this committee, when I say I am
    grateful, grateful that we have had your expertise and
    leadership, helping to see our Nation through so many public
    health challenges. Thank you for your service, from all of us.
        And with that, I will turn it over to Senator Blunt for his
    remarks.

                         statement of senator roy blunt

        Senator Blunt. Well, thank you, Chair Murray. This is your
    first hearing as the Labor, Health and Human Services chair. I
    certainly look forward to working with you in this role. We
    have had a lot of success working together in the past 6 years
    on this subcommittee, and I am sure we can continue with that
    this year.
        I also want to share your welcome to the CDC director and
    the principal deputy director.
        Dr. Schuchat, thanks for your service to our country, and
    your incredible time at CDC. As I mentioned to you earlier as
    we were visiting, I am sure there is not a single person who
    knows as much about CDC as you do. And there may never be a
    person who knows as much as you do after a 33-year career
    there, and that long list of things that we have worked
    together on in the last several years, but a list that goes
    beyond that.
        So Dr. Walensky, Dr. Schuchat, this is really an important
    opportunity for us to hear about the CDC's budget proposal, and
    understand more about CDC's priorities for this year. I don't
    think there has been a year that CDC got more attention than it
    got in the last year. And so the profile of CDC, the
    understanding of the importance of CDC I think, is at a high
    point.
        I want to recognize the tireless efforts of the CDC staff,
    working across the country during the pandemic. It has been a
    challenging year for all Americans, but particularly for those
    in public health.
        Dr. Walensky, I look forward to hearing your testimony
    today on the administration's fiscal year 2022 Budget.
    Unfortunately, your comments will be limited somewhat by the
    fact that we are really waiting for more information about that
    budget. But from what we do know from the limited details
    released last month, there are several areas of alignment where
    we can work together.
        For example, addressing the needs of the hard-hit public
    health infrastructure, responding to the opioid crisis, which
    has been exacerbated during the pandemic, along with other
    mental health and behavioral health challenges, and continuing
    the Ending the HIV Epidemic Initiative are important to both of
    us.
        These are critical areas that may need even more attention
    as we emerge from the pandemic and gain an understanding of the
    full impact, of the health impact, and the behavioral health
    impact that the pandemic has had.
        It also appears that Global Health Security and
    Preparedness programs will continue as a priority for this
    administration, as it has been for this subcommittee over the
    past 6 years. During that time the subcommittee invested
    heavily in these programs, increasing funding across the
    department of HHS (Department of Health and Human Services) by
    46 percent. Unfortunately, the so-called ``skinny budget'' also
    includes what I believe are excessive areas of increases in
    areas that are extremely partisan. I hope we can set those
    issues aside and invest in areas of common ground that benefit
    all Americans.
        As this subcommittee thinks about the priorities for fiscal
    year 2022, I hope we can spend time learning from the lessons
    of the pandemic.
        In 2020, Congress passed five bipartisan COVID relief
    bills, total more than $16 billion for CDC. During the
    infectious disease pandemic, that funding was critical for
    State and local public health preparedness and response. I
    think we would all agree that our focus on local public health
    in this country is not what it was just a few decades ago, and
    we can do better. Certainly those agencies and State
    governments, generally, have been critical in the vaccine
    distribution and planning.
        Now, the other point to make is that $16 billion is a lot
    of funding to absorb. To put it in perspective that is about
    double your annual budget, or more than $50 million per day for
    the CDC's response efforts last year.
        Pretty hard to spend all of that as effectively as this
    committee would like, but I think we understood that when we
    were sending money to CDC to try to respond to a pandemic that
    was unlike anything we had dealt with before.
        We also really need to incorporate the lessons learned from
    the pandemic, moving forward. It is important we highlight what
    went right, when communities stepped up, when neighbors helped
    neighbors, when innovators came forward to provide novel
    solutions to some of the problems that plagued the pandemic.
        Senator Durbin, and I, and seven of our colleagues went out
    Monday to NIH (National Institutes of Health), and we saw what
    happened there with testing and other things that, clearly, I
    think as we look down the road, those are going to be great
    advantages for us. In Missouri we saw a lot of those unique
    things happen.
        For example, the pandemic brought out innovation with
    Washington University in St. Louis--Dr. Walensky, where you got
    one of your degrees--developing their own COVID test, when
    there was a nationwide shortage of testing, there was a test
    that was developed at the Washington University campus to be
    used on that campus.
        Other resilience came through, other resourcefulness came
    through. Throughout Missouri, independent and rural pharmacists
    would drive 200 miles, some of them, to be sure they had the
    vaccine that would be available at their location the very next
    day, literally, going the extra mile, and the University of
    Missouri developed a cutting-edge technology to track COVID
    variants through wastewater epidemiology.
        So I am proud of Missourians. I am proud of Americans
    across the country, as we reached out to deal with this. We are
    clearly not out of the woods yet. We need to continue to
    understand and learn from the mistakes we made to figure out
    where we fell short or missed the mark.
        Also to understand, frankly, that there were lots of things
    we know now that we did not know then. And looking back at
    decisions where you don't have the same information, or
    anything like it that we did now is a challenge. We need to
    figure out what we learned from that, how we could have found
    out more, earlier. I expect the budget to do just that. I want
    to work with Senator Murray and others on this committee to do
    that.
        But under your leadership Dr. Walensky, I hope the agency
    will make the difficult decisions necessary to make great
    strides toward the enormous opportunity that I think public
    health has at this moment, for the rest of this century. So
    thank you for being with us today.
        Chair, again, let me say, I look forward to your leadership
    and the things that we can do together, and I really appreciate
    where we are now compared to where we were 6 years ago. And I
    think our partnership was an important part of that.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Thank you, Chair Murray. This is your first hearing as the Labor/
    HHS Chair and I look forward to working with you in this role. We have
    had a lot of success the past six years working together on this
    Subcommittee and I'm sure it will continue this year. I also want to
    share your welcome to the CDC Director and the Principal Deputy
    Director.
        Dr. Walensky and Dr. Schuchat, this is an important opportunity for
    us to hear about the CDC's budget proposal and understand more about
    the CDC's priorities for this year. I also want to recognize the
    tireless efforts of the CDC staff working across the country during the
    pandemic. This has been a challenging year for all Americans, but
    especially those who work in public health.
        Dr. Walensky, I look forward to hearing your testimony today on the
    Administration's fiscal year 2022 budget. Unfortunately, I think your
    comments will be limited because we are still waiting for the
    Administration to release their budget. What we do know, from the
    limited details released last month, is that there are several areas of
    alignment where we can work together. For example, addressing the needs
    of the hard hit public health infrastructure; responding to the opioid
    crisis, which has been exacerbated during the pandemic; and continuing
    the Ending the HIV Epidemic initiative, are important to both of us.
    These are critical areas that may need even greater attention as we
    emerge from the pandemic and gain a better understanding of its full
    impact on our nation's public health.
        It also appears that global health security and preparedness
    programs will continue as a priority for this Administration, as it was
    for the Labor/HHS Subcommittee over the past six years. During that
    time, this Subcommittee invested heavily in these programs, increasing
    funding across the Department of Health and Human Services by 46
    percent.
        Unfortunately, the so-called ``skinny'' budget also includes
    excessive increases in areas that are extremely partisan. I hope we can
    set those issues aside and invest in areas of common ground that
    benefit all Americans.
        As this Subcommittee thinks about priorities for fiscal year 2022,
    I hope we will spend time learning from the lessons of the pandemic. In
    2020, Congress passed five bipartisan COVID relief bills, totaling more
    than $16 billion for the CDC. During a global infectious disease
    pandemic, that funding was critical for state and local public health
    preparedness and response; for public health data modernization; and
    for COVID-19 vaccine distribution.
        However, $16 billion is a lot of funding for the CDC to absorb. To
    put it in perspective, that is about double your annual budget or more
    than $50 million per day for the CDC's response efforts last year. Our
    Subcommittee has a responsibility to provide oversight and ensure
    accountability of that funding for the taxpayers.
        We also must incorporate the lessons learned during the pandemic
    moving forward. But as important, we should highlight what went right.
    When communities stepped up. When neighbors helped neighbors. And when
    innovators came forward to provide novel solutions to some of the
    problems that plagued the pandemic.
        And in Missouri, we saw a lot of that.
        For example, the pandemic brought out innovation, with Washington
    University in St. Louis developing their own COVID-19 diagnostic test
    when there was a nationwide testing shortage.
        It brought out resilience and resourcefulness. Throughout Missouri,
    independent and rural pharmacists will drive 200 miles a day to provide
    vaccines to vulnerable and underserved populations. They are literally
    going the extra mile to ensure communities and rural areas across our
    state have access to the vaccine.
        And it brought out ingenuity. The University of Missouri is
    developing cutting-edge technology to track COVID variants through
    wastewater epidemiology.
        I am proud of how Missourians, and Americans across the country,
    stepped up to respond during this crisis.
        But, we are not out of the woods yet. We need to continue to
    understand and learn from the mistakes we made. Figure out where we
    fell short or missed the mark. And I would expect the CDC's fiscal year
    2022 budget to do just that. This is the time to think about a long-
    term strategy and not continue to jump from one disease outbreak to the
    next.
        The CDC is facing unprecedented challenges, but the agency is also
    presented with an enormous opportunity to bring public health into the
    21st Century. Under your leadership, Dr. Walensky, I hope the agency
    will make the difficult decisions necessary to make great strides to
    that end. Thank you for being with us today and I look forward to your
    testimony.
        Thank you.
        Senator Murray. Thank you, Senator Blunt. And yes, I do
    look forward to working with you on this as we always have. So
    I appreciate it.
        I want to welcome both of our witnesses again. Thank you
    for being here.
        Dr. Rochelle Walensky is the director of the Centers for
    Disease Control and Prevention, and the administrator of the
    Agency for Toxic Substances and Disease Registry.
        Dr. Anne Schuchat is the principal deputy director of CDC,
    and has twice served as acting director of the agency. Welcome
    to you both.
        Dr. Walensky, we will begin with you for your opening
    remarks.
    STATEMENT OF DR. ROCHELLE WALENSKY, DIRECTOR, CENTERS
                FOR DISEASE CONTROL AND PREVENTION
        Dr. Walensky. Chairman Murray, Ranking Member Blunt, and
    everyone on the committee, I am grateful for the committee's
    support of the CDC.
        I am here today, as you noted, with Dr. Anne Schuchat,
    CDC's principal deputy director. I have enormous gratitude for
    Dr. Schuchat's leadership and contributions over three decades,
    as well as during this very challenging period during our--for
    our country, and for her rock-solid support of me in my
    transition into this role.
        Anne embodies selfless public service, the pinnacle of
    scientific and intellectual standards, and has given her heart
    to our agency and the public health community. I will be
    forever grateful that our paths crossed even for such a short
    period of time.
        The COVID-19 pandemic threw the United States and the world
    into a health, economic, and humanitarian crisis. As the crisis
    unfolded, it put a spotlight on the fragility of our public
    health infrastructure. It illuminated great disparities in
    health outcomes by race and ethnicity; reminding us that--thus
    far--we have failed to address the systemic racism that results
    in poorer health for people of color in the United States.
        I am committed to working with you, the administration, and
    our public health partners to ensure that every lesson from
    this horrible crisis is used to build a better, stronger,
    healthier America.
        I also commit to using our public health expertise and
    experience in partnership with the global community to move the
    world into a safer, healthier future. CDC's fiscal year 2022
    Discretionary Budget Request of $8.7 billion is an increase of
    $1.6 billion over fiscal year 2021--the largest increase CDC
    has received in nearly 20 years.
        The increase is focused on four critical areas: building
    public health infrastructure, reducing health disparities,
    using public health approaches to reduce violence, and
    defeating diseases and epidemics.
        These increases build on the investments made in the COVID-
    19 supplementals, and are an important first step in addressing
    deficits in the public health infrastructure. COVID-19 not only
    exposed the vulnerabilities within the United States public
    health infrastructure, but also how underlying chronic
    conditions and lack of access to healthcare, put too many
    Americans at great risk.
        Across the globe we see billions of people without access
    to vaccines and medical care, which means that SARS-CoV-2, its
    variants, and other infectious disease threats will continue to
    threaten us all. Experts had warned for years that a pandemic
    of this scale was coming, and we must expect additional
    diseases to emerge.
        We need to ask ourselves, are we ready? We must have a
    strong infrastructure that can identify and detect outbreaks at
    their source and can take quick action before diseases take
    hold.
        Over the last 12 years, the United States has faced four
    significant emerging infectious disease threats: the H1N1
    influenza pandemic, Ebola, Zika, and COVID-19; we also
    confronted a drug overdose epidemic with nearly 500,000 people
    dying from an opioid-related overdose between 1999 and 2019.
    This increase continued into 2020 and appeared to accelerate
    during the COVID-19 pandemic.
        These experiences show that public health emergencies are
    here to stay. Each of those threats demanded a rapid and unique
    response, but none resulted in a sustained public health
    improvement. Long-term investments in flexible infrastructure
    will save lives and avert economic losses caused by public
    health emergencies and chronic public health problems.
        The fiscal year 2022 request makes initial investments to
    continue public health data modernization, build the public
    health workforce, enhance global health security, and
    strengthen our immunization infrastructure.
        In addition, we are requesting funds to help states and
    communities be climate-ready and prepare to confront new health
    risks, such as those associated with vector-borne diseases. The
    fiscal year 2022 Budget Request also makes specific investments
    in programs that work to improve health equity, such as
    maternal mortality review committees. With these new outlined
    resources in this request, CDC will also significantly expand
    efforts to address the social determinants of health.
        Proposed increases will address public health problems that
    have been exacerbated by this pandemic, such as opioids,
    violence, HIV, and sexually-transmitted diseases.
        We, at CDC, are grateful for your support and look forward
    to working together to build a sustainable and resilient public
    health system that can respond effectively to emerging threats,
    and meet the public health needs of every American. We will
    work tirelessly to ensure the health of this Nation and the
    world.
        Thank you. Dr. Schuchat and I look forward to your
    questions.
        [The statement follows:]
         Prepared Statement of Rochelle P. Walensky, M.D., M.P.H. and
                              Anne Schuchat, M.D.
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Committee, it is an honor to appear before you today to discuss
    how investments in the Centers for Disease Control and Prevention (CDC)
    are protecting American's health, now and in the future. I am grateful
    for this opportunity to address this committee, as well as for your
    long-standing and consistent leadership on issues of critical
    importance to the health of Americans, and the world.
        It is my privilege to represent CDC at this hearing. CDC is
    America's health protection agency. For 75 years, CDC has been trusted
    to carry out its mission to protect America's safety, health, and
    security. Even during the unprecedented circumstances of the past year,
    CDC's scientific expertise, determination, selflessness, and innovation
    has helped the agency continue to advance its mission. We work 24/7 to
    prevent illness, save lives, and protect America from threats to our
    health, safety, and security. Addressing infectious diseases and
    pandemics, like COVID-19, is central to our mission. CDC's expertise
    lies in our ability to study emerging pathogens like SARS-CoV-2, to
    understand how they are transmitted, and to translate that knowledge
    into timely action to protect the public's health. CDC identifies and
    mitigates other causes of morbidity and mortality beyond infectious
    diseases, such as environmental and workplace hazards and intentional
    and unintentiona l injuries (such as those from falls, violence, or
    overdose). CDC promotes healthy behaviors, such as exercise and
    nutrition, to prevent chronic diseases such as diabetes and heart
    disease, and to prevent outcomes such as stroke. We promote healthy
    communities by increasing access to nutritious food and safe walking
    and green space.
        By deploying experts on the ground to support our state, Tribal,
    local, territorial and global partners, we translate science into
    implementing guidance that protects individua ls, communities, and
    populations. In our work with other Federal agencies we ensure the safe
    and appropriate use of medical countermeasures, including vaccines, and
    collaborate with the academic and private sector to further our
    understanding of new diseases and problems that affect health.
        The COVID-19 pandemic threw the United States and the world into a
    health, economic, and humanitarian crisis. As the crisis unfolded, it
    put a spotlight on pre-existing weaknesses and gaps that threaten the
    health of Americans. It brought into stark light the great disparities
    in health outcomes by race and ethnicity. We must acknowledge the long-
    standing and too often unstated impact that racism has on public
    health. The pandemic has also highlighted our frail public health
    infrastructure, and the way that frailty impacted our ability to
    respond at thenecessary scale and speed.
        Experts had warned for years that a pandemic of this scale was
    coming. Today, we know to expect additional novel and currently rare
    diseases to emerge and gain footing as a result of our changing
    climate, closer interaction with animals, and globalization. Over the
    last 12 years, the United States has faced four significant emerging
    infectious disease threats--the H1N1 influenza pandemic, Ebola, Zika,
    and COVID-19. These experiences show that public health emergencies
    and, specifically, infectious disease threats, are here to stay. While
    urgency demanded rapid and unique responses to each of these threats,
    none resulted in the sustained improvements needed in our nation's
    public health infrastructure. This lack of robust public health
    infrastructure continues to present significant challenges in our
    ongoing fight against COVID-19. In fact, emergencies have resulted in
    the rapid build-up of infrastructure needed to address the emergency,
    then dissolution of that infrastructure, often leaving no sustainable
    infrastructure in place to address the next threat. This lack of robust
    public health infrastructure continues to present significant
    challenges in our ongoing fight to tackle COVID-19.
        World-wide, billions of people do not and will not have immediate
    access to COVID-19 vaccines. Cases will continue to increase, and
    variant COVID-19 strains are likely to emerge, persist, and cause
    outbreaks. As this becomes more common, our public health system at
    home and abroad must be ready with highly sophisticated detection and
    sequencing, combined with a rapid response at the source. The
    unprecedented investments provided to CDC through COVID-19 supplemental
    appropriations have helped our efforts to control COVID-19, and will
    also go a long way toward addressing deficits in the core components of
    the public health infrastructure that has long been ignored. Our
    ability to respond to the next public health crisis will depend on
    whether we invest in a public health system that is highly functional
    on a day-to-day basis and pivots to meet new threats, rather than
    continue our partial defense, which ramps up in response to an urgent
    and often short-term event.
        A resilient public health system can be realized with careful
    planning that builds on the gains made with COVID-19 emergency
    supplementals and incorporates lessons learned as a result of this
    crisis, including reliable, flexible funding. The FY 2022 Discretionary
    Budget Request for CDC and ATSDR includes a total funding request of
    $8.7 billion, an increase of $1.6 billion over FY 2021 Enacted. This is
    the largest increase in budget authority for CDC in nearly two decades
    and defends Americans' health in four ways: 1) building public health
    infrastructure, 2) reducing health disparities, 3) using public health
    approaches to reduce violence, and 4) defeating other diseases and
    epidemics.
        First, building the public health infrastructure. CDC's FY 2022
    request prioritizes foundational funding to rebuild the public health
    infrastructure needed to safeguard the Nation's health and economic
    security. Drawing on lessons learned, as well as the latest information
    and technologies, CDC will begin to address long-standing
    vulnerabilities in the U.S. public health network by training a larger
    cadre of experts who can deploy and support public health efforts, and
    building capacity to detect and respond to emerging global biologica l
    threats.
        Public health action is driven by data. Earlier improvements in our
    systems for collecting information after other public health
    emergencies, including Ebola and EVALI, facilitated exchange of health
    information, linking local, state, and federal public health systems
    with healthcare systems and the public. With investments in public
    health data modernization in the FYs 2020 and 2021 appropriations and
    the COVID-19 supplementals, CDC increased the scale and speed of these
    systems during the COVID-19 response to protect people who are at risk
    for severe illness (such as older Americans), those with chronic
    medical conditions, and those from racial and ethnic minorities. These
    advancements must be applied across the public health system and at all
    levels of government. The funds requested in FY 2022 will be used to
    continue building a modern disease surveillance system at CDC, which
    will catalyze a multi-sectoral, comprehensive, and cohesive approach to
    documenting evidence, using state-of-the-art technology and analytical
    tools. CDC will continue working diligently to ensure its research and
    data are of the highest quality and are disseminated nationally to
    inform decision-making throughout the public health system, while
    supporting advances in data systems at all levels.
        The COVID-19 pandemic made clear the role that CDC labs and public
    health labs across the nation play in conducting critical surveillance
    and responding to outbreaks and emerging threats. CDC and state
    laboratories were required to flex and surge during peak periods of
    illness, far beyond routine clinical testing. In FY 2019, CDC was only
    able to meet 50% of state and local health departments' stated needs
    for epidemiology and laboratory capacity funding, with personnel
    support being the biggest unfunded need, followed by equipment and
    supplies.
        The FY 2022 request will foster innovation, collaboration with the
    clinical system, and a commitment to quality. Improving technologies at
    the state and local levels would enable public health labs to quickly
    utilize and scale up essential laboratory analyses. In a post-COVID-19
    world, investments to maintain and improve laboratories will help
    prevent the failures we experienced while trying to address COVID-19.
        The U.S. needs a workforce of qualified public health professionals
    who will prepare for, respond to, and prevent public health crises.
    Physicians working for states often earn less than$150,000 per year.
    This is after having taken on medical school debt of $200,000 on
    average. The FY 2022 request includes an increase to build a diverse
    and culturally competent workforce who can rapidly develop innovative
    approaches in surveillance and detection, risk communications,
    laboratory science, data systems, and disease containment. With this
    funding, CDC will support critical training programs for public health
    professionals that develop strategic and systems thinking, data
    science, communication, and policy evaluation. Existing cooperative
    agreement mechanisms will be leveraged to support public health jobs
    that meet current needs and attract new personnel to work in
    underserved and rural areas.
        Addressing gaps in capacity across levels of government to detect
    and respond to outbreaks while maintaining and surging in other problem
    areas requires investments to be disease-agnostic and flexible. With FY
    2022 funding, CDC will provide support to health departments to meet
    national quality standards, conduct performance improvement activities,
    increase communication and collaboration across the public health
    system, and reshape health departments to meet changing conditions and
    needs. Funding will help health departments strengthen their abilities
    to effectively respond to a range of public health threats, such as
    COVID-19, and build capacities that do not currently exist.
        COVID-19 is a sobering reminder that a disease threat anywhere is a
    disease threat everywhere. Or as stated by WHO: no one is safe unless
    everyone is safe. We cannot adequately protect American lives and the
    U.S. economy without addressing global disease threats wherever they
    may arise. CDC's strategic investments in global health security are
    critical to U.S. health security by building sustainable global
    capacity to prevent, detect, and respond to emerging infectious disease
    threats. CDC works in more than 60 countries on more than 150 projects
    and is a key implementing agency for the U.S. Government's leadership
    role in the Global Health Security Agenda. With additional resources
    requested in FY 2022, CDC will build on existing partnerships with
    Ministries of Health, public health agencies, infectious disease
    research institutions, and international organizations to strengthen
    global laboratory capacity for early disease detection, enhance disease
    surveillance for accurate data to drive decision making, and foster
    effective regional and global coordination.
        Next, I'd like to talk about reducing health disparities. The
    disparities seen over the past year among communities of color were not
    a result of COVID-19. In fact, the pandemic illuminated inequities that
    have existed for generations and revealed a known, unaddressed, and
    serious public health threat: racism. The well-being of our entire
    nation will be compromised as long as we fail to address this.
        Racism is not just discrimination against one group based on the
    color of their skin or their race or ethnicity, but the structural
    barriers that impact racial and ethnic groups differently to influence
    where a person lives, where they work, where their children play, and
    where they worship and gather in community. The social determinants of
    health (SDOH)--such as high-quality education, stable and fulfilling
    employment opportunities, safe and affordable housing, access to
    healthful foods, commercial tobacco-free policies, and safe green
    spaces for physical activity--are critical drivers of health inequities
    in this country. CDC is building the evidence-base for collaborative
    approaches to SDOH through community accelerator planning and expanding
    a network of community health workers to develop a sustainable
    infrastructure to improve health equity. CDC's FY 2022 budget request
    includes an increase of $150 million to use a social determinants of
    health approach to improve health equity and health disparities in
    racial and ethnic minority communities and other disproportionately
    affected communities around the country.
        This budget directly responds to health disparities recorded in our
    public health data. For example, about 700 women die each year in the
    U.S. as a result of pregnancy or delivery complications, and American
    Indian, Alaska Native, and Black women are two to three times more
    likely to die than White women. Data show that about 2/3 of these
    deaths may be preventable. Children from lower-income and racial and
    ethnic minority households experience a disparate, increased risk for
    lead exposure.
        Achieving health equity is central to addressing the HIV epidemic.
    The U.S. government spends $20 billion per year in direct health
    expenditures for HIV care and treatment. An estimated 1.2 million
    persons have HIV and approximately 15% are unaware they have it. With
    recent advancements in antiretroviral therapy and biomedical
    advancements in HIV prevention, such as pre-exposure prophylaxis
    (PrEP), along with effective care and treatment, we have the tools to
    end the HIV epidemic. An increased investment requested in FY 2022 for
    the Ending the HIV Epidemic (EHE) initiative will enable CDC to advance
    the four key strategies needed to end the epidemic in the 57 EHE focus
    jurisdictions. In addition, CDC will address health equity in the
    entire HIV prevention portfolio, test innovation in service delivery
    models to increase access to prevention services, use syndemic
    approaches to broaden reach to key populations and create efficiencies,
    and strengthen engagement of grassroots community-based organizations
    in implementing EHE initiative.
        Third, the budget request also addresses the public health epidemic
    of violence. We know too well how this epidemic permanently alters the
    lives of its victims and their families and puts enormous strain on our
    communities and local economies. Increases in CDC's FY 2022 budget
    request will help address violence through public health approaches,
    which include improving reporting systems that provide the data needed
    to understand and address violent deaths and injuries in the United
    States.
        And fourth, we must defeat other diseases and epidemics. Just as
    racism underlies a number of public health issues, climate issues
    underlie a number of infectious diseases and have significant health
    impacts. Climate changes are associated with changes in the
    geographical range of mosquitos, ticks, and other disease vectors.
    Climate-related events impact a wide range of health outcomes. Some of
    the most significant climate-related events--such as heat waves,
    floods, droughts, and extreme storms--affect everyone. These climate
    events compromise our access to clean air, clean water, and a reliable
    food supply. In addition, climate events can impact the presence of
    allergens and vectors, like ticks and mosquitoes, and the subsequent
    health outcomes that can result from these changes in exposures. We
    know that a changing climate can intensify existing public health
    threats, and that new health threats will emerge: unequally distributed
    risks (age, economic resources, location), increased respiratory and
    cardiovascular disease, injuries and premature deaths related to
    extreme weather events, changing prevalence and geography of foodborne
    and waterborne illnesses and other infectious diseases, and threats to
    mental health as people feel less safe.
        CDC works with states, cities, and tribes to apply the best climate
    science available, predicting health impacts, and preparing public
    health programs to protect their communities. To do this, CDC developed
    the Building Resilience Against Climate Effects (BRACE) framework to
    help communities prepare for the health effects of climate change by
    anticipating climate impacts, assessing vulnerabilities, projecting
    disease burden, assessing public health interventions, developing
    adaptation plans, and evaluating the impact and quality of activities.
    With the requested increase in FY 2022, we can further expand the
    Climate and Health Program by providing a larger number of health
    departments with technical assistance and funding and finding
    innovative ways to protect health via climate adaptations. As with
    every other public health threat, we will inform our effort by building
    and examining systems that collect data on conditions related to
    climate, including asthma and vector-borne diseases, and coordinate
    programs and communication that improve health outcomes.
        The opioid epidemic has shattered families, claimed lives, and
    ravaged communities across the Nation--and the COVID-19 pandemic has
    only deepened this crisis. Addressing the current overdose epidemic
    remains a priority for CDC. The Administration's strategy brings
    together surveillance, prevention, treatment, recovery, law
    enforcement, interdiction, and source-country efforts to address the
    continuum of challenges facing this country due to drug use. CDC's role
    is to prevent drug-related harms and overdose deaths.
        The additional funding requested in FY 2022 to address the opioid
    epidemic will enable CDC to provide more funding to all States,
    Territories, and select cities/counties. CDC will prioritize support to
    collect and report real-time, robust overdose mortality data and to
    move from data to action, building upon the work of the Overdose Data
    to Action (OD2A) program. To do so, CDC will partner with funded
    jurisdictions to implement surveillance strategies that include
    contextual information alongside data, as well as increase surveillance
    capabilities for polysubstance use and emerging substance threats such
    as stimulants. The additional resources requested will enable CDC to
    support investments in prevention efforts for people put at highest
    risk, for example, supporting risk reduction and access to medications
    for opioid use disorder for people transitioning from alternate
    residence (jail/prison, treatment facility, homeless shelter). CDC will
    also address infectious disease consequences, such as viral hepatitis,
    of the opioid epidemic.
        I look forward to working together to address both the immediate
    challenges ahead in our fight against COVID-19, as well as the
    weaknesses in the public health infrastructure that left our country
    vulnerable to this pandemic. We at CDC are grateful for your support.
    We will continue to work tirelessly to ensure the health of this nation
    and the world. Together, we can build a sustainable and resilient
    public health system that can respond effectively to emerging threats
    and also to ongoing public health needs of every American.
        Senator Murray. Thank you very much. And we will now begin
    a round of 5-minute questions of our witnesses. And I do ask my
    colleagues to keep track of the clock, and if you can stay
    within those 5 minutes.
        Dr. Walensky, COVID has really exposed the importance of
    having a robust and well-funded public system before a crisis
    strikes; which is why I said it is so important that we make
    sustained investments in public health infrastructure and
    workforce a priority, including in CDC.
        Over the last year Congress provided more than $8 billion
    to support public health data modernization and expand the
    public health workforce through six COVID supplemental bills.
    What more needs to be done to sustain our public health
    infrastructure and our workforce, so we don't lose gains when
    the funding runs out?
        Dr. Walensky. Thank you so much, Senator, for that
    question.

                         INFRASTRUCTURE AFTER EMERGENCY

        You have highlighted that we have had challenges with our
    public health workforce, indeed. We have 56,000--we are down
    56,000 jobs just in the last decade. We need to train and
    upskill that workforce, in addition to bolster that workforce
    over the years ahead. We need to keep them trained because the
    science continues to evolve, we need training in
    bioinformatics, in genomic epidemiology, and all of that needs
    to live in our State and localities so that they are well
    informed and trained over time, not just in creating a
    workforce, but in keeping them skilled.
        We need to do data modernization, as you noted, an initial
    investment in data modernization. When I spoke early on in my
    tenure to State and local health officials, I was hearing about
    faxes of test results for COVID, and then manual data entry of
    those results, and that those results were not received with
    racial and ethnic data in them. So we had no way of tracking
    how we were doing with racial and ethnic diversity across this
    pandemic.
        And then we need to build our public health labs. We don't
    have--did not have the capacity to do genomic sequencing in all
    of these labs, we have had to scale that up. And there is many
    more, and in the infrastructure in the machinery, in the
    technology that we need to put and deploy, not just at CDC, so
    we are ready at CDC for this, but also in our public health and
    localities.
        Senator Murray. So I am curious; if we had had all that in
    place before this pandemic, how would have things been
    different?
        Dr. Walensky. I think they would have been extraordinarily
    different. We would have had contact tracers on the ground
    ready to go. We would have been able to identify cases quickly.
    We would have been able to see single, single outbreaks than in
    clusters that we might have been able to pin down to contact
    trace and not have outbreaks expand. I think we would not have
    seen the diverse--the racial discrepancy and what happened with
    this pandemic that----
        Senator Murray. Because we would have known prior and made
    more of a focus?
        Dr. Walensky. Exactly. We would have been able to find it.
    I think the testing, the inability of our public health systems
    to be able to conduct these tests in massive scale up, did not
    allow us to find the disease where it was, certainly, we had
    not done genomic sequencing until January, we did not know
    anything about the variants that were circulating here. There
    are numerable ways that this could have gone better if we had
    had a more robust public health infrastructure across all of
    those domains.
        Senator Murray. Thank you. That is a lot to think about. We
    should all remember. We have now seen a lot of encouraging
    progress against COVID over the last several months, and as
    more people get vaccinated, and case counts, and
    hospitalization, deaths are falling.

                              PANDEMIC TRAJECTORY

        Dr. Walensky, speak to us about where we are in this fight.
    How the funds Congress has provided have helped? And what we
    need to focus on next to bring this crisis to an end?
        Dr. Walensky. Today, I am cautiously optimistic. We have,
    in the last several weeks, seen a stark downward trend in
    cases. The last 2 days we have had case rates that have been
    less than 20,000 per day. Our case rates now are around 30,000
    per day, on average, for the last seven days; death rates, we
    have been seeing at around 500 a day, still too high, but the
    lowest we have seen since this pandemic began.
        We have over 86 percent of Americans over the age of 65 who
    have received their first dose of vaccine. And just yesterday--
    today we have now 60 percent of Americans over the age of 18
    having received their first dose of vaccine. I think that we
    have had extraordinary progress, and we have needed the
    resources to get here.
        Senator Murray. So what do we need to focus on next?
        Dr. Walensky. Certainly, a sustainable public health
    infrastructure that is not necessarily just tied to one
    disease, to one outbreak, to one disaster. We need longitudinal
    money so that we are able to have sustainable infrastructure
    that is up to date with the times. We need to focus on our
    racial and ethnic minority groups.
        They were previously under-vaccinated. We have made a huge
    amount of strides just in the last 2 weeks in getting those
    groups vaccinated. But we need to--and we need to get into the
    communities. We need to have a public health infrastructure
    that looks like the communities that they serve, and that
    serves those communities a lot.
        Senator Murray. Should we be worried about the variants?
        Dr. Walensky. I think we would be remiss to say that we are
    out of the woods. This pandemic, this virus has sent us too
    many curve balls to say that we--too early to declare victory.
    Certainly, with the virus circulating in other parts of the
    world that is in high degree that it gives the opportunity for
    more variants to emerge, so I still am--it is among the things
    that keeps me up at night. But right now the variants that we
    see here and we are doing a lot of sequencing now, demonstrate
    that our current vaccines are working.
        Senator Murray. Okay. Thank you very much.
        Senator Blunt.
        Senator Blunt. Thank you, Chair.

                     CHANGES TO MASK GUIDANCE AND REOPENING

        Let's talk about the guidance that came out last week on
    masks for people who have been fully vaccinated. There seems to
    be some concern about how that would be applied. I listened
    this morning to the CEO (Chief Executive Officer) at Target,
    who was on CNBC, and he said that--they had followed all the
    CDC guidance up till now, which meant until last week people in
    their stores had a mask on, this week people in their stores
    don't have a mask on unless they want to have a mask on.
        In the Capitol, the attending physician, who has been the
    person we look to, put out guidance last week that said: on the
    Capitol grounds you would not need to wear a mask if you were
    vaccinated, but the Speaker decided that she was going to keep
    the mask mandate in place for the House until everyone was
    vaccinated.
        What are you seeing there? And what kind of further
    direction have you been able to give? I know just yesterday the
    President had his mask on part of the time, largely based, it
    seemed to me, on what other people around him were comfortable
    with. But give us some more thoughts on that.
        Dr. Walensky. Thank you, Senator, for that question. I
    think the first thing that we should do is celebrate where we
    are in this pandemic, that we can even be having this
    conversation, that cases are now down to 19,000 a day, reported
    this morning. As those cases are coming down, people are
    longing to understand what this means next.
        How do we open up again? How do we take our masks off? With
    those cases coming down, and now the fact that every American
    who wants a vaccine has access to one, if you have not texted,
    text your zipcode to GETVAX (438829), you can find vaccine
    wherever you are in the country. Five pharmacies will show up
    so you can get the vaccine.
        So we now have cases coming down and access to vaccines for
    everyone who wants one. Just in the last 2 weeks, we had
    scientific data emerge in three important areas, (1) that the
    vaccines are working in the public the way they worked in the
    clinical trials. That doesn't always happen, but it happened
    here. And we had one of the largest studies published on Friday
    in the MMWR (Morbidity and Mortality Weekly Report).
        (2) That the vaccines are working against the variants we
    have here circulating in the United States. There have been
    data, neutralizing data that demonstrates against B.1.1.7,
    against B.1.351. These vaccines are working.
        And (3), something that was not studied in the clinical
    trials is, can you--if you were to get infection with SARS-CoV-
    2 and were vaccinated, could you give it to somebody else? Were
    you silently able to spread it? Those data were not covered in
    the clinical trials, but now data have emerged again, that have
    demonstrated, even if you were to get infected during post-
    vaccination, that you cannot give it to anyone else.
        Senator Blunt. Yes.
        Dr. Walensky. So that scientific data was enough for us to
    move forward. People had said we moved too slowly, people have
    said we have moved too fast, we moved at the speed that the
    science gave us.
        Senator Blunt. Well, I think that is right. I do think on
    the last topic if we--not evaluating, whether we could have
    made that decision quicker. But I do think that decision that
    you don't have to wear a mask once you have been fully
    vaccinated, will encourage people to get vaccinated. I think
    the fact that that is out there is good. I hope we got it out
    there as quick as you were comfortable having it out there.

                               RACIAL DISPARITIES

        On your comments about racial health disparities which, of
    course, I am not for racial health disparities, and more than
    happy to look at that; what about the other obvious health
    disparities, like how low income, health disparities regardless
    of race, or rural health disparities? Are we just going to
    focus on racial health disparities, and leave those others
    behind? Or why were those the disparities you specifically
    mentioned in your comments?
        Dr. Walensky. We have seen a lot of data on racial health
    disparities in this pandemic. But, Senator, you are absolutely
    right. Twenty percent of Americans live in rural areas. As we
    talk about social determinants of health, this is not just
    racial--on racial lines, this is urban and rural.
        We just, yesterday, had an MMWR come out that demonstrated
    that rural Americans were getting vaccinated around 39 percent,
    while non-rural counties were at 46 percent. So we are intent,
    and our values are going to be, to have public health reach all
    areas, all Americans.
        Senator Blunt. I am glad to hear that. My last question
    here before I run out of time would be on drug overdose deaths.
    You know, we saw this committee work really hard on this topic
    for about four straight years, and we felt we were making some
    real progress. And I think we were, the numbers were going down
    every year, but in 2020 we had the highest number to date of
    drug overdose deaths. Just comment briefly on that before my
    time is up here.
        Dr. Walensky. It is tragic. Before being here, I was an
    infectious disease doc on the wards at Mass General, and while
    we were talking about deaths, the people on the wards were also
    talking about chronic infections, endocarditis, epidural
    abscesses, leaving young people paralyzed.
        So we were making some progress, and this pandemic hindered
    that progress. And we, again, need to address this issue.
        Senator Blunt. Thank you.
        Senator Murray. Thank you.
        Senator Durbin.
        Senator Durbin. Thank you, Madam Chairman.
        And Dr. Schuchat, let me join the chorus. Thank you for 33
    years of remarkable service. I have a question for you in a
    minute, but I wanted to start with a little different approach.

                                LESSONS LEARNED

        And let me say that I think this pandemic has not broken
    us, but it has taught us where our system is broken, and there
    are many areas we need to look at seriously. If you take a look
    at the public health scorecard and try to find an objective
    measure, the one that I return to frequently is the fact that
    the United States has less than 5 percent--has less than 5
    percent of the world's population, yet 20 percent of the COVID-
    19 infections and deaths. And that tells us we can improve
    dramatically.
        Where did we shine in this effort? Certainly vaccines, the
    quick response as we learned again this week, and the visit to
    the NIH, was because we were prepared, and we had the science
    ready, and we had good fortune in identifying the culprit, and
    in devising an effective strategy to go after it with vaccines.
        I would also add that the Warp Speed program appears to
    have dedicated and invested funds in a dramatic way at a time
    when it was very important. And I think that accelerated the
    availability of the mass vaccines, and I give the Biden
    administration credit for administering them, and distributing.
    So those are the positive sides.
        But one of the messages learned, that I learned out at NIH,
    was now let's get honest about this. We not only have to bring
    this pandemic to an end, we have to prepare for the next
    pandemic, which may be 5 years away or 15 years away. We don't
    know. But history tells us there will be another one. And the
    question is: will we be ready for it?
        The CDC is going to play a critical role in this. And the
    first question I have to ask is to Dr. Schuchat. After 33 years
    of observing this agency and its role in the American scene
    when it comes to public health, there is a fear that it has
    been politicized in the last 4 years, or maybe even before.
    That now public health issues are so political, with the
    division on whether to get a vaccine, or a vaccination or not,
    seems to break out on party lines and political lines. We have
    reached a new stage.
        What is your thinking? And having observed and worked with
    the CDC all these years, about this politicization--if that is
    the word--of public health?
        Dr. Schuchat. Thank you so much for your comments and your
    question. The viruses don't vote, and the pandemic has really
    told us that everyone is vulnerable, everyone in America, and
    everyone around the world. And CDC is a science-based agency,
    and we lead from science. We are data-driven, and we work
    together with State and local partners who reflect the values
    of their communities. So I think that focusing on the science
    and the service mission of the agency is what we need to do.
        Senator Durbin. Have you noticed any change, recent change
    in terms of the political image of CDC, which tries to be
    apolitical?
        Dr. Schuchat. You know, this pandemic has been so difficult
    for--you know, for the Nation, I think for all of us in public
    health, and certainly for our colleagues around the world. The
    messaging has really been difficult, you know, very conflicting
    messages that left Americans confused.
        And so I think we are committed to clear, honest
    communication of what we know, and what we don't know, and what
    we recommend people do. So I do think the messaging environment
    during this pandemic has been really tough.
        Senator Durbin. I would agree with that.

                                  GUN VIOLENCE

        Dr. Walensky, I am worried about gun violence. I believe it
    is a public health issue because I represent the State of
    Illinois and the City of Chicago. And we have the equivalent of
    a mass shooting every weekend in Chicago. It is a disaster in
    terms of its impact on the lives of many people, and the life
    of the city.
        You have a proposal to make a-hundred-million-dollar
    investment through the CDC, in community-based violence
    intervention, working with neighborhood organizations and
    hospitals to deliver services. I recommend to you a program,
    which we started in Chicago called the HEAL Initiative. I will
    send you some information on it. But I would like for you to
    say a few words about what you anticipate that $100 million is
    going to be used for.
        Dr. Walensky. Thank you, Senator. Our intent here is to
    look for areas in high-violence cities, where we can accumulate
    data, we can get accurate information, where we have actionable
    interventions to prevent all areas of violence, community
    violence, domestic violence, suicide, to increase public health
    using those resources in areas that have been highly impacted.
    We want actionable interventions for prevention.
        Senator Durbin. Thank you.

                              CHILD MENTAL HEALTH

        Madam Chair, I would just say in closing, you are in a
    unique position being on the Authorizing and Appropriating
    Committee, but one element I hope we don't overlook, and I know
    you feel sensitive to this as I do, is the need in schools to
    have access to counselors, mental health counselors, and maybe
    traditional school nurses, so that any public health effort,
    which should focus first on our children, has the wherewithal
    to do that effectively. I find that we have allowed that to
    lapse in many areas of my State.
        Senator Murray. Thank you, Senator Durbin.
        Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Chairwoman Murray, and
    Ranking Member Blunt for having this hearing. And I certainly
    appreciate the speakers that are here today.
        And Dr. Walensky, I appreciate being able to visit with you
    last week to discuss your work as director at the CDC. I
    thought we had a very good conversation, I certainly admire the
    work that you have done.
        And Dr. Schuchat, I certainly admire the work that you have
    done over the past many years.

                            RURAL HEALTH DISPARITIES

        I will be brief with my questions, but one thing that I am
    really concerned about is rural healthcare. I had the
    opportunity this past Saturday morning to visit with David
    Ready. He is a pharmacist in a town in Mississippi, Monticello,
    Mississippi; that has less than 1,500 people, and the concerns
    that he has about them being able to get their medicines. The
    reimbursements they get, because they are so small, they don't
    buy in bulk.
        So those are things that I am sure that we will be having
    other conversations about. But the COVID-19 pandemic has
    highlighted numerous aspects, obviously, of our healthcare
    system that need improvements. One of them that we all
    recognize is the disparities of Americans living in rural
    health areas.
        Addressing health infrastructure in rural areas is a
    serious concern, and as I said, one of my top priorities, and
    while the CDC has undertaken efforts to address that, there is
    no entity within the CDC tasked specifically with this work.
    And that is concerning to me.
        I believe establishing a new Office of Rural Health within
    the Center of Disease Control would be an important way to
    support rural communities through the end of this pandemic, and
    to prepare for any other future public health crises that we
    could be faced with.
        And, you know, I just envision this office to be empowered
    to look across CDC programs, to ensure the work of the agency
    is properly addressing the health needs of the 57 million
    Americans who live in rural communities.
        Director Walensky, how strongly do you support establishing
    an official Office of Rural Health within the CDC? And how can
    we work together to get this done, if you see that the way that
    I see this?
        Dr. Walensky. Thank you, Senator. As you noted, we have 20
    percent of Americans, 57 million Americans living in rural
    areas. Part of the deep need for investment in a public health
    infrastructure is to develop a workforce that looks like the
    community, that is from these communities, that knows how to
    access and reach these communities, which is exactly one of the
    challenges that has that has occurred during this pandemic. And
    one of the reasons we had a differential distribution of
    vaccines between rural and non-rural communities.
        We also know that there are other issues, outside of COVID,
    where we have learned from COVID, such as telehealth. We had a
    previous MMWR that demonstrated, ironically, that telehealth
    was not reaching rural communities. And that is, in fact, one
    of the areas that we should be using telehealth. So why was it
    not reaching their rural communities? CDC is investigating this
    just by virtue of the fact that they have had several MMWRs in
    the last 2 weeks examining these issues.
        So as part of the public health infrastructure and the
    disease agnostic infrastructure that works on labs, that works
    on workforce that works on data; we are invested in urban
    communities as well as rural communities.

                              FUNDING FLEXIBILITY

        Senator Hyde-Smith. And I think a lot of that is broadband
    issues as well, that we have to get addressed. But I understand
    the CDC has a highly categorical manner for providing funding
    to State health departments, with most funding tightly tied to
    specific diseases, or specific purposes. And I am concerned
    that restricting CDC money to specified activities prevents
    States from being able to address issues that vary from State
    to State, because all of them are different, and it makes it
    difficult to respond efficiently to emerging challenges like
    COVID-19.
        And I have always been big on flexibility because the
    States really know where their needs are, and I believe greater
    flexibility on funding might allow States to better target
    resources. So I just wanted to mention that to you, of the need
    for flexibility there, that we sure saw that our hands were
    tied in some cases during COVID. So I just wanted to address
    that with you.
        Dr. Walensky. I would just echo your thoughts and say, yes.
    That one of the things that has been challenging for us at CDC
    is the line items that have to go to X or Y, when in fact what
    we need is the infrastructure, the disease agnostic
    infrastructure, so that when we see community--this community
    needs this, but they may both need to establish a lab, but one
    needs broadband and the other needs a genomic sequencer that
    we--it is flexible enough to be able to make sure that each of
    the communities can scale up for what they need. Absolutely.
        Senator Hyde-Smith. Thank you. That is very encouraging.
    Thank you.
        Dr. Walensky. Thank you.
        Senator Murray. Senator Reed.
        Senator Reed. Well, thank you, Madam Chairwoman; and thank
    you Director for your extraordinary work.

                            317 IMMUNIZATION PROGRAM

        I have been now working and trying to bolster the Section
    317 Immunization Program for many years. And as we recognize
    this year, because of the pandemic, there has been significant
    increases in vaccination funding going out, and building an
    infrastructure. But I don't want to take our eyes off the long-
    term need for Section 317 programs to sustain improvements that
    have been made in terms of routine immunization, which must be
    given.
        And so will the CDC be requesting an increase in funding
    for the 317 Program this year, Madam Director?
        Dr. Walensky. I am going to let Dr. Anne Schuchat take that
    question.
        Dr. Schuchat. I want to thank you for your long-time
    support for the immunization needs of the Nation, and the
    incredible progress we have been able to make, particularly
    among children. COVID, the pandemic, has really highlighted
    that we are not where we needed to be with adults. And that was
    part of the slow start that we had in terms of getting--you
    know, having the scale up of vaccination.
        So there is a lot more work to do to catch up for the
    vaccines that were not given during the pandemic, in children,
    and to strengthen our infrastructure for adults going forward.
    And so that work is part of the priorities for the agency.
        Senator Reed. Thank you very much.

                               SUICIDE PREVENTION

        Dr. Walensky, this is not the first time I think this
    thought has been bridged, but the suicide epidemic has been
    startling across the country related to the pandemic, and
    perhaps related to other factors, and CDC has released some
    startling statistics recently about suicide. And I know that
    the CDC has launched some new suicide prevention efforts over
    the last couple of years, and let me you to continue to do
    that. But I understand only a handful of grant applications
    were able to be funded. And one of those that were not funded
    was from my State, but we were not alone. And what are you
    intending to do with respect to the overall suicide epidemic
    and also the more robust funding for prevention?
        Dr. Walensky. Thank you, Senator. This is such a
    challenging area it was--we had scale-up of mental health
    challenges before the pandemic, right? So these were issues
    that we really needed to tackle before the pandemic. And we saw
    during the pandemic that these have only gotten worse, among
    our youth, among our middle aged, we have seen challenges even
    since the pandemic began.
        So part of our resources that we are requesting are to
    scale up these efforts. Again, we need surveillance data. We
    need to understand how much this is a challenge. How many
    people are presenting to the emergency room. We need toolkits
    to deliver to States, to physicians, organizations, so that
    they can--they are empowered as to how to prevent it. And then
    we need actionable implementation that we can do for prevention
    in areas of mental health.

                           LEAD POISONING PREVENTION

        Senator Reed. Thank you. One final topic is lead exposure,
    which I have been working on through my responsibilities on the
    Banking Committee, and also the Appropriations Subcommittee on
    Housing and Urban Development, over the last year rates of
    screening for lead poisoning have decreased, obviously, as you
    know, movement and these types of activities have been
    curtailed. And then I think the statistics, although it would
    probably be very dubious coming out of the last year because of
    all these other factors, but it is a continuing problem.
        And right now the CDC's Lead Poisoning Prevention Program
    is at a high mark of $39 million. But we know more funding is
    needed, and we also know that this initiative
    disproportionately impacts lower-income communities because of
    the housing circumstances, generally.
        And I would hope that the President's CDC budget will
    prioritize this work, keep increasing funding and focus. I
    would note, he is going after the lead pipes, which I applaud.
    But in many respects, particularly in older communities like
    mine, the issue is not lead pipes, it is housing and lead
    paint, and it is a whole series of issues.
        Dr. Walensky. Thank you. I think this raises a very similar
    point, as was previously raised by Senator Hyde-Smith, that
    each community needs individual things to improve the health of
    their community, which is why the public infrastructure
    flexibility, the funding to be able to get the resources that
    you need in individual communities.
        One will be--you know, we need resources for broadband, but
    one will be, we need resources for lead. And as you note we,
    again, had an MMWR that demonstrated exactly what you said.
    Screening for lead this past year has gone down. We know we
    have missed lead toxicity that we really need to make up for.
        Senator Reed. Thank you very much.
        Thank you, Madam Chairwoman.
        Senator Murray. Thank you.
        Senator Moran.
        Senator Kennedy.
        Senator Kennedy. Thank you. Madam Chair.
        Madam Director, thank you for being here today; I know how
    busy you are. I have been in my office listening to some of the
    testimony of both of you. And I am a little uncertain about
    some of the answers, which is probably a shortcoming on my
    part.

                                 MASK GUIDANCE

        Madam Director, could you, in one minute, summarize for me
    what the recommendations are today from your agency about
    wearing masks?
        Dr. Walensky. Absolutely. First of all, can I just say,
    thank you for your YouTube video, for promoting vaccines, which
    I just adored.
        Senator Kennedy. Did you like my singing?
        Dr. Walensky. Yes, I did. Thank you very much for doing
    that.
        Senator Kennedy. You are under oath, now, madam.
        [Laughter.]
        Dr. Walensky. Yes, I did--even so, I did.
        Senator Kennedy. Thank you for that.
        Dr. Walensky. Last Thursday, we released guidance that
    demonstrated for an individual who is able--who is fully
    vaccinated and not immunocompromised, that they are able to
    safely unmask with the exceptions--certain exceptions, of
    course, in travel corridors, healthcare settings, that if you
    are an individual you can safely unmask if you are fully
    vaccinated.
        Senator Kennedy. Inside and outside?
        Dr. Walensky. Inside and outside.
        Senator Kennedy. Okay. What role do the State regulations
    play with respect to that?
        Dr. Walensky. We are working now to update all areas of
    guidance, but here is what is really, I think, important to
    understand. We are not a homogeneous United States. We have
    counties that have less than 20 percent vaccinated.
        Senator Kennedy. Yes, ma'am. But I don't want to get too
    off, off the question here. If I walk over to the House of
    Representatives, do I have to wear a mask?
        Dr. Walensky. Those are locally-driven policies, but we
    felt that it was important for the science to--for us to convey
    the science of what is safe for individuals.
        Senator Kennedy. Well, I am trying to understand the CDC
    recommendations, and I appreciate it. Based on the CDC
    recommendations, if I walk over to the House, are you
    recommending I wear a mask?
        Dr. Walensky. If you are--if you are by yourself walking
    over to the House and you are fully vaccinated?
        Senator Kennedy. No, ma'am. Once I am over there. I am
    vaccinated. Once I am over there and I am talking to some of my
    colleagues?
        Dr. Walensky. We have really encouraged that the policies
    of mask-wearing be locally driven. And the reason for that is
    because every community, every county, has different rates of
    disease and different rates of vaccination. And that is really
    what----
        Senator Kennedy. What is different about the House? Do you
    know?
        Dr. Walensky. I don't actively--I don't know the rate of
    vaccination around the Capitol, nor the rate of disease around
    the Capitol off the top of my head.
        Senator Kennedy. Okay. What about airplanes?
        Dr. Walensky. What is the policy on airplanes? Currently,
    the policy on airplanes is to wear a mask.
        Senator Kennedy. Okay. And why is it different on an
    airplane as opposed to a restaurant?
        Dr. Walensky. So the CDC provides guidance for what is safe
    to do. The Federal policy is obviously an interagency policy
    that we need to look at across different agencies. What I will
    say though, is that there is very little choice when you board
    an airplane as to----
        Senator Kennedy. Right.
        Dr. Walensky  [continuing]. Who is going to be sitting next
    to you, who is around you. And also, airplanes may be a place
    where we have more variants, because of the travel from
    international places.

                                 VIRUS ORIGINS

        Senator Kennedy. Okay; last question. What, in your
    opinion, was the origin of the virus?
        Dr. Walensky. This has been studied by the WHO----
        Senator Kennedy. Ma'am, I am asking your opinion.
        Dr. Walensky. I don't believe I have seen enough data,
    individual data, for me to be able to comment on that.
        Senator Kennedy. What are the possibilities?
        Dr. Walensky. Certainly, the possibility is that most
    coronaviruses that we know of are of origin from--that have
    infected the population, SARS-CoV-1, MERS, generally come from
    an animal origin, and----
        Senator Kennedy. Are there any other possibilities?
        Dr. Walensky. Certainly, a lab-based origin is one
    possibility.
        Senator Kennedy. Okay. Is the United States funding gain-
    of-function research?
        Dr. Walensky. Not to my knowledge.
        Senator Kennedy. Okay. Can you give an answer to that for
    me, and let us know, let the committee know?
        Dr. Walensky. Dr. Fauci would be the one who knows best,
    and he testified last week----
        Senator Kennedy. Dr. Fauci seems confused. I am asking--
    with all due respect--I am asking you to get us that
    information. Where throughout the world, including, but not
    limited to the United States of America, are we doing research
    on these viruses to make them contagious in order to study
    them? That is what I mean by gain-of-function.
        Dr. Walensky. I understand. I understand. We certainly can
    have our staff look into this. I don't know that we have access
    to labs across the world, just the ones that are funded here in
    the U.S.
        Senator Kennedy. Yes. But you are the Head of the CDC. I
    bet if you--I bet that you get your phone calls returned.
        Dr. Walensky. Okay.
        Senator Kennedy. Would you get us that information?
        Dr. Walensky. I would be happy to give you the information
    to the best of my ability.
        Senator Kennedy. Okay. And I am going to do long--a
    complete album of my singing. I will send you--I will send you
    a courtesy----
        Dr. Walensky. Would you sign that, please?
        Senator Kennedy. Sure. Thank you. Thank you, both, for
    being here.
        Thank you, Madam Chair.
        Senator Murray. Senator Baldwin.
        Senator Baldwin. Thank you. Madam Chair.

                              MASKS IN WORKPLACES

        I want to pursue a similar line of questioning that we just
    heard from Senator Kennedy, with regard to masking guidance.
    And when I reflect from the period of time when the pandemic
    was first identified, the Department of Labor and the agency
    charged with occupational safety and health, did not issue any
    sort of emergency temporary standard with regard to workplaces
    relating to this pandemic.
        And, frankly, while there has been much work done on that
    in this new administration, we don't have one yet, and so I am
    just delighted by the progress we are seeing. Generally, I see
    that light at the end of the tunnel, getting brighter, and
    brighter, and brighter, and certainly the CDC's updated mask
    guidance for those who are vaccinated is a reflection of that
    progress.
        But I am concerned about the impact of this guidance on
    workers, and particularly those who work in crowded conditions,
    such as meat-packing facilities, where we have seen horrendous
    outbreaks in the past year.
        So, Dr. Walensky, I am wondering when we can expect perhaps
    more detailed guidance for workplaces, such as meat-packing
    plants, and other crowded facilities where there is going to be
    a mix of vaccinated and unvaccinated workers? And how that is
    going to interact with the very recent CDC guidance on mask use
    for those who are vaccinated? What should workplaces be doing
    right now?
        Dr. Walensky. Thank you so much, Senator Baldwin. The meat-
    packing situation was really, really difficult, so many, people
    affected and lives lost. And a real challenge for the Nation to
    react to that.
        Updating guidance for workplaces, including the higher-risk
    ones is a high priority for us that we are actively working on.
    As you know, the initial individual guidance came out last
    week, but updating guidance for particular settings is
    critical. Our National Institute of Occupational Safety and
    Health is working closely with OSHA around getting the best
    science to the Department of Labor who has regulatory
    authority, but we are at CDC, updating our guidance for the
    particular settings in light of the newer science.
        Senator Baldwin. I appreciate that.

                          PUBLIC HEALTH COMMUNICATION

        I want to ask a question of you, Dr. Schuchat, about the
    importance of communication in public health. Early in the
    pandemic, again, we had to get out a lot of information on what
    COVID-19 is, how it is spread, what precautions people can
    take. And, likewise, now we are in the vaccination phase, and
    we have to communicate about its safety, efficacy,
    availability, et cetera.
        Last year, I wrote the CDC requesting that they provide
    information on the spread of COVID-19 in Hmong language. The
    CDC later updated their material, which was extremely helpful
    for Wisconsin's vibrant Hmong community. But we also need to
    make sure that we are doing exactly the same to make
    information on the COVID-19 vaccine accessible and available
    for all communities.
        So, Dr. Schuchat, how is the CDC using what it learned from
    sharing information about the spread of COVID-19 to communicate
    the importance of getting vaccinated, to those who have limited
    English proficiency? And will the CDC be making information on
    the COVID-19 vaccine, and how to get vaccinated available in
    more languages?
        Dr. Schuchat. Yes. Thank you so much for that set of
    questions. I think that communication has never been more
    important, nor more difficult than the past year, and reaching
    people with limited English proficiency has been really
    important.
        We have a toolkit available in 34 languages, and our
    vaccine information, including our V-safe, the little app that
    helps people follow side effects after getting vaccinated, is
    available in multiple languages. But it is not just what we
    say, it is how we say it, and who says it; and so one of our
    strategies is working through trusted messengers and partners
    of the community, from the community, who work with groups day
    in and day out, and so part of our strategy is funding of
    jurisdictions for them to have community-based groups really
    get that message out in ways that are accessible.
        These are really important issues, as we know. You know,
    back to the meat-packing outbreaks, we had people speaking
    multiple languages in very close quarters at risk for spread,
    but also not necessarily knowing who they could trust in what
    they should do. So we clearly want to get the vaccine
    information to them.
        Another thing I would mention is the partnership that CDC
    and the administration has had with HRSA (Health Resources and
    Services Administration), around the federally-qualified health
    programs, because they have--the federally-qualified health
    centers have a real concentration of patients served with
    limited English proficiency, in both mobile clinics for
    vaccination, and through community clinicians--community
    vaccination sites. They have been able to reach those groups.
        Senator Baldwin. And Senator, if I am might add, just real
    briefly. One of the things that would be really helpful for us,
    is working with those industries to encourage employers to get
    their employees vaccinated, that time off, paid time off, to
    ensure that they--when they returned to work they are
    vaccinated.
        Senator Murray. Thank you, Senator.
        Senator Braun.
        Senator Braun. Thank you, Madam Chair.

                    MASK GUIDANCE FOR VACCINATED INDIVIDUALS

        Dr. Walensky, I am glad that the recent ruling was made
    that if you are vaccinated, you don't need to wear a mask. I
    think it was getting very confusing for not only getting more
    people vaccinated because they were saying, well, why should I
    get vaccinated if I still have to wear a mask? So thank you for
    that.
        But I do have a question. I know that on March 29, the
    President was criticizing some governors about removing mask
    mandates. And of course that now has changed. And I think the
    reason is what I have just said. But what about, since the
    science now, and the guidance is clear, what about local mayors
    and governors that are not following the science, when that has
    kind of been ballyhooed as the thing to do. I believed in that
    from the get-go as well, especially when the tools were very
    uncertain, distancing and all that stuff, made sense. And I
    thought you were silly not to abide by it.
        What about now? For the places that are--I think there is a
    liberation feeling out there, and thank goodness for the Warp
    Speed, and getting the vaccines in the arms. Is this
    unnecessary for governors and mayors across the country to
    still keep a mask mandate in place?
        Dr. Walensky. Thank you for that question, Senator. We
    released guidance on Thursday that said for individuals, if you
    are vaccinated, fully vaccinated, you can take off your mask
    with several exceptions. One of the things I think that is
    really key in this is to recognize that we are not a
    homogeneous country.
        That there are some areas that--some counties that still
    have less than 20 percent of people vaccinated. There are some
    counties that still have greater than a hundred cases per
    hundred thousand in a seven-day period of time. And so I
    actually think, as I look at the map, a very heterogeneous map
    of how we are doing with cases, how we are doing with
    vaccinations, the decisions about whether to take off a mask
    mandate will have to be made at the local level, have to be
    made at the community level.
        There are still some communities who are suffering. We know
    African-Americans lost 2.9 years of life compared to White
    Americans losing 0.8 years of life. And they are probably the
    communities that got access to vaccines last. We are working on
    that. We have had extraordinary improvements in our access to--
    in our racial and ethnic minorities having access to vaccines.
    But I do think that these need to be made at the local and
    community level for exactly that reason.
        Senator Braun. Do you think it will be confusing though,
    even for those places that have lagged in getting their
    citizens vaccinated to see that there is not that incentive in
    place, even in the places that have been slower to do it, that
    would be an encouragement. If they see people without a mask
    and they say, well, they are vaccinated. I want to get one.
        Dr. Walensky. I think it would be really amazing if our new
    guidance got more people vaccinated, and was an incentive for
    more people to get vaccinated. But I don't make CDC guidance,
    my whole agency does not make CDC guidance based on what it
    will help people do. We have to do it based on the disease that
    is out there, the access to vaccines, and based on the science
    that has emerged.
        I really am hopeful that that will help to incentivize
    people to get vaccinated, but that was not the reason for our
    guidance.

                                 COVID IN INDIA

        Senator Braun. Okay. Another subject, since we are kind of
    at least ebbing into a situation, it looks like here in the
    U.S., other countries, some places it is still running rampant
    like India. When do we turn the focus? And I think we have been
    lucky that vaccinations have come this quickly, but
    therapeutics would seem to be that final defense for anyone
    that did not have a vaccination available. And now for the few
    cases that could still slip through the cracks to where it is
    impacted with so much data, such a small portion of the
    population, disproportionately, and horrifically, elderly
    predisposed with other conditions.

                               COVID THERAPEUTICS

        When do we start turning our attention to helping them once
    they get it? Because we are going to still have cases,
    depending on variants, how strong they are, to where the
    emphasis goes to therapeutics, and not vaccinations, especially
    for places where the vaccine is generally working, but you
    still want to have tools to help those who get it?
        Dr. Walensky. Absolutely. And I know--first of all, I think
    we are--you know, we are working now, we have said, if anyone
    is not safe, then no one is safe. We really do need to make
    sure that we have resources to other places, if variants emerge
    they will come to our shores. So we have to be able to do that.
        I also know that NIH has invested in making sure that we
    have therapeutics. One of the first things that we had when I
    was rounding on the wards last May, was Remdesivir. And that
    was the first sign of an antiviral.
        We don't have anything really that we can give quickly over
    the--you know, by prescription to outpatients. Right now we are
    relying on monoclonal antibodies. They are hard, they are
    clumsy, they take a lot of resources, and they are expensive.
    And so I do believe that we need, in this next phase, after we
    get the majority of Americans vaccinated, we do need to turn to
    antivirals that are able to be easily administered in an
    outpatient setting.
        Senator Braun. And a final comment. I think that is going
    to be important because we don't know how much variants will
    become an issue. And at some point when we have generally
    tamped it down, I think it is incumbent on us to put focus on
    how to help those that end up getting it, especially that are
    so predisposed with bad outcomes. Thank you.
        Dr. Walensky. Thank you.
        Senator Murray. Thank you.
        Senator Manchin.
        Senator Manchin. Okay. Thank you, Madam Chairwoman.
    Appreciate it very much. And I want to thank all of you for
    being here.
        Dr. Schuchat, first of all, thank you for your service,
    many, many years of service. And I appreciate very much, what
    you have done. And my first question would go to you because
    you probably have the historical knowledge of how we got to
    where we are.

                        VULNERABLE PUBLIC HEALTH SYSTEM

        Over the last decade, the United States has lost over
    50,000 public health jobs. And during that time we have faced
    the H1N1 flu outbreak, Ebola, Zika, and now COVID, within the
    last 5 years alone, West Virginia has lost nearly 30 percent of
    our public health workforce. One thing we know from this
    pandemic is that we were not prepared. While we have been able
    to hire temporary public health workers in the last year, as
    these positions they were not permanent, and are at risk of
    disappearing after the public emergency, health emergency is
    over.
        So can you speak to how we became so vulnerable and fell
    behind the curve in our ability to respond to this pandemic,
    and how can we keep it from not happening again? I know you
    have all touched on it, but I just cannot believe we were
    this--we were this unprepared.
        Dr. Schuchat. Yes. I think the state of our preparedness
    was a real tragedy. And part of that relates to the public
    health infrastructure over and over, we invest in response to a
    crisis, but in ways that haven't provided sustainable capacity
    at that frontline where the problems happen, so----
        Senator Manchin. But these decisions made higher up within,
    whoever the administration may have been, whether they were
    Republican or Democrat. Was it made at that level? Or was it
    made at the Head of the CDC?
        Dr. Schuchat. The biggest funding increases we have gotten
    have been emergency funds from Congress that, you know, happily
    supported response for H1N1, and Ebola, and Zika, and COVID.
    But the dollars that were there day in and day out to provide
    reliable jobs for the local public health workforce were not
    there. And whether it was State budgets or Federal budgets
    that, you know, you cited the statistics of the job loss.
        Beyond that, the jobs were not the same anymore. You know,
    we talked about the data. Our data systems have really not kept
    up with the times. We have very fragmented data systems that
    have not been modernized.
        Senator Manchin. And my time--my time is limited, and I
    want to ask Dr. Walensky this question.
        But on this Dr. Schuchat, what type of time basis would you
    say that we should be looking at for funding? I mean, to have
    confidence in the funding, permanent funding, over what, a 5-
    year, a 10-year period? So it is consistent you know what you
    can do and be prepared?
        Dr. Schuchat. You know, I think the approach that was taken
    for NIH to strengthen their capacity for vital biomedical
    research is what needs to happen for the vital public health
    infrastructure in the country, where it is not a feast and
    famine.
        Senator Manchin. Sure.
        Dr. Schuchat. But that local, State, and Federals can plan.
        Senator Manchin. And now will be the time to do it. If we
    are ever going to do it, we should do it now, since it is all
    very fresh in what we have been able to endure.

                            OPIOIDS IN WEST VIRGINIA

        Dr. Walensky, as you are aware, we are facing an epidemic
    within the pandemic, West Virginia is ground zero for the drug
    epidemic, with the highest rate of drug overdose deaths in the
    country. To make matters worse, 2020 was the worst year yet
    with over 90,000 deaths, and we saw at least 47 percent
    increase in the State of West Virginia with overdose deaths. So
    what resources is CDC providing to States to combat the
    epidemic?
        Dr. Walensky. Thank you, Senator, for that question.
        Senator Manchin. And also, I would have made--and the
    second part of that would be: in working on helping--what CDC
    is--are working on helping increasing the testing for viral
    hepatitis and HIV? We have had a tremendous--horrendous
    situation with that.
        Dr. Walensky. I can tell you, just before coming here, I
    spoke to one of my infectious disease colleagues in West
    Virginia, and she was telling me that they have opened neonatal
    detox units, I understand, that it is unbelievable.
        Senator Manchin. Unbelievable, unbelievable.
        Dr. Walensky. It is unbelievable. And so we know that we
    need to tackle this. We need to counter this. We need accurate
    data. We need interventions that can--and we need resources to
    be able to invest in Opioid Naloxone Programs that are reaching
    the community. Community health workers that can do the
    outreach to talk to people and intervene at the local level
    where these are happening, we need toolkits, we need
    information, and mental health support services to intervene.

                         AMERICAN MEDICAL MANUFACTURING

        Senator Manchin. Right. My time is running out. I want to
    ask you that one other thing that--we produce very little of
    the things that we basically needed for medicine, penicillin,
    do you think penicillin should be produced in America? Do you
    think doxycycline should be produced, an antibiotic in America?
    And if so, what should we do in order to do that? Or stockpile
    strategically for our own protection?
        Dr. Walensky. I think we need to have a public health
    infrastructure and a pipeline that allows us to respond to
    pandemics, and to epidemics, and to infectious threats.
        Senator Manchin. Do we have any manufacturers that are
    producing these in America?
        Dr. Walensky. There are limited manufacturers producing
    penicillin, that I can talk to. Because, in fact, we have had
    penicillin shortages, penicillin has gotten extraordinarily
    expensive. And in fact, some colleagues of mine have once said,
    it should be cheaper than the pipe--than the tubing it runs
    through. And in fact, it is not.
        Senator Manchin. Should the CDC basically--I mean, your
    recommendation would be for production. We should be producing
    these in America. You know, we need to have something from a
    professional, like yourself, to get back to producing things in
    American, and not depending on supply chains.
        Dr. Walensky. So one of the things I can just mention for
    penicillin specifically, is it is particularly hard given the
    allergies related to penicillin. It is actually, particularly
    hard to do. There are limited plants that make penicillin. But
    your point is well taken.
        Senator Manchin. Thank you.
        Thank you, Madam Chair.
        Senator Murray. Thank you.
        Senator Moran.
        Senator Moran. Chairwoman, thank you. Thank you and Senator
    Blunt for this hearing. And welcome to our two Doctors, thank
    you for service.

                     COLLABORATION ON BIODEFENSE FACILITIES

        I have four questions I am going to try to accomplish in 5
    minutes. Let me first highlight something that is occurring in
    my home State. Kansas will soon be the home to the National Bio
    and Agro-Defense Facility. It is a $1.25 billion research
    facility, nearing completion. Its mission is to--or the
    facility is to protect U.S. livestock from foreign animal
    diseases, including zoonotic diseases that can pose significant
    threats to human health. NBAF (National Bio and Agro-Defense
    Facility) will be the first bio containment facility in the
    U.S. where there is a BSL4 laboratory, which zoonotic pathogens
    for which there no treatments, currently, exist.
        NBAF is operated by the U.S. Department of Agriculture with
    cooperation from the Department of Homeland Security, right, so
    truly going to be as a state-of-the-art facility, COVID-19,
    which possibly is a zoonotic disease, has only highlighted the
    importance for the U.S. to invest in this type of research.
        Are you engaged with USDA (U.S. Department of Agriculture)
    or Homeland Security on future research that could be conducted
    at NBAF in regard to the zoonotic diseases? What kind of
    research NBAF would be able to provide you with benefits in
    your mission of protecting human life?
        Dr. Schuchat. Let me just say that what we call One Health,
    the idea of human and animal health, and the environment has
    been a global issue for preparedness and response. We have seen
    so many terrible diseases emerge from the animals, and we have
    not been sufficiently ready for them.
        Whether we are dealing with the genetic sequencing of
    strains, and whether the animals' strains have adapted better
    to humans, or research into containment interventions, it is
    really important. And so our principle of collaboration between
    Health and Human Services, and the Department of Agriculture,
    and Department of Homeland Security is very important.
        I can say that the CDC and USDA both have oversight over
    select agents that, you know, are evaluated in those BSL4
    facilities. And we work very closely with them to make sure
    that animal health is protected, and that human health is
    protected, and laboratories that are sending these pathogens do
    so safely without risk to the surrounding community.
        As to exactly where we are with collaboration, I think we
    will have to get back to you, but it's a--congratulations on
    the facility. And I think we will look forward to working
    together.
        Senator Moran. This is a post\1/1\1 development, and
    designed to replace the Plum Island and the research done there
    on a new advanced laboratory. I would welcome the opportunity
    to connect you and the folks at either Agriculture or--and
    those in Kansas as well.

                          INTERNATIONAL COLLABORATION

        What, if anything, is steps that CDC, or perhaps broader,
    the Federal Government should do to bring China into this world
    of helping us combat diseases, the spread of viruses? Is there
    any opportunity for us to get better information, in any way
    that we can insist, encourage or demand that China behave
    differently than what they did, after the arrival of this--the
    evidence of this disease in China?
        Dr. Walensky. I think that we are all a global community at
    this point, and that when there is a threat anywhere, there is
    a threat everywhere. And so when it comes to our health, when
    it comes to science, it is helpful to have these connections we
    have in office, our regional office in China, where we exchange
    scientific information. So I think around the global community,
    it is important that we--that we convey scientific inference.
        Senator Moran. What is your evaluation of what cooperation
    occurred between China and the United States in regard to
    COVID-19? And has anything changed to increase or decrease that
    cooperation now?
        Dr. Walensky. The WHO (World Health Organisation) has done
    a study--has numerous interactions to evaluate this. My
    understanding is that there is another phase of that study
    underway. And I think that that is really critically important,
    because quite honestly, and in my review of that study, and
    many have spent many hours reviewing this study--these studies,
    there was not a lot of transparency in line-level data that is
    able--that we are able to use to interpret.
        Senator Moran. Dr. Walensky, there is probably a longer
    answer than that. And maybe we can have that when you and I
    have a chance to have a conversation.
        A couple of things in the 30 seconds I have left. I would
    highlight that you and I have had this conversation, Dr.
    Frieden encouraged me in regard to the Global Health Security
    Program, and I have tried to be an advocate for that program in
    this appropriations subcommittee, with some success.
        And I just would--I am interested now, you don't have to
    answer this question in the lack of time that I have for you to
    do so, but I would love an answer that tells me how I should
    prioritize. You have said it, what happens elsewhere matters to
    us, and absolutely the truth and we have known that for a long
    time, but how do we prioritize now with the consequences of
    this pandemic in the United States?
        How do we prioritize the appropriations that will go to
    programs that are outside the United States, that are
    protecting us as well as citizens of the world, as compared to
    things that need to be done domestically, which are
    significant? So I would love to have a broader discussion about
    where those priorities should lie.

                          LEARNING LESSONS FROM COVID

        And finally, I would indicate, I am reading a book, which I
    do regularly, The Premonition, and I don't know whether you
    have read it, but I am two-thirds the way through. It is not
    terribly derogatory, but not terribly complimentary of the CDC.
    And I would welcome any suggestions you have of what the
    takeaway should be for the CDC, or if it is a book that is
    worthy of learning something from.
        Dr. Walensky. Thank you, Senator. I would be happy to
    engage in those conversations. I have not read The Premonition,
    although I know of it, and I know many people who are in it.
    And what I will say is, there are many lessons that we can
    learn, some things that we have to do better at the CDC, and
    some things that we have to do better as a country, and
    investing in multiyear public health infrastructure.
        I think among the comments in the book that I am familiar
    with was one of the issues that I heard firsthand, you know,
    labs receiving results by fax and, you know, people working in
    data entry to do that. That is not a public health
    infrastructure of the future. It is not a way to respond to a
    pandemic.
        And so I think the lessons to be learned from the book, are
    yes, we have to understand where things could have gone better
    at CDC, and we need multi-year infrastructure resources to make
    sure that we have, you know, work force, and data, and labs up
    to snuff to tackle whatever they need to tackle in the future.
        Senator Moran. It seems well written to me, and by a
    credible author. And I would encourage you to learn from it, as
    I am trying to.
        Madam Chairwoman, the last comment I would make is. One of
    the things, my takeaway is the failure for CDC to authorize
    testing early on in circumstances in which it appears to me,
    testing should have been occurring.
        Senator Murray. Thank you.
        Senator Shaheen.
        Senator Shaheen. Thank you, Madam Chairman. And thank you,
    Dr. Walensky, and Dr. Schuchat, for your service to the
    country, and for being here this morning.

                            OPIOIDS IN NEW HAMPSHIRE

        Dr. Walensky, I very much appreciated our conversation
    earlier this week. And one of the things we talked about is the
    continuing challenge of the opioid epidemic that we are facing
    in this country. New Hampshire, like West Virginia, has been
    very hard hit. We are one of the 10 States in the country that
    has been hardest hit by the epidemic.
        And I was pleased that Congress provided some new
    flexibility to deal with the epidemic last year, by including
    meth and cocaine as part of the drugs that could be included in
    programs to address opioid--the opioid epidemic. But can you
    talk--one of the things we discussed was the challenge that I
    have heard from providers in New Hampshire that we don't have a
    response for those overdosing on meth in the same way that we
    have Narcan for those who have overdosed on opioids.
        Can you talk about what the CDC is doing to approach this
    issue and what kind of help you might have available for States
    like New Hampshire?

                            COMMUNITY HEALTH WORKERS

        Dr. Walensky. Thank you, Senator. You know, I am thinking
    back to, sort of, 6 months ago and what we needed to do when we
    knew that one of our patients had relapsed, and how we get them
    into care. And it was our community health workers that knew
    where to find them. They knew where they were getting their
    drugs, and they knew where to find them, and to say, somebody
    cares for you, and brought them back.
        And that, I think, is what we need in our public health
    infrastructure. We need the community workers who live in the
    community, who are from the community to make those
    interventions, to find the people. And that is really among the
    things that I think this public health infrastructure is going
    to be able to do. Certainly, we don't have something like
    Naloxone for meth overdose and that, you know, is unfortunate
    right now, and we need to address that.
        And then quite honestly, we have statistics of the
    overdoses and the lethal overdoses. They are terrible. And yet
    we also have statistics of, you know, all these
    hospitalizations that are happening among young people that I
    was taking care of just 6 months ago, 30-year-olds getting
    their second valve replacement.
        So this is something that we have to tackle, and it is not
    just that we have to tackle it with Narcan in a given
    community. We have to tackle it community by community, because
    there are all different kinds of communities, and we need the
    workers to be able to do so.
        Senator Shaheen. Well, thank you. I hope that--and I know
    this is not a CDC issue--but I hope that you will weigh in, if
    you have the opportunity, with the administration on the
    importance of the set-aside funding for States like New
    Hampshire that have been hardest hit, because that has allowed
    us to up a real statewide response to the epidemic.

                               PFAS CONTAMINATION

        I want to go on to PFAS, which is an emerging contaminant
    until we get the EPA (Environmental Protection Agency) to
    designate it as something else. But it is one that we have seen
    very directly in New Hampshire, and especially appreciate the
    response from the Agency for Toxic Substances and Disease
    Registry, which has been so helpful in undertaking a
    comprehensive health study in New Hampshire, Portsmouth, and
    Pease former Air Force base, have been one of the sites
    designated.
        But one of the things we have learned is that too many of
    our members of the medical community don't have any idea about
    PFAS. They don't know what it is. They don't know how to
    respond to it. They don't know whether testing is appropriate
    or not.
        And I worked with Chairman Murray and Ranking Member Blunt
    last year to fund a grant program to help educate our
    physicians. And I am very interested in how that unfolds, and
    the work that the CDC might be doing to help an ATSDR (Agency
    for Toxic Substances and Disease Registry) to educate our
    medical community.
        So I don't know if either of you can speak to that on the
    update on where that effort stands.
        Dr. Schuchat. This has been such a complex and challenging
    area, and I really appreciate the leadership that you have
    shown, and the----
        Senator Shaheen. Thank you.
        Dr. Schuchat [continuing]. Support you have given, and also
    the advocacy for us to learn what we need to learn so that
    people who have been exposed, and the clinicians that they see
    know what to do to get a result, and then not know what it
    means and what you are supposed to do about it is challenging.
    So we really are incredibly grateful for the resources that are
    letting us begin to pave the way to get those answers.
        I don't have specifics on the results of studies yet, but I
    know it is a very high priority for ATSDR and the leadership
    here.
        Senator Shaheen. And do you know that, at one point in the
    last year, there was a suggestion that there was a connection
    between exposure to PFAS and severity of COVID-19. Do we have
    any more information about that?
        Dr. Schuchat. You know, I know that question came up and
    that we were looking into it. I don't believe we have a final.
    But we can get back to you if we do.
        Senator Shaheen. That would be great. Thank you. If you
    could just let me know, either way, what we know about that, I
    would appreciate it. Thank you.
        Thank you, Madam Chair.
        Senator Murray. Senator Capito.
        Senator Capito. Thank you, Madam Chair. And thank you for
    our witnesses today. Both of, Dr. Walensky and Dr. Schuchat,
    and I wish you the best in your--we won't call it retirement--
    in your repurposing. How about that? Wherever you may land?
        Let me ask specifically. Senator Shaheen and Senator
    Manchin mentioned, obviously, the overdose rates in the State
    of West Virginia, so I won't go back through that. But I am
    concerned.

                              HIV IN WEST VIRGINIA

        Dr. Walensky, I know you have a focus on ending the HIV
    epidemic. I know this is in your academic career as well. You
    mentioned it in the President's budget. West Virginia received
    a grant in the Integrated Viral Health--or Hepatitis, excuse
    me, Surveillance targeted funds to help us address certain
    areas, hotspots, I guess you would call them. But we are not--
    we are not in ending HIV epidemic focused jurisdiction, nor any
    of our counties. And in your testimony, you state that
    increased funding in the budget is for four key strategies in
    the focus areas, but not to increase the amount of focus areas.
        So my question is, I think we need to be a focus area
    because we have some of the highest incidence. And how do you
    expand that footprint? Or, how can you help me with that?
        Dr. Walensky. Thank you, Senator. As I think you noted, my
    20-year career prior to January 20 was in doing exactly that.
    And I was really encouraged by ending the--the mission to end
    the HIV epidemic, really through a diagnosis, prevention,
    treatment and response. And, you know, when the initial tranche
    of HIV and the HIV epidemic money went out, it was to areas
    with the highest numbers, with truly a multi-year plan to
    expand to other areas that we needed to really curb things in
    the areas with the highest numbers.
        Take some of the lessons that we learned and expand to some
    of the other areas. And so I have a vision, and hope that we
    will be able to do that in the--in the years ahead, and to
    continue that expansion.
        Senator Capito. Thank you. Thank you. So expansion into
    areas such as ours, I think that would be welcome. I would make
    note that in the initial disbursement of the vaccine, our State
    of West Virginia did an incredible job working with our public
    health infrastructure. But I think one of the lessons that we
    learned, and that I hope this becomes part of a manual to
    address future issues, is public health infrastructure cannot
    do this by themselves, not to what we saw at the--the breadth
    of what we saw.
        So what happened? We had volunteers, we had county city
    governments, and we had our National Guard. And so I would
    encourage you while, I think, increasing our public health
    infrastructure is absolutely essential. I think growing those
    partnerships could be even more essential because there is a
    roadmap there to success. And so I just put that on your radar
    screen, as you are--as you are looking to expand.

                            MASK POLICY JURISDICTION

        One thing I would like to ask, and Senator Blunt and I were
    in the Oval Office when the announcement was made with the
    President that we were going to lift the mask mandate. And I
    cannot tell you how joyful we all were as we ripped our masks
    off and had a great meeting after that.
        But there is confusion still. And, you know, if we are
    going to get more people vaccinated, which is the ultimate goal
    all the way down through the age levels, we cannot have this
    confusion, because it is just: should I get my child
    vaccinated? You know, should I--how old can my child be to get
    vaccinated?
        Does my child need to wear a mask at school? Who is the
    ultimate decider here? Is that the CDC? Is it the President? Is
    the governor? Is it the NIH? I mean, there is just too much
    coming at young families in particular, I think, to be able to
    feel, number one; that their child is safe, and they are doing
    the right thing for them to go to school. But also to get rid
    of that, I would say not anti-vaxxer, but vaccine hesitation. I
    think that is a large part of the people that are left as yet
    to be vaccinated. So how would you respond to that question?
        Dr. Walensky. Thank you. The guidance that we put out on
    Thursday was individual guidance for people who are fully
    vaccinated can take off their masks.
        Senator Capito. Right. Right.

                 COVID-19 VACCINES FOR CHILDREN AND ADOLESCENTS

        Dr. Walensky. I have--or I was pleased actually the day
    before that the FDA (Food and Drug Administration) had
    authorized and the CDC had recommended vaccination with Pfizer
    vaccine for individuals as young as 12 years old, that is now
    recommended. And my 16-year-old has been vaccinated, and we
    have a lot of community workers out there encouraging
    vaccination of youth.
        And, in fact, over 600,000 people between the ages of 12
    and 15 have been vaccinated just in this last week. In terms of
    guidance, the CDC provides science-based, evidence-based
    guidance to anybody who is the consumer of said guidance,
    whether it be industries, jurisdictions, importantly the
    country is not uniform. And so I think you really do need to
    interpret our guidance in the context of what is happening in
    your community. And that is really important in the context of
    a transmissible agent.
        Why is that important? Because the virus is going to be an
    opportunist, if you have a county that has low vaccination
    rates and high rates of disease, that county may interpret our
    guidance differently than a county that has high vaccination
    rates, and low incidence of disease.
        So we really do have to do this at the local level because,
    in fact, the virus will--where there is less vaccination, the
    virus will emerge.
        Senator Capito. So what do you say to the under-12
    population, elementary school? The parents of those children
    who have low vaccination rates, which is probably close to
    nothing, they have low incident of infection and, you know, all
    the studies that show the younger generation is not as affected
    as older and even more senior. What do you--what do you tell
    them? Listen to your governor? Listen to your school Board?
        Dr. Walensky. So what we would say is, vaccines are coming
    for youth. We are hopeful to have, they are doing dose de-
    escalation studies now down to 9 years old, soon thereafter
    down to six, soon thereafter down to three, and then down to 6
    months. So we are working towards getting a vaccine that will
    be available for all people.
        Senator Capito. So when would that be?
        Dr. Walensky. Well, some of it depends on how much disease
    is out there in the community. So we cannot exactly predict,
    but we are hoping to have more available in late fall, and by
    the end of the year but through dose de-escalation studies.
        And then of course, I think that the guidance that we have
    had for schools has actually demonstrated that even in the
    absence of vaccinations schools can be a very safe place, given
    the guidance that we have. We have recommended that schools not
    change anything for this school year, because it will be hard
    for our youth to get fully vaccinated before the end of this
    school year. We will be updating that soon. And then given that
    guidance it will be--there will be policies at the local and
    jurisdictional levels.
        Senator Capito. Well, I still think it--I mean, I know you
    probably would agree that it is a bit confusing to folks all
    around the country who have children in school. I would just--
    just be as clear, and concise, and definitive, when this
    science comes forward and more vaccinations come forward,
    because I think it really is--it is really difficult, I think,
    for parents to decide how to do the right thing. Thank you.
        Senator Murray. Thank you. That ends our first round of
    questions. And I will start a second round for any Senators who
    wish to ask additional questions.

                         RACIAL AND ETHNIC DISPARITIES

        And Dr. Walensky, I will begin with you. You know, the
    pandemics deadly impact on communities of color show we do have
    a long way to go to address systemic racism and health
    inequities. Black and Latino populations are receiving
    vaccinations at disproportionally low rates, even as some of
    our recent polls suggest both groups are more likely than White
    people to say they want to get vaccinated.
        And according to the CDC website data on race and ethnicity
    is available for just over half of vaccinated people. How is
    CDC working to improve vaccination access and collect more data
    on these demographic issues that we need to see in front of us?
        Dr. Walensky. Thank you very much for that question,
    because we are working hard. We have placed our community
    vaccination centers, or mass vaccination centers in areas that
    have high Social Vulnerability Index, they are doing an
    extraordinarily good job in getting our minority communities.
        Our Federal Retail Pharmacy Program sites were selected
    initially, in collaboration with the State, to see how we could
    get vaccine to the most vulnerable communities, to Black and
    Brown communities. And just this last 2 weeks, Federal Retail
    Pharmacy Programs, 47 percent of vaccines that they delivered
    were to minority communities.
        And then our federally-qualified healthcare centers, in
    collaboration with HRSA, we have been delivering to people who
    are migrant workers, to people in rural communities, and people
    who have less access. One of the things we have been able to do
    to improve our race and ethnicity data, and this has been
    challenging because some people are electing not to report it,
    is to use HIPAA (Health Insurance Portability and
    Accountability Act)-compliant electronic case reporting, so
    that we can use cases--or this is on the case level, not the
    vaccine level, but looking at cases and then match it medical
    records via Cerner, via Epic, to be able to get case-level
    data.
        We are working really hard with the counties to get both
    racial and ethnic minority data at the case and disease level,
    but then also the vaccination level. And this is, again, one of
    the areas where data has--you know, our data infrastructure has
    not been robust enough to deliver this to us in real time.
        Senator Murray. Are you seeing any political ideology plan
    to this decision to get vaccinated?

                               VACCINE HESITANCY

        Dr. Walensky. This is a personal choice. I think once we
    start saying: this group wants vaccine, this group doesn't,
    then we start telling the wrong message. When I was taking care
    of patients with HIV, and I was told--the new patient I had to
    deliver a new diagnosis. They always said to me, you deliver
    the diagnosis and then you pause, and you see what means to
    them, right?
        Could it mean that they are worried about their baby, they
    are going to lose their job, they think they are going to die,
    they can't afford their meds? I think vaccines hesitancy is
    exactly this.
        What is it about the vaccine that is making you hesitant?
    Is it that you are scared? Do you have to take the day off of
    work to get it? Is it that you saw a friend get it and they had
    a reaction? Is it that, wow, how did the science come so fast?
        And so this is not about politics, this is about
    understanding where individuals are, meeting them where they
    are, and understanding what it is that is making them--making
    them hesitant.
        Senator Murray. Okay. Thank you.

                             VACCINES IN PREGNANCY

        Dr. Schuchat, recent research on the impact COVID-19
    infection has on pregnant women is really alarming. One study
    last month showed pregnant women with COVID-19 are 22 times
    more likely to die compared to women who are not pregnant who
    contract the virus. What is the latest vaccine guidance for
    pregnant women?
        Dr. Schuchat. Yes. Thanks so much for that issue. COVID
    complicates pregnancy, so women who are pregnant and get COVID
    have worse experiences with the infection, than do non-pregnant
    women. More time in the intensive care unit, more risk of
    severe outcomes, including those rare deaths. COVID also
    complicates pregnancy by increasing the risk of prematurity,
    and leading to other types of complications.
        While, as you know, clinical trials rarely enroll pregnant
    women, we are fortunate that there has been intense effort to
    get data about women who do get vaccinated while pregnant, to
    understand what happens, so that other women can learn from
    that.
        Based on what we know right now, we recommend that women be
    offered vaccines during pregnancy, that they are eligible to
    get them, and that they make a choice about it; that choice
    might be based on how they value that risk or that unknown. But
    we do have reassuring data right now about vaccines given,
    particularly in the third trimester that have been followed and
    reported. We are continuing to follow and working closely with
    FDA on that. And so we will be expecting this summer to have
    even more data, particularly about vaccines given earlier in
    pregnancy.
        Senator Murray. Is there any research about pregnant or
    lactating women who are vaccinated--who are vaccinated,
    transferring antibodies to their infants?
        Dr. Schuchat. We have emerging data that the antibody is
    transferred. And so we hope it will be like the influenza,
    where, getting vaccinated during pregnancy against influenza is
    really important because newborns and young children are very
    high risk for influenza complications. So, good news so far,
    and continuing to follow that.
        Senator Murray. Thank you.
        Senator Blunt.
        Senator Blunt. Thank you, Chair.

                                VACCINE BOOSTERS

        The issue of a booster vaccine obviously is out there, so
    far most of the people that have said they think we are going
    to need it are from the companies that are making the vaccine.
    Dr. Fauci, former CDC Director Tom Frieden, others have said
    there is growing evidence that there will be enduring
    protection with the vaccine we have.
        Now, I have been a big supporter of the Warp Speed effort
    to invest early in vaccines that were not approved yet, which I
    think made a big difference in availability. I do question the
    BARDA (Biomedical Advanced Research and Development Authority)
    decision to purchase 400 million doses of Moderna and Pfizer as
    a booster dose.
        Were you asked about whether that was the right decision to
    make or not? And if you weren't, should CDC be involved in a
    $7.9 billion decision about a booster before we know whether we
    need one or not?
        Dr. Walensky. Thank you, Senator. I think the first thing
    to recognize, and this has been miscommunicated, so I think it
    is very important, in the media, is that if you have received
    two doses of your Pfizer and Moderna vaccine, you are right now
    protected.
        Senator Blunt. Right.
        Dr. Walensky. What we are looking at is whether we will
    need boosters over time. And I think that this is really--given
    how hard we were hit by this pandemic, I think it is really
    important to understand where we will be with that. Data
    suggest from SARS, not SARS-CoV-2, but from SARS, that is
    similar to coronavirus, that people have waning immunity over
    time.
        And if you looked at what happened in the SARS outbreak
    several years ago, you saw that people were eligible for
    reinfection. So there is biologic plausibility that there would
    be waning immunity after you were infected. And we just don't
    know when that will be.
        One of the concerns has been that if we first vaccinated
    our very most vulnerable, our people in nursing homes, that
    they may not have had as robust a response, and that they might
    be the first to--they would be a first who would need a booster
    anyway, because they were vaccinated first. But in fact that
    they may not have had a robust response is in----
        Senator Blunt. If we spend $7.9 billion, which I guess we
    did decide to do on May the 2nd, do we think those vaccines
    last for some time?
        Dr. Walensky. I am not under the impression those are being
    made right now. I think part of the issue is what do they need
    to look like? Are we going to boost with the exact same mRNA
    structure as we do now? Or might we want to boost with a
    variant structure? And I think those are all conversations that
    are happening.
        Senator Blunt. Yes. Well, I think that is a pretty big
    spending decision to make based on the information we have. But
    we can talk about that more, later. If we do go forward with
    booster vaccines, are you all working to see if in an adult
    immunization program, we would try to combine more things with
    that booster? A flu shot, or whatever other shot that an adult
    might need at this point?
        Dr. Walensky. I think it is pretty clear that we have had
    an immunization program for adults that was not prepared for
    what we needed in this, in this structure.
        Senator Blunt. Right.
        Dr. Walensky. And yes, I think it would be advantageous.
    Currently, we don't have data as to whether you can co-
    administer vaccines, those data we are looking for. And in
    fact, the ACIP (Advisory Committee on Immunization Practices)
    just opined on this last week, because we are so behind on
    childhood immunizations, 11 million behind on childhood
    immunizations. So those are all the data that we are looking
    for, because I think it would be really great to be able to
    leverage what we are doing for COVID for influenza as well, and
    vice versa.

                               DATA MODERNIZATION

        Senator Blunt. Exactly. And I hope you will keep us posted
    on that as that happens. On data, that was actually where I was
    going next. You know, the data, we obviously had a data
    shortage, a shortage and some confusion about what data to
    input, which was not as helpful as it might have been.
        Now, the committee, in what was then a fairly controversial
    decision, even among our colleagues, we decided, before COVID,
    to invest $50 million in base funding over the last 2 years for
    data. When COVID occurred, you know, and the numbers we were
    suddenly looking at and dealing with, we did another $500
    million.
        Dr. Schuchat, tell me where you think we are on better data
    preparation in the future? Or being better ready in the future
    to have data, and the tracking that comes with data? Where are
    we, and where would you think--that had CDC in the next fiscal
    year, for instance?
        Dr. Schuchat. This is essential. The $50 million base
    appropriations were vital, but you saw how behind we were. This
    is critical. We are so far behind, even with the increased
    resources. This is a long-term need; we are better, but we are
    not where we need to be. We have made huge progress this past
    year with electronic lab reporting of enormous numbers in terms
    of how many people were being tested, and getting us daily
    data. But the data were not necessarily complete, and as you
    heard the race/ethnicity data often missing.
        We have a need to move to the cloud for many of our
    systems. We have a need to become--have a workforce that can
    handle the data at the local level, at the State level, that
    can use these sophisticated tools and not just react, but
    predict. So we still have a long way to go, but COVID, we have
    made a lot of progress on. We need to make that progress across
    the spectrum of public health issues.
        Senator Blunt. Well data, and tracking, and other things I
    think are an important part of the future of health. And we
    want to be helpful. And I would hope that the $550 million,
    collectively, in the last couple of years has made a
    substantial difference in where we are headed.
        Thank you, Chair.
        Senator Murray. Senator Blunt. Thank you.
        I have one additional question for you. The CDC faced
    unexpected difficulties, as we all remember during those
    opening phases of the pandemic, especially around testing, and
    delays in establishing a large-scale testing, likely allowed
    the virus to spread undetected, as we know, one of the several
    factors that really hampered our efforts to contain that
    outbreak.

                             EARLIEST COVID LESSONS

        Dr. Walensky, I just wanted to ask you today, what lessons
    has CDC learned from the experience in those first few weeks?
        Dr. Walensky. There has been a lot of research going into
    what we could have done better during that period of time. My
    responsibility is to own that and to make sure that we are
    better. Among the challenges were quality--assurance quality
    control programs that were not in place the way they should
    have been. And in fact, among the things that we are doing is
    to ensure that all labs, research and diagnostic labs are fully
    accredited.
        So we are learning those lessons. Those were hard lessons
    to learn. I do also think that we need to recognize that among
    CDC's responsibilities is that when we have a new infectious
    pathogen, we are responsible for creating the diagnostics for
    that pathogen. Once we have done so, we need interagency
    collaboration with ASPER, with FDA to make--with the private
    sector to ensure that we can bring it to scale.
        We are now at 1.1--we did one million tests yesterday, we
    are testing one to two million a day. That scale up has to be
    interagency. And so, yes, we have a lot of lessons that we can
    learn from what occurred, and we are learning them and taking
    resources that have been provided to us so that we can, not
    just take a line--a line item and improve X-lab, but we can
    improve all of the labs and through this accreditation process,
    for example, but then also to be able to scale at the national
    level.
        Senator Murray. Okay. Thank you. Thank you very much. That
    will end our hearing today.
        But I do want to thank both Director Walensky, and
    Principal Deputy Director Schuchat for joining us.
        Thank you to all of our colleagues on the committee who
    participated as well.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due one week after the
    President's budget is delivered at 5:00 p.m. The hearing record
    will also remain open until then for members who wish to submit
    additional material for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                  Questions Submitted to Dr. Rochelle Walensky
                  Questions Submitted by Senator Patty Murray
        Question. Researchers in the United States continue to discover new
    variants of the coronavirus that are spreading throughout the country.
    Congress provided $1.75 billion in the American Rescue Plan for CDC to
    increase genomic sequencing of SARS-CoV2 to identify emerging variants.
    President Biden's fiscal year 2022 budget proposal includes $8.7
    billion for the CDC, a $1.6 billion increase from fiscal year 2021's
    budget.
        How will the CDC's budget be used to help state and local public
    health offices expand their surveillance capabilities to keep pace with
    new and emerging variants?
        Answer. In May 2021, CDC awarded $240 million in American Rescue
    Plan (ARP) funds to state and local health jurisdictions to build
    sequencing and analytic capacity for all pathogens of interest,
    including SARS-CoV-2. CDC plans to fund these state and local labs for
    additional years, with ARP funds, to continue and to build on these
    activities, including funding support for equipment, supplies, and
    staffing. These activities build on expertise gained through the
    Advanced Molecular Detection (AMD) program. In addition, CDC is
    currently soliciting proposals for construction and renovation costs
    necessary to modernize the sequencing units of the nation's public
    health labs, which will also be funded through ARP funds. All of these
    labs are currently sequencing bacterial foodborne pathogens, and at
    last count, more than 60 labs were sequencing SARS-CoV-2. A subset of
    these labs are sequencing other pathogens, such as antimicrobial-
    resistant bacteria and fungi, influenza virus, and the agents of
    tuberculosis and Legionnaire's disease. The number of labs sequencing
    these pathogens, as well as the number of pathogens they are
    sequencing, is expected to increase with the availability of these
    funds. CDC is also providing technical assistance, as well as support
    in planning and administration.
        Question. How long will it take to revitalize all state and local
    jurisdictions so they are equally equipped to help stop the spread of
    COVID-19 and other future disease outbreaks?
        Answer. All state public health laboratories, and an increasing
    number of county/local public health laboratories, have the potential
    to perform next-generation sequencing. At the beginning of the
    pandemic, the main limiting factors were (1) limited staffing; (2) the
    large number of competing priorities in responding to the pandemic; (3)
    a lack of bioinformatics capacity; and (4) limited experience and
    knowledge among epidemiologic staff in how to use genomic data as part
    of the response. With the long-term investments to strengthen public
    health infrastructure as proposed in the fiscal year 2022 Budget,
    including public health laboratories, we will be in a better position
    to respond and control future outbreaks. With experience from COVID-19,
    these organizations are already in a better position to apply genomic
    epidemiology during the next public health emergency. But over the next
    three to 5 years, with both the investments above as well as
    investments in the sequencing Centers of Excellence (also supported by
    the ARP funds) and large increases in training, state and local
    jurisdictions will be in a much better position to apply genomics to
    intervene at the start of a public health emergency.
        Question. Thus far, the available COVID-19 vaccines protect against
    most of the variants currently circulating. A group of biostatisticians
    at Fred Hutchinson Cancer Research Center, based in Seattle, WA, are
    studying breakthrough infections of COVID-19 following full vaccination
    to determine which variants are able to evade the body's immune
    response. By understanding the correlation between needed level of
    protection and infection prevention, they hope to simplify the process
    of booster shots or vaccines against new variants.
        What other research or studies would the CDC conduct to make sure
    the United States can quickly and proactively protect people from new,
    and potentially more dangerous, variants?
        Answer. CDC has monitored for variant viruses since the beginning
    of the pandemic and continues to monitor for variants nationwide, in
    support of ongoing efforts by the SARS-CoV-2 Interagency Group. We use
    genomic information in combination with hospitalization and other case
    and outcomes data to identify the spread of, and potential consequences
    of, variants of concern.
        CDC leads the National SARS-CoV-2 Strain Surveillance (NS3)
    program, which identifies new and emerging SARS-CoV-2 variants to
    determine implications for COVID-19 diagnostics, treatments, and
    vaccines authorized for use in the United States. Genomic sequencing
    allows scientists to identify SARS-CoV-2 and monitor how it changes
    over time into new variants, understand how these changes affect the
    characteristics of the virus, and use this information to better
    understand how it might impact health. A notable strength of NS3 is the
    regular collection of specimens from across the United States to
    support variant characterization efforts, which provides important data
    to inform public health decision-making.
        Since January 2021, CDC has significantly increased domestic
    genomic surveillance platforms to monitor circulating viruses. NS3 was
    scaled up to process 750 specimens per week from public health
    laboratories across the U.S. CDC also is contracting with large
    commercial diagnostic laboratories to sequence samples. CDC has
    commitments from these laboratories to sequence more than 20,000
    samples per week, pending the availability of SARS-CoV-2 positive
    specimens, with the capacity to scale up in response to the nation's
    needs.
        Since 2014, CDC's Advanced Molecular Detection Program has been
    integrating next-generation sequencing and bioinformatics capabilities
    into the U.S. public health system. Many state and local health
    departments have been applying these resources as part of their
    response to COVID-19. Public health departments support local
    investigations, conduct studies, and make genomic data available to
    public databases. To further support these efforts, on December 18,
    2020, CDC released $15 million from COVID supplemental funds through
    the Epidemiology and Laboratory Capacity Program.
        In May 2021, CDC made available $240 million in American Rescue
    Plan funds to state and local health jurisdictions through the
    Epidemiology and Laboratory Capacity for Prevention and Control of
    Emerging Infectious Diseases (ELC) cooperative agreement. These funds
    are to be used over 3 years to build sequencing and analytic capacity
    for all pathogens of interest, including SARS-CoV-2. In addition, CDC
    plans to fund these state and local labs for at least an additional 3
    years, with ARP funds, to continue and to build on these activities,
    including funding support for equipment, supplies, and staffing. These
    activities build on expertise gained by the Advanced Molecular
    Detection (AMD) program since 2014 in the application of pathogen
    genomics to public health.
        Furthermore, we have issued 29 awards, totaling approximately $37
    million, as part of the SARS-CoV-2 Sequencing for Public Health
    Emergency Response, Epidemiology, and Surveillance (SPHERES)
    Initiative. These awards are intended to fill knowledge gaps and
    promote innovation in the U.S. response to the COVID-19 pandemic and
    will help integrate next-generation genomic sequencing technologies
    with bioinformatics and epidemiology expertise across the US public
    health system.
        As CDC and our public health partners sequence more SARS-CoV-2
    genomes, we will continually improve our understanding of which
    variants are circulating in the US, how quickly variants emerge, and
    which variants are of most concern to public health, and thus the most
    important to characterize and track.
        Question. Is the CDC continuing to monitor other public health
    concerns such as influenza?
        Answer. Yes, CDC has continued to maintain and strengthen its
    surveillance systems during the COVID-19 pandemic. For example, in
    preparation for the 2021-2022 influenza season, CDC made several
    enhancements to influenza surveillance systems, which improve detection
    of influenza circulation and illness, to differentiate influenza from
    COVID-19, and support COVID-19 surveillance. Data enhancements include
    adding more than 1,000 emergency departments to the U.S. Outpatient
    Influenza-like Illness Surveillance Network (ILINet), adding new data
    sources from the National Long Term Care Facility Surveillance system
    that reports data from approximately 15,400 facilities weekly, and
    integrating HHS Protect hospital data from approximately 6,000
    hospitals. Differentiation between influenza and COVID-19 is supported
    by the CDC-developed multiplex assay for use by CDC-supported public
    health laboratories, which simultaneously tests for type A and B
    seasonal influenza viruses and SARS-CoV-2. These and other updates have
    further strengthened the U.S. influenza surveillance system.
        Question. I am alarmed by increasing antimicrobial resistance, and
    the fact that high levels of antibiotic use during the COVID-19
    pandemic have likely driven the development of new resistance threats
    that have not yet been identified. The 2020-2025 National Action Plan
    for Combating Antibiotic Resistant Bacteria calls for expanded efforts
    that will only be possible with significant new Federal resources.
    Addressing AMR is central to preparedness, as resistant secondary
    infections complicate public health emergencies.
        How does the President's Budget Proposal support the CDC Antibiotic
    Resistance Solutions Initiative in fiscal year 2022 to expand efforts
    to preserve the effectiveness of antibiotics, reduce inappropriate
    antibiotic use, increase surveillance and ensure that we are prepared
    to address this public health threat, as outlined in the 2020-2025
    National Action Plan for Combating Antibiotic Resistant Bacteria?
        Answer. The fiscal year 2022 President's Budget has $172 million
    for the Antibiotic Resistance Solution Initiative, consistent with the
    fiscal year 2021 appropriation. CDC is working to effectively leverage
    resources and invest in key prevention strategies, such as early
    detection and containment, infection prevention, and ensuring the
    appropriate use of antibiotics. The availability of safe, effective,
    and quality-assured antibiotics underlies much of modern medicine, and
    the emergence and spread of AR threatens to undo this progress at
    enormous human and economic cost.
        COVID-19 has potentially created a perfect storm for antibiotic
    resistance (AR) infections in healthcare settings, with longer lengths
    of stay, crowding, severely ill patients, antibiotics frequently
    prescribed upon admission, and infection control challenges like PPE
    shortages. CDC supports a robust domestic infrastructure through its AR
    Solutions Initiative to respond to emerging threats wherever they occur
    across healthcare, the community, and the environment while building
    key capacity to address AR internationally. CDC continues to use a One
    Health approach to tackle AR and to gain a better understanding of AR
    transmission, interactions, and impact between humans, animals, and the
    environment.
        CDC has also proposed ambitious plans to strengthen international
    public health infrastructure as outlined in the 2020-2025 National
    Action Plan for Combating Antibiotic-Resistant Bacteria (CARB). Over
    the next 5 years of the plan, it proposes that CDC would establish two
    networks--the Global Action in Healthcare Network and Global
    Antimicrobial Resistance Laboratory & Response Network, which would
    expand CDC's surveillance efforts globally.
        Working together, these new global networks would enhance detection
    and response to infectious disease threats internationally, and
    implement prevention and containment strategies at local, national, and
    regional levels. CDC also has proposed plans to expand surveillance of
    AR threats in the environment, domestically and globally. These
    activities would help to better understand resistance in the
    environment, the connections between resistance in healthcare,
    agriculture, and environmental settings, and its impact on human
    health. CDC is piloting investments in these activities in fiscal year
    2021.
        Question. The COVID-19 pandemic laid bare the gaps resulting from
    decades-long erosion of support for the public health workforce, which
    did not have the people or resources needed to surge to meet the
    demands of the emergency response. Strategic investments in a diverse,
    robust, well-trained public health workforce at the community level are
    critical to ensure that we are able to tackle local public health
    challenges and be prepared for the next infectious disease outbreak.
    President Biden's fiscal year 2022 budget proposal includes a request
    for $106 million, a $50 million increase above fiscal year 2021, to
    develop the next generation of essential public health workers.
        How does CDC envision this proposed investment in fellowship and
    training programs will translate in rebuilding the public health
    workforce of epidemiologists, contact tracers, lab scientists,
    community health workers, data analysts, behavioral scientists, and
    communicators?
        Answer. The COVID-19 response shone a stark light on deficiencies
    in the nation's investment in its public health workforce, which did
    not have the people or resources to surge to meet the demands of a
    pandemic emergency response. Strategic investments in a diverse, well-
    trained public health workforce are needed. CDC's fellowships and
    training programs continue to supply a competent and sustainable
    workforce capable of surging in response to imminent public health
    threats.
        CDC hosts approximately 300 fellows across seven fellowship
    programs each year in 45 U.S. states and five territories. In fiscal
    year 2021, all 137 EIS officers and Laboratory Leadership Services
    (LLS) fellows contributed to the COVID-19 response, leading COVID-19
    responses in their assigned states and publishing key findings in the
    MMWR leading to actionable recommendations around mitigating the spread
    of disease. CDC designs its fellowships and curricula to meet the
    evolving needs of the public health workforce. A survey of human
    resources directors identified the highest priority workforce needs as
    epidemiologists, laboratory scientists, and public health informatics
    specialists. CDC's fellowships are a pathway for training the next
    generation of public health leaders.
        Actions taken now to invest in developing the next generation of
    essential public health workers will better position our communities
    and the nation to respond to the current pandemic and to build back a
    better workforce to safeguard Americans' health. With the fiscal year
    2022 request of $106,000,000 for Public Health Workforce, CDC will
    rebuild the workforce of epidemiologists, contact tracers, lab
    scientists, community health workers, data analysts, behavioral
    scientists, and communicators who can help protect America's health.
        While health departments are the frontlines of emergency response,
    Federal investment in workforce development is essential to a
    coordinated national health workforce strategy. In fiscal year 2022 CDC
    will:
      --Expand the pathway of critical public health workers through
            fellowship programs; assisting state, tribal, and local health
            departments to conduct barrier assessments and implement best
            practices for recruitment, hiring, and retention, and
            publishing training materials for state, tribal, and local use
            and STEM resources highlighting pathways to careers in public
            health.
      --Modernize workforce development information technology systems.
      --Increase participants in CDC fellowship programs and place them in
            areas of critical need.
        CDC will invest in understanding barriers and facilitating
    solutions around matching graduates in critical discipline areas with
    positions serving local, tribal, and state communities. Developing
    robust pathways to attract graduates to public health is essential to
    future health security of the United States.
        CDC will expand fellowship opportunities, from the Public Health
    Associate Program to Epidemic Intelligence Officers. CDC will enhance
    recruitment efforts and pave pathways for careers in public health at
    the Federal, state, tribal, and local levels. Increasing the cohort of
    EIS officers will provide critical applied learning and pathways for
    the next generation of public health leaders. CDC will increase the
    number of fellows in the field that provide essential assistance and
    expertise to CDC and state, local, territorial, and tribal health
    departments.
        CDC will also strengthen the laboratory workforce to support
    clinical and public health laboratory practice. Of the 800,000
    laboratory professionals who work across 295,000 CLIA-certified
    laboratories, less than 10 percent of the nation's clinical laboratory
    professionals currently access CDC training and workforce development
    resources. CDC will:
      --Expand the reach of CDC's training and workforce development
            resources beyond the public health laboratory community into
            the broad clinical laboratory community, including those who
            perform point-of-care testing, building critical bridges
            between healthcare and public health.
      --Continue data-driven development, promotion, and dissemination of
            laboratory capacity- building initiatives and resources that
            enhance the laboratory community's ability to combat emerging
            threats, learn evolving practices, and stay current with the
            newest standards and technologies
      --Formalize partnerships to expand its reach and accessibility of its
            training products and resources to the laboratory community
            through its learning course syndication system.
      --Expand development of its virtual reality training portfolio to
            meet the evolving needs of laboratory professionals.
        Question. How will state and local health departments benefit from
    an expansion of these training programs?
        Answer. With investment in CDC's fellowship and training programs,
    CDC will rebuild the workforce of epidemiologists, contact tracers, lab
    scientists, community health workers, data analysts, behavioral
    scientists, and communicators who can help protect America's health.
    These investments are essential to build a competent and empowered
    public health workforce prepared to respond to future public health
    emergencies. CDC will work with state, tribal, local, and territorial
    health departments to rebuild the workforce and support these partners
    to assist in hiring and recruitment; identify and address barriers to
    hiring at the state and local levels; address workforce gaps; and build
    capacity to respond to current and future public health threats. These
    funds will support recruitment and training of public health leaders
    through Epidemic Intelligence Services (EIS), Laboratory Leadership
    Service fellowship programs, and Public Health Associate Program
    (PHAP). They will complement other initiatives including:
      --Public Health AmeriCorps, a new public health workforce program in
            partnership with AmeriCorp, supported by investment from the
            American Rescue Plan, will deploy a nationwide cohort of
            workers, who will receive applied learning training and a
            stipend in non-Federal term positions.
      --Modernization of the public health workforce in which CDC will work
            with public health leaders across Federal, state, local, and
            territorial jurisdictions to create a new grant program to
            provide under-resourced health departments with the support
            they need to hire staff and build a public health workforce for
            the future.
                                     ______

                 Questions Submitted by Senator Jeanne Shaheen
        Question. Given that diabetes is one of the co-morbid conditions
    that puts patients with COVID-19 at highest risk, I was pleased to see
    CDC guidance that recommended prioritization of both Type 1 and Type 2
    diabetes patients for vaccination. With 34 million Americans currently
    living with diabetes, the economic cost of the condition now exceeds
    $300 billion per year. Now more than ever, we need to do more to help
    prevent Type 2 diabetes where possible and help people with diabetes
    improve their management of the condition, so that we can see improved
    outcomes.
        How is CDC approaching the rapid growth in diabetes prevalence in
    this country and what can we do in Congress to help?
        Answer. CDC established the National Diabetes Prevention Program
    (National DPP) to address the growing epidemic of type 2 diabetes. The
    National DPP lifestyle change program is led by trained coaches who
    facilitate participants' strategies for eating a healthy diet,
    increasing physical activity, and developing coping skills. The
    Diabetes Prevention Program clinical trial showed that participants who
    engage in these lifestyle changes through a structured program can lose
    five to 7 percent of their body weight and reduce development of type 2
    diabetes by as much as 58 percent (71 percent for those 60 years of age
    and older).
        CDC supports state health departments and other stakeholder
    organizations in expanding access to the National DPP for populations
    at greatest risk for type 2 diabetes. Achieving insurance coverage is a
    critical step for increasing access to this highly effective program.
    Based on recipient reported data from September 30, 2018 to June 30,
    2019, state health departments and other partners have secured health
    insurance coverage for the National DPP for more than 1 million public
    employees and their dependents in 24 states. In addition, the National
    DPP lifestyle change program is currently a covered benefit for more
    than 2.2 million private sector employees and their dependents across
    21 states, a 61 percent increase from 2018. More than 1.4 million
    Medicaid beneficiaries have the National DPP lifestyle change program
    as a covered benefit, which includes participation from 30 states.
        In March 2016, the Centers for Medicare & Medicaid Services (CMS)
    certified the expansion of the National DPP into the Medicare program.
    This was the first preventive service model from the CMS Innovation
    Center to become eligible for expansion into the Medicare program--a
    landmark for public health. The future of the MDPP as a covered service
    will be determined by the outcome of the CMS Innovation Center's
    expanded model evaluation. However, based on findings from the original
    DPP research trial, subsequent translation studies demonstrating the
    program's effectiveness in non-clinical settings, and the 15-year
    results of the DPP Outcomes Study, this intervention has been studied
    extensively and already has substantial evidence supporting its
    effectiveness across settings and populations.
        Question. Can you provide an update on CDC's investments in the
    Division of Diabetes Translation (DDT) and the National Diabetes
    Prevention Program (NDPP)? How is CDC measuring success for those
    programs?
        Answer. More than 550,000 people at high risk for developing type 2
    diabetes have participated in the National DPP lifestyle change program
    across the U.S. Evaluated participants have lost an average of 5.5
    percent of their body weight. To date, there are almost 1,900 CDC-
    recognized organizations offering the program in-person, virtual and
    through distance learning. CDC aims to enroll 1 million participants
    into the National DPP lifestyle change program by 2025.
        Since the onset of the COVID-19 pandemic, a majority of the CDC-
    recognized organizations are offering virtual (telehealth) options for
    the National DPP lifestyle change program, an especially critical
    feature to ensure participant safety. A 2017 study (Vadheim, L.M, et
    al., 2017) found that participants who received the National DPP
    lifestyle change program through telehealth videoconferencing (distance
    learning) had similar rates of participation and achieved similar
    weight loss as participants who attended the program in-person.
        Through implementation of the National DPP, CDC aims to reduce the
    number of adults newly diagnosed with type 2 diabetes. The national
    rate of diabetes incidence (6.4 new cases per 1,000 adults in 2018) has
    successfully moved below the Healthy People 2020 target (7.2 new cases
    per 1,000 adults). The continued growth of the diabetes burden in terms
    of absolute prevalence, lifetime risk, years spent with diabetes, and
    the incidence rate remaining considerably higher than it was in the
    1990s, are all contributing factors indicating a need for continued
    prevention efforts like the National DPP.
        Question. The COVID-19 pandemic has exacerbated challenges in our
    response to the substance use disorder epidemic. As you know, the 2020
    state-level CDC data on opioid overdose deaths will also dictate the
    distribution of Federal opioid response dollars through the State
    Opioid Response (SOR) grant program administered by the Substance Abuse
    and Mental Health Services Administration (SAMHSA).
        When does CDC expect to publish state-level data for 2020 on drug
    poisoning deaths per capita? When CDC does publish the data, please
    keep my office informed.
        Answer. The National Center for Health Statistics provides
    provisional drug overdose death data by state: Products--Vital
    Statistics Rapid Release--Provisional Drug Overdose Data (cdc.gov).
    Provisional data currently provides information on drug overdose deaths
    occurring through October 2020. Final drug overdose death data for 2020
    will be available in late 2021.
        Question. Often there are discrepancies in state rankings on opioid
    overdose deaths per capita compared to overall drug poisoning deaths
    per capita. For instance, in examining CDC's WONDER data on 2018 opioid
    overdose deaths per capita, as reported by the National Institute on
    Drug Abuse (NIDA), compared to CDC's publication of 2018 overall drug
    poisoning deaths per capita, New Hampshire ranks third in opioid
    overdose deaths per capita and sixth in overall drug poisoning deaths
    per capita. Will CDC publish data on opioid specific overdose deaths
    per capita by state for 2020, as a supplement to its publication of
    overall state-by-state drug poisoning deaths per capita in 2020?
        Answer. Yes. In addition to drug overdose death data (including
    deaths attributed to opioids) CDC provides analyses on final drug
    overdose death data, including deaths related to prescription opioids,
    heroin, synthetics opioids, and psychostimulants. CDC will update the
    data once final 2020 overdose data are available.
        CDC currently funds 47 states and the District of Columbia to
    improve the timeliness and comprehensiveness of unintentional/
    undetermined drug overdose mortality data. The State Unintentional Drug
    Overdose Reporting System (SUDORS) captures detailed information on
    toxicology, death scene investigations, route of administration, and
    other risk factors that may be associated with a fatal overdose from
    funded recipients. CDC continues to release analyses of data received
    through this program. For example, CDC published a report describing
    decedent demographic characteristics and circumstances surrounding
    overdose deaths during January--June 2019 among 25 jurisdictions
    participating in SUDORS, and it highlights the involvement of opioids
    and stimulants, separately and in combination.
        Question. I was pleased to see that the administration's budget
    proposal calls for a continued commitment to efforts to defeat HIV in
    this country. At the same time, we are also seeing significant
    increases in the spread of sexually-transmitted diseases, including a
    heartbreaking 40 percent increase in congenital syphilis passed from
    mother to child during pregnancy in recent years. I have been concerned
    that we have underfunded state and local STD prevention efforts for a
    long time, which may impede our abilities to stop the spread of STDs.
        Can you discuss how CDC is addressing growing rates of STD
    infections, and congenital syphilis infections in particular?
        Answer. CDC provides national leadership, research, policy
    assessment, and scientific information about STDs to the medical
    community and the public. CDC coordinates and publishes national STI
    Treatment Guidelines and Recommendations, which translates research
    into practice and serves as the gold standard for STI care in the
    United States. Further, CDC supports health departments in all 50
    states, Washington, D.C., and select cities and territories to conduct
    core and essential STD prevention work through our flagship STD
    prevention program, totaling $95.5million in 2020. CDC also has seventy
    field staff embedded in state and local STD programs around the
    country, who provide technical assistance and capacity building in
    disease investigation to support communities and public health
    partners, including investigating STDs in the community through field
    testing, public health detailing, outbreak response, and contact
    tracing.
        COVID-19 mitigation necessitated innovative approaches to
    delivering STD care that may prove to be valuable investments into the
    infrastructure for STD care in the U.S. for years to come, including
    (but not limited to):
      --STD express clinics, which provide walk-in testing & treatment
            without a full clinical exam
      --Partnerships with pharmacies & retail health clinics, which can
            provide new access points for STD services (e.g., on-site
            testing and treatment)
      --Telehealth/telemedicine, which can close gaps in testing and
            treatment, ensure access to healthcare providers, support self-
            testing or patient-collected specimens, and is especially
            critical in rural areas
        These strategies and more are outlined in HHS's first ever STI
    Federal Action Plan, which provides a roadmap to develop, enhance, and
    expand prevention and care programs at the national, state, tribal and
    local levels over the next 5 years to reverse the course of the STD
    epidemic.
        Further, through its flagship STD prevention program, CDC supports
    state and local public health departments to prioritize and strengthen
    their efforts to eliminate congenital syphilis by matching syphilis
    surveillance data with birth and mortality data and strengthening
    congenital syphilis morbidity and mortality case review boards. On July
    13, CDC funded four state STD programs, working in cooperation with the
    state epidemiologist, to ensure that the implementation of congenital
    syphilis projects prioritize sustainable system level or policy level
    interventions in alignment with local epidemiology.
        Finally, CDC is working diligently to support the Disease
    Intervention Specialists (DIS) Workforce with funding from the American
    Rescue Plan. For many years, DIS have provided invaluable support to
    prevent and control STDs, tuberculosis, HIV, and other infectious
    diseases. More recently, DIS were called to support the COVID-19
    response, conducting case investigation and contact tracing in a
    variety of community settings. CDC is making a $1.13 billion investment
    over a five-year period to continue supporting the COVID-19 response
    and other infectious disease prevention and response, by:
        1. Expanding and enhancing frontline public health staff
        2. Conducting DIS workforce training and skills building
        3. Building organizational capacity for outbreak response
        4. Evaluating and improving recruitment, training, and outbreak
    response efforts
        In addition to helping to contain and prevent COVID-19, we expect
    that this cadre of culturally competent and experienced DIS will be
    able to address STDs, such as congenital syphilis, as well as other
    infectious diseases.
        Question. In 2016, the New Hampshire Department of Health & Human
    Services requested that the CDC's Agency for Toxic Substances and
    Disease Registry (ATSDR) conduct health consultations for the public
    water systems and private wells in the Merrimack-area of southern New
    Hampshire after the discovery of per- and polyfluoroalkyl substances
    (PFAS) contamination in drinking water. It is my understanding that
    these health consultations remain ongoing, and I am concerned that
    residents are still waiting and wondering about their exposure risks.
        Can you provide an update on the status of these health
    consultations and when you expect they will be concluded and released?
        Answer. ATSDR continues to work on the private well and public
    water health consultations. ATSDR received comments on the private well
    health consultation from the state environmental department through our
    data validation review process and is working to address those
    comments. After the comments are addressed the document is reviewed
    through CDC's clearance process, it will be released for public
    comment.
        In addition, ATSDR is currently completing a draft of the public
    water health consultation and preparing for internal review and
    clearance.
        Question. The last thing firefighters should have to worry about is
    the safety of the equipment they wear while in the line of duty. Yet
    many active and retired firefighters are deeply concerned about
    exposure to harmful PFAS chemicals from their protective gear. I was
    proud to include my bipartisan Guaranteeing Equipment Safety for
    Firefighters Act provisions in the fiscal year 2021 National Defense
    Authorization Act (NDAA), which as you know, includes collaborative
    efforts at the National Institute of Standards and Technology (NIST)
    and National Institute for Occupational Safety & Health (NIOSH) to
    study of the personal protective equipment worn by firefighters. I have
    also worked through the Appropriations process to kick start this
    research at NIST.
        Can you discuss the CDC's current collaboration with NIST as they
    work to identify a firefighter's relative risk of exposure to PFAS
    released from their protective gear? How will NIST's study inform the
    CDC's work--within both ATSDR and NIOSH--to better understand the
    health effects of PFAS exposure?
        Answer. CDC's collaborates with NIST, sharing information,
    presentations, and collaborating on research activities such as
    characterizing PFAS in turnout gear textiles. In 2021, NIST and NIOSH
    provide overviews of PFAS activities and identified three topics for
    further discussion, analytical and collection methodologies, selection
    of and access to turnout gear textiles, and PFAS toxicity testing.
    Meetings on these topics were conducted with smaller groups to help
    facilitate targeted discussions.
        NIST's research into PFAS in firefighter turnout gear is
    anticipated to provide valuable information on potential exposures for
    firefighters by identifying PFAS present in textiles and the conditions
    contributing to the release of PFAS from said material. The analytical
    methods included in NIST's study comprise a larger panel of PFAS than
    is currently used in many studies of human exposure. Results from this
    expanded panel will help guide future PFAS analyses of serum collected
    from this occupationally exposed population as well as inform future in
    vivo and in vitro studies of toxicity. When paired with studies of
    dermal absorption and exposure assessments of firehouse air or dust,
    NIST's research will also provide insight into the contribution of PFAS
    from gear to a firefighter's total exposure, providing a more complete
    understanding of the relevant pathways and routes of exposure in this
    population.
        NIOSH's National Personal Protective Technology Laboratory (NPPTL)
    has been collaborating with NIST to determine which PFAS compounds are
    on firefighter turnout gear and if they are released through
    laundering. NPPTL collaborated with NIST, providing 20 different
    textile swatches laundered using current fire service protocols. These
    samples will undergo additional aging and stressing techniques to
    measure PFAS release from textiles by NIST researchers.
        NPPTL's comprehensive laundry study to identify and quantify the
    individual PFAS compounds on firefighter textiles and to measure their
    release through a series of washings, supplements the ongoing NIST work
    . Additional NPPTL research studies the ability of PFAS compounds to
    migrate through the 3-layered garment to be in direct contact with a
    wearer's skin.
        The NIST-NIOSH research collaboration will provide valuable
    information regarding possible PFAS exposures related to firefighter
    PPE and will yield time and monetary cost savings to both institutes.
        Question. The Firefighter Cancer Registry Act, which was passed by
    Congress and signed by the President in 2018, directed the CDC to
    establish and maintain a voluntary National Firefighter Registry to
    better understand the link between on-the-job exposure to toxic
    substances and cancer in firefighters. The National Firefighter
    Registry will be used to track and analyze cancer trends and risk
    factors among firefighters. I have heard from firefighters in my state
    interested in volunteering to participate. It is my understanding that
    at this time, however, enrollment for the National Firefighter Registry
    is not yet open.
        Can you provide an update on the work being done to establish the
    registry and a timeline of when it will be open for enrollment? When
    the registry is opened for enrollment, will you work with my office to
    provide information to active and retired firefighters about how to
    participate if they so choose?
        Answer. The National Firefighter Registry (NFR) has made
    substantial progress in developing a rigorous scientific protocol,
    enrollment questionnaire, and consent form. These documents have been
    posted publicly at www.cdc.gov/niosh/bsc/nfrs. The enrollment
    questionnaire has been submitted to OMB for review under the Paperwork
    Reduction Act. The NFR program has also drafted an Assurance of
    Confidentiality (AoC), which provides additional protection for
    identifying information.
        The NFR program has also made progress on the online NFR
    Registration System. However, any public-facing data collection portal
    must meet numerous Federal data security regulations and requirements--
    some of which are relatively new and costly. NIOSH is working closely
    with our IT and security specialists to ensure that the NFR
    Registration System is compliant with these requirements. This has
    extended the original timeline for the launching of the NFR. NIOSH also
    recognizes that the registration system not only needs to be highly
    secure, but also needs to be relatively easy for firefighters to
    complete in order to maximize voluntary participation across the United
    States.
        The NFR team has been working closely with key scientific and fire
    service stakeholders to determine the optimal design of the NFR
    Registration System and what data must be collected. Launching of the
    NFR Registration System is one step in many that will be needed over
    the next several years to ensure the success of the program and meet
    the requirements under the Firefighter Cancer Registry Act of 2018.
        Once the NFR opens for registration, NIOSH will work with numerous
    fire service organizations and other stakeholder groups to encourage
    firefighters throughout the country, including career and volunteer,
    active and retired, and firefighters with and without cancer, to enroll
    in the NFR. The NFR team has developed a robust communications plan and
    strong connections to fire service organizations such as the
    International Association of Fire Fighters (IAFF) and National
    Volunteer Fire Council (NVFC), which are the two largest organizations
    representing career and volunteer firefighters, respectively. We
    welcome opportunities to work with congressional offices to reach
    firefighters within your state or district.
        Question. Can you discuss how you expect this epidemiological
    information and analysis will help public safety officials,
    researchers, scientists and medical professionals find better ways to
    protect those in the fire service?
        Answer. The enrollment questionnaire will serve as the primary data
    collection instrument when firefighters initially register collecting
    information about work history (including large or unusual responses),
    implementation of control measures, family history of cancer, and
    healthy behaviors. The questionnaire will also ask for identifying
    information, such as name and date of birth, which can be used to make
    linkages to state cancer registries. Collecting identifying information
    will allow NIOSH to periodically link to existing cancer diagnosis
    databases to detect new cases of cancer long-term that may not have
    been reported.
        Additional follow up questionnaires will allow for analysis of
    specific workplace factors as well as topics of special interest to the
    public safety community. The NFR program also plans to work with fire
    departments to capture fire and incident information to build an
    exposure profile for the NFR participants. Over time and with broad
    participation, all this data can be used to better understand the
    amount and types of cancer among firefighters; the prevalence of cancer
    risk factors and healthy behaviors among firefighters; and the
    relationship between firefighter cancer and workplace characteristics,
    exposures, and practices. We will explore cancer risk among
    understudied firefighter groups including women, minorities,
    volunteers, and firefighters in sub-specialty assignments like wildland
    firefighters or fire-cause investigators. We will also evaluate how the
    adoption of certain control measures, like routine laundering of
    turnout gear, affects cancer risk. These analyses will help scientists
    at CDC/NIOSH identify the most important factors associated with
    firefighters' risk of specific types of cancer, including rare forms of
    cancer. Results can then be used by public safety officials to
    implement new evidence-based policies or procedures to reduce
    firefighters' cancer risk. Medical professionals will also have more
    knowledge about the types of cancer that are most elevated among the
    different groups of firefighters, which could assist them in providing
    advanced screening and healthcare for firefighters.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. The Food and Drug Administration reports that nearly 40
    percent of finished drugs and roughly 80 percent of active
    pharmaceutical ingredients are manufactured abroad. During the COVID-19
    pandemic we saw factories shut down in order to prevent spread of the
    virus, drug supply chains disrupted, and drug shortages increase. As a
    result American's access to essential medicines was put into jeopardy.
    To avoid future shortages of essential medicines, domestic
    manufacturing is key to shoring up our supply chain.
        How important is a strong domestic supply chain for essential
    medicines?
        Answer. Ensuring a safe and consistent public health supply chain
    for medical materials, ingredients, and supplies is critical for any
    national response to public health emergencies.
        Question. How can we ensure we don't experience future drug
    shortages when global supply chains are disrupted?
        Answer:
      --Investments in securing the industrial base and domestic supply
            chain require dedicated and persistent management and
            engagement.
      --Throughout the COVID-19 response, ASPR has leveraged the
            authorities delegated to the Secretary under the Defense
            Production Act (DPA) to issue 62 priority ratings for United
            States Government (USG) contracts for health resources, eight
            priority ratings for USG contracts for industrial expansion,
            three priority ratings for non-USG contracts to support the
            production of resins for both diagnostics and infusion pumps,
            and the manufacture of closed suction catheters for treatment
            of patients with COVID-19--all to ensure private sector
            partners making life-saving products are able to acquire the
            raw materials, components, and products requisite to deliver
            for the response.
      --Also under the DPA, ASPR is strengthening the industrial base to
            secure and develop domestic capacity, retool and expand
            industry machinery, scale production facilities, train
            workforces, and ultimately infuse the supply chain and
            marketplace with products the US needs to contain further
            pandemic waves. ASPR continues to invest in critical funding in
            expanding domestic manufacturing including investments of: $250
            million in manufacturing PPE; $268 million in manufacturing of
            testing consumables; $14.8M in vaccine raw material
            manufacturing; $160 million in fill finish capacity; $65
            million in vaccine vial manufacturing; $168 million in
            manufacturing capacity for at home and point of care tests;
            and, $53.8M in testing raw materials. Each of these domestic
            manufacturing initiatives meets current, as well as future
            COVID-19 needs, and seeks to create or sustain high-value
            domestic jobs.
        Question. Last week, the CDC announced $7.4 billion from the
    American Rescue Plan to support the public health workforce and the
    response to the COVID pandemic. This funding included $2 billion for
    state health departments. This will go a long way to shoring up our
    public health workforce as you outlined, in particular the requirement
    for at least 40 percent of the funding to support local hiring through
    local health departments or community-based organizations. West
    Virginia led the country in vaccination rates in large part due to our
    local health departments and health centers across the state
    establishing Local Leadership Planning teams to roll out vaccination
    plans in all 55 counties. These teams are multisector,
    multidisciplinary local health leaders. They know their communities,
    and have stepped up to respond to this virus.
        In addition to this funding, what is CDC doing to support local
    initiatives like West Virginia's Local Leadership Planning teams?
        Answer. Partnerships and trusted community members have been
    critical to reaching communities disproportionately affected by the
    pandemic. Community health workers (CHW) are frontline public health
    workers who have a trusted relationship with the community and are able
    to facilitate access to a variety of services and resources for
    community members. Scaling up and sustaining a nationwide program of
    CHWs who support populations hit hardest by COVID-19 is critical. In
    addition to the $7.4 billion to support the public health workforce
    awarded from the American Rescue Plan, CDC also plans to provide $300
    million to jurisdictions for CHW services to support COVID-19
    prevention and control. CDC plans to provide an additional $32 million
    for training, technical assistance, and evaluation. CDC expects to
    award funds to approximately 75 organizations through the ``Community
    Health Workers for COVID Response and Resilient Communities.'' Notices
    of awards will be issued in the summer, with the amount each
    jurisdiction receives determined by population size, poverty rates, and
    COVID-19 statistics.
        CDC also provided funding with specific guidance to focus on
    reaching disproportionately affected communities, including:
      --$3 billion to strengthen vaccine confidence (awarded early April
            2021): Funding focuses on reaching 64 communities hit hardest
            by the pandemic, including those in rural areas, to ensure
            greater equity and access to vaccine and expand COVID-19
            vaccine programs. To ensure health equity and expanded access
            to vaccines, 75 percent of funding must focus on specific
            programs and initiatives intended to increase vaccine access,
            acceptance, and uptake among racial and ethnic minority
            communities, and 60 percent must go to support local health
            departments, community-based organizations, and community
            health centers.
      --$3 billion in cooperative agreements to support broad-based
            distribution, access, and vaccine coverage (awarded Jan. 2021):
            A minimum of 10 percent to jurisdictions must be allocated for
            high-risk and underserved populations, including rural
            communities.
        --75 percent of the total funding must focus on specific programs
                and initiatives intended to increase vaccine access,
                acceptance, and uptake among racial and ethnic minority
                communities; and,
        --60 percent must go to support local health departments,
                community-based organizations, and community health
                centers.
      --$2.25 billion in grant funding to states and localities
            (anticipated to be awarded June 2021) to address COVID-19 in
            high-risk and underserved communities, including rural
            communities and communities with large populations of racial
            and ethnic minorities. Recipients are strongly encouraged to
            collaborate with and provide funding and resources to reach
            organizations such as community-based and civic organizations,
            faith-based organizations, non-governmental organizations, and
            state offices of rural health or their equivalent such as state
            rural health associations.
        Question. How can we maintain local efforts like these to ensure
    they continue to operate after the public health emergency?
        Answer. CDC must build on initial investments and lessons learned
    from COVID-19 with sustained, flexible investments in the nation's
    public health infrastructure as proposed in the fiscal year 2022
    Budget. This work must include public health workforce development, as
    well as public health data modernization and epidemiology and
    laboratory capacities, so that we can address the broader public health
    consequences of the pandemic such as opioids, injuries, violence,
    immunization, and chronic disease control. It will also help us prepare
    for the future, because there are and will be more public health
    threats.
        Question. Just last week the CDC updated its guidelines in regards
    to people who have been fully vaccinated. One guideline has caused
    confusion in my state, specifically in regards to reporting and the
    quarantining of people who have been vaccinated with a known exposure
    to COVID. Currently, the guidelines require a fully vaccinated person
    to quarantine for 10 days only if they develop symptoms. However, there
    does not appear to be a clear reporting requirement for persons who
    have been exposed and develop minor symptoms. Nor is there flexibility
    for a fully vaccinated person to quarantine for a shorter period of
    time if their symptoms disappear. Tracking these breakthrough cases is
    important to ensure we know if and when a booster may be needed to
    ensure protection for our population, and tracking potentially
    problematic COVID variants.
        How does the CDC plan to effectively monitor breakthrough cases?
        Answer. The goal of national surveillance for COVID-19 vaccine
    breakthrough infections is to identify unusual patterns, such as trends
    in age or sex, the vaccines involved, underlying health conditions, or
    which of the SARS-CoV-2 variants made people sick. To date, CDC's
    monitoring of breakthrough cases shows there are no unusual patterns in
    cases that have been detected in the data CDC has received. Despite the
    high level of vaccine efficacy, it is expected that a small percentage
    of fully vaccinated persons will develop symptomatic or asymptomatic
    infections (i.e. breakthrough infections) with SARS-CoV-2, the virus
    that causes COVID-19.
        Vaccine breakthrough surveillance focuses on those cases resulting
    in hospitalization or death. CDC coordinates with state and local
    health departments to investigate vaccine breakthrough cases and
    identify patterns or trends. Health departments report breakthrough
    cases to CDC on a voluntary basis. However, it is important to note
    that tracking and publicly reporting vaccine breakthrough via national
    surveillance is just one way CDC measures vaccine effectiveness. CDC is
    leading multiple vaccine effectiveness studies, some of which include
    information on vaccine breakthrough infections, to ensure COVID-19
    vaccines are working as expected. Through these studies in various
    populations, locations, and settings, CDC can obtain more
    representative, scientifically valid, and complete information about
    these types of infections.
        CDC is also using the Coronavirus Disease 2019 (COVID-19)-
    Associated Hospitalization Surveillance Network (COVID-NET) to track
    and analyze breakthrough infections. This population-based surveillance
    system includes data on laboratory-confirmed COVID-19- associated
    hospitalizations in 99 counties in 14 states, representing
    approximately 10 percent of the U.S. population. COVID-NET cases are
    hospitalizations occurring in residents of a designated COVID-NET
    catchment area who are admitted within 14 days of a positive SARS-CoV-2
    test. COVID-NET personnel collect COVID-19 vaccination status (doses,
    dates administered and product) from state Immunization information
    systems (IIS) for all sampled COVID-NET cases in 13 sites, which also
    include information on clinical outcome. Some sites have expanded
    collection of vaccination status to non-sampled cases, which were
    included for analysis if all cases in a single month had vaccination
    status available.
        Question. Is the CDC considering reducing the required isolation
    period for fully vaccinated persons after their symptoms disappear?
        Answer. CDC data indicates that vaccinated people are less likely
    to contract COVID-19 and are much safer from having serious outcomes if
    they do contract it. If they become infected, they can spread the virus
    to others. Moreover, if the infection is caused by the Delta variant,
    based on what we know at this time, they can likely spread it as easily
    as unvaccinated people who are infected, at least initially. As
    infection progresses, vaccinated persons with COVID-19, including
    COVID-19 caused by the Delta variant, appear to be infectious for a
    shorter period of time than infected unvaccinated people.
        CDC is reviewing all the emerging evidence and will continue to
    monitor the data on duration of infectiousness for breakthrough cases.
    Throughout the pandemic, CDC has updated guidance to reflect the latest
    available information about COVID-19 and would consider changing
    recommendations for isolation periods for vaccinated people who have
    breakthrough infections if the accumulating science indicates such a
    change were both safe and reasonable.
        Question. As you are aware we are facing an epidemic within a
    pandemic. West Virginia is ground zero for the drug epidemic, with the
    highest rate of drug overdose deaths in the country. To make matters
    worse, 2020 was the worst year for drug overdoses, with over 90,000
    deaths. West Virginia saw at least a 47 percent increase in overdose
    deaths last year. The drug epidemic has led to a sharp increase in
    opioid-related infectious diseases, including HIV and viral hepatitis.
    This has stretched the resources of our public health departments and
    health providers even further.
        What resources is the CDC providing to states to combat this
    epidemic?
        Answer. CDC is providing resources to states through Overdose Data
    to Action (OD2A), a cooperative agreement that began in September 2019.
    It combines strategies from previous surveillance and prevention
    funding agreements to address the complex and changing nature of the
    drug overdose epidemic. Through OD2A, 47 states, Washington D.C., 16
    localities, and two territories are receiving almost $300 million in
    funding.
        CDC is also addressing the infectious disease consequences of the
    opioid epidemic. Nearly $13 million of combined fiscal year 2019 and
    fiscal year 2020 funding was awarded through the Infectious Disease and
    the Opioid Epidemic initiative to state and local health departments
    and national organizations to address the infectious disease
    consequences of drug use.
        In light of the COVID-19 pandemic, CDC has worked to provide
    flexibilities to the 66 grantees by extending the funding for an
    additional year and providing additional guidance and assistance as
    needed. We have also engaged grantees to identify innovative ways to
    respond during the pandemic. We are also using COVID-19 funding to:
      --Understand how substance use patterns and attitudes among youth
            have changed due to COVID-19 and disseminate tailored public
            health messaging and interventions to help address increased
            substance use during this period of time and prevent
            detrimental long-term consequences.
      --Identify innovative harm reduction practices to assess the extent
            to which these strategies can be sustained and scaled. CDC
            plans to summarize these strategies and disseminate them to
            state, local, and Federal partners.
        In addition, CDC is Combating Opioid Overdose Through Community-
    level Intervention Initiatives (COOCLI). CDC, through its Opioid
    Response Strategy partnership, provided funding to the Office of
    National Drug Control Policy to create public health/public safety
    interventions at the local level. COOCLI sub-awards funded pilot
    programs to implement innovative, evidence- based, community-level
    interventions.
        Question. Is the CDC working on helping increase testing for viral
    hepatitis and HIV as well as linking patients to care?
        How can CDC help improve testing and surveillance of opioid-related
    infectious diseases with our current substance use treatment programs
    and recovery facilities?
        Answer. Our nation has seen steady increases in infectious
    diseases--including viral hepatitis and HIV--among people who use drugs
    since the start of the opioid crisis over a decade ago. Making testing
    for viral hepatitis and HIV accessible, convenient, and routine is
    critical, especially in populations disproportionately affected by
    these diseases, including people who inject drugs (PWID). CDC developed
    programs to increase infectious disease testing among PWID and
    continues to invest in these programs through state and local health
    departments and through community-based organizations. Specifically,
    CDC is focusing investments on scaling up HIV self-testing--like the
    Take Me Home self-testing program that provides free HIV self-tests--
    making HIV screening a regular part of healthcare, and delivering viral
    hepatitis and HIV testing in non- traditional settings, such as
    correctional facilities and syringe services programs (SSPs).
        As viral hepatitis, HIV, and substance use disorders continue to
    impact communities throughout the United States, CDC is not only
    increasing support for testing, but also diagnosis, linkage to care,
    and treatment. CDC is also improving implementation of and access to
    high-quality SSPs across the country, where legal, through
    dissemination of best practices and providing technical assistance.
    CDC's core Integrated HIV Surveillance and Prevention for Health
    Departments program (PS18-1802) supports the implementation of
    comprehensive SSPs as part of a key community-level HIV prevention
    strategy. In addition, CDC's National HIV Behavioral Surveillance
    system collects important data among persons at high risk for HIV
    infection, including persons who inject drugs. These programs work to
    ensure the provision of high-quality, comprehensive harm reduction
    services, which include testing for infectious diseases, linking
    patients to opioid use disorder treatment, and providing infectious
    disease care for clients of syringe services programs.
        In addition to testing and treatment for infectious diseases, CDC
    works to increase linkage to substance use disorder treatment within
    SSPs and during healthcare encounters for PWID.
        Question. The COVID-19 pandemic has revealed public health data
    infrastructure shortcomings within both our Federal and state
    institutions. West Virginia's response to the COVID-19 pandemic,
    however, shows our ability to adapt in times of crisis. In addition to
    the strong leadership of our National Guard, our local health
    information exchange stepped up to track important health data, such as
    hospitalization and vaccination rates, demographic data, and much more.
    Most importantly, our health information exchange helped us build out
    systems so that West Virginia health providers were able to fully
    utilize the CDC's Vaccine Administration Management System (VAMS). As
    outlined in President Biden's national strategy, we need improved
    systems for public health data exchange and surveillance. This will
    allow us to better track outbreaks, testing, vaccination rates and much
    more.
        How will you ensure Federal investments into public health data
    will support data sharing between public health and healthcare
    delivery, such as the West Virginia's health information exchange?
        Answer. The success of CDC's Data Modernization Initiative (DMI) is
    critical for our nation's response to COVID-19 and beyond. Improving
    data sharing between public health and healthcare delivery is key to
    realizing the full potential of public health data modernization.
    Monitoring and evaluation are how we make sure we are delivering on the
    promise of data to protect America's health. The need for modernization
    never stops. Within DMI, we are monitoring progress on a growing suite
    of modernization projects. These investments touch nearly every part of
    the public health data ecosystem.
        All of CDC's data modernization investments are guided by a Roadmap
    of Activities and Expected Outcomes that guides all current and future
    investments in data modernization. This strategic roadmap lays out our
    priorities and keeps our end goals in front of us. It ensures work
    going on through any given stream ties into and benefits the others--
    and that we are moving toward the same definition of success. The
    roadmap is the basis for our DMI monitoring and evaluation framework.
    Robust monitoring and evaluation will maximize our impact on public
    health. This is where we track our progress consistently and
    scientifically to see what our investments have produced. We can also
    see which solutions are working well and which may need additional
    support to reach their goals.
        Electronic case reporting (eCR) has demonstrated success in
    improving data sharing between public health and healthcare. eCR is the
    automated, real-time exchange of case report information between
    electronic health records (EHRs) and public health agencies for review
    and action. It moves data quickly, securely, and seamlessly from EHRs
    in healthcare facilities to state or local health departments. All 50
    states, D.C., and 11 large local jurisdictions are now capable of
    receiving COVID-19 electronic case reports, up from only a handful of
    jurisdictions in late 2019. As of May 15, more than 8.1 million COVID-
    19 reports have been sent to 61 public health agencies and more than
    7,900 healthcare facilities in all 50 states can send COVID-19
    electronic case reports. There are currently 236 facilities in West
    Virginia actively using eCR, including West Virginia University.
        CDC is actively working to expand the number of healthcare
    organizations implementing eCR and support public health agencies to
    fully use the case reports within their data ecosystem. This includes
    collaboration with healthcare systems, EHR vendors, and with the Office
    of the National Coordinator for Health Information Technology (ONC) to
    improve exchange of health information.
        Question. Will you work with state partners like WVU Health
    Sciences to continue to improve data analytics?
        Answer. Support and engagement with partners to improve data and
    analytics is an important component of the CDC Data Modernization
    Initiative (DMI). Data modernization requires an ongoing commitment and
    partnership across the public health sector--and especially with our
    state, tribal, local, and territorial partners. CDC will continue to
    support and engage with partners to improve data collection,
    interoperability and data analytics. CDC is working closely with public
    health partners to provide technical assistance focused on:
      --Developing interoperable data systems to reduce the burden on
            healthcare systems, facilities and laboratories that report
            critical data to jurisdictions
      --Increasing the overall efficiency of public health data systems at
            the state level
        CDC also supports public health partners like the Association of
    Public Health Laboratories (APHL) and the Council of State and
    Territorial Epidemiologists (CSTE). These partners are providing
    technical assistance to jurisdictions focused on improving data
    sharing, accelerating use of shared decision support services, data
    science upskilling of the public health workforce, and developing and
    increasing use of standards to improve quality and timeliness of
    reported data.
                                     ______

                    Questions Submitted by Senator Roy Blunt
        Question. Dr. Walensky, several of the COVID-19 vaccine developers
    have indicated we may need a vaccine booster. To that end, BARDA
    notified an intent to purchase 400 million doses of COVID-19 vaccine
    from Moderna and Pfizer for $7.9 billion on May 2nd as booster shots.
        Was that the right decision? Because many public health experts
    indicate, including former CDC Director Tom Frieden, that there is
    growing evidence that a first round of global vaccinations may offer
    enduring protection. What is your opinion here? What I think could be
    very dangerous is if vaccine companies, rather than public health
    experts, are setting the public's expectations around COVID-19
    boosters.
        Answer. CDC will update its recommendations on re-vaccination or
    additional doses of COVID-19 vaccines when additional information is
    available. CDC is closely collaborating with Federal partners and the
    global science and public health community to determine next steps on
    COVID-19 vaccine boosters. Currently, there is not enough data to
    support recommending boosters.
        Question. Adult immunization programs are not typically done well
    in the U.S.
        Should we face the prospect of COVID-19 boosters next year, what is
    CDC doing now to plan for that possibility?
        Answer. CDC will update its recommendations on re-vaccination or
    additional doses of COVID-19 vaccines when additional information is
    available. CDC is closely collaborating with Federal partners and the
    global science and public health community to determine next steps on
    COVID-19 vaccine boosters. CDC works continuously with our state and
    local immunization programs to strengthen their capacity to deliver
    vaccines, monitor their safety and effectiveness and address identified
    gaps.
        The fiscal year 2022 budget request includes nearly a $100 million
    increase to expand existing efforts to enhance the adult immunization
    infrastructure to increase routine vaccination rates, detect and
    respond to outbreaks of VPDs, and address vaccine hesitancy. Adult
    immunization program funding will build on recent investments in the
    COVID-19 vaccine program to support essential activities aimed at
    strengthening the safety net for uninsured adults, addressing
    disparities in adult vaccine coverage, and supporting vaccine efforts
    across the lifespan.
        Question. Will you try to team other adult vaccinations with the
    COVID vaccination?
        Answer. COVID-19 vaccines were previously recommended to be
    administered alone, with a minimum interval of 14 days before or after
    administration of any other vaccines. This was out of an abundance of
    caution and not due to any known safety or immunogenicity concerns.
    However, substantial data have now been collected regarding the safety
    of COVID-19 vaccine currently authorized by FDA for use under Emergency
    Use Authorization. Although data are not available for COVID-19
    vaccines administered simultaneously with other vaccines, extensive
    experience with non-COVID-19 vaccines has demonstrated that
    immunogenicity and adverse event profiles are generally similar when
    vaccines are administered simultaneously as when they are administered
    alone.
        COVID-19 vaccines and other vaccines may now be administered
    without regard to timing. This includes simultaneous administration of
    COVID-19 vaccine and other vaccines on the same day, as well as
    coadministration within 14 days. When deciding whether to co-administer
    vaccine(s) with COVID-19 vaccine, vaccination providers should consider
    whether the patient is behind or at risk of becoming behind on
    recommended vaccines, their risk of vaccine-preventable disease (e.g.,
    during an outbreak or occupational exposures), and the reactogenicity
    profile of the vaccines.
        Question. There are reports, many of which the CDC has published,
    highlighting the toll this pandemic has had on our nation's public
    health. And there's an increasing number of reports that the overall
    health of Americans has suffered as a result of the pandemic. It is
    increasingly evident that in the coming months, as we emerge from under
    the shadow of this pandemic, existing and emerging public health
    challenges will have to be addressed.
        How are you planning to address these challenges and how does the
    fiscal year 2022 budget reflect those needs?
        Answer. CDC is committed to upgrading the public health system so
    the nation is ready for whatever may come next by building on
    investments and lessons learned during the pandemic. Key priorities
    include modernizing our public health data systems, supporting a
    diverse and skilled public health workforce, enhancing laboratory
    capacity, and promoting global health security. We now know that long-
    term and flexible funding--as proposed in the fiscal year 2022 budget--
    will be required to sustain improvements and address broader
    consequences of the pandemic and historical underinvestment in areas
    like health equity, opioid use and misuse, injuries and violence,
    immunization planning, and hypertension control.
        Question. What are the areas where this budget request may fall
    short--perhaps because we're only just beginning to understand the vast
    impact of the pandemic in areas such as chronic conditions, delayed
    care and immunizations, or reemerging infectious diseases, such as STDs
    and hepatitis?
        Answer. The nation's public health system has not recovered from
    the economic downturn in 2008, which resulted in significant reductions
    in public health staffing at the state and local level. Similarly, CDC
    has become increasingly reliant on infusions of supplemental funds to
    address specific health crises. Building back a robust public health
    infrastructure will take sustained investments over time to address
    both foundational needs like data, lab capacity and workforce as well
    as strategic investments to address health equity and social
    determinants of health. The fiscal year 2022 President's budget
    includes request for increased funding needed to address some of the
    consequences of the pandemic including mental health, opioids, and
    prevention of chronic and infectious diseases.
        Question. Conversely, our nation has made great strides these last
    several months against the COVID pandemic and we've gained a greater
    understanding as to what is needed for a robust public health system--
    from the public health laboratories to health statisticians and
    academic researchers to private enterprise--advancements have been made
    across the board.
        How does the fiscal year 2022 budget request account for the
    lessons learned over the last year to improve our public health
    infrastructure?
        Answer. The ability to respond to a public health emergency
    requires a strong day-to-day public health system, supported by
    infrastructure that is not highly segmented by disease, condition, or
    activity. In addition to the COVID-19 pandemic, over the past 24
    months, CDC has also responded to diverse public health threats from E-
    cigarette or Vaping Product Use-Associated Lung Injuries (EVALI),
    Ebola, complex multi-state food-borne disease outbreaks, wildfires, and
    hurricanes. Responding to the unique characteristics of each of these
    public health emergencies has required deep scientific expertise to
    deploy a specialized approach and called for a robust public health
    system with world-class infrastructure nationwide to stop disease at
    its source. Unfortunately, this recent history has revealed the effects
    of inadequate public health infrastructure. Ongoing health disparities
    made us as a nation more vulnerable to pandemics and large-scale public
    health emergencies, as well as burdening large segments of our
    population with chronic public health concerns. Additional investment
    in both domestic and global public health infrastructure is needed as
    requested in the fiscal year 2022 Budget.
        With investments requested in fiscal year 2022, CDC will begin to
    address mission-critical gaps in public health infrastructure and
    capacity nationwide. Transitioning from sporadic influxes of
    supplemental funding tied to a specific emergency to flexible funding
    that can prevent another crisis will strengthen the current public
    health system. Flexible, sustainable investments in infrastructure and
    capacity are critical for saving lives and averting economic losses
    caused by public health emergencies and chronic public health problems.
    In fiscal year 2022, CDC will prioritize funding to rebuild the most
    critical public health infrastructure needed to safeguard the nation's
    health and economic security.
        Question. The budget includes $400 million for Public Health
    Infrastructure Capacity.
        How does this request account for the flexibility needed to scale
    certain functions or respond in the future to a wholly different public
    health threat?
        Answer. CDC will expand its ability to leverage public health
    infrastructure to address emerging and longstanding issues by providing
    direct funding for capacity-building resources, guidance, and
    collaboration to states, localities, and territories. These resources
    will be disease-agnostic investments in core public health
    infrastructure and capacity to expand programs and systems that address
    long-standing public health issues and support public health response.
        Question. How, specifically, will this $400 million be divided
    between the different activities outlined in the budget?
        Answer. This investment must be flexible, stable, and keep pace
    with inflation and technological advancements in order for states,
    localities, and territories to address their most urgent needs, such
    as: a diverse, data-savvy workforce with secure funding that attracts
    the best talent to public health; robust technological infrastructure
    that is nimble and scalable; innovations and collaborations with
    multiple sectors; and programs that address disparities during and
    after the COVID-19 pandemic.
        Question. Unfortunately, there is no question that the pandemic has
    been challenging for many people--our nation has faced an unprecedented
    mental health crisis and a rise in overdoses. CDC's provisional data
    shows a 28 percent increase in overdose deaths in the 12-month period
    ending in October 2020. More than 88,000 lives were lost to an overdose
    during that period, the highest number of fatal overdoses ever recorded
    in the U.S. in a single year, three-quarters of which were opioid-
    related. Throughout my time on this Subcommittee, I made it a priority
    to combat the opioid crisis and I'm concerned we have suffered a
    significant setback. We need to better understand the impact that the
    pandemic has had on overdoses and substance abuse.
        What can you say about these trends in fatal overdoses and what are
    some of the immediate needs to combat them?
        Answer. Provisional 2020 data reveal that over 93,000 people died
    of an overdose in 2020, a nearly 30 percent increase over 2019. The
    recent increase in drug overdose mortality began in 2019 and continued
    into 2020, prior to the declaration of the COVID-19 National Emergency
    in the United States in March.
        There are many factors that can be driving the increase in overdose
    deaths including:
      --The changing illicit drug marketplace and the wider availability of
            illicitly manufactured fentanyl and fentanyl analogs,
      --Co-use of illicitly manufactured fentanyl with other drugs such as
            cocaine and methamphetamine, and
      --Mixing of illicitly manufactured fentanyl into the drug supplies of
            methamphetamine and cocaine
        CDC's Overdose Data to Action (OD2A) funds health departments in 47
    states, the District of Columbia, two territories, and 16 cities and
    counties to obtain high-quality, comprehensive, and timely data on
    fatal and nonfatal drug overdoses to inform prevention and response
    efforts. To help curb this epidemic, Overdose Data to Action strategies
    focus on enhancing linkage to and retention in substance use disorder
    treatment, improving prescription drug monitoring programs,
    implementing post-overdose protocols in emergency departments,
    including naloxone provision to patients who use opioids or other
    illicit drugs, and strengthening public health and public safety
    partnerships, enabling data sharing to help inform comprehensive
    interventions.
        The President's Budget for fiscal year 2022 includes a requested
    increase of $237.8 million for opioid overdose prevention and
    surveillance. Immediate needs to combat the acceleration in overdoses
    include:
      --Expanding the provision and use of naloxone and overdose prevention
            education;
      --Expanding access to and provision of treatment for substance use
            disorders;
      --Intervening early with individuals at the highest risk for
            overdose; improving detection of overdose outbreaks due to
            fentanyl, novel psychoactive substances (e.g., fentanyl
            analogs), or other drugs to facilitate an effective response;
      --Continued partnerships with public safety to monitor trends in the
            illicit drug supply, including educating the public that drug
            products might be adulterated with fentanyl or fentanyl analogs
            unbeknownst to users.
        A comprehensive and coordinated approach from clinicians, public
    health, public safety, community organizations, and the public must
    incorporate innovative and established prevention and response
    strategies, including those focused on polysubstance use.
        Question. The Labor/HHS bill provides funding for opioid-related
    programs at the CDC, and a particular area of focus addresses
    infectious diseases associated with the opioid epidemic. Those
    resources help strengthen our understanding of the full scope of the
    burden of infectious diseases associated with substance use disorders.
    As a result of the pandemic, many public health departments' staff that
    would normally work on surveillance and prevention of infectious
    diseases, such as hepatitis, have been detailed to work on the COVID
    response.
        What do we know about the impact of the pandemic on surveillance
    and prevention of infectious diseases associated with the opioid
    crisis?
        Answer. The COVID-19 pandemic has deepened the opioid crisis and is
    having a profound impact on the fight against infectious diseases
    associated with this epidemic. We don't yet know the full impact but we
    are concerned that the major disruptions in access to prevention
    services and deferral of healthcare services during the pandemic may
    result in more infections and lead to severe health consequences in the
    long run. Deferral of healthcare services ultimately delays diagnosis
    and treatment, leaving people living with Hepatitis C and/or HIV
    unaware of their status and vulnerable to disease progression while
    also increasing the risk of spreading the viruses. Available data from
    CDC's funded programs also indicates that 50 percent of syringe
    services programs (SSPs) have reduced operations and 25 percent have
    closed further impacting opportunities for hepatitis testing and
    linkage to care. The closures of these SSPs severely limited access to
    vital hepatitis C virus and HIV prevention services, including
    referrals to treatment services as well.
        In October 2020, CDC released a health advisory about the
    possibility of new injection-related HIV infections and outbreaks and
    noted how prevention efforts could be hindered because of the COVID-19
    pandemic. Many HIV and viral hepatitis program staff were reassigned to
    support the COVID-19 response which further hindered prevention
    efforts. In the context of the pandemic, ongoing delivery of core
    public health services to address the injection drug use crisis and the
    infectious diseases associated with this epidemic, like hepatitis C and
    HIV are essential. CDC is committed to helping states build capacity to
    combat both epidemics and will continue to provide guidance as we
    address new and evolving challenges.
        Question. In response to the COVID pandemic, states have received
    billions of dollars in aid, with the intent of giving them maximum
    flexibility to respond to their unique needs and challenges. Congress
    passed five bipartisan emergency supplemental funding bills last year,
    four of which included funding specifically for CDC activities totaling
    $16.25 billion for the agency. The vast majority of the funding,
    roughly 75 percent, is to support state and local public health
    preparedness and response, laboratory capacity, and surveillance. It is
    my understanding there is a sizable portion of unobligated funds
    remaining from the bipartisan emergency supplemental bills. And now
    there is even more funding provided as part of the American Rescue Plan
    reconciliation bill for the same purpose. While it is important to know
    how fast CDC is getting this funding into the hands of the frontline
    responders on the state level, it is just as important to know if
    they're spending the money.
        What are the spend rates that CDC is seeing at the state level?
        Answer. States have multiple funding sources, including
    disbursements from the treasury, that are used for public health
    purposes. The amounts and purposes vary greatly by state and it is not
    possible to generalize about spend rates. Recipient cash drawdowns are
    a lagging indicator of recipient performance because the recipient
    draws down cash to reimburse at the time of, or after, they pay their
    bills. In addition, as recipients have their own project plans and cash
    management processes, cash drawn totals provide a high-level picture
    for that recipient and are generally not comparable across a cohort of
    recipients in the same program.
        Question. What accountability do the States have to tell you how
    they have used the funds?
        Answer. Recipients regularly report on their use of funds and the
    outcomes they achieved per the terms of the funding agreement by which
    they are awarded the funds.
        Question. Given the unprecedented volume of funding going out from
    the CDC as a result of the partisan reconciliation bill--can you
    explain CDC's decisionmaking infrastructure, process, and planning
    mechanisms for deploying unprecedented sums of money in such a short
    period of time? How does CDC plan for states and the public health
    infrastructure to sustain these advancements when the supplemental and
    mandatory funding runs out?
        Answer. CDC is allocating funding to states based on the provisions
    included in the statute. CDC uses funding mechanisms available to fit
    the purpose outlined in the statute, and where needed, has developed
    new ones.
        The ability to respond to a public health emergency requires a
    strong day-to-day public health system, supported by infrastructure
    that is not highly segmented by disease, condition, or activity. In
    addition to the COVID-19 pandemic, over the past 24 months, CDC has
    also responded to diverse public health threats from E-cigarette or
    Vaping Product Use-Associated Lung Injuries (EVALI), Ebola, complex
    multi-state food-borne disease outbreaks, wildfires, and hurricanes.
    Responding to the unique characteristics of each of these public health
    emergencies has required deep scientific expertise to deploy a
    specialized approach and called for a robust public health system with
    world-class infrastructure nationwide to stop disease at its source.
    Unfortunately, this recent history has revealed the effects of
    inadequate public health infrastructure. Ongoing health disparities
    made us as a nation more vulnerable to pandemics and large-scale public
    health emergencies, as well as burdening large segments of our
    population with chronic public health concerns. Additional investment
    in both domestic and global public health infrastructure is needed as
    proposed in the fiscal year 2022 Budget.
        With investments requested in fiscal year 2022, CDC will begin to
    address mission-critical gaps in public health infrastructure and
    capacity nationwide. Transitioning from sporadic influxes of
    supplemental funding tied to a specific emergency to flexible funding
    that can prevent another crisis will strengthen the current public
    health system. Flexible, sustainable investments in infrastructure and
    capacity are critical for saving lives and averting economic losses
    caused by public health emergencies and chronic public health problems.
    In fiscal year 2022, CDC will prioritize funding to rebuild the most
    critical public health infrastructure needed to safeguard the nation's
    health and economic security.
        Question. The Administration has placed an emphasis on addressing
    health equity, especially as it relates to the pandemic response
    efforts.
        What trends are you seeing in rural communities right now with
    regard to the pandemic?
        Answer. Data continue to show the disproportionate impact of COVID-
    19 on population groups, including people living in rural or frontier
    areas. CDC's publication examining disparities in COVID-19 vaccination
    coverage found COVID-19 vaccination was lower in rural counties (38.9
    percent) than in urban counties (45.7 percent). These data are
    available on the county tracker, which provides an integrated, county-
    level view of key data for monitoring the COVID-19 pandemic in the
    United States. It allows for the exploration of standardized data
    across the country. The footnotes describe each data source and the
    methods used for calculating the metrics. For the most complete and up-
    to-date data for any particular county or state, visit the relevant
    health department website.
        Question. How does the CDC's health equity work account for the
    needs of rural communities?
        Answer. Rural areas face unique challenges both during the COVID-19
    pandemic and when confronting ongoing public health challenges. The CDC
    COVID-19 Response Health Equity Strategy, developed under the
    leadership of the Chief Health Equity Officer Unit, affords a robust
    platform from which CDC and its partners are pursuing deeper
    engagements of diverse communities, stronger infrastructures to better
    support data-driven action, and culturally responsive approaches
    optimized for serving diverse, differentially impacted populations in
    different areas, including rural and frontier populations. CDC has
    provided historic funding to address health disparities, including
    support for rural areas, as follows:
      --$3.0 billion to strengthen vaccine confidence (awarded early April
            2021): Funding will focus on reaching communities hit hardest
            by the pandemic, including those in rural areas.
      --$3.0 billion to ensure broad-based distribution, access and vaccine
            coverage (awarded Jan. 2021): A minimum of 10 percent to
            jurisdictions must be allocated for high- risk and underserved
            populations, including rural communities.
      --$2.25 billion to states and localities to address COVID-19 in
            medically underserved communities including rural communities
            and communities with large populations of racial and ethnic
            minorities
        Additionally, the Federal Retail Pharmacy Program continues to be
    an important component in our commitment to address the
    disproportionate and severe impact of COVID-19 on communities of color
    and other underserved populations, including rural populations. From
    February 10 to May 19, 2021, 46,811,020 vaccine doses had been
    administered and reported by retail pharmacies across programs in the
    U.S. A total of 21 retail pharmacy partners are participating in the
    program, with more than 41,000 locations online and administering doses
    nationwide.
        CDC has numerous initiatives working to reduce disparities in rural
    populations. A few examples include:
      --Community Health Workers for Covid Response and Resilient
            Communities (CCR) supports the training and deployment of
            community health workers (CHWs) to response efforts and by
            building and strengthening community resilience to fight COVID-
            19 through addressing existing health disparities. Priority
            populations are those with increased prevalence of COVID-19 and
            are disproportionately impacted by long-standing health
            disparities. Recipients to be announced at the end of August
            2021.
      --Racial and Ethnic Approaches to Community Health (REACH) program
            works to reduce racial and ethnic health disparities, including
            those found in rural communities. Interventions focus on proper
            nutrition, physical activity, tobacco use and exposure, and
            chronic disease prevention, risk reduction, and management.
      --The Healthy Tribes Program funds tribal communities across the
            country to strengthen connections to culture to promote healthy
            lifestyles and reduce risk factors for chronic diseases. These
            programs together support community-developed strategies that
            work in rural settings to address the unique challenges that
            contribute to health disparities for these communities.
      --Scaling the National Diabetes Prevention Program in Underserved
            Areas funds 10 national organizations to expand the reach of
            the National Diabetes Prevention Program lifestyle change
            program to underserved areas and populations, including hard-
            to-reach rural regions of the US with fewer resources to
            address health disparities. Priority populations include
            Hispanic/Latino, African American, American Indian/Alaska
            Native, and Asian American persons; Pacific Islanders; and
            noninstitutionalized people with visual impairments or physical
            disabilities.
        Question. Dr. Walensky, as more Americans are vaccinated, there are
    certainly going to be more ``breakthrough'' cases--individuals who test
    positive for COVID-19 even after being fully vaccinated. This is to be
    expected since no vaccine is 100 percent effective. What concerns me is
    that while we're seeing breakthrough cases, for example the New York
    Yankees reported a staggering number of breakthrough cases in the
    spring, the CDC announced it will no longer track all breakthrough
    cases.
        Are we letting down our guard--should all COVID-19 cases continue
    to be counted?
        Answer. Despite the high level of vaccine efficacy, a small
    percentage of fully vaccinated persons will develop symptomatic or
    asymptomatic infections (i.e. breakthrough infections) with SARS-CoV-2,
    the virus that causes COVID-19. The goal of national surveillance for
    COVID-19 vaccine breakthrough infections is to identify unusual
    patterns, such as trends in age or sex, the vaccines involved,
    underlying health conditions, or which of the SARS-CoV-2 variants made
    these people sick. To date, no unusual patterns in cases have been
    detected in the data CDC has received.
        Question. Can you explain why the change was made and exactly what
    CDC is now tracking with regard to breakthrough cases?
        Answer. State and local health departments report COVID-19 vaccine
    breakthrough cases to CDC voluntarily. The number of COVID-19 vaccine
    breakthrough infections reported to CDC likely are an undercount of all
    SARS-CoV-2 infections among fully vaccinated persons. Reports may not
    be complete and because not all infected persons get tested, not all
    breakthrough cases will be identified. This is particularly true in
    instances of asymptomatic or mild illness. The shift to focus on
    hospitalized or fatal cases will help maximize the quality of the data
    collected on cases of greatest clinical and public health importance,
    while representative, scientifically valid data on vaccine
    effectiveness comes from studies CDC is leading across the country.
        Reporting vaccine breakthrough cases through national surveillance
    is only one of the ways CDC measures COVID-19 vaccine effectiveness.
    CDC continues to lead studies in multiple U.S. sites to evaluate
    vaccine effectiveness and to collect information on COVID-19 vaccine
    breakthrough infections from these sites regardless of clinical status.
    For example, CDC is working with Emerging Infection Program (EIP) sites
    in nine states to compare SARS-CoV-2 sequence data from vaccinated and
    unvaccinated cases, regardless of clinical severity. CDC also is
    working on more than 30 ongoing studies to assess vaccine
    effectiveness, some of which include information on vaccine
    breakthrough infections in patients with asymptomatic and milder
    illness. Through these studies in various populations, locations, and
    settings, CDC can obtain more representative, scientifically valid, and
    complete information about these types of infections.
        CDC is also using the Coronavirus Disease 2019 (COVID-19)-
    Associated Hospitalization Surveillance Network (COVID-NET) to track
    and analyze breakthrough infections. This population-based surveillance
    system includes data on laboratory-confirmed COVID-19-associated
    hospitalizations in 99 counties in 14 states, representing
    approximately 10 percent of the U.S. population. COVID-NET cases are
    hospitalizations occurring in residents of a designated COVID-NET
    catchment area who are admitted within 14 days of a positive SARS-CoV-2
    test. COVID-NET personnel collect COVID-19 vaccination status (doses,
    dates administered and product) from state Immunization information
    systems (IIS) for all sampled COVID-NET cases in 13 sites, which also
    include information on clinical outcome. Some sites have expanded
    collection of vaccination status to non-sampled cases, which were
    included for analysis if all cases in a single month had vaccination
    status available.
        This strategic, deliberative approach will yield better information
    on vaccine effectiveness and provide critical insight on cases of
    greatest concern.
        Question. Related, there is increasing concern about the public
    health impact of long-term symptoms weeks or months after an individual
    has had COVID-19.
        What monitoring or tracking is the CDC undertaking with regard to
    COVID ``long-haulers''?
        Answer. CDC is spearheading rapid and multi-year studies to further
    investigate post-COVID conditions (PCC), also known as ``long COVID''
    or ``long-haul COVID.'' These studies will help us better understand
    post-COVID conditions and how to treat patients with these longer-term
    effects. For example, ongoing studies will follow patients for up to 3
    years and provide information on the percent of persons who develop
    post-COVID conditions, assess risk factors for development of post-
    COVID conditions, and evaluate different virus strains and antibody
    responses.
        Question. How many long-haulers would you estimate are living with
    post-COVID related symptoms?
        Answer. At this time, we do not have a precise way to measure and
    capture the prevalence of persons living with post-COVID-19 related
    symptoms, but we know there are many people who are suffering from
    this.
        Currently, CDC and its Federal partners have proposed a new PCC
    ICD-10 code and are looking at all considerations on how this may
    impact the final version of this new code. The new ICD-code could
    potentially be used for a range of conditions, including subsequent
    chronic respiratory failure to help track and monitor people living
    with PCC. CDC's National Center for Health Statistics (NCHS) presented
    a proposal for public input to implement the code U09.9, post-COVID-19
    condition, based on a proposed international classification of
    diseases, tenth revision (ICD-10) code from the World Health
    Organization (WHO) last year. This proposal is expected to move forward
    after public input and may be implemented in October 2021 (as part of
    the regular ICD-10 code process/timelines) to allow clinical data
    systems and health insurers to adapt and fully implement it. We hope
    this will provide us with a better estimate of those who may be living
    with PCC.
        Question. How does CDC plan to continue to monitor and track the
    long-term impacts of COVID?
        Answer. CDC is using multiple de-identified electronic health
    record (EHR) databases to examine persistence of symptoms and incidence
    of post-COVID conditions. CDC has also partnered with health systems to
    perform in-depth medical record reviews, which can provide insight into
    the patterns of health effects that patients are experiencing.
        Question. Dr. Walensky, CDC has received a lot of criticism
    throughout the pandemic. A lot of it is justified. And most of it
    transcends political leadership at the agency. There are a lot of
    lessons to be learned from what we did right and what we did wrong. As
    I said in my opening statement, we did a lot right--so much so, in
    fact, that we have three FDA authorized vaccines that are getting into
    Americans' arms as we speak. But we also must recognize the missteps
    when they happen as well. That is how we learn and how we become better
    for the next public health emergency. Unfortunately, much of the
    criticism about our pandemic response, that continues to this day,
    revolves around the CDC. As Chair Murray and Senator Burr work on a
    pandemic reform bill in the health authorizing Committee, I think it
    would be a benefit to this Subcommittee to hear from you on these
    issues as well. Can you please respond to the comments below:
        Answer. First, CDC is risk adverse. I think that we have seen that
    in several cases, from mask mandates for campers to discouraging travel
    for the fully vaccinated.
        Question. Second, CDC guidelines are impractical. The agency simply
    doesn't issue guidelines that are clear and straightforward enough to
    be useful. What I continually heard is that Federal guidance needs to
    be practical for implementers on the ground or the American people to
    follow it.
        Answer. Since the early days of the pandemic, scientists at CDC
    have been using evidence from systematic reviews and expert judgement
    to develop guidance that informs various populations on how to slow the
    spread of COVID-19 and protect their health and their communities. The
    process and information communicated can be complex and evolves as our
    understanding of the virus increases. CDC's group of multidisciplinary
    stakeholders assesses the benefits and risks informed by data from the
    field and issues evidence-based guidelines. State and local health
    departments then decide how the research and guidance is implemented.
        Question. Third, CDC has an entrenched bureaucracy that is
    unwilling or unable to think big or implement on a large scale. The
    perfect, and befuddling, example is why CDC didn't engage with private
    sector partners like Abbott or Roche to commercialize their assay.
    Testing was one of the early failures. Was this the reason why?
        Further, at the outset, lab testing followed the flu model.
    Asymptomatic spread requires significant testing, but this was low-
    balled and kept in-house which could only produce about 100,000 tests
    when what needed to happen was to engage the private sector labs to get
    1-2 million higher volume throughput.
        Answer. CDC aids and equips state and public health laboratories in
    diagnostic testing for novel pathogens. When a new virus emerges or a
    public health need for a new diagnostic tool arises, CDC may develop a
    new diagnostic tool and, in partnership with state and local public
    health partners and non-governmental organizations, strategize
    distribution. This process is intended to fulfill needs within the
    public health scope of outbreaks or new technologies. It is not
    currently intended to replace or fulfill testing that may need to be
    developed or distributed by commercial vendors to meet broader health
    sector needs.
        Furthermore, the EUA process for diagnostic (IVD) test development
    and analysis/validation follows a predetermined framework at CDC, as
    does deployment of the test after FDA authorization.
        Question. Lastly, the Center structure at CDC is stove piped and
    hampered the response. As a result, response efforts were locked into
    the flu center, which treated COVID-19 like the flu--which spreads
    symptomatically. Is this the reason we missed asymptotic spread?
    Because we didn't have the right experts in charge or a CDC-wide body
    responsible?
        Answer. On January 7, 2020, the Director of the National Center for
    Immunization and Respiratory Diseases (NCIRD) issued the directive
    authorizing a Center Level Response, Novel Coronavirus (nCoV) 2019
    Response, for the pneumonia outbreak in Wuhan, China in consultation
    with the CDC Director. This Directive was effective January 6, 2020. As
    the situation evolved, CDC escalated its response from the Center and
    activated its Emergency Operations Center facilitating a CDC-wide
    response on January 20, 2020.
        When reports of asymptomatic spread first emerged, CDC's guidance
    addressed the current circumstances. CDC proactively and aggressively
    investigated evidence from the field, and updated its guidance
    accordingly based on the best available data.
        Question. Dr. Walensky, the Influenza Hospitalization Surveillance
    Network (FluSurv-Net) is a population-based surveillance system that
    collects laboratory confirmed influenza associated hospitalizations
    from 14 states. The coverage area for FluSurv-Net is roughly 29 million
    people, or 9 percent of the U.S. population. There is no site in
    Missouri and the Midwest is not represented at all, except for Iowa.
        How can the CDC accurately track an influenza outbreak without
    real-time data from 36 states?
        Answer. CDC's influenza surveillance systems are a collaborative
    effort between CDC and its many partners in state, local, and
    territorial health departments, public health and clinical
    laboratories, vital statistics offices, healthcare providers, clinics,
    and emergency departments. The system consists of complementary
    components that capture virologic surveillance, outpatient illness
    surveillance, hospitalization surveillance, and mortality surveillance.
    This comprehensive surveillance infrastructure is used to identify when
    and where influenza activity is occurring, determine which influenza
    viruses are circulating, detect changes in influenza viruses, and
    measure the impact influenza is having on outpatient illness,
    hospitalizations, and deaths. Surveillance is performed continuously
    throughout the year and data are presented in FluView, a weekly
    influenza surveillance report, and FluView Interactive, an online
    application which allows for more in-depth exploration of influenza
    surveillance data, which are updated weekly.
        Additionally, the HHS Protect Hospital Data reporting system
    provides daily information on the number of patients hospitalized with
    influenza-related and COVID-related illnesses from over 6,000 hospitals
    in all 50 states and U.S. territories. This system provides situational
    awareness of severe respiratory illness and local hospitalization
    trends for influenza and COVID-19 on a daily basis that is beneficial
    for monitoring severe illness during an outbreak.
        Question. And how did the lack of real-time data stymy the response
    to COVID-19?
        Answer. COVID-19 highlighted the importance of real-time data
    needed to get ahead and stay ahead of the disease. CDC must build on
    initial investments and lessons learned from COVID-19 by investing in
    the nation's public health infrastructure. The ability to respond to a
    public health emergency requires a strong day-to-day public health
    system, including efficient data sharing, and supported by
    infrastructure that is not highly segmented by disease, condition, or
    activity. With investment in fiscal year 2022, CDC will begin to
    address mission-critical gaps in public health infrastructure and
    capacity nationwide. Transitioning from sporadic influxes of
    supplemental funding tied to a specific emergency to flexible funding
    that can prevent another crisis will strengthen the current public
    health system. Flexible, sustainable investments in infrastructure and
    capacity are critical for saving lives and averting economic losses
    caused by public health emergencies and chronic public health problems.
        Question. Reports are already speculating that the next flu season
    may be bad after a year of hardly any flu cases.
        How concerned should we be that many Americans are left without an
    immunity to flu--especially children--who may be more susceptible than
    any other recent year?
        Answer. A flu vaccine is the best way to protect children from flu.
    CDC recommends that everyone 6 months and older should get a flu
    vaccine every season. Annual vaccination is important to protect both
    yourself and to provide protection for those who are more vulnerable to
    serious flu illness, including children, older adults, and people with
    certain chronic health conditions.
        The flu can be dangerous for children. During the 2019--2020
    season, nearly 200 flu deaths in children were reported to CDC in the
    United States, which was the highest reported number of pediatric
    influenza deaths on record. About 80 percent of those children were not
    vaccinated. Last year, childhood influenza vaccination coverage is
    estimated to have dropped 4.1 percentage points from 62 percent during
    2019-2020 to 58 percent.
        CDC is working diligently to support the vaccination of as many
    Americans as possible during the upcoming influenza season. Vaccine
    manufacturers have projected that they will supply 188 to 200 million
    doses of influenza vaccine for the 2021-2022 season. CDC will continue
    to emphasize the importance of influenza vaccination through targeted
    communication outreach. CDC will build off its 2020-2021 communication
    campaign, which was estimated to have been seen more than 5 billion
    times. This year's media campaign will include population-wide outreach
    and will have a special emphasis on targeting disproportionately
    affected audiences, including people ages 40-64 with chronic medical
    conditions, African American and Hispanic persons, essential workers,
    pregnant women, and parents.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
        Question. The Alabama Department of Public Health saw a delay in
    the reporting of vaccine distributions upon the initial allocation of
    vaccine allotments to states. Ultimately, there was not a delay in the
    distribution of the vaccine, but in the reporting of administered
    vaccines. In the last 15 months, Congress has appropriated $1.1 billion
    to the CDC for the purpose of public health data modernization and
    addressing public health data reporting issues that were experienced in
    Alabama. In 2019, CDC stakeholders requested $1 billion over a ten-year
    period to tackle public health data modernization, which CDC has
    indicated is needed and Congress has far surpassed to this point. $500
    million was appropriated through both the CARES Act and the American
    Rescue Plan Act of 2021, and $50 million was appropriated for both
    fiscal years 2020 and 2021 annual appropriations for the funding of
    public health data modernization through the CDC.
        Could you give a detailed description of how that $1.1 billion has
    been used to date, who that funding has gone to (e.g., through
    contracts, cooperative agreements, and grants), and for how much?
    Please also provide a detailed plan for the remaining funds.
        Answer:

                             ANNUAL APPROPRIATIONS

              Table 1. Budget Plan for Annual Appropriations \1,2\
    ------------------------------------------------------------------------
                                                        Fiscal Year
                 Major Activity              -------------------------------
                                                   2020            2021
    ------------------------------------------------------------------------
    Partnering with State and Local Public            $32.5M          $32.5M
     Health, Partners, and Health Care
     Systems................................
    Accelerating Public Health Data for               $15.5M          $15.5M
     Action.................................
    Sustaining Innovation...................      $2 million      $2 million
        Total...............................     $50 million     $50 million
    ------------------------------------------------------------------------
    \1\ Working Capital Fund and program support costs are spread across all
      activities.
    \2\ Amounts per activity are based on current information and may
      require adjustment.

    Data Modernization Base Funding
        Congress recognized the need to modernize CDC's data systems and
    provided funding in fiscal year 2020 dedicated specifically to data
    modernization. DMI base funding is focused on strengthening and
    sustaining the core foundational surveillance systems that state, local
    and territorial jurisdictions use every day. These systems benefit all
    of public health and serve as ``early warning signals'' for our biggest
    threats--systems that handle emergency room visits, case reporting,
    notifiable diseases, lab results, and death data. Investments to date
    have laid the groundwork and spurred real progress, but much work
    remains to be done.
        In fiscal year 2020, CDC focused on solutions for the timely,
    secure, and accurate flow of health data from electronic health
    records, laboratories, and other primary data sources to state and
    local jurisdictions and the multi-directional data flows between these
    jurisdictions and CDC. The focus of these efforts has been on the
    following:
      --Expanded use of eCR and connectivity to Electronic Health Records
            (EHR)
      --Increasing the number of emergency departments and use of syndromic
            and disease surveillance data through the NSSP
      --Enhancing automated electronic laboratory reporting (ELR) and
            implementation of Electronic Test Orders and Results (ETOR) at
            clinical and public health laboratories
      --Implementing improvements to birth and death reporting in NVSS
      --Modernization of disease reporting through NNDSS and of states'
            National Electronic Disease Surveillance System (NEDSS) Base
            System (NBS)
        CDC has continued to reimagine what its core surveillance systems
    could deliver in fiscal year 2021. CDC works closely with public health
    partners to reduce their reporting burden and make sure everyone has
    the capacity to connect with each other. The pandemic drove huge leaps
    in electronic case reporting (eCR), with thousands of healthcare
    facilities now exchanging automated, real-time health information. All
    50 states, D.C., and 11 large local jurisdictions are now capable of
    receiving COVID-19 electronic case reports, up from only a handful of
    jurisdictions in late 2019. The National Vital Statistics System (NVSS)
    expanded its modernization community and began delivering provisional
    COVID-19 death data and new data on excess deaths. Currently, 67
    percent of deaths are reported electronically in less than 10 days, up
    from 7 percent in 2010. CDC has dramatically improved the quality of
    laboratory report data received by public health through nationwide use
    of standardized messaging with Electronic Laboratory Reporting (ELR),
    with 56 jurisdictions reporting lab data directly to CDC, up from zero
    in 2019. Data from 70 percent of all U.S. emergency departments is
    reported to CDC through the National Syndromic Surveillance Program
    (NSSP), with 75 percent of emergency department data received in less
    than 24 hours of a visit. As a result, more early warning signals from
    systems that track emergency department visits and notifiable diseases
    were and are being captured.
        In fiscal year 2020, approximately $22.5 million was distributed
    through a cooperative agreement to 58 awardees, including states,
    cities, and territories, with an average award of $391,417. These funds
    supported specific strategies, activities, and outcomes to improve
    health information systems infrastructure, workforce development, and
    public health laboratories. States have used these funds to conduct
    needs assessments, strengthen technical and informatics skills,
    streamline changes to surveillance systems, and identify a lead person
    in each jurisdiction to support data modernization.
        CDC is continuing to improve core public health data systems,
    enhance data science and informatics workforce capabilities across the
    public health systems, improve interoperability and innovation through
    adoption of new standards and approaches for public health reporting
    such as Fast Healthcare Interoperability Resources (FHIR) standards,
    and support ongoing data modernization at CDC and with its partners.
        Our focus in fiscal year 2021 has been on providing technical
    assistance to state and local jurisdictions to leverage progress made
    at the Federal, state, and local levels on electronic case reporting
    (eCR) and Electronic Test Orders and Results (ETOR), as well as other
    core systems and processes for data exchange. Technical assistance is
    being provided by CDC and through a cooperative agreement with public
    health partners like the Association of Public Health Laboratories
    (APHL) and the Council of State and Territorial Epidemiologists (CSTE).
    These partners are providing technical assistance to jurisdictions
    focused on improving data sharing, accelerating use of shared decision
    support services, data science upskilling of the public health
    workforce, and developing and increasing use of standards to improve
    quality and timeliness of reported data. Focus on continuing to improve
    core public health data systems, enhance data science and informatics
    workforce capabilities across the public health systems, improve
    interoperability and innovation through adoption of new standards and
    approaches for public health reporting (such as FHIR standards) and
    support of ongoing data modernization at CDC and with its partners
        CDC also provided funding through a cooperative agreement to three
    tribal health entities to focus on three activity areas: augmenting
    workforce development and capacity, identifying and deploying specific
    enhancements in public health data and health information systems, and
    employing shared services to improve data quality, exchange, and
    management. CDC has provided funding to tribal entities in fiscal year
    2021 to focus on the improving access to data, modernizing
    infrastructure for data collection and analysis, and expanding
    workforce data skills.
        To keep CDC at the forefront of innovative, data-driven public
    health solutions, we are strengthening skills for a state-of-the-art
    data science workforce by supporting workforce development to assure
    capable data scientists and informatics-skilled staff are available to
    state, territorial, local, tribal, and Federal public health agencies.
    In fiscal year 2020, CDC completed a pilot cohort of team training
    through the Data Science Upskilling (DSU), which included 79 unique
    learners on 18 teams. DSU is a new model of team training using
    experiential learning tailored to agency priorities. Teams include both
    CDC staff and fellows from the Public Health Informatics Fellowship
    Program utilizing curated online courses and in-depth, boot-camp-style
    training on topics like machine learning. Team projects align with
    agency DMI priorities, CDC's winnable battles, or COVID-19 response.
    CDC also funded the Council of State and Territorial Epidemiologists
    (CSTE) to implement a similar program, Data Science Team Training
    (DSTT).
        DSTT was designed as a replica to CDC's Data Science Upskilling
    program, with modifications to better meet state, tribal, local, and
    territorial, needs. Training activities began in January 2021 with 20
    teams and 86 learners. There is representation from a mix of state,
    local, tribal, and territorial health departments.
                                cares act funds
        Together with base funding, the Coronavirus Aid, Relief, and
    Economic Security (CARES) Act extended and accelerated CDC's data
    modernization goals for the nation. CARES funding focuses on
    infrastructure, innovations, and connecting systems and data sources.
    Rather than discrete, one-off projects or a narrow focus on individual
    capacities, we have looked at the entire surveillance and data
    ecosystem and identified the areas most in need of investment and
    modernization. While COVID-19 is the priority, the end goal of DMI is
    to create lasting, adaptable solutions that will make public health
    more responsive and resilient in the future.
        CARES funding is being invested across three major areas:
      --Data Sharing across the Public Health Ecosystem
      --Modernizing critical tracking capabilities and core surveillance
            systems
      --Extending data lakes and services that support electronic
            laboratory reporting and immunization information
      --Expanding the type, variety, and quality of data available to CDC
            programs and STLT
      --Automating the flow of data from electronic health records and
            other sources
      --CDC Systems and Service Enhancements for Ongoing Data Modernization
      --Expanding enterprise cloud services to bring in and use large
            datasets from partners in new ways
      --Expanding CDC's enterprise data hub, orchestration, warehouse,
            lake, analytics, and visualization capacity
      --Building a state-of-the-art data science workforce
      --Ensuring open and accessible data while protecting privacy and
            security
      --New Standards and Approaches for Public Health Reporting
      --Implementing new standards and approaches, such as FHIR across the
            public health ecosystem
      --Assessing policy/legal barriers to sharing data, including STLT
            data
        Our work focused on data sharing across the public health ecosystem
    includes modernizing critical tracking capabilities and surveillance
    systems, such as the National Healthcare Safety Network (NHSN), Public
    Health Environmental Tracking Network, the National Electronic Injury
    Surveillance System-All Injuries Program (NEISS-AIP), and the National
    Vital Statistics System (NVSS). We are also rapidly expanding
    electronic case reporting (eCR) from healthcare to public health. We
    have rapidly extended data lakes and services that support electronic
    laboratory reporting and immunization information, including the
    creation of a new immunization data lake that is now actively receiving
    and making available 3.1M administration records per day. Funding has
    also supported the creation of the Pan Respiratory Surveillance
    Initiative, informing our knowledge of molecular surveillance, viral
    evolution, and helping track trends in emerging variants.
        Enhancements to CDC systems and service enhancements for ongoing
    data modernization include deploying cloud-based technology to bring in
    and use large data sets from partners in new ways, while also providing
    highly scalable data analytic and visualization capabilities. This is
    already strengthening our data sharing capabilities. For example, we
    modernized data sharing with Homeland Security to ingest daily
    international passenger arrival contact tracing information, parse it,
    and provide it overnight to states through a secure, cloud-based file
    transport system for STLTs to ingest into their individual tracking
    systems. In the past year, the percentage of usable data has improved
    to over 95 percent and time to transmit to STLTs has decreased from
    days to overnight. Ongoing work to expand CDC's enterprise data hub,
    orchestration, warehouse, lake, analytics, and visualization capacity
    makes us better able to support modernization project needs across the
    agency. We have streamlined identity proofing and access management,
    use of enterprise code repositories, and enterprise security and code
    complexity scanning. The CDC Data Hub actively continues to ensure that
    analytics, including machine learning and artificial intelligence, are
    enabled in cloud-based data pipelines. At the same time, we have
    Initiated training opportunities to build a state-of-the-art data
    science workforce, including CDC's Data Academy, which has delivered
    more than 1000 hours of free training.
        Our modernization efforts include developing new standards and
    approaches for public health reporting. We are preparing CDC and our
    STLT and healthcare partners to implement technologies and standards
    that make systems interoperable and help these systems ``speak the same
    language.'' Federal policies and advancements in technologies are
    opening doors to make new connections for exchanging public health
    data, and a major focus is on implementing Fast Healthcare
    Interoperability Resources, or ``FHIR,'' across the public health
    ecosystem. FHIR application programming interfaces (APIs) can help
    public health to access detailed and timely data from EHRs while
    lowering burden on and delivering greater value to data providers. We
    are also working closely with jurisdictions and research partners to
    innovate toward FHIR-based interoperability at every level. This will
    give us more complete data and surveillance capabilities nationwide.
    Our goal is to take what works and scale nationwide, through pragmatism
    and collaboration to realize significant benefits to the way we use and
    share data across all of public health.

             Table 2. Budget Plan for CARES Act Appropriations \1,2\
    ------------------------------------------------------------------------
                                                             Funding Levels
                         Thematic Area                      for  Fiscal Year
                                                                2020-2021
    ------------------------------------------------------------------------
    Data Sharing Across the Public Health Ecosystem.......          $140.55M
    CDC Systems and Service Enhancements and Ongoing Data           $120.62M
     Modernization........................................
    New Standards and Approaches for Public Health                   $13.83M
     Reporting............................................
    Additional fiscal year 2020 funding for Emergency                $41.44M
     Operations Center public health surveillance
     activities...........................................
    Future fiscal year 2022-2023 funding..................          $183.56M
        TOTAL.............................................      $500 million
    ------------------------------------------------------------------------
    \1\ Working Capital Fund and program support costs are spread across all
      activities.
    \2\ Amounts per activity are based on current information and may
      require adjustment.

                           american rescue plan funds
        CDC appreciates further appropriations in data modernization
    awarded through The American Rescue Plan Act. Where possible CDC is
    evaluating recent investments made in national data infrastructure and
    working with states to understand the gaps that still exist and
    barriers to modernizing to further drive the best practices for
    efficient and effective data modernization across the public health
    ecosystem. Planning is currently underway to apply ARP data
    modernization resources to drive a flexible, responsive, and modern,
    response- ready data infrastructure.
                                     ______

                   Questions Submitted by Senator Jerry Moran
        Question. In February, the CDC issued an order requiring face masks
    on conveyances and at transportation hubs. Last week, you updated your
    guidance for fully vaccinated individuals, saying they can stop wearing
    masks indoors and outdoors. However, the CDC has not taken any steps to
    update the February transportation order.
        When can we expect such an update?
        Answer. While those who are fully vaccinated may resume many
    activities without wearing a mask, the travel environment presents a
    unique set of circumstances based on the number and close interaction
    of travelers (both vaccinated and unvaccinated). Traveling on public
    transportation increases a person's risk of getting and spreading
    COVID-19 by bringing people in close contact with others, often for
    prolonged periods. Staying 6 feet away from others is often difficult
    on public transportation conveyances. People may not be able to
    distance themselves by the recommended minimum of 6 feet from other
    people seated nearby or from those standing in or passing through the
    aisles on airplanes or buses, for example.
        Correct and consistent use of masks on public transportation
    conveyances and at transportation hubs protects travelers and workers,
    enables safe and responsible travel during the pandemic, and helps to
    reduce the spread of coronavirus disease 2019 (COVID-19).
        CDC will update the Order and other recommendations as more people
    get vaccinated, as rates of COVID-19 change, and as additional
    scientific evidence becomes available.
        Question. Given the different risk levels of COVID transportation
    across the transportation network, for instance traveling on public
    transportation verses operating a freight locomotive, can we expect
    different guidance?
        Answer. CDC will continue to evaluate the requirements of its Order
    and determine whether other changes are warranted by examining
    characteristics like the transportation environment as well as indoor
    and outdoor locations. CDC will update the Order and other
    recommendations as more people get vaccinated, as rates of COVID-19
    change, and as additional scientific evidence becomes available.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. There are two FDA-approved buprenorphine products for the
    treatment of moderate to severe chronic pain. Both buprenorphine-based
    products have been classified by the U.S. Drug Enforcement
    Administration (DEA) as Schedule III meaning they have less abuse and
    addiction potential compared to Schedule II drugs like oxycodone,
    fentanyl, and oxymorphone. Furthermore, buprenorphine provides an
    important safety advantage as it is the only opioid with a demonstrated
    ceiling effect on respiratory depression, which is what typically leads
    to death in an opioid overdose. In addition, there are several
    buprenorphine-based products approved to treat opioid addiction. This
    means that one of the same drug compounds that help millions of
    Americans curb their addiction to illicit and prescription opioids can
    also be used effectively to treat chronic pain with a lower chance of
    addiction, abuse and overdose. However, it's my understanding that the
    CDC's Guideline for Prescribing Opioids for Chronic Pain, which was
    published in 2016, doesn't include any language about the benefits of
    Schedule III buprenorphine products, even though they have less
    potential for addiction and abuse, for the treatment of chronic pain.
    Instead, the Guideline recommends starting opioid therapy with
    immediate release Schedule II opioids, which have been shown to have
    higher rates of addiction, abuse and overdose.
        Do you know why the Guideline doesn't differentiate between
    Schedule II and Schedule III opioids and recommend the use of Schedule
    III opioids given their enhanced safety profile and lower risk of
    abuse, addiction and overdose?
        Answer. The evidence reviews informing the 2016 Guideline found
    evidence of increased risks from extended-release/long acting (ER/LA)
    full agonist opioids but did not identify other differences in safety
    or effectiveness by type of opioid, including by schedule. Therefore,
    there was no evidence on which to base recommendations to use different
    types of opioids (except recommendations on ER/LA vs. short-acting
    opioids).
        Question. Can you provide an update on the process and timing of
    the CDC's efforts to update the Guideline? Do you expect the updated
    Guideline to consider DEA scheduling and recommend prescribers begin
    opioid therapy with Schedule III drugs, when clinically appropriate,
    before advancing to a Schedule II Drug?
        Answer. CDC funded the Agency for Healthcare Research & Quality
    (AHRQ) to conduct systematic reviews of the scientific evidence that
    has been published since the Guideline's release in March 2016. These
    reviews are the following:
      --Noninvasive Nonpharmacological Treatment for Chronic Pain (An
            Update)
      --Nonopioid Pharmacologic Treatments for Chronic Pain
      --Opioid Treatments for Chronic Pain
      --Treatments for Acute Pain: A Systematic Review
      --Acute Treatments for Episodic Migraine
        Based on AHRQ's completed reviews, CDC has determined that an
    update to the Guideline and an expansion of the Guideline to certain
    acute conditions is warranted.
        On December 4, 2019, the Board of Scientific Counselors of the
    National Center for Injury Prevention and Control (BSC/NCIPC)
    established the Opioid Workgroup (OWG). The OWG will report to the BSC/
    NCIPC, a Federal advisory committee. The primary purpose of the OWG is
    to review the updated draft Guideline for opioid prescribing (as
    prepared by CDC) and to develop a report that will provide the
    workgroup's findings and observations about the draft GL to the BSC/
    NCIPC.
        The OWG began reviewing a draft Guideline for opioid prescribing
    (as prepared by CDC) in March 2021. The OWG met for a total of 11 times
    since October 2020 and developed a report of findings and observations
    about the draft Guideline update (prepared by CDC). The OWG presented
    its findings at the July 2021 BSC/NCIPC meeting. The BSC/NCIPC will
    then review the OWG's report and provide recommendations for CDC to
    consider as part of the Guideline update process.
        It is anticipated that a revised Guideline will be posted in the
    Federal Register for a 60-day public comment in late 2021, which will
    provide a critical opportunity for diverse input from the public.
        Release of a final updated Guideline is anticipated to occur in
    late 2022.
        On opioid therapy--there are very limited clinical trial data
    comparing safety and efficacy of partial agonist buprenorphine with
    full agonist/schedule II opioids for chronic pain. In order to ensure
    that the updated guideline would be informed by available clinical
    evidence on types of opioids, CDC asked AHRQ to specifically address,
    in its evidence review on opioids for chronic pain to inform CDC's
    guideline update, the following questions on effectiveness and safety
    of opioids by type of opioid:
        ``Key Question 1. Effectiveness and Comparative Effectiveness . . .
            . b. How does effectiveness vary depending on . . .  (4) the
            type of opioids used (e.g., pure opioid agonists, partial
            opioid agonists such as buprenorphine or drugs with mixed
            opioid and nonopioid mechanisms of action such as tramadol or
            tapentadol)?''
        ``Key Question 2. Harms and Adverse Events . . . . b. How do harms
            vary depending on . . .  (5) the mechanism of action of opioids
            used (e.g., are there differences between pure opioid agonists
            and partial opioid agonists such as buprenorphine or drugs with
            opioid and nonopioid mechanisms of action such as tramadol and
            tapentadol) . . . ?''
        The AHRQ evidence review published in 2020 found very limited
    evidence on comparative safety or effectiveness of opioids for chronic
    pain by type of opioid. Please see the report for additional detail,
    which can be found at https://effectivehealthcare.ahrq.gov/sites/
    default/files/pdf/opioids-chronic-pain.pdf.
        CDC is considering all findings from the AHRQ evidence reviews in
    developing updated recommendations.

                              SUBCOMMITTEE RECESS

        Senator Murray. The committee we will next meet in Dirksen
    562, Wednesday, May 26 at 10 a.m., for a hearing on the Biden
    Administration's Budget Request for the National Institutes of
    Health.
        Thank you very much.
        [Whereupon, at 11:50 a.m., Wednesday, May 19, the
    subcommittee was recessed, to reconvene at 10 a.m., Wednesday,
    May 26.]

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

                                  ----------

                            WEDNESDAY, MAY 26, 2021

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:01 a.m., in room SD-562, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Reed, Shaheen, Schatz, Baldwin,
    Murphy, Manchin, Blunt, Shelby, Graham, Moran, Kennedy, Hyde-
    Smith, Braun, and Rubio.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF FRANCIS S. COLLINS, M.D., PH.D., DIRECTOR
    ACCOMPANIED BY:
            DIANA BIANCHI, M.D., DIRECTOR, EUNICE KENNEDY SHRIVER NATIONAL
                INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT
            ANTHONY FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY
                AND INFECTIOUS DISEASES
            GARY GIBBONS, M.D., DIRECTOR, NATIONAL HEART, LUNG, AND BLOOD
                INSTITUTE
            ELISEO PEREZ-STABLE, M.D., DIRECTOR, NATIONAL INSTITUTE ON
                MINORITY HEALTH AND HEALTH DISPARITIES
            NED SHARPLESS, M.D., DIRECTOR, NATIONAL CANCER INSTITUTE
            BRUCE TROMBERG, PH.D., DIRECTOR, NATIONAL INSTITUTE OF
                BIOMEDICAL IMAGING AND BIOENGINEERING

                   OPENING STATEMENT OF SENATOR PATTY MURRAY

        Senator Murray. Good morning. The Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education and
    Related Agencies will please come to order.
        Today, we are having a hearing on the Biden
    Administration's fiscal year 2022 Budget Request for the
    National Institutes of Health. Senator Blunt and I will each
    have an opening statement, and then I will introduce our
    witnesses. And after the witness testimony, Senators will each
    have 5 minutes for a round of questions.
        Before we begin, I do want to walk through the COVID-19
    safety protocols that are in place today. And again, I really
    want to thank all of our clerks and everyone who has really
    worked hard to get this set up and help us all stay safe and
    healthy. So, thank you to them.
        For today, we are going to be conducting this hearing
    following similar COVID protocols to what we have used in the
    past. Committee members are seated at least 6 feet apart. Some
    Senators are participating by videoconference. However, I do
    expect that this will be our final hybrid hearing, and we will
    be able to return to regular, in-person hearings at our next
    hearing.
        Consistent with CDC guidance, those who are fully
    vaccinated do not need to wear a mask, though they may still
    choose to do so. And while we are unable to have the hearing
    fully open to the public or media for in-person attendance,
    live video is available on our committee website. And if you
    are in need of accommodations, including closed captioning, you
    can reach out to the committee or the Office of Congressional
    Accessibility Services.
        As of today, almost half of U.S. adults are fully
    vaccinated. And while we have a lot of work left yet to do to
    reach communities who still cannot get vaccines and reassure
    people who still have many questions about them, we can see the
    light at the end of the tunnel. And, I really want to thank all
    of our witnesses, especially Dr. Collins and Dr. Fauci, for
    putting in long hours and putting science first.
        Where we are at today is a testament to the tireless work
    scientists at NIH have been doing to study this disease and how
    we can best fight it, and oversee clinical trials for vaccines
    and therapeutics and more, to ensure they are safe and
    effective. And, of course, as our witnesses know, our
    historically fast progress in fighting COVID-19 and developing
    safe and effective vaccines was actually years in the making.
        The pace of discovery we have seen this past year was made
    possible by research into mRNA vaccines we funded in response
    to Ebola and other viruses, and biomedical research enterprise
    that has been built over decades to become one of the most
    cutting edge in the world.
        This should be an important reminder when it comes to
    biomedical research. You can never fully predict how the
    discoveries of today will prepare you for the challenges of
    tomorrow. That is why you have to build the robust research
    enterprise and recruit diverse, world class talent, and make
    sure scientists can do their work free from political
    interference.
        And President Biden's budget, which proposes over $40
    billion for NIH (National Institutes of Health), the largest
    increase in the agency's history, will go a long ways towards
    making sure we can continue to prioritize this. This budget
    will reinforce our work to fight COVID-19, along with many
    other diseases and disorders that threaten families in my home
    State of Washington, or Missouri, or across the Country.
        It includes funding to improve treatments for addiction and
    substance use disorders, and funding to aid the fight against
    cancer, Alzheimer's disease, and rare diseases families across
    the Country are grappling with.
        President Biden's budget request will also fund research to
    help us study the health effects of climate change, which may
    be increasing the number of infectious disease outbreaks;
    identify solutions to gun violence, which continues to claim
    tens of thousands of lives each year in this Country; and root
    out the health inequities in our Country, which are undermining
    the health of people of color, people with disabilities, rural
    communities, those paid low incomes, and more.
        The President has also proposed $6.5 billion for a new
    initiative--the Advanced Research Projects Agency for Health.
    Like the defense initiative it is inspired by, ARPA-H is
    envisioned as breaking the mold for how cutting-edge research
    is conducted, speeding up the development of medical treatments
    by funding innovative projects. I am interested to hear more
    about how it can add to NIH's work and operate as something
    truly distinct from its other traditional, biomedical research
    programs.
        Of course, at the end of the day, innovation is not just
    driven by new programs and new investments. It is driven by
    people, which is why with as much as we invest in NIH each
    year, and as important as its work to its families, our
    families, we cannot afford to have this agency's potential
    limited or its success threatened by bias, discrimination,
    harassment, or assault in the workplace.
        Unfortunately, we know that in the biomedical research
    community, the prevalence of researchers of color is too low,
    and the prevalence of sexual harassment is too high. These are
    real problems with real consequences for biomedical research
    and the people who do the lifesaving work we are all
    benefitting from today.
        I commend NIH for the efforts it has taken on both of these
    fronts so far. NIH has done work to examine barriers to
    diversity among its researcher ranks and how its own practices
    have reinforced structural biases that allow discrimination to
    persist. But, more work remains to tear down barriers and
    create lasting change.
        And when it comes to sexual assault, Director Collins, I am
    glad you have taken some forceful action to address the problem
    among the NIH workforce, but NIH must do more to use its
    enormous influence with the research community to enforce
    change in the Nation's universities and research institutions.
    I expect NIH to continue building on its efforts so far to
    remove racism, discrimination, and harassment from research,
    and I will continue to follow up on that progress.
        Finally, as proud as we all are of our Nation's biomedical
    research institutions, we do not invest billions of dollars in
    biomedical research out of pride, nor do we invest in them to
    help pharmaceutical companies make astronomical profits. We do
    it to bring new treatments, cures, and hope to people across
    the Country and across the world. It is important that we never
    lose sight of this because even the most brilliant miracle cure
    can only save people if they can actually get it.
        Just as I hope to work with my colleagues on both sides of
    the aisle to make lifesaving investments in biomedical research
    like those proposed in the President's budget, I also hope we
    can work together to bring down the cost of healthcare,
    especially for prescription drugs; keep working towards
    universal health coverage; and bring the cures we are investing
    in to the families who need them.
        With that, I will turn it over to Senator Blunt for his
    remarks.

                         STATEMENT OF SENATOR ROY BLUNT

        Senator Blunt. Well, thank you, Chair Murray. I appreciate
    having this hearing today and appreciate being able, again, to
    start this process with you as we did last week on our first
    hearing.
        I am certainly glad that Dr. Collins and the Institute
    directors are here with us today. I think two of the directors
    are testifying before the committee for the first time, and,
    so, welcome to the two of you. And this is a helpful
    relationship for us, and hopefully for you.
        Certainly, the challenges we have faced over the past year
    have been unanticipated and significant. I think the global
    pandemic reinforced the importance of the National Institutes
    of Health. In less than a year, NIH was able to take this novel
    coronavirus and help develop two FDA (Food and Drug
    Administration)-authorized vaccines, two FDA-authorized
    therapeutics, and 16 rapid diagnostic tests, including the
    first FDA-authorized point-of-care diagnostic test for COVID-19
    to combat its spread and its effects.
        A year ago, when we would have had a similar discussion,
    one of the big topics would be, why can't we get enough tests?
    NIH stepped up and really played a big role in seeing that we
    had enough tests. We have not heard that discussion for a long
    time. And that does not mean that millions of tests are not
    being taken every day. It just means we figured out at this
    committee and NIH to be part of meeting that need.
        It was revolutionary to watch NIH work, but it did not just
    happen. In a time of crisis, during shutdowns, during social
    distancing, dealing with a disease that has never been seen
    before, the system and its nationwide grantees were able to use
    their expertise and infrastructure to, again, develop tests,
    treatments, and vaccines. Our research infrastructure was
    tested like never before and, in my opinion, it succeeded in
    remarkable ways.
        I believe there are really three reasons for that. First,
    in the past 6 years, this committee and the Congress, in a
    bicameral, bipartisan way have prioritized and invested in NIH.
    Within that 6-year timeframe, funding for medical research
    increased by almost $13 billion, or nearly 43 percent over that
    6 years after a decade at virtually level funding. This
    investment encouraged young scientists, young researchers, and
    mid-career researchers that were leaving the field before that
    to stay in the field. And, with your insistence, Dr. Collins,
    some of that money every time was set aside to be sure that it
    was going to first-time grantees.
        We were able to shore up the research infrastructure across
    the Country and provide research into mRNA, an idea that had
    never produced a vaccine before and, of course, became the
    foundation for the two principal vaccines that were developed
    very much with the involvement of NIH.
        Our ability to pivot so quickly and so successfully to
    fighting COVID-19 could not have been accomplished had we
    stayed at the funding levels we were at 7 years ago. The buying
    power was not where it needed to be. Young researchers were
    leaving the field. Tough budgetary decisions meant that people
    were not only getting their applications rejected at
    significant levels; they just, frankly, stopped making a lot of
    applications. That is not your problem, by the way, today.
        Second, at the height of the pandemic, Congress gave the
    Department of Health and Human Services significant funding and
    flexibility to create Operation Warp Speed. It was successful
    in developing two FDA-authorized COVID-19 vaccines and
    commercializing another with the help of NIH because we united
    in our effort to make that happen.
        One of the things we did was to really invest in vaccines
    that we did not think were certain to work, but thought were
    likely to work, and that meant that vaccines were available
    when they got FDA authorization rather than months after they
    got FDA approval. Because of that, fully half of all adults
    have been vaccinated now in the United States as we work toward
    a bigger number than that.
        We pushed private industry and worked with private industry
    in ways we had not before. I have said at the time, one way to
    win the horse race is to bet on all the horses. And I think to
    a great extent we did in the vaccine effort, bet on all the
    horses we thought had a chance to finish the race, and it made
    a difference.
        Finally, one of the most important lessons learned from the
    pandemic is the value of having the Federal Government, on
    occasion, as a more active partner in research and development
    instead of just a sponsor. The ambitious speed and goals that
    pushed private companies to research, develop, and manufacture
    a COVID-19 vaccine, along with what we did in testing, really
    created the kind of breakthroughs we needed.
        RADx and Warp Speed, I think put us in a different place
    than we would have been 2 years ago in thinking about how we
    can look at some of our research efforts in another way. That
    is why I want to work with the Administration to support the
    ARPA-H initiative. This will be a new institute, or is proposed
    to be a new institute, and I think that is what should be the
    case. They will have the flexibility and tools necessary to
    both nimbly and innovatively respond to both the next pandemic
    and also some of the big health issues we face today.
        This is a critical moment in a rapidly changing healthcare
    world. Finding those things that the kind of Warp Speed, Shark
    Tank, RADx relationship could enhance in cancer, in
    Alzheimer's, in every disease where there is an opportunity;
    where we see that moment and know that this is something that
    does not necessarily call for a 5-year research grant, but some
    sort of partnership different than that that moves toward a
    real conclusion sooner than we might otherwise be able to do
    that.
        ARPA-H should not do what the other institutes do, but it
    should do what the other institutes cannot do in a crosscutting
    way that goes throughout the institutes, looking for
    opportunities, frankly, in the other institutes where there is
    a breakthrough moment that we could look at differently. I
    think we can help fill gaps here that otherwise would not be
    filled and look forward to that discussion.
        Now, also, as someone working with Senator Murray for the
    last 6 years to increase the funding and the focus in what NIH
    has been doing, we clearly want to be sure that this somehow
    does not take away from the solid research that proves so
    effective in getting us ready for what we just saw.
        So, Dr. Collins, I look forward to working with you and
    Chair Murray and the Administration in making ARPA-H a reality.
    I think the moment is ready for that. I think because of what
    has happened in the last 2 years, NIH is ready for that, and
    look forward to the discussion today.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Thank you, Chair Murray. I appreciate Dr. Collins and the other
    Institute Directors for being here today.
        The challenges we have faced over the past year in a global
    pandemic reinforced the importance of the National Institutes of
    Health.
        In less than a year, NIH was able to take this novel coronavirus
    and develop two FDA-authorized vaccines, two FDA-authorized
    therapeutics, and 16 rapid diagnostic tests, including the first FDA-
    authorized point-of-care diagnostic test for COVID-19, to combat its
    spread and effects.
        This was revolutionary, and it didn't happen without decades of
    preparation.
        In a time of crisis, during shutdowns and social distancing, for a
    disease never seen before, the NIH and their nationwide system of
    grantees were able to use their expertise and infrastructure to develop
    tests, treatments, and vaccines for COVID-19. Our research
    infrastructure was tested like never before, and it succeeded. And I
    believe there were three key reasons behind this success.
        First, for the past six years, this Committee and Congress have
    prioritized and invested in NIH. Within this timeframe, funding for
    medical research increased by $12.85 billion, or nearly 43 percent,
    after having spent the previous decade at virtually level funding.
        This investment encouraged young and mid-career scientists in the
    field, who often have the most novel and innovative research ideas,
    shored-up the research infrastructure across the country, and provided
    research into mRNA, which is the foundation for two of the COVID-19
    vaccines.
        Our ability to pivot so quickly and so successfully to fighting
    COVID-19 could not have been accomplished had this Committee let NIH
    funding stagnate for another decade, dragging down its buying power,
    and letting young researchers leave the field. Making the tough
    budgetary decisions necessary to prioritize the NIH paid off.
        Second, at the height of the pandemic, Congress gave the Department
    of Health and Human Services significant funding and flexibility to
    create Operation Warp Speed. It was successful in developing two FDA-
    authorized COVID-19 vaccines and commercializing another, with the help
    of NIH, because it united the federal government, private companies,
    and researchers around a common goal.
        The reason that we have been able to fully vaccinate half of all US
    adults is because there was a deliberate strategy in the last
    Administration to focus and provide funding for any COVID-19 vaccine or
    therapeutic that had the likelihood to work. We took financial risks to
    manufacture vaccines as the development process was still underway.
        We pushed private industry to innovate their own approaches. And we
    forever changed the drug approval process. As I have said before, the
    way to win a horse race is to bet on all the horses. That is what this
    Committee and the previous Administration did.
        Finally, one of the most important lessons learned from the
    pandemic is the value of having the Federal Government become a more
    active partner in research and development, instead of just a sponsor.
        The ambitious speed and goals that pushed private companies to
    research, develop, and manufacture a COVID-19 vaccine through Operation
    Warp Speed demonstrated that active collaboration in public-private
    partnerships, in conjunction with significant funding, are game
    changers in creating scientific breakthroughs.
        Now we must learn from these lessons. There is an opportunity to
    build upon Operation Warp Speed and NIH's RADx diagnostic testing
    program to leverage public-private partnerships to dramatically
    accelerate the development and approval of new treatments and
    technologies. What two years ago would have been termed risky and
    financially unpalatable now is possible.
        And that is why I want to work with this Administration to support
    the ARPA-H initiative. This will be a new Institute that will have
    flexibility and tools necessary to nimbly and innovatively respond to
    both the next pandemic and also to some of the biggest health issues
    Americans face today, like cancer and Alzheimer's disease.
        ARPA-H should do what other NIH Institutes cannot. It needs to be
    cross-cutting throughout all the NIH Institutes and collaborative both
    internally with NIH and HHS and externally with partners. It needs to
    be innovative. And it should help fill the gaps we clearly saw during
    the pandemic between basic science and commercialization of COVID-19
    vaccines and therapeutics.
        Simply put, there are aspects of NIH research that could move much
    faster outside the traditional NIH grant cycle. The NIH peer review
    process is the gold standard, but we also need to recognize that it
    doesn't work for all research at all times.
        I look forward to working with you, Dr. Collins, and you, Chair
    Murray, on making ARPA-H a reality.
        It will take collaboration between the Administration, NIH, and
    Congress. But as we work toward a new Institute to accelerate the
    application and implementation of health discoveries, we must make sure
    that basic science is not abandoned. ARPA-H should not be the shiny new
    toy we all focus on, especially not to the detriment of the NIH
    research community as a whole.
        If there is one lesson we must take from this pandemic, it is that
    our nation's success depends on the medical research infrastructure
    across this country supported by the NIH. Now is not the time to
    abandon it. Now is the time to make it even stronger.
        Thank you.

        Senator Murray. Thank you very much, Senator Blunt.
        I will now introduce our witnesses.
        Dr. Francis Collins is the director for the National
    Institutes of Health.
        Dr. Diana Bianchi is the director of the Eunice Kennedy
    Shriver National Institute of Child Health and Human
    Development.
        Dr. Anthony Fauci is the director of the National Institute
    of Allergy and Infectious Diseases.
        Joining us virtually is Dr. Gary Gibbons. He is the
    director of the National Heart, Lung and Blood Institute.
        Dr. Eliseo Perez-Stable is the director of the National
    Institute on Minority Health and Health Disparities.
        Dr. Ned Sharpless is the director of the National Cancer
    Institute.
        And, finally, Dr. Bruce Tromberg is the director of the
    National Institute of Biomedical Imaging and Bioengineering.
        So, Dr. Collins, we will turn to you for your opening
    remarks.

                  SUMMARY STATEMENT OF DR. FRANCIS S. COLLINS

        Dr. Collins. Thank you, Chair Murray and Ranking Member
    Blunt and distinguished members of the subcommittee. I am
    honored to be here today with my colleagues representing the
    National Institutes of Health, the NIH.
        I could spend hours describing the exciting work the
    President's budget is proposing for NIH, including major
    investments to address impacts of the COVID-19 pandemic, reduce
    health disparities in maternal mortality, improve mental
    health, broaden approaches to pain and opioid addiction, and
    establish a bold, new agency within NIH called ARPA-H.
        But, in our brief time together, it is also important to
    emphasize how steady funding increases that you have provided
    to NIH, starting well before the pandemic, made it possible for
    NIH to meet the challenges of the pandemic and to prepare for
    what comes next.
        Often at these hearings, I share a story of a patient whose
    life has been saved by NIH research, but in this uniquely
    challenging year, it is hard to single out any one person. In
    fact, all of the more than 160 million Americans who have
    received COVID-19 vaccines as of today are success stories made
    possible by the sustained investment that this committee made
    years ago to basic biomedical research.
        The road to these mRNA vaccines actually started back in
    the 1960s when the function of messenger RNA was first
    understood. These messengers carry instructions from the cell's
    DNA manual to produce the proteins that do the work. Now, for
    vaccines, we knew that certain proteins, like the spike
    proteins on the coronavirus, could spur an immune response.
    But, might it be safer and just as effective to use the RNA,
    the codes for those spike proteins, to instruct the patient's
    body to produce them? And it took a lot of obstacles to
    surmount to get there over more than 20 years, but we are blown
    away by how well it works.
        In parallel, other NIH-supported scientists, including some
    at our own Vaccine Research Center, learned that locking those
    spike proteins into the right configuration could make an even
    better vaccine. So, when COVID hit, we knew exactly what to do,
    but we needed the help of the American people enrolling in
    clinical trials to finish the job. To facilitate that, NIH
    opened a dialogue with communities disproportionately affected
    by COVID to ensure that they had access to the vaccine trials.
        The Community Engagement Alliance, or CEAL, c-e-a-l,
    Initiative built on some existing, long-term partnerships with
    trusted leaders in underserved communities to engage directly
    on trial enrollment, and later with hesitant individuals on
    issues related to vaccine safety and efficacy.
        We were able to use the enrollment techniques we learned in
    the large, longitudinal studies, such as All of Us, that you
    have championed. The result is that all Americans can look at
    the major vaccine trials and see that people like them were
    included.
        While the vaccines were in early trials, the world was
    clambering for rapid diagnostics to understand and manage our
    risks. Members of this committee, most notably Senator Blunt,
    asked what NIH could do to ramp up innovation. And thanks to
    your support, and using a novel Shark Tank approach, NIH took
    on a new role as a venture capitalist through the Rapid
    Acceleration of Diagnostics, or RADx program.
        Today, there are 33 novel testing platforms helping perform
    just today, millions of tests daily, due to RADx. This program
    demonstrated the remarkable innovations that are possible when
    NIH brings together experts in engineering, business, and
    manufacturing to fund big ideas.
        Now, the President's budget proposes a major investment to
    build on this momentum the Advanced Research Projects Agency
    for Health, or ARPA-H. This new agency within NIH will catalyze
    novel strategies to speed transformational and innovative
    ideas, ideas such as simple blood tests to detect free-floating
    DNA or protein markers that signal a cancer is growing
    somewhere in the body; a micro needle patch that delivers a
    vaccine to hard-to-reach communities in the mail; using an
    innovation funnel to recruit, test, and scale up new
    technologies for ambulatory blood pressure measurement with the
    potential to transform the management of hypertension.
        These are just a few of the bold ideas that ARPA-H could
    tackle, but they are not science fiction. With standard
    approaches, well, they might happen in a decade or two. With
    ARPA-H, we believe it could take half that time.
        The President believes that with your help, we can learn
    from the lessons of pandemic and transfer this scientific
    momentum into big improvements in the health of all Americans.
    I do, too.
        My colleagues and I would be pleased to answer your
    questions.
        [The statement follows:]
        Prepared Statement of Francis S. Collins, M.D., Ph.D., Diana W.
    Bianchi, M.D., Anthony S. Fauci, M.D., Gary H. Gibbons, M.D., Eliseo J.
     Perez-Stable, M.D., Norman E. Sharpless, M.D., and Bruce J. Tromberg,
                                     Ph.D.
        Good morning, Chairwoman Murray, Ranking Member Blunt, and
    distinguished Members of the Subcommittee. I am Francis S. Collins,
    M.D., Ph.D., and I have served as the Director of the National
    Institutes of Health (NIH) since 2009. It is an honor to appear before
    you today.
        First, I want to thank this Subcommittee for your commitment to
    NIH, which allowed the biomedical research enterprise to respond
    quickly to the greatest public health crisis in our generation over the
    past year. We mounted vigorous research efforts to understand the viral
    biology and pathogenesis of the coronavirus disease 2019 (COVID-19),
    develop vaccines in record time, support and commercialize diagnostics
    at the point of care, and test therapeutics for both outpatient and
    inpatient settings. This work is far from finished.
        The President's Discretionary Request proposes budget authority of
    $51 billion for NIH in fiscal year (FY) 2022. The Biden Administration
    places great emphasis on research and development in general. At NIH in
    particular, the Request proposes to build on the successes of pandemic
    era research and to put the research enterprise to work on some of our
    Nation's most persistent and perplexing health challenges, including
    cancer, Alzheimer's disease, opioid use disorder, health disparities,
    maternal mortality, HIV/AIDS, gun violence, climate change, and other
    areas with major implications for our Nation's health.
        First and foremost, the President's Request proposes $6.5 billion
    to establish the Advanced Research Projects Agency for Health--ARPA-H
    to drive transformational innovation in health research and speed
    application and implementation of health breakthroughs. ARPA-H will
    tackle bold challenges requiring large scale, cross-sector
    coordination, employing a non-traditional and nimble approach to high
    risk research, modeled after DARPA in the Department of Defense. To
    achieve this, ARPA-H will invest in emergent opportunities by
    conducting advanced systematic horizon scans of academic and industry
    efforts, leveraging novel public-private partnerships, recruiting
    visionary program managers, and using directive approaches that provide
    quick funding decisions to support projects that are results-driven and
    time-limited. Potential areas of transformative research driven by
    ARPA-H include: the use of the mRNA vaccines to teach the immune system
    to recognize any of the 50 common genetic mutations that drive cancer;
    development of a universal vaccine that protects against the 10 most
    common infectious diseases in a single shot; development of wearable
    sensors to measure blood pressure accurately 24/7; and leveraging of
    artificial intelligence technology to advance care for individual
    patients and improve detection of early predictors of disease.
        ARPA-H represents the kind of transformative idea for biomedical
    research that only comes along once in a long while. Our confidence
    that NIH is ready has been greatly advanced by our experience in
    addressing the COVID-19 pandemic--developing vaccines in record time,
    establishing an unprecedented public-private partnership on
    therapeutics that has made it possible to test more than a dozen
    possible therapeutics in rigorous trials, and building a venture
    capital model for assessing SARS-CoV-2 diagnostic technologies that has
    yielded millions of daily tests in just months.
        But while we begin to imagine a life after COVID-19, we must
    acknowledge that there are COVID-related impacts that we have yet to
    understand and address, including the full impact of the pandemic on
    children. Children were largely spared from COVID-19 but for some
    children, exposure to the COVID-19 virus led to Multisystem
    Inflammatory Syndrome in Children (MIS-C), a severe and sometimes fatal
    inflammation of organs and tissues. The Eunice Kennedy Shriver National
    Institute of Child Health and Human Development (NICHD) is leading a
    multi-institute initiative known as the Collaboration to Assess Risk
    and Identify loNG-term outcomes for Children with COVID (CARING for
    Children with COVID), which will assess both short-term and long-term
    effects of MIS-C and other severe illness related to COVID-19 in
    children, including cardiovascular and neurodevelopmental
    complications.
        For many Americans, this pandemic and its related socioeconomic
    effects have had an overwhelming impact on their mental health. Prior
    research on disasters and epidemics has shown that in the immediate
    wake of a traumatic experience, large numbers of affected people report
    distress, including new or worsening symptoms of depression, anxiety,
    and insomnia. To aid in mental health recovery from the COVID-19
    pandemic, NIH will continue to focus on research in this area. This
    will be done, in part, by utilizing participants in existing cohort
    studies, who will be surveyed on the effect of the pandemic and various
    mitigation measures on their physical and mental health.
        The COVID-19 pandemic has brought into sharp focus the dramatic
    health disparities that exist across the American population. In
    addition, the Nation has been shaken by the killing of George Floyd and
    other attacks on people of color, forcing a recognition that our
    country is still suffering the consequences of centuries of racism. NIH
    will continue to address these disparities, specifically through
    research managed by the National Institute on Minority Health and
    Health Disparities (NIMHD), the National Heart, Lung, and Blood
    Institute (NHLBI), the National Institute of Nursing Research (NINR)
    and the Fogarty International Center (Fogarty).
        NIMHD looks to better understand the human biological and
    behavioral mechanisms and pathways that affect disparity populations,
    better understand the long-term effects of disasters on health care
    systems caring for populations with health disparities and research
    focusing on the societal-level mechanisms and pathways that influence
    disease risk, resilience, morbidity and mortality. NINR and Fogarty
    both look to better understand and reduce rural health disparities in
    low-income counties in the southern United States, support nursing
    science focused on racial, ethnic, and socioeconomic health
    disparities, with the goal of closing the gap in health inequities and
    increase health disparity research in low and middle income countries.
        In addition to the core health disparities research, the
    President's Request puts an additional specific focus on maternal
    morbidity and mortality (MMM), which disproportionately affect specific
    racial and ethnic minority populations. Black and American Indian/
    Alaska Native individuals are two to four times more likely to die from
    pregnancy-related or pregnancy-associated causes compared to white
    individuals. Furthermore, Black, Hispanic and Latina Americans, Asian,
    Pacific Islander, and American Indian/Alaska Native individuals all
    have higher incidence of severe maternal morbidity (SMM) compared to
    white individuals. The Implementing a Maternal Health and Pregnancy
    Outcomes Vision for Everyone (IMPROVE) initiative supports research on
    how to mitigate preventable MMM, decrease SMM, and promote health
    equity in maternal health in the United States.
        As the climate continues to change, the risks to human health will
    grow, exacerbating existing health threats and creating new public
    health challenges. Major scientific assessments document a wide range
    of human health outcomes associated with climate change. While all
    Americans will be affected by climate change, underserved populations
    are disproportionately vulnerable. These populations of concern include
    children, the elderly, outdoor workers, and those living in
    disadvantaged communities. NIH is poised to lead new research efforts
    to investigate the impact of climate on human health, with the goal to
    understand all aspects of health-related climate vulnerability.
    Therefore, the President's Request includes a $100 million increase for
    research on the human health impacts of climate change.
        The FY 2022 President's Discretionary Request makes a major
    additional investment to address the opioid crisis. The crisis of
    opioid misuse, addiction, and overdose in the United States is a
    rapidly evolving and urgent public health emergency that has been
    exacerbated by the coronavirus pandemic. Since the declaration of a
    public health emergency for COVID, illicit fentanyl use and heroin use
    have increased, and overdoses in May 2020 were 42 percent higher than
    in May 2019.
        The use of opioids together with stimulants, such as
    methamphetamine, is increasing; and deaths attributed to using these
    combinations are likewise increasing. Taking note of these trends, FY
    2021 appropriation language expanded allowable use of Helping to End
    Addiction Long-term (HEAL) funds to include research related to
    stimulant misuse and addiction. Identifying how opioids and stimulants
    interact in combination to produce increased toxicity will enhance our
    ability to develop medications to prevent and treat comorbid opioid and
    stimulant use disorders and overdoses associated with this combination
    of drugs.
        Finally, I'd like to take a moment to thank this Subcommittee for
    its recognition over the last two years that America's continuing
    leadership in biomedical research requires infrastructure and
    facilities that are conducive to cutting-edge research. With your
    support, we will break ground in the near future on a new Surgical,
    Radiological, and Laboratory Medicine division of our Clinical Center,
    which will replace severely outdated and deteriorating operating suites
    and lab space with state-of-the-art facilities. NIH continuously works
    to ensure that the buildings and infrastructure on its campuses are
    safe and reliable and that these real property assets evolve in support
    of science--but NIH's backlog of maintenance and repair is now nearly
    $2.5 billion. The President's FY 2022 Discretionary Request includes
    $250 million to make progress on reducing this backlog and requests
    flexibility for Institutes and Centers to fund construction, repair,
    and improvement projects.
        COVID-19 compelled us to perform a stress test on biomedical
    research enterprise. The enterprise performed nobly. We found what
    worked, and also identified barriers we hadn't fully appreciated
    before, and invented new ways around them. The President's FY 2022
    Discretionary Request is a roadmap for how to build on the successes of
    research, address our gaps, and apply our insights to the most
    important problems we face as a nation. With your support, the future
    is filled with opportunity. My colleagues and I look forward to
    answering your questions.

        Senator Murray. Thank you very much, Director Collins. I
    have to say, I have always loved your success stories. They are
    usually really beautiful. But, I will say, I think many of us
    in this room are grateful to be your success story this time.
    So, thank you.
        We will now begin our 5-minute rounds of questions, and Dr.
    Collins, I will start with you.
        As you just talked about, the President's budget includes
    $6.5 billion to create the ARPA-H within NIH that is modeled
    after DARPA. DARPA is a small, $3.5 billion agency that is
    composed mostly of program managers and empowered to push the
    limits of their disciplines and shape some milestone-driven
    breakthrough technologies in short 3- to 5-year stints.
        Given that the nature of NIH's work is different, relying
    on a peer review system or multi-year grants that is
    traditionally risk-adverse, where progress is often measured in
    decades, how do you envision ARPA-H fitting into the NIH
    ecosystem?

                                ARPA-H STRUCTURE

        Dr. Collins. Senator, it is a great question. I think you
    are right that much of what NIH does requires this kind of
    careful, deliberative, investigator-initiated, hypothesis-
    driven research, and that is going to be the mainstay of what
    we do going forward. That has been the success story of NIH for
    many decades.
        But, there are opportunities, as we have seen happen during
    COVID, such as the need to develop diagnostics in a hurry, to
    develop vaccines in a hurry, that are not really amenable to
    that approach, where you need to have program managers that are
    empowered to move things swiftly and have the flexibility and
    the resources to do so. And that is the DARPA model. We have
    studied that closely, and we do think that there are projects
    in biomedicine now that would be greatly advantaged by that.
    That is not the typical peer review process that may take a
    year from the idea to the first award. With RADx, we made those
    first awards 5 days after the Congress gave us the budget for
    it, and that played out really well.
        So, we want to incorporate that mindset, and we want to
    bring on perhaps a hundred of these program managers, give them
    the opportunity to build the kind of collaborative ventures
    that include such organizations as small businesses that might
    otherwise not be likely to write an NIH grant.
        Ride herd over these things carefully so that if they are
    not doing well, they get basically stopped immediately. We
    expect there will be failures--this is high risk--but identify
    the areas of greatest opportunity. And every Institute at NIH
    is now coming forward saying, I have at least five ideas of
    what I would like to do with ARPA-H that I cannot do right now.
        So, this should not be seen as competing with the
    Institutes. It is going to be a synergistic relationship that
    will allow us to do things otherwise that would take a very
    long time.
        Senator Murray. Okay. Well, you have said that it should be
    within the office of the director. In that structure, how would
    decisions be made about what projects to fund?
        Dr. Collins. So, we will need to hire a director for ARPA-
    H, who will need to be a visionary person, and the idea is to
    bring on somebody who is not probably going to be doing this as
    their long-term career, but maybe for one term, 5 years, with
    one possible renewal.
        That person will be very much engaged then in bringing
    onboard these very creative program managers who have to make a
    pitch about what kind of projects they think are worth
    investing in and convince the director that that is the case.
    And, then, they are given the flexibilities to go out and find
    the right partners and see what can happen. But, that is all
    going to be done in a way that is quite nimble. It is not going
    to involve our traditional peer review process.
        Senator Murray. Okay.

                      STRUCTURAL RACISM AND HEALTH EQUITY

        Dr. Perez-Stable, your career has really focused on
    improving the health of communities of color and underserved
    populations. And NIH recently released a $30 million funding
    opportunity to study the impact of structural racism and
    discrimination in order to promote health equity and eliminate
    health disparities. Can you talk to us a little bit about what
    more can NIH, and particularly NIMHD (National Institute on
    Minority Health and Health Disparities), be doing to address
    those issues, and what would be the benefit of making
    additional investments?
        Dr. Perez-Stable. Thank you, Senator Murray, for that
    question. So, first of all, we had to recognize that structural
    racism could be operationalized as a research construct and not
    just an organizational construct, and we went through a
    workshop and scientific reflection on this. I think the moment
    earlier this year for all of the NIH Institutes and Centers
    agreed that this was an area that we needed to move on and
    advance more quickly in the research side. And, so, we had a
    commitment from all the institutes that do this, although NIMHD
    was leading it from the beginning.
        We believe that two areas are susceptible for improvement.
    One would be the healthcare setting, where I think through
    interventions at the structural, as well as the clinician and
    the patient level will help. And, also, in promoting healthy
    communities so that we can have easier access to green space,
    to healthy food, accessible healthcare in community health
    centers.
        These are two areas that we believe are susceptible for
    improvement, although we will depend on our scientific
    community to promote and submit ideas that will be reviewed and
    hopefully funded within fiscal year 2022.
        Senator Murray. Okay. Thank you very much. I look forward
    to working with you and hearing more about that.
        Senator Blunt.
        Senator Blunt. Thank you, Chairman.

                              ARPA-H FUNDING LEVEL

        Dr. Collins, on the ARPA-H budget request, $6.5 billion,
    one part of the question will be, how do you think that number
    was arrived at, and is that a realistic number to commit in
    year one?
        And two, our concern would also be that we do not get in a
    position that--we have already given NIH $6.5 billion and level
    fund everything else. I do like the President's $2.5 billion. I
    am sure you could figure out how to spend more than that in the
    other institutes. That is pretty close to the average of the
    last 6 years from our committee. I would certainly like to stay
    at least at that level.
        But, how do you think those two numbers compete with each
    other? And how do you feel about actually being able to commit
    $6.5 billion in that first fiscal year of ARPA-H?
        Dr. Collins. That is a great question, Senator, and we have
    thought a lot about it. I am pleased the President's budget
    proposes that this would be 3-year money because, obviously,
    you are going to start from a standing start whenever the
    budget actually gets approved for fiscal year 2022. We hope
    that will be September 30th, right? Well, it might not be. So,
    at any rate, we would then really be benefitted by being able
    in that first year to stretch those dollars over a little bit.
        I do think we could, with a hundred program managers,
    readily come up with a number of projects that would fit within
    that envelope on an annual basis. But, I hear what you are
    saying about a concern because I have heard it also that this
    might in some way compromise the interest of the Institutes. I
    guess I would look at it a different way, though.
        As I said earlier, every one of the Institutes is coming
    forward with great ideas about how they would like to use ARPA-
    H. They think of this as an augmentation of their capabilities,
    not a subtraction. And, so, they will be feeding ideas into
    this and have a lot to do about how those are chosen. So, even
    though the base number that is being proposed, $2.5 billion for
    the ICs (NIH Institutes and Centers), may sound like a sort of
    average one, in terms of the science they can do, ARPA-H is
    going to add to that.
        Senator Blunt. All right. Thank you.

                           ARPA-H AND CANCER RESEARCH

        Well, Dr. Sharpless, one of the things the President, of
    course, talks about in this issue, in this topic, is more
    rapidly moving toward ending cancer. Obviously, we want to do
    that. We also want to make the point that that is not the only
    thing that ARPA-H would be focused on, nor would it just be
    cancer or Alzheimer's. But, on that topic, how do you envision
    the ARPA-H role in cancer research and what might you be able
    to do with ARPA-H that you are not able to do in the
    traditional restraints of the National Cancer Institute?
        Dr. Sharpless. Thank you for the question, Senator Blunt.
    It is great to be testifying in front of this committee again.
    Good to see you virtually, at least, today.
        Yes, as the President has said, ending cancer as we know it
    is a top domestic priority for this Administration. We are
    obviously, the cancer research community, is galvanized by this
    notion and very excited.
        I think, as you know, the National Cancer Institute does
    some things really well. You know, we fund basic foundational
    science very well. We can do clinical trials quite well. But,
    there are some areas where we are challenged, where we have
    struggles, and I think the scale and nimbleness and ability to
    interact with industry is very appealing about ARPA-H for
    certain kinds of cancer projects.
        I think a good example of that is this blood-based cancer
    detector technology that Dr. Collins mentioned in his opening
    statement where you can, you know, find cancers at a very early
    stage in otherwise asymptomatic, healthy people, and that could
    have a profound effect on cancer mortality.
        So, you know, getting up a huge trial of that technology as
    quickly as possible is the kind of thing that I think would be
    a good fit for ARPA-H.
        Senator Blunt. Okay. Thank you, Dr. Sharpless.

                               RADX PARTNERSHIPS

        Dr. Tromberg, let me see if I can get one more question in.
    I think what you were part of at RADx is one of the reasons
    that gives me real optimism about new kinds of relationships
    that we might develop at ARPA-H. But, would you talk just a
    little bit about RADx and how that partnership continued right
    through the entire process of these companies that you were
    choosing to invest money with, going ahead and making the first
    home-based test, and I think producing well over two million
    tests every day now, in addition to the tests that would have
    come through the regular process?
        Dr. Tromberg. Yes. Thank you so much, Senator Blunt, and
    thank you for your question and for your generous support of
    the RADx program.
        The bioengineering-technology community has formed
    partnerships all across the government. That has included
    working with BARDA, FDA, DOD (Department of Defense), CDC
    (Centers for Disease Control and Prevention), HHS (Department
    of Health and Human Services), and the White House Testing
    Board. More than 900 scientists are working across government,
    academia, and the private sector in a very unique way to make
    this work.
        And, as you have mentioned, if we fast-forward to now,
    about 1 year later, we now have 33 RADx-supported companies
    that have increased the Nation's testing capacity by more than
    300 million new tests, and there have been 23 new FDA
    authorizations. And we have really changed the dialogue from
    laboratory testing of symptomatic folks to over-the-counter,
    widely available tests, point-of-care tests that are accessible
    to all. Greater choice and greater capabilities. And this has
    really happened because of all of these partnerships that we
    formed, the accelerated innovation.
        We have brought out new technologies. About 20 percent of
    our portfolio actually--not many people know about--has been
    based in nanoscience and nanotechnology.
        Senator Blunt. Good.
        Dr. Tromberg. So it has been a tremendous surge for
    innovation.
        Senator Blunt. Thank you, Doctor.
        Thank you, Chairman.
        Senator Murray. Yes. Senator Reed.
        Senator Reed. Thank you very much.
        I want to welcome all the panelists and thank them for
    their distinguished service to the Nation, particularly during
    this difficult and challenging COVID pandemic.
        Dr. Collins, one of the things that is becoming
    unfortunately and painfully obvious is the increase in
    suicides, and this is very disturbing. And we are concerned,
    also, about the impact of COVID-19 on accelerating, perhaps,
    that phenomenon.

                               SUICIDE PREVENTION

        So, the question I would have is, what research is NIH
    doing on suicide prevention so that we can recognize the
    warning signs, better communicate with friends and family, and
    also give healthcare providers more insight? I am told that
    many suicide victims visit emergency rooms frequently before
    their suicide and those signs are not picked up. So, your
    comments would be appreciated.
        Dr. Collins. Well, I appreciate the question, Senator, and
    it is a source of great concern and obviously great heartache
    for the way in which this is taking a toll amongst people
    across our Nation, and certainly at a time where mental health
    issues have been even further heightened by all the stresses of
    COVID-19. One can see this also becoming even more of a threat
    to people who have lost hope.
        NIH is deeply engaged in trying to understand ways to
    prevent this terrible outcome, and the National Institute of
    Mental Health has in fact invested in a number of new
    initiatives as a result of that concern.
        One that I would point to that has turned out to be a
    pretty encouraging development is the recognition that the drug
    Ketamine, which is used in anesthesia and sometimes used as a
    party drug, unfortunately. It also turns out to have benefits
    for people with serious depression, including people with
    suicidal ideation. Now approved by FDA, and the drug
    Esketamine, this is now available and it is being used in those
    acute situations of acute suicidal threat.
        You also mentioned that many people who are on the brink do
    end up visiting healthcare facilities. We have worked hard to
    try to make sure that this idea of having a screening tool that
    was used in emergency rooms for individuals who are there, even
    if they do not appear to be there for psychiatric reasons, gets
    used to identify, particularly with adolescents, whether they
    might be in a situation of contemplating self-harm.
        On top of that, certainly NIMH is investigating other means
    of treating depression, and also thinking hard about other
    interventions that might be beneficial here in terms of
    cognitive behavioral therapy combined with pharmacotherapy to
    try to assist those individuals who are in this difficult
    place. But, it is a terribly difficult problem.
        I will say, it is interesting, but it is not necessarily
    that encouraging, the actual suicide rate, as best we know, in
    the course of the last year has not gone up. It has actually
    gone down slightly, and that has tended to be the case in
    national crises before. But, what I worry about is what happens
    when we seem to be getting past the crisis, is there a pent up
    backup there that might in fact result in an even greater risk
    in the coming months.
        I would be glad to give you more information. I am sure Dr.
    Gordon would, as well, in terms of all the things that we are
    doing.
        Senator Reed. Thank you very much.

                                   LONG COVID

        Very quick question to both--to Dr. Fauci. The long haul
    COVID-19 is beginning to trouble a lot of people. They never
    seem to be able to recover from it and recurrences. What
    attention are we paying to that issue?
        Dr. Fauci. Thank you for that question, Senator. We are
    paying a considerable amount of attention to it. In fact, we
    have a program to the tune of $1.15 billion, looking at
    developing cohorts of individuals so that we can study them for
    the incidence, the prevalence, underlying pathogenesis, and, if
    possible, if we can find this out, anything that we can do from
    an intervention. So, the NIH is taking this very seriously.
    Thank you.
        Senator Reed. Thank you very much.
        I have to commend Dr. Sharpless for his efforts on
    childhood cancer. I was teamed up with Senator Capito. We
    passed the Childhood Cancer STAR Act. We have been funding it,
    thanks to the Chairwoman, at $30 million a year, and I want to
    commend NIH on its renewed emphasis on childhood cancer, not
    only treatments, but also gathering data about these victims as
    they age so that we can see if there is any interventions that
    we can use later on. So, thank you, Dr. Sharpless, and thank
    you, panelists. Thank you very much.
        Senator Murray. Thank you. Senator Graham.
        Senator Graham. Thank you, Madam Chairman.

                              VACCINE DEVELOPMENT

        The vaccine, developing the vaccine as fast as we did, what
    is your biggest takeaway, Dr. Collins? How did we do that? And
    how can we do it again if we have to?
        Dr. Collins. It is really important to look and see that
    this was built upon decades of research in basic science that
    many people might have said would not probably end up being as
    relevant as it turned out to be.
        Senator Graham. So, all of our money in the past paid off
    here, right?
        Dr. Collins. Absolutely. This committee, and then the
    Congress, especially over the course of the last 6 years where
    you have increased the NIH support by 40 percent, has made it
    possible for us to do a lot of things that otherwise we would
    still not have been able to start. So, yes, it is all built
    upon that foundation.
        Senator Graham. Do you feel like the budget request being
    made is enough to continue to build on what we have done?
        Dr. Collins. I am very supportive of the President's budget
    request, as you might expect I would be. And I am particularly
    excited about this new proposal of ARPA-H, a new component of
    NIH that would give us kind of a DARPA attitude that we could
    bring to projects that are waiting for that kind of
    opportunity.
        Senator Graham. Well, I just hope we can memorialize what
    we did to get the vaccine out so quickly.

                          GLOBAL VACCINE DISTRIBUTION

        The developing world--Dr. Fauci, one thing I worry about is
    getting the vaccine out into the developing world, particularly
    Africa. What can we do better in that regard? And why should
    we?
        Dr. Fauci. Well, first of all, the answer to your second
    question, which is very relevant, Senator, is why should we?
    And the reason we should is that a global pandemic requires a
    global response. And even though, as you well know from the
    numbers, we are doing extremely well in this Country--we now
    have over 60 percent of adults having at least one dose, and
    about almost 50 percent of the adult population in this Country
    fully vaccinated.
        However, even if we get this pandemic under control, which
    I believe we will within a period of a few months, there is
    always the danger, when you have viral dynamics in other parts
    of the world, for the generation of variants that might
    actually undermine the protectiveness of the vaccines that we
    have.
        Senator Graham. So, it is in America's interest to get the
    vaccine out to as many people as possible?
        Dr. Fauci. It is absolutely to our interest. I believe--not
    only do I think it is a humanitarian, moral responsibility, but
    it is in what I call enlightened self-interest for us to do
    that.

                               ORIGIN OF COVID-19

        Senator Graham. So, let's talk about our enlightened self-
    interest for a moment. Has there ever been a pandemic that we
    know of that started in a laboratory somewhere?
        Dr. Fauci. To our knowledge, no.
        Senator Graham. Okay. If this were in fact a breach of
    protocols in China, if it did come out of a lab, that would be
    a first for the world; is that right?
        Dr. Fauci. I believe so. There was a situation with an
    influenza where there was a suspicion that it might have
    escaped from a laboratory in Russia.
        Senator Graham. But this----
        Dr. Fauci. But that has never been validated or confirmed.
        Senator Graham. So, have we found any animals that carry
    COVID-19 that could have been the source of the transmission to
    humans thus far?
        Dr. Fauci. Thus far, not. I mean, if what you are referring
    to, Senator, is an intermediate host----
        Senator Graham. Right.
        Dr. Fauci [continuing]. We know clearly, for example, with
    SARS-CoV-1 that a bat virus went into a civet cat, which then
    transmitted it into the human population. With MERS, it was a
    bat to a camel to human.
        The intermediate host, if there is one, has not yet been
    found.
        Senator Graham. And we have been looking for that
    intermediate host; is that fair to say?
        Dr. Fauci. That is fair to say, sir.
        Senator Graham. At what point in time would it become more
    likely it came from the lab if we do not find an intermediate
    animal host? How much longer?
        Dr. Fauci. I do not think we can give a time element on
    that, Senator, for the simple reason we still have not yet
    confirmed what the host is from Ebola. We know that Ebola jumps
    from an animal reservoir to human, and it has been many years
    now since the original Ebola outbreaks, and we have not yet
    nailed that down.
        Senator Graham. But we believe that Ebola did not come from
    a lab?
        Dr. Fauci. Yes.
        Senator Graham. Okay.
        Dr. Fauci. Yes.
        Senator Graham. So, I guess my point is, who should look,
    what should we be doing to make sure we find out how it
    started?
        Dr. Fauci. Right.
        Senator Graham. And finally, what should be the
    consequences to any country, China included that allowed this
    to happen? What should the world expect of a country if they in
    fact allowed this virus to come from one of their labs through
    negligence?
        Dr. Fauci. Well, first of all, when you said, who should,
    you know, the WHO (World Health Organization) did what they are
    referring to now as phase one of an investigation, which they
    felt was not completely adequate, as you know. You have heard
    me and Dr. Collins and others in the Administration calling for
    a continuation of the investigation.
        I do not think I can comment on your second question. It
    would have to be the circumstances under which something like
    that happened, if indeed it happened.
        Senator Graham. Well, just very briefly--I know my time is
    out--I think we should send a clear signal to China--seems to
    be a source of a lot of pandemics--that if this did occur in
    the lab, expect something to happen because if we do not, we
    are just going to reinforce this in the future. And what that
    something is, I am open-minded to, but I am closed-minded to
    the idea of doing nothing.
        Senator Murray. Thank you. Senator Shaheen.
        Senator Shaheen. Thank you, Madam Chairman, and thank you
    to you, Dr. Collins, and everyone at NIH for all of your hard
    work over the last very difficult year and for everything else
    you are doing.

                              ARPA-H AND DIABETES

        As you are aware, diabetes is one of the most expensive and
    pervasive of our chronic diseases, and I was pleased that in
    the authorization at the end--re-authorization at the end of
    the year, we funded the Special Diabetes Program for 3 years
    and the work that is being done to advance treatment for Type
    1.
        But, can you talk about this new ARPA-H agency and to what
    extent it might be looking at ways to help address diabetes?
        Dr. Collins. I would love to, and thank you for the
    question, Senator. This is the hundredth anniversary year of
    the discovery of insulin, so we have come a long way in those
    hundred years, but we are not where we really need to be to say
    we have conquered this one.
        ARPA-H, because of its ability to tackle problems in a
    team-oriented, nimble way, offers us some new opportunities
    here. Certainly, one of the ones that the Diabetes Institute
    has been promoting to me of late, sending me ideas, is to
    transform the way that we actually develop and test
    therapeutics, shouldn't we at this point be able to come up
    with therapeutics for diabetes that do not require injections.
    A totally new approach to how we would treat this disease.
        Another one that I am excited about, and I know you have
    done a lot of encouragement about this, is the artificial
    pancreas.
        Senator Shaheen. Right.
        Dr. Collins. And we have made real progress there, Senator.
    But, I think we could go a lot faster if we had this
    coordinated, ARPA X kind of attitude brought to this, both for
    artificial pancreases that are built on engineering and sort of
    a feedback loop that gives insulin when it needs to, but maybe
    even more so the ones that built upon the patient's own stem
    cells that can be converted into that.
        Senator Shaheen. And how do we make sure that diabetes is
    one of those diseases that ARPA-H addresses?
        Dr. Collins. Well, fortunately, because I think we do have
    a pretty good budget being proposed here, and diabetes is
    already mentioned by the President as one of the three areas of
    interest, I think diabetes is extremely likely to be on the
    list.
        Senator Shaheen. Good. Thank you. I am glad to hear that.

                         COVID-19 VACCINE BOOSTER SHOTS

        Dr. Fauci, the question that everybody is asking is, are we
    going to need a booster shot to complement our COVID
    vaccination? Do you have any sense of that and what the timing
    might be for that?
        Dr. Fauci. Two parts to that question, and they are
    separate but important. I do not anticipate that the durability
    of the vaccine protection is going to be infinite. It is just
    not.
        Senator Shaheen. Right.
        Dr. Fauci. So, I would imagine we will need at some time a
    booster. What we are figuring out right now is what that
    interval is going to be. We know from studies following people
    from the original clinical trials that the protection goes out
    at least 6 months, and likely a year. But, we do not know right
    now how long that will be.
        So, what we are doing is we are following those cohorts
    because there is a level of protection that is called a
    correlate of immunity, and we know that if you are above that
    level, you are in quite good shape to be protected.
        The vaccine itself gives you a level up here. So, how long
    it takes to start coming back down, we are following it, and
    two ways of understanding that. One, does, from a lab
    standpoint, it get below a certain level; or, do we start
    seeing a lot more breakthrough infections. Either of those
    would be a trigger. But, we are following that very carefully.
        So, in answer to your first part of your question, I
    believe we will need a booster. I am not exactly sure when.
        Senator Shaheen. Thank you.

              SUBSTANCE USE DISORDER AND METHAMPHETAMINE RESEARCH

        And, Dr. Collins, you may remember that New Hampshire is
    one of the hardest hit States by the substance use disorder
    epidemic. And we have seen a decline over the last year because
    of the pandemic, but we have also seen a replacement of many of
    those opioids by meth. I think there is a belief among some
    people who use substances that meth cannot kill you in the same
    way that an opioid can. And, yet, as I talk to providers, they
    tell me there are very few treatments that they have available
    to them to deal with meth.
        So, can you tell me what the National Institute on Drug
    Abuse is doing to try and address the meth piece of substance
    misuse?
        Dr. Collins. Absolutely. This is an area of intense
    interest and concern because what was primarily an opioid
    crisis is now very much becoming a mixed crisis of opioids and
    stimulants, and particularly methamphetamine.
        I was pleased to see that NIDA (National Institute on Drug
    Abuse) ran a trial, a phase three trial, on treatment for
    methamphetamine addiction, which is a combination of injectable
    Naltrexone and oral Bupropion, and showed benefit. We have not
    previously had anything to offer to help people who are
    addicted to meth. That is one step forward.
        We also now are running this effort to vaccinate people
    against methamphetamine. I know that sounds odd, but you could
    immunize against that compound in a way that it would no longer
    provide anybody much of a benefit if they decided to use it
    anyway. We are doing that for heroin and Fentanyl, and we are
    doing it for meth. But it is very helpful.
        Senator Shaheen. Excuse me for interrupting. Does that work
    if people have already been users?
        Dr. Collins. It will. So, basically, getting your immune
    system to make an antibody so that in the future, if you
    encounter that drug, it cannot get to your brain because the
    antibodies grab onto it.
        Senator Shaheen. I will have to learn more about that.
    Thank you. My time is up.
        Thank you, Madam Chair.
        Senator Murray. That is very interesting. Thank you.
        Senator Kennedy.
        Senator Kennedy. Thank you, Madam Chairman, Chairwoman.

                       GAIN-OF-FUNCTION RESEARCH IN CHINA

        Dr. Fauci, I believe you have testified that you did not
    give any money to the Wuhan lab to conduct gain-of-function
    research. Is that right?
        Dr. Fauci. That is correct.
        Senator Kennedy. How do you know they did not lie to you?
        Dr. Fauci. Excuse me, sir?
        Senator Kennedy. How do you know they did not lie to you
    and use the money for gain-of-function research anyway?
        Dr. Fauci. Well, we have seen the results of the
    experiments that were done and that were published and that the
    viruses that they studied are on public databases now. So, none
    of that was gain-of-function, so----
        Senator Kennedy. How do you know they did not do the
    research and not put it on their website?
        Dr. Fauci. There is no way of guaranteeing that, but in our
    experience with grantees, including Chinese grantees, which we
    have had interactions with for a very long period of time, they
    are very competent, trustworthy scientists. I am not talking
    about anything else in China. I am talking about the
    scientists. That you would expect that they would abide by the
    conditions of the grant, which they have done for the years
    that we have had interactions.
        Senator Kennedy. So you do not think the Chinese would lie
    to you?
        Dr. Fauci. Well, when you say the Chinese, the Chinese are
    a rather broad group. I know the scientists that we have dealt
    with have been trustworthy.
        Senator Kennedy. You think all the scientists have told the
    truth in terms of the origin of the Wuhan virus and not been
    influenced by the communist party of China, do you?
        Dr. Fauci. I do not have enough insight into the communist
    party in China to know the interactions----
        Senator Kennedy. Right.
        Dr. Fauci [continuing]. Between them and the scientists,
    sir.
        Senator Kennedy. Right. Why are we giving them money in the
    first place?
        Dr. Fauci. Well, that is a very good question, and thank
    you for giving me the opportunity to----
        Senator Kennedy. You are welcome.
        Dr. Fauci [continuing]. Answer it. Well, SARS-CoV-1 started
    in China in Guangdong Province, and it went from a bat to a
    civet cat to a human.
        Senator Kennedy. Yes, and excuse me, Doc, for interrupting
    you, but our time is so limited.
        Dr. Fauci. No, no. I am going to be real quick.
        Senator Kennedy. Our time is so limited. Why are we giving
    money to the labs in China to study virology?
        Dr. Fauci. Well, I am going to give you a rather succinct
    answer to that, sir.
        Senator Kennedy. I would appreciate that.
        Dr. Fauci. And that is why I was saying the SARS-CoV-1,
    clearly the bats that have the viruses that are the
    coronaviruses are in China. As I said a couple of times, it is
    not in Fairfax County, Virginia or is it in New York. It is in
    China. So, if you want to show and study importantly the
    animal-human interface, the viral----
        Senator Kennedy. Because that is where the bats are?
        Dr. Fauci. Yes, the bats.
        Senator Kennedy. Okay. I got it.
        Dr. Fauci. That is where the bats are.
        Senator Kennedy. I want to be sure I understand your
    testimony. You did not give money to the Wuhan lab to do gain-
    of-function research?
        Dr. Fauci. That is correct.
        Senator Kennedy. And you believe they did not do gain-of-
    function research because they told you they did not?
        Dr. Fauci. We have seen the results of the studies that
    they conducted and they were not gain-of-function.
        Senator Kennedy. Including any private studies?
        Dr. Fauci. Excuse me? Including?
        Senator Kennedy. Any private studies.
        Dr. Fauci. I am not sure what you are getting at, sir.
        Senator Kennedy. Here is what I am getting at. You gave
    them money and you said, don't do gain-of-function research.
        Dr. Fauci. Correct.
        Senator Kennedy. And they said, we won't?
        Dr. Fauci. Correct.
        Senator Kennedy. And you have no way of knowing whether
    they did or not except you trust them; is that right?
        Dr. Fauci. Well, we generally always trust the grantee to
    do what they say, and you look at the results----
        Senator Kennedy. Have you ever had a grantee lie to you?
        Dr. Fauci. I cannot guarantee that a grantee has not lied
    to us because you never know.
        Senator Kennedy. Yes. Can we agree that if you took
    President Xi Jinping and turned him upside down and shook him,
    the World Health Organization would fall out of his pocket?
        Dr. Fauci. I do not think I can answer that question, sir.
    I am sorry.
        Senator Kennedy. Well, do you think President Xi Jinping
    has undue influence over the World Health Organization, do you?
        Dr. Fauci. I have no way of knowing the influence of the
    president of China over the WHO.
        Senator Kennedy. Okay. So you think the WHO is a completely
    independent body and level playing field, call-it-like-you-see-
    it, and they really want to get to the bottom of the origin of
    the virus? Do you believe that?
        Dr. Fauci. My interaction with the WHO and for Dr. Tedros,
    the Director General, has been one----
        Senator Kennedy. Okay.
        Dr. Fauci [continuing]. That I do believe he is a person of
    high degree of integrity.

                     INVESTIGATION INTO ORIGIN OF COVID-19

        Senator Kennedy. I got it. I want to ask one last question.
    Why did you guys spike--not guys, and ladies. Why did you all
    spike the prior administration's investigation into the origins
    of the coronavirus and whether it could have come out of the
    Wuhan lab?
        Dr. Fauci. Sir, I--we did not spike anything in the prior
    administration. I am not sure what you mean by spike. But, we
    have no influence----
        Senator Kennedy. The State Department spiked the prior
    administration's study.
        Dr. Fauci. But that has nothing to do with the National
    Institutes of Health.
        Senator Kennedy. So they did not consult with you all?
        Dr. Fauci. They did not.
        Senator Kennedy. Did they consult with you, Dr. Collins?
        Dr. Collins. I read about it in the press this morning.
        Senator Kennedy. Doc.
        Dr. Bianchi. No.
        Senator Kennedy. They just spiked it without talking to
    their experts?
        You do not want to answer that one, do you?
        Dr. Collins. I just read about it.
        Senator Kennedy. Thank you, Madam Chair.
        Senator Murray. Senator Murphy.
        Senator Murphy. Thank you very much, Madam Chair.
        Listen, the World Health Organization is the most
    influential global public health institution in the world,
    whether my friends like it or not. They have more people and
    more influence on the ground across the world than anybody
    else, including the United States.
        And, so, if the complaint is that any country, including
    China, has too much influence, the answer is not for the United
    States to walk away. The answer is for the United States to
    double down and make sure that any grievances we have are
    addressed. Otherwise, the problem for which you are identifying
    is exacerbated by the United States not being at the table with
    the WHO.
        And while the major donors to that organization certainly
    have lots of influence, as is the case with every international
    organization, it is an oversimplification to suggest that they
    are in the pocket of the Chinese government. China has
    influence. The United States has influence, as well, so long as
    we are at the table.

                               FIREARMS RESEARCH

        I have two areas to cover, and the first I wanted to raise
    with you, Dr. Collins, and that is around the budget request to
    double the firearm injury and mortality prevention research
    account. Let me place myself solidly behind that request. Thank
    you for making it, and I was hoping you might--I apologize if
    you have gotten a question on this already. I have been
    listening but in and out a bit.
        I am hoping that you might be able to talk a little bit
    about how you might prioritize that additional funding,
    especially as it might relate to research on community-based
    interventions and what works and what does not. And, then, you
    know, how to make sure that all that information gets out to
    community partners, folks who are boots on the ground, maybe
    not the exact set of players that NIH is used to disseminating
    information to.
        Dr. Collins. Well, I appreciate the question, and we are
    enthusiastic about expanding our approach and the amount of
    funds we can put into research on firearm violence. After all,
    some 40,000 deaths happen each year from firearms. About 60
    percent of those are suicides, which is another topic that came
    up earlier and is also part of our suicide prevention, is to
    think about availability of guns.
        I think you are right, though, that community approaches
    are very much ripe for this kind of approach, where you might
    not just try to change one thing in the community, but see if
    by coordinating the efforts across multiple different ways in
    terms of making sure that firearms are not accessible to those
    people who might misuse them; in terms of particularly
    adolescent and youth risks of violence and how to intervene.
        Maybe we could take an approach that would be more holistic
    as opposed to trying to fix one thing at a time. With a larger
    amount of funding here and a community focus, I think we might
    be able to do that.
        Senator Murphy. The President has proposed, I think, $5
    billion to support these community-based interventions. Maybe
    some of that will be used for assessment and study. But, given
    the fact that I think we probably can get bipartisan agreement
    about supporting these investments in prevention, it really
    would be helpful to use some of this increased funding to
    assess which ones work and which ones do not.

                         SOCIAL DETERMINANTS OF HEALTH

        Second broad topic, and maybe I will address this both to
    Dr. Collins and I think, via video, Dr. Perez-Stable, is on the
    topic of social determinants of health. And I am just
    interested to hear a little bit about how we have adjusted
    research based upon our growing understanding that people's
    health is dictated by where they live and how much money they
    make and how close they are to pollution sources.
        My sense is that, you know, this is not an easy sort of
    thing to incorporate into a research community that is sort of
    used to working in labs and not always used to thinking about
    how factors outside the body impact health. What have we
    learned? How has that changed the way that we fund research and
    encourage applications to come to NIH that might support social
    determinant research?
        Dr. Collins. I am going to ask Dr. Perez-Stable to respond.
        Dr. Perez-Stable: Thank you, Dr. Collins, and thank you,
    Senator Murphy, for that important question.
        At the National Institute on Minority Health and Health
    Disparities, and throughout NIH, the topics of social
    determinants of health have always been present. We consider
    self-identified race and ethnicity and socioeconomic status
    standard measures to be fundamental factors that influence
    health in ways that we do not really understand, and that is
    why we believe that all research with human beings should
    measure these routinely and follow them.
        In addition to these two, though, there are other
    demographic and individual social determinants of health, of
    which many are issues related to age and gender, sexual
    orientation, but then structural social determinants of health
    that you refer to. Where one lives, plays, and prays, relate to
    both transportation, housing, and issues around green space
    and, of course, Internet access, which has become incredibly
    important, as we know, in the last year. So, we have these
    fundamentally incorporated into our standard research, and
    community engagement is really part of everything that we do at
    NIMHD, and increasingly across the Agency.
        Senator Murphy. Well, thank you for that. I appreciate the
    new focus you are putting on this. Again, this is an area of
    potential bipartisan agreement. Senator Sullivan and I have
    legislation in this space and look forward to working with you
    on it.
        Thank you, Madam Chair.
        Senator Murray. Thank you. Senator Shelby, are you ready?
    You want me to----
        Senator Shelby. Yes, I am ready.
        Senator Murray. Okay.
        Senator Shelby. I just got here. Thank you. I have been at
    another hearing, and this question may have been asked.
        Dr. Collins, always good to see you.
        Dr. Collins. Likewise.
        Senator Shelby. I agree with a lot of people on this
    committee that the money we put in to biomedical research
    benefits mankind, period. Not just our people, but the world,
    what it has taught.

                       AUTOIMMUNE RESEARCH BREAKTHROUGHS

        Two or three promising areas, biomedical research in the
    area of autoimmune--that is a big, big topic. You know it
    better than anybody. What are we--what are the breakthroughs
    there, the hopes, in two or three of those top areas?
        Dr. Collins. Well, thank you, Senator. It is good to see
    you, and I know you are running from one place to another. I am
    glad you are here.
        I just had a wonderful experience yesterday afternoon
    listening to presentations from a consortium of researchers
    that we have funded jointly with industry. So, this is called
    the Accelerating Medicines Partnership, and it is focused on
    rheumatoid arthritis and lupus.
        What they have done is to take this field, which was
    looking at immunology in a way that was pretty cutting edge 5
    years ago, and now completely transformed it by looking at
    individual immune cells in the synovium of people with
    rheumatoid arthritis--the lining of the joint--and say, what
    are you doing there, immune cells, and how does that teach us
    what the real pathogenesis about----
        And for lupus, they are looking at kidney biopsies,
    because, of course, lupus affects the kidney and that is one of
    its serious consequences. Same thing, looking at individual
    cells.
        It has completely revamped our understanding of these
    diseases. We have learned, for instance, that the pericyte,
    which was just sort of a cell that we thought was hanging out
    watching in the kidney of somebody with lupus, might be the
    driver of what is really happening there as far as the immune
    response. This is not p-a-r-a. This is p-e-r-i, cyte, in case
    that is not clear. For rheumatoid arthritis, it is the
    fibroblasts.
        And we are so excited about this. We are now planning to
    expand that same approach to other autoimmune diseases, to
    psoriasis, to psoriatic arthritis, to Sjogren's Syndrome, and
    maybe others, as well.
        So, you hit me at a great moment. I was so jazzed yesterday
    to see what has been possible.
        Senator Shelby. All based on bacteria, is it?
        Dr. Collins. It is all based on this ability to look at
    single cells, one at a time. We have not really been able to do
    that until about 5 years ago. We would have to look at
    thousands of cells and try to infer what was there, and now you
    can ask each one. And the cell is, after all, the basic unit of
    all life, and it has been outside of our reach, but not
    anymore.
        Senator Shelby. What could that do for the autoimmune area?
        Dr. Collins. I think it can have a huge impact because we
    now have new targets coming out of this recognition that I
    think in the next 4 or 5 years, we are going to see a whole new
    generation of drugs for autoimmune diseases based upon that
    insight that is just now emerging.

                            CYSTIC FIBROSIS RESEARCH

        Senator Shelby. I brought this up many a time, but in the
    area of cystic fibrosis, there have been so many breakthroughs
    in that area, extending children's lives, adults' lives, and
    everything. Where are we going there? We have come a long way,
    but we are not there yet.
        Dr. Collins. We are not completely there, but, oh, boy,
    have we come a long way, especially in the last 2 years now
    with this 30-year effort, and I have been deeply engaged in
    this having had a role in----
        Senator Shelby. I know.
        Dr. Collins [continuing]. Discovering the gene back in
    1989. And, now, we have this triple drug therapy, which for 90
    percent of patients with cystic fibrosis is dramatically
    beneficial. I get messages almost every week from somebody who
    was really in tough shape, and now they are back at work; or
    somebody who was on a transplant list, and now they were taken
    off of it because their lungs are doing so much better.
        But, there is still that 10 percent. This is where I think
    the gene-editing approach, where you actually figure out how to
    fix that misspelling of the cystic fibrosis gene in the lungs
    of somebody who is affected, might be the way to get to 100
    percent, and there is a lot of work going on that.

                                 LUPUS RESEARCH

        Senator Shelby. What promises are out there that you have
    talked about before dealing in lupus, which is an autoimmune
    disease?
        Dr. Collins. Well, as I mentioned, we have this ability now
    to be able to see individual immune cells, what are they up to
    in lupus, both in the kidney and in other areas, as well. I
    think that is teaching us some new things about what the real
    fundamental cause is. And it will tell us that some of the
    treatments we have been giving, like steroids, are kind of a
    little bit too much of a sledgehammer, and what we need now is
    something much more subtle to go after the fundamental problem.
    We have a better chance at that now.

                           PANCREATIC CANCER RESEARCH

        Senator Shelby. What about the area of pancreatic cancer?
    That is a fast-moving thing, I know.
        Dr. Collins. It is, indeed. And if Dr. Sharpless is
    listening, maybe he would like to quickly give a response since
    that is his area at the Cancer Institute. Ned, are you there?
        Dr. Sharpless. Sure. Yes. Thank you, Francis.
        Pancreatic cancer is an area where we have not seen the
    success that we have seen in other cancers, but it is not for
    lack of good ideas. So, there are a number of----
        One of the realizations is that pancreatic cancer comes in
    lots of flavors, and each one needs its own treatment. So, now
    we are working on the subset approach to pancreatic cancer. I
    think there is also a real opportunity to detect pancreatic
    cancer earlier at a more curable stage.
        So, I think those are the exciting areas of pancreatic
    cancer research.
        Senator Shelby. Thank you. I would like to get in--I know
    my time is moving on. The chairperson has been very kind.

                                  CTSA PROGRAM

        Dr. Collins, in the area of the CTSA Program, the Clinical
    and Translational Science Award Program. The CTSA hubs and
    their partners, I think, have done a lot of good work in that
    area, and valuable work, especially during the COVID-19 thing.
    It is my understanding that the NIH, National Institutes of
    Health that you head, is considering significant changes to
    that program that would discourage hubs, like UAB, for example,
    in Birmingham, from forming partnerships with certain non-
    clinical universities in research questions.
        Is this true, and why is that?
        Dr. Collins. That is not a correct assumption. I know there
    are some rumors flying around about that, and there will be a
    public announcement about this.
        Basically, just, without trying to get too far ahead of
    what has not been revealed publicly, I think we are trying to
    simplify the application process to make it easier for those
    hubs, and we intend to keep them going in vigorous ways; to
    apply when they are up for renewal in a way that does not
    require an application of 2,000 pages, which is what it has
    been. But, we would not want to do anything to discourage these
    collaborations that you are mentioning. Take that from me.
        Senator Shelby. Thank you. Madam Chair, thank you.
        Senator Murray. Thank you. Senator Manchin.
        Senator Manchin. Thank you, Madam Chairman, and thank all
    of our presenters. I appreciate very much them being here.

                           DOMESTIC DRUG SUPPLY CHAIN

        My first question will go to Dr. Fauci. The Food and Drug
    Administration reports that nearly 40 percent of finished drugs
    and roughly 80 percent of active pharmaceutical ingredients are
    manufactured abroad. During the COVID-19 pandemic, we saw
    factories shut down in order to prevent the spread of virus,
    drug supply chains disrupted, and drug shortages increase. As a
    result, America's access to essential medicines was really put
    into jeopardy.
        As a preeminent infectious disease doctor, you know better
    than anyone how important it is to have access to essential
    medicines. So, my question will be, Doctor, can you comment on
    the importance of a strong domestic supply chain for essential
    medicines? And how can we ensure we do not experience future
    drug shortages when the global supply chains are disrupted?
        Dr. Fauci. Thank you very much for the question, Senator
    Manchin. I think it is absolutely critical that we have the
    capability, independent of supplies from foreign countries, to
    be able to supply the necessary medicines that we need in the
    United States. I have been of that opinion for a very long
    period of time.
        The solution to the problem is to be doing much less of the
    outsourcing to foreign countries for the important ingredients
    of many of our medications. So, right now, we are not in that
    good position, and I believe, particularly since the
    disruptions of the supply chain that have occurred with the
    COVID-19 pandemic, that this might be a good lesson for us for
    the future to make sure we have much more dependency on what we
    can do domestically as opposed to in foreign nations.
        Senator Manchin. Doctor, have you all looked at why? Why
    has most of the manufacturing left the United States and why
    are we not able to manufacture? Are we at a disadvantage in the
    United States for other reasons, cost wise, or basically
    different types of things, that we make people jump through
    hoops and everything else as far as permitting and all that?
    What would be the cause?
        Dr. Fauci. You know, Senator, to be honest with you, I do
    not know why that has happened. I think it was because it was
    felt it would be much less expensive to get this done outside,
    but I do not really know the answer to your question of why we
    have so much of a dependency of important materials outside of
    the Country. But, certainly, whatever the reason, I believe it
    needs to be corrected.
        Senator Manchin. Well, I need to work with you on that,
    Doctor, if I can, basically, in making sure this
    Administration--I think they understand the urgency we need to
    start basically manufacturing again, not only just our drugs,
    but so many things in our Country. So, I look forward to your
    support on that.

                             RURAL HEALTH OUTCOMES

        Dr. Collins, West Virginia is constantly ranked last in the
    Nation for health outcomes. In 2020, the America's Health
    Rankings reported my State of West Virginia 50th for premature
    deaths, frequent mental distress, and multiple chronic
    conditions. We also ranked last in life expectancy.
        What is the NIH doing to bridge this gap in health
    outcomes? And how do you ensure that the medical research that
    you do benefits people in poor, rural communities?
        Dr. Collins. Well, it is very troubling to see the fact
    that you have just cited that health outcomes are not what we
    would all want them to be. And, of course, there are many
    factors that play into that, Senator, and we are deeply engaged
    in research in trying to identify the ones that are
    addressable.
        Certainly, one of the things I might point to is the
    increasing focus we have on disease prevention. If we simply
    are limiting ourselves to trying to help people who have
    already developed a serious disease, we have kind of missed the
    opportunity. Unfortunately, our healthcare system does not do a
    great job in that situation of providing support for disease
    prevention, and it seems happier to pay for things once people
    are already quite ill, so there is additional work that needs
    to be done there.
        One of the things that I think I would point to is a series
    of large-scale efforts to really understand what are the
    factors that play out in people staying healthy or getting a
    chronic disease or how you manage that.
        The All of Us Program, which this Congress has supported,
    on the way to enrolling a million participants, including in
    West Virginia, is a way in which we can collect that kind of
    evidence, including their electronic health records and lots of
    information about their environmental exposures, and try to
    figure out in a holistic way, how can we take that information
    and bring forward a better chance for people to live not just a
    good lifespan, but a good health span. So, we are----
        Senator Manchin. Thank you, Doctor.
        Dr. Collins [continuing]. Deeply engaged.
        Senator Manchin. Thank you, sir.
        Dr. Fauci, finally, you know, my home State of West
    Virginia is battling an epidemic during the middle of a
    pandemic. We have been devastated by the drug epidemic, COVID-
    19, and now--we now lead the Nation in new HIV infection rates.
    You spent much of your career focused on prevention, diagnosis,
    and treatment of HIV/AIDS, and your research has been
    instrumental in saving countless lives in the United States and
    around the world.

                    INFECTIOUS DISEASE SURVEILLANCE EFFORTS

        So, Doctor, what is being done to replicate testing and
    surveillance efforts we saw put into place for COVID-19 for
    other infectious disease, like HIV/AIDS? And what public health
    infrastructure would be required to bring better infectious
    disease testing and surveillance to fruition?
        Dr. Fauci. Thank you for that question, Senator. The HIV
    testing situation, unfortunately, has been somewhat interrupted
    by the COVID-19 pandemic because of the interruption of
    multiple services.
        But, as you know, we have a 10-year plan to end HIV as an
    epidemic in the United States, and that is going to require
    access to testing for those who are not infected to put them
    on, if they are at risk, to pre-exposure prophylaxis; and those
    who are infected to immediately put them on antiretroviral
    therapy. Because, as we know, when you bring the level of virus
    to below detectable, not only do you save the life of the
    individual, but you make it essentially impossible for that
    individual to infect someone else.
        So, testing is really at the fundamental basis of how you
    address the epidemic and, for that reason, it is going to be
    extremely important to get our testing capabilities back up to
    snuff once we get the Country back on a degree of normality
    following control of the COVID-19 pandemic.
        Senator Manchin. Thank you. Thank you, Madam Chairman.
        Senator Murray. Thank you. Senator Braun.
        Senator Braun. Thank you, Madam Chair.
        Dr. Fauci, I was listening with interest in Senator
    Kennedy's line of questioning, which probably was asking you to
    maybe answer some things based upon what the WHO should do or
    not.

                     INVESTIGATION INTO ORIGIN OF COVID-19

        I would like to discuss something that is probably a little
    simpler to answer in terms of transparency in general. From the
    time I have known you and Dr. Collins, it has generally been in
    this seat, and we have been talking about something related to
    COVID. Would you agree that in the whole process of--now that
    there are second thoughts on how this thing derived, that it
    may have come from a lab, that we should emphasize as much
    transparency as possible in pursuit of getting the answer?
        Dr. Fauci. Without a doubt, Senator. No doubt.
        Senator Braun. And the next logical question would be that
    we do not know what we are going to get from the communist
    regime or the WHO, but we do know that through our Director of
    National Intelligence and probably DHS (Department of Homeland
    Security), from Haines and Mayorkas, that they have probably
    got information there. And, so, since you believe in
    transparency, wouldn't you think that we should declassify all
    the information that we own so that you, Americans, independent
    researchers, can see what we have got to sort through how this
    thing started?
        Dr. Fauci. Well, Senator, I have said publicly and most
    recently that I believe that there should be transparency, and
    open, fair, and independent, continue to look. As I have said,
    I still believe that the most likely scenario is that this was
    a natural occurrence, but no one knows that 100 percent for
    sure. And since there is a lot of concern, a lot of
    speculation, and since no one absolutely knows that, I believe
    we do need the kind of investigation where there is open
    transparency and all the information that is available to be
    made available to scrutinize.
        Senator Braun. So, since you have been the point person on
    just a variety of topics through the COVID saga, does that mean
    then that you will ask President Biden to declassify that
    information?
        Dr. Fauci. I do not think I can promise you----
        Senator Braun. But, I mean, would you ask him since you
    believe in transparency? Wouldn't it make sense that we get the
    information that we have? And I think if it does not come from
    you, Dr. Collins, someone that has been in the mix from the
    get-go, that we will not see it. And we owe it to the American
    people with what we have been through to at least look at the
    information that we have.
        Dr. Fauci. Yes. I am not sure the information we have,
    but--I am not sure if it is my place to tell the President of
    the United States to declassify----
        Senator Braun. But you have been very engaging on a wide
    range----
        Dr. Fauci. Right.
        Senator Braun [continuing]. Of topics, and I think he would
    respect your opinion as much as anyone.
        Dr. Collins, where are you at on that subject of giving the
    American people the information that we house?
        Dr. Collins. Well, I am very much where Dr. Fauci is with
    the desire to be as transparent as possible in this situation
    and really try to find out what happened. I agree with him that
    it is most likely that this is a virus that arose naturally,
    but we cannot exclude the possibility of some kind of a lab
    accident. That is why we have advocated very strongly that WHO
    needs to go back and try again after the first phase of their
    investigation really satisfied nobody, and this time we need a
    really expert-driven, no-holds-barred collection of
    information, which is how we are mostly really going to find
    out what happened.
        I am just not in a position to know what might be in the
    classified documents and what else might be there that would
    not be relevant to this and might actually be harmful to
    national security. I get--I take your point. But, I know the
    President is very interested, also, in seeing truth come out
    here, so it may not require Tony or me to tell him that this
    would be good, to make this as visible as possible.
        Senator Braun. Well, I think for the American public, if we
    are relying on the WHO to do it again, even though it seems
    like they have had somewhat of an epiphany that we need to dig
    deeper. I think if it does not come from the two of you to ask
    for simply the release of information, of course, keeping
    hidden anything that would be something that could not be
    exposed. But, I am guessing there is a good bulk of that that
    would be benign in terms of just the information we have about
    the origin of the disease.
        So, I think for many of us, many Americans, with what we
    have gone through, we ought to at least be willing to look at
    the information that we have to get people satisfied that we
    are getting to the bottom of it. So, I would ask each one of
    you to think about that and see if it makes sense, have our
    President declassify it so we can see it.
        Dr. Collins. Thank you.
        Senator Braun. Thank you.
        Senator Murray. Thank you. Senator Moran.
        Senator Moran. Chairman, thank you.
        Dr. Collins--well, Doctors, welcome. Good to be here with
    you, and I appreciate your presence and your work.
        Let me talk about clinical and translational science, if I
    could. Under Dr. Austin's prior leadership, the National Center
    for Advancing Translational Science at NIH has been essential
    in facilitating clinical and translational research, and I have
    seen it in Kansas. In fact, I have seen it with the director of
    that directorate.

                                  CTSA PROGRAM

        In Kansas, NCATS' Clinical and Translational Science Award
    Program has served for a catalyst to bring lots of
    organizations in the research community and community partners
    together to advance research.
        I have concerns with potential changes that are under
    consideration for the CTSA Program. In particular, changes that
    would lower hub awards and limit CTSA partners.
        Moving forward, will there continue to be consideration for
    ensuring that CTSA centers are located in regions in the U.S.
    which do not already have those hubs? There is already a
    limited number in the Mid-West, and I would be concerned if any
    new changes to the program that would make it more difficult
    for these hubs to compete.
        And, then, I would ask the question about partners. At the
    University of Kansas, for example, they partner with Children's
    Mercy, Kansas City University of Medicine and Biosciences,
    Kansas State University, St. Luke's Health, University of
    Kansas Health System, KU Office of Research, KU School of
    Medicine in Wichita, and University of Missouri in Kansas City.
    Since the CTSA Program is focused on partnerships between
    regional research hubs and community partners, why would NCATS
    limit the ability of the program, in my view, to accomplish its
    goal?
        Dr. Collins. Well, Senator, thank you for the question. I
    am a big fan of the CTSA Program and enjoyed my opportunity to
    travel to Kansas with you and see some of the things they were
    doing a few years ago.
        And this is, I think, one of those circumstances where
    there seems to be some anxiety in the CTSA community about
    something that has not actually been announced yet, and I would
    like to be reassuring about this. The real intention of the
    change that is being proposed is to de-complicate the renewal
    process, which currently requires an application of about 2,000
    pages that I do not think anybody enjoys putting together, and
    to try to make this more straightforward.
        There is no intention to reduce the number of hubs.
    Certainly, every hub has to compete to show that they are
    actually using the funds wisely, and we will continue that
    process. And this notion that somehow the new process will
    discourage collaborations with other institutions I find a
    little hard to understand because I have no knowledge that that
    is at all intended to be the case, and I would personally
    oppose that.
        Senator Moran. Thank you for your reassurance. My question
    was more complicated than I wanted it to be, but your answer
    was very comforting.
        Let me ask just a couple of specific questions.

                          NCATS RARE DISEASE RESEARCH

        What can this committee do to support NCATS' efforts to
    enable and facilitate advanced important research in rare
    diseases for patients living particularly in rural communities?
        Dr. Collins. Well, the NCATS is deeply engaged in rare
    diseases. Our former director, Chris Austin, not only was a
    personal promoter of that; he was the head of the international
    committee for rare diseases, and that tradition will continue
    under Acting Director, Dr. Rutter.
        Certainly, the support that this committee has provided to
    NCATS to make it possible for that kind of investment to happen
    in rare diseases, for which companies probably are not going to
    make an investment because the market is too small, is one of
    the reasons that we have now made really significant progress
    in dozens of these rare diseases.
        We are also engaged right now in a serious conversation
    with industry about whether there is a way, with gene therapy
    emerging as an even more attractive opportunity for rare
    diseases, to make sure that we move that forward at all due
    speed and not have it held up by such things as a limitation in
    manufacturing of viral vectors.
        So, they are right in the middle of that, and the support
    that you all have provided has made that possible, particularly
    through the Cures Acceleration Network, which is part of NCATS.

                          ALZHEIMER'S DISEASE RESEARCH

        Senator Moran. Can one of the directors talk about the
    improved science this additional investment in Alzheimer's
    research will help fund, including a better understanding of
    risks and protective factors in individuals, again perhaps with
    a focus on rural populations?
        Dr. Collins. That is probably me because Dr. Hodes is not
    here. So, yes, this committee, this Congress, has increased
    funding for Alzheimer's research by five-fold over the course
    of the last 7 or 8 years, and that has made possible all kinds
    of bold approaches we otherwise would not have had.
        We now have dozens of new drug targets that have emerged
    from the very careful analysis of who gets Alzheimer's and who
    does not. Of course, we are all waiting to see what happens
    maybe next month when FDA makes a review decision about the
    monoclonal antibody from Biogen, Aducanumab, and that will make
    a big difference if they decide there is something there. But,
    we are not depending on that.
        So, yes, I might add, this ARPA-H proposal, which is part
    of the President's budget, specifically calls out Alzheimer's
    as an area of great opportunity to do some of these very bold,
    aggressive, and nimble approaches that would probably not
    happen so easily by our standard grant mechanism.
        Senator Moran. Dr. Collins, I was confused by what I
    thought was all the directors were appearing, although just not
    all of them in person. But, thank you. You can pinch-hit for
    each and every one of them and you did it----
        Dr. Collins. I will try.
        Senator Moran [continuing]. This morning. I am going to see
    if I can get Dr. Sharpless to come to Kansas and join us again
    on a visit.
        Dr. Collins. Well, he is listening, so he heard you.
        Dr. Sharpless. Oh, I look forward to that.
        Senator Moran. All right. Consider yourself invited, and I
    consider you just accepted.
        [Laughter]:
        Senator Murray. Thank you. Senator Schatz.
        Senator Schatz. Thank you, Chair Murray and Ranking Member.

                           PSYCHEDELIC DRUG THERAPIES

        Dr. Collins, in 2019, I wrote to you and the then-FDA
    commissioner requesting an update on efforts by NIH and FDA to
    research psychedelic drugs to treat mental health illnesses.
    Since then, there have been a number of potentially promising,
    peer-reviewed clinical research on this topic. Can you give me
    an update on what the next steps may be?
        Dr. Collins. I appreciate the question. Yes, there has been
    a resurgence, I think, of interest in psychedelic drugs, which
    for a while were sort of considered like not an area that
    researchers legitimately ought to go after. And I think as we
    have learned more about how the brain works, we have begun to
    realize that these are potential tools for research purposes
    and might be clinically beneficial.
        I will just mention one, which is Psilocybin, which has now
    been tried in no less than three randomized, controlled trials
    for depression, and is showing a signal there of potential
    interest, and that could be quite exciting because we are
    looking for new approaches to that.
        But, there are other trials going on with MDMA, even with
    Psilocybin--with LSD. I think at the moment, it is the
    Psilocybin that has gotten the greatest attention.
        Senator Schatz. And what are your next steps?
        Dr. Collins. I have been talking with the Drug Abuse
    Institute--and I am sorry they are not here--and the Mental
    Health Institute--and they are not here, so I am pinch-hitting
    for them, as well--about whether it is a good moment to
    consider having perhaps a workshop to say, okay, what have we
    learned so far, and what more might we want to do as far as
    designing the next generation of clinical trials, to see where
    these provide benefit going beyond depression to such things as
    PTSD (Post-Traumatic Stress Disorder).
        So, I think over the course of the next year, we are going
    to want to have a hard look at this.

                               MARIJUANA RESEARCH

        Senator Schatz. Thank you. In 2019, you wrote to me that
    the NIH is committed to advancing research on the risks and
    potential benefits of marijuana for therapeutic uses. In that
    letter, you cited a number of barriers to advancing this type
    of research. Are we making any progress?
        Dr. Collins. We are making some progress. You may know
    that, in the past, researchers who wanted to do a clinical
    study on marijuana had all kinds of limitations. It took
    generally at least a year to get through the process of
    paperwork to be allowed to utilize marijuana because it is a
    Schedule 1 agent.
        But, it was also an issue that there was only one source,
    which was our marijuana farm in Mississippi. When I became NIH
    director, I was told, hey, you are running a marijuana farm.
    Who knew? And that, of course, is an issue because it is a
    limited opportunity for access. DEA (Drug Enforcement
    Administration) has now given permission to expand the number
    of suppliers. That will help.
        But, frankly, what we really need is to moderate the
    Schedule 1 limitation. Dr. Volkow and I have been proposing for
    a while something called Schedule 1-R, which would be basically
    a different pathway if you are going to use this material for
    research.
        Senator Schatz. So, I have a bill with Senators Feinstein
    and Grassley, which passed the Senate, did not pass the House,
    to address some of these barriers. Do I have your commitment to
    work with my office on this legislation?
        Dr. Collins. I would be glad to.

                    NON-OPIOID ALTERNATIVES TO CHRONIC PAIN

        Senator Schatz. Thank you. I want to talk to you finally
    about chronic pain and non-opioid alternatives. I passed a
    couple of laws in this area to enable research. And I think
    when people think about alternatives to opioids, they move
    right to--in their mind, they move right into alternative
    medicine. And, what I am talking about is a non-opioid,
    pharmaceutical solution to chronic pain, and I am wondering
    whether we are making progress in that space.
        Because, certainly, if people find other ways to alleviate
    their pain--physical therapy, yoga, whatever, mindfulness--I am
    for all of it. But, there is still a space here for a pill that
    you can take to alleviate chronic pain without getting you
    hooked on an opioid. Where are we with this?
        Dr. Collins. That is a critical issue, and this Congress
    has supported NIH in something we call the HEAL Initiative,
    which is--stands for Helping End Addiction Long Term. Part of
    that is about how to better treat people who are addicted to
    opioids, but a big part of it is coming up with alternatives
    for chronic pain management that are not addictive, that are
    not opioids.
        As a result of that, we have partnered up with industry to
    basically identify promising therapeutics that attack different
    targets in the pain mechanism that might, therefore, be
    beneficial. Such things as a sodium channel, for instance,
    called Nav1.7, that is involved in the pain transmission. But,
    if you block that, it should not give you any risk of
    addiction. We are making real progress there.
        We have something called EPPIC-Net, which is bringing
    onboard promising compounds, getting them into Phase 2 trials
    as part of the HEAL Initiative. I could give you a lot more
    information about that if you would like.
        Senator Schatz. Thank you. And I will just submit this one
    that you can consider for the record.
        The U.S. has the same Federal trust responsibility for
    native Hawaiians as it applies to Alaska natives and American
    Indians, and I am hoping that you will consider expanding the
    scope of the Tribal Health Research Office to include native
    Hawaiians. I will get you a more full question for the record
    and look forward to your response. Thank you.
        Dr. Collins. Glad to look at that.
        Senator Murray. Thank you. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Madam Chairman. Thank you
    for holding the hearing, and thanks to all the witnesses who
    are participating today, and I certainly appreciate your
    willingness to serve. That is not lost here, for sure, with the
    past year that we have had.

                    FIREARMS RESEARCH AND FIREARM REGISTRIES

        Dr. Collins, I wrote to you last November to express my
    concerns that projects recently funded by NIH disregard the
    spirit, long-established policies against creation of a Federal
    firearms registry. And particularly, an NIH grant to Northwell
    Health of New York provided Federal funds for the hospital to
    ask the questions about lawful gun ownership of every patient
    seeking healthcare for any reason whatsoever at the hospital's
    emergency department.
        Even more concerning, every member of the advisory
    committee overseeing the grant has been a very outspoken
    advocate for expansive gun control, including bans on large
    classes of common and popular firearms.
        I have long been concerned about how firearm registries can
    undermine the ability of law-abiding citizens to exercise their
    Second Amendment rights. Several provisions of Federal law
    already prohibit data collection related to lawful gun
    ownership, and I have introduced legislation to strengthen
    these provisions even further.
        Dr. Collins, given that President Biden is seeking
    increased funding for grants like the one awarded to Northwell,
    how are you making sure that such projects do not infringe on
    Americans' constitutional gun rights or violate Federal
    statutory prohibitions on gun registries as they stand right
    now?
        Dr. Collins. Senator, I recall your letter, and we looked
    closely at that particular grant from Northwell and what they
    were proposing to do.
        First of all, I think we can all agree that gun violence,
    which takes about 40,000 lives every year, is something that
    does deserve close attention and scrutiny as far as the
    research that we might be able to do to understand what are the
    causes and how to save those lives if it is possible to do so.
    So, we will actually be glad to pursue those opportunities.
        But, we are mindful of the prohibition that Congress has
    put forward many years ago about not advocating for gun
    control, and we have been pretty careful about that. I think in
    that instance, the particular grant, while you are right that
    they were asking for this information, it fell somewhat short
    of what most people would have called a broad concept of a gun
    registry. And I think that is, if I remember, what we said in
    the letter in response to you.
        But, I want to promise you, we are going to be very
    sensitive to those issues, as we now, with the President's
    budget, seek to see if we can do more to try to identify
    reasons that gun violence is so prominent and what research
    might teach us about how to save lives.
        Senator Hyde-Smith. Thank you. I appreciate your
    consciousness of that.

                               ORIGIN OF COVID-19

        And this question may have been asked before. I have been
    in another hearing. I hope I am not being redundant. But, like
    many of my colleagues, I firmly believe we need to get to the
    bottom of the origin of COVID-19, and this seems even more
    important after this week's Wall Street Journal report that
    three researchers from China's Wuhan Institute of Virology
    sought hospital care in November 2019--for symptoms consistent
    with COVID-19.
        First, I want to go down the line for all of our witnesses
    of how strongly do you believe that it is possible that the
    origin of the COVID-19 pandemic resulted from a leak of the
    virus from the Chinese lab?
        And second, Dr. Fauci, I would like to ask you
    specifically, how is your institute working to get to the
    bottom of the origins of COVID-19, including exploring the
    laboratory leak theory?
        So, I am going to start with the entire panel for the first
    question of, how strongly do you believe that this is possible?
        Dr. Collins. Well, I will start, and then others can
    respond. Again, I will say, I think the most likely reason,
    mechanism, by which SARS-CoV-2 arose was a natural process of
    transfer from an animal to humans, but it is certainly possible
    that other options might have occurred, including a possible
    lab leak. We just do not have evidence to be able to say what
    that likelihood is.
        Dr. Bianchi.
        Dr. Bianchi. Yes. So, I would agree with Dr. Collins. We
    have no personal knowledge of anything that might have happened
    in China at the National Institute of Child Health and Human
    Development, but we fully support a full investigation of
    getting at the facts.
        Dr. Collins. Dr. Gibbons. Dr. Gibbons, are you there?
        Dr. Gibbons. Yes. I concur with my colleagues in terms of
    transparency is a critical part of this.
        Dr. Collins. Dr. Sharpless, I think I saw you on the
    screen.
        Dr. Sharpless. Sure. Yes, Senator Hyde-Smith, I saw the
    same report and I found that concerning. I think lab accidents
    happen and we need to investigate the possibility. Although I
    think many of us feel zoonotic transfer is perhaps more likely,
    I think we should investigate all possible explanations.
        Dr. Collins. Dr. Perez-Stable.
        Dr. Perez-Stable. I concur with my colleagues. I think of
    concern, but certainly we need evidence.
        Dr. Collins. And Dr. Tromberg.
        Dr. Tromberg. Yes, I agree with my colleagues, as well, and
    would like to see more investigation.
        Dr. Collins. Dr. Fauci.
        Dr. Fauci. Yes. As I have said many times, I feel the
    likelihood is still high that this is a natural occurrence.
    But, since we cannot know 100 percent whether it is or is not,
    other possibilities exist and, for that reason, I and my
    colleagues have been saying that we are very much in favor of a
    further investigation to the next phase from the WHO, who has
    already done a phase one. And, we are strongly in support of
    continuing that to a phase two investigation.
        Senator Hyde-Smith. Thank you----
        Senator Murray. Thank you.
        Senator Hyde-Smith [continuing]. Very much, and I yield my
    time.
        Senator Murray. Thank you so much. Senator Baldwin.
        Senator Baldwin. Thank you, Madam Chair.
        Last week, I had the privilege of joining some of my
    colleagues on a visit to the National Institutes of Health.
    While much of our discussion was centered on the response to
    the COVID-19 pandemic, I was struck by the broad applications
    of the innovation that we have seen during this time.

              ADVANCES IN VACCINE AND THERAPEUTIC DELIVERY SYSTEMS
                                 (RADX PROGRAM)

        And, I have often spoken about the Wisconsin-based company,
    FluGen, which is working to make vaccines that can be
    administered as a nasal spray. I also believe that this type of
    innovation is key in terms of how we think about our ability to
    respond to future pandemics.
        Dr. Tromberg, it was great to see you on that trip to NIH.
    I wonder if you could describe how engineering advancements
    have contributed to our response to COVID-19. And, how are you
    thinking about the future of delivery and administration of
    vaccines and therapeutics? And, how will these advancements
    help us prepare for the future?
        Dr. Tromberg. Thank you, Senator Baldwin, for the question,
    and it was great to meet you last week, or I guess it was 2
    weeks ago when you came to visit.
        So, for COVID, we have supported a wide range of
    technologic advances in medical imaging and artificial
    intelligence, digital health platforms, PPE (Personal
    Protective Equipment), ventilators, new therapeutic approaches.
    Of course, the biggest probably and most impactful has been the
    RADx testing program, which has delivered, as you have seen,
    more than 300 million tests, including over-the-counter tests
    with very advanced technologies from nanoscience.
        In terms of vaccines, this is a very exciting area. Another
    one that we have had in our portfolio, one of the strategies
    that we have been supporting, are micro needle patches. So,
    imagine a dime-sized micro needle patch that has got--the
    needles are entirely soluble in water, and as soon as you put
    them into your skin, they start to deliver the vaccine. After
    the delivery, the needles are all gone, and you throw the patch
    away. You get a new one in the mail. So, this has moved into
    Phase 1 clinical trials. Efficacy has been shown.
        I might, if you have a moment, toss it over to Dr. Fauci
    because we have collaborated with his institute in the
    development of these new delivery approaches and they may have
    some other approaches, as well.
        Senator Baldwin. Please. Dr. Fauci.
        Dr. Fauci. Thank you, Bruce. Yes. We have an active
    collaboration with Dr. Tromberg's Institute and we are looking
    towards the future about how we can make it much easier to get
    people vaccinated. This is of particular relevance right now
    because, with COVID-19, even though we are doing really very
    well with vaccination, we still have a group of individuals who
    were really difficult to get to. And hopefully, when we have a
    much easier way to administer the way Dr. Tromberg has
    mentioned, that will make it easier for us.
        Senator Baldwin. Excellent. In April, the University of
    Wisconsin launched the Center for Health Disparities Research
    Center, which has a leadership team comprised entirely of
    women, will focus on how physical environment and social
    conditions intersect to influence an individual's health.
        Their first initiative, funded by the NIH, will use data
    from 22 Alzheimer's disease research centers throughout the
    U.S. to examine how social determinants of health throughout a
    person's lifetime impact their brain health.
        The pandemic has made it clear that we need to do more
    research like this to better understand and respond to health
    inequities, and I applaud the work of Dr. Amy Kind and the
    University of Wisconsin. It is imperative that we maintain our
    commitment to this into the future.

                        COVID-19 AND HEALTH DISPARITIES

        So, Dr. Perez-Stable, how has the impact of the COVID-19
    pandemic on communities of color informed how NIH thinks about
    studying health disparities going forward? And what additional
    investments are needed to fill these gaps?
        Dr. Perez-Stable. Thank you, Senator Baldwin, for that
    question. I think a year ago, when we understood the dimension
    of the dramatic, disproportionate burden by race, ethnicity,
    and socioeconomic status on the population, there was sort of
    an aha moment for all of NIH to say, this problem has been with
    us for a long time. We have made limited progress. It is time
    we put our innovation, our efforts, to address this.
        Out of this effort, we created the Community Engagement
    Alliance Against COVID-19. Dr. Gibbons and I are co-chairing
    that. Dr. Collins mentioned it in his opening statement. And I
    think to heighten the importance of community engagement, so
    talk to the people that are affected, bring them in as full
    partners, identify the problems, and then mobilize all sectors
    that we can mobilize. Not just the researchers and the
    healthcare clinicians, but also the housing, transportation,
    zoning, all the different sectors of society, to see how we can
    begin to make a difference in this setting.
        And I applaud the effort of Dr. Kind. She was a grantee of
    ours, as well as others, and also applaud the effort of looking
    at existing data with standardized measures to address problems
    of this kind, like Alzheimer's disease.
        Senator Baldwin. Yes. Thank you so much.
        Madam Chair, I yield back.
        Senator Murray. Thank you. Senator Rubio.
        Senator Rubio. Thanks, all of you, for being here.
        I think I will direct this to Dr. Fauci, but I welcome
    everybody's answer. I just want to go through, so, what we do
    know. We have heard a lot about what we do not know.
        So, here are the things that we do know, okay?

                               ORIGIN OF COVID-19

        So, SARS-1, we identified the host animal within 4 months.
        MERS, I believe, we identified the host animal within 9
    months.
        It has now been 15 and a half, 16 months, we have still not
    seen and China has not produced any evidence of the host animal
    that transmitted COVID-19 to a human.
        We know that China has a history of lab accidents. I think,
    Dr. Fauci, you answered Senator Graham's question. I think he
    phrased it as, has there ever been a pandemic that came out of
    a laboratory, and the answer was no.
        But, we know of outbreaks that came out of a laboratory. I
    believe back in 2004, two researchers in Beijing were infected
    doing research on SARS and it led to an outbreak. China has a
    history of lab accidents.
        This outbreak happened in a city that happened to be the
    home, coincidentally, of a lab which we know is involved in
    extensive research. And, what they do is they take this
    naturally-occurring virus and they manipulate it and they
    change it to make it infectious to humans. We know that they do
    that there. They have published about it.
        And, it also happened in a city in a lab where a Rutgers
    biosecurity expert raised concerns about its safety, and our
    diplomats in 2018 were cabling back to Washington expressing
    concern about the safety.
        So, I take all those facts together, right?
        SARS, we knew the host in 4 months.
        MERS we knew the host in 9.
        We still do not know the host in--for COVID, even though--
    and China is not being transparent about it even though they
    have a vested interest in producing the host so they can put
    all this down.
        In a lab that we know is involved in changing viruses
    synthetically so that they become infectious for humans.
        In a lab that diplomats have told us is unsafe.
        In a country that had history of lab leaks.
        And, by the way, in a virus that we know can be
    synthetically-created because the Swiss did it. The Swiss
    created an exact replica of this virus in the lab for purposes
    of answering it.
        All of these facts were available to us last May, last
    April. Why--I will start with Dr. Fauci. Why did you dismiss
    the lab leak theory as credible?
        Dr. Fauci. I have always said that the high likelihood is
    that this is a natural occurrence. I did not dismiss anything.
    I just said it is a high likelihood that this is a natural
    occurrence from the environment of an animal reservoir that we
    have not yet identified, and I still maintain that.
        But, as I just mentioned in response to other questions,
    that since you do not know 100 percent about that, because no
    one knows, including me, 100 percent what the origin is, is the
    reason why we are in favor of further investigation.
        Senator Rubio. Well, given everything I have just cited--
    and if anything I just cited is incorrect, I hope I will be
    corrected. I am relying--obviously, not my field of study, so I
    am relying on what other experts have published. What is the
    basis for this high likely--what is the basis for the
    conclusion that it is likelier to have been naturally occurring
    than a lab accident?
        I asked a specific question to the Director of National
    Intelligence, and how I posed it is, is it not true that it is
    the assessment that they are equally likely, based on our
    information that we have.
        So, as I outline all of these things here, is she wrong
    when she answered me yes? And, based on everything I have just
    cited, why the--what is it that we are basing the higher
    likelihood of naturally occurring? Is it simply because that is
    all we have ever seen in the past?
        Dr. Fauci. Well, we have historical experience that
    happened with SARS-CoV-1. It happened with MERS. It happened
    with HIV. It happened with virtually all the influenza
    pandemics. So, the historical basis for pandemics evolving
    naturally from an animal reservoir is extremely strong, and it
    is for that reason that we felt that something similar like
    this has a much higher likelihood.
        But, again, getting back to what I said--and let me repeat
    so there is no lack of clarity in that. No one knows, not even
    I, 100 percent at this point, which is the reason why we are in
    favor of further investigation.
        Senator Rubio. But, going back to precedent, precedents
    require them to be similar. The difference between this one and
    that one is--as I said, 4 months we knew the host for SARS, at
    9 months we knew the host for MERS. China has all the incentive
    in the world to produce this host and has not done so. And,
    then, you add up all these other things, I mean, is it just a
    coincidence it happened in the city that is doing this kind of
    research, which, by the way, is controversial? I know you and
    others have been supportive of it, but it is controversial. It
    is not widely accepted as good.
        My whole point is there are people out there who had
    Facebook posts taken down. They are called kooks, conspiracy
    theorists, for saying publically a year ago what we now say may
    be possible. I think those people deserve an apology, at a
    minimum.
        Thank you.
        Senator Murray. Thank you.

                               COVID-19 AND MIS-C

        Dr. Bianchi, thank you. NICHD (National Institute of Child
    Health and Human Development) is trying to develop ways to
    identify children at high risk for multi-system inflammatory
    syndrome in children. It is a rare and life-threatening after
    effect of COVID-19. Now, while most children who become
    infected, I know, have mild or no symptoms, some do go on to
    develop this severe and sometimes fatal condition. I know your
    research is still in the early stages, but could you describe
    the NICHD's efforts to develop clinical, predictive models
    using machine learning to identify children at risk and how
    physicians are using this testing device and data?
        Dr. Bianchi. Thank you very much for your question, Senator
    Murray. As you know, there are almost four million children who
    have been infected with SARS-CoV-2, but the key is to figure
    out which is the one-in-a-thousand child who is going to get
    very sick with this MIS-C, and that child could get critically
    ill, although most do recover. So, as a parent, you would want
    to know if my child tests positive, what is going to happen.
        And, so, as part of the RADx RAD program--NIH is supporting
    this. It is four different programs CARING for Children with
    COVID, but the predictive one that is using artificial
    intelligence and machine learning is called the PreVAIL Kids
    Program. And what that is, is it is eight different programs
    around the Country, with some international partners, that are
    using existing cohorts, as well as prospectively enrolled
    cohorts, to collect biospecimens and use artificial
    intelligence in conjunction with the electronic health records.
        The program started within the past few months, so we do
    not have evidence yet. But, the enrollments are on target, and
    we are expecting to enroll about 12,000--actually, we have
    already enrolled about 12,000 children out of 16,000 that are
    expected.

                           A.I. DETECTION OF CANCERS

        Senator Murray. Okay. And Dr. Sharpless, artificial
    intelligence has been shown to help improve the detection of
    breast cancer in mammograms, and lung cancer in CT scans. And
    suggesting that AI appears well suited for imaging, are you
    looking at the potential for AI to help early detection of
    other cancers?
        Dr. Sharpless. Oh, yes. This is a very important topic. I
    think artificial intelligence has really the ability to
    transform cancer research and cancer clinical care in dramatic
    ways.
        We have a very lively set of collaborations going on with
    the Department of Energy that has extensive expertise in this
    topic. To use, you know, AI to try and identify drug targets
    for medicinal chemistry, or to use AI to read 600,000 pathology
    reports that we get for the SEER database every year, or to use
    artificial intelligence for image analysis, both pathology
    images and radiology images.
        So, I think this is a tremendously exciting technology that
    has real opportunities to advance cancer research and cancer
    care in many important ways.
        I think we were also worried about the ethical issues of
    AI, and we want to make sure that we use practices that will
    not reinforce biases that are latent in some of our data sets.
        But, overall, I think the promise of AI is very exciting
    for cancer research.
        Senator Murray. Interesting. Okay.

                           CLIMATE CHANGE AND HEALTH

        Dr. Gibbons, the request, budget request, includes $110
    million to study the impact climate change is having on health.
    Talk to us about what kind of serious effects have we been
    seeing from climate change, and what kinds of research do you
    expect NHLBI (National Heart, Lung, and Blood Institute) to
    support with this kind of funding?
        Dr. Gibbons. Yes. Thank you for that question. As we know,
    climate change often involves these changes in our air, in our
    air quality, particularly it is likely to promote more air
    pollution. Certainly, the constituents on the West Coast are
    familiar with the impact of wild fires on air quality.
        And although air is all around us, air pollution tends to
    concentrate and have its greatest impact on certain
    communities, particularly communities in which those
    neighborhoods are closer to sources of air pollution, and
    therefore, the impact is also inequitable in terms of the
    health consequences of air pollution, and that is falling on
    the most vulnerable.
        We know that it exacerbates certain chronic conditions,
    certainly cardiopulmonary ones like chronic obstructive
    pulmonary disease, asthma, heart failure. Heart attacks are
    increased in the context of higher air pollution promoted by
    climate change.
        And, we anticipate that there will be a need to not only
    mitigate the impact of climate change, but also to enhance
    resilience to the effects of air pollution on health, and we
    anticipate that that will involve enhancing healthy communities
    that are disproportionately affected by the consequences of air
    pollution derived from climate change. And our programs that
    are community-engaged research with that health equity lens
    should be promising in that regard.
        Senator Murray. Okay. I think this is really important, and
    I think we all should recognize that this is an area we need to
    look at, so I appreciate your work on this and we will be
    following it closely.
        I will turn to----

                            SEXUAL HARASSMENT AT NIH

        Okay. I have one additional question and that is for Dr.
    Collins. In 2018, the National Academies, as you know, released
    a report that found that nearly 60 percent of women in academia
    have experienced--60 percent--have experienced sexual
    harassment on the job and recommended that Federal research
    agencies require institutions to notify them when individuals
    on grants have violated harassment policies or put on
    administrative leave due to harassment allegation. And other
    science agencies, like National Science Foundation, have
    implemented these changes.
        Tell me, what is NIH doing to require its research
    institutes to do the same?
        Dr. Collins. Senator, I share the sense that this is an
    extremely important issue. The National Academy report that you
    mentioned I think really got everybody to recognize how
    pervasive sexual harassment is and what a significant negative
    it has been for far too long for women in our scientific
    workforce.
        We conducted our own working group in the Advisory
    Committee to the Director that reported to me in December of
    2019 and made a series of very significant recommendations
    about how we might change our approach to this. We have been
    working through those and have already implemented a
    significant fraction of them. There are some that still require
    some additional legal authority that is hard for us to be able
    to do at the present time.
        In terms of what you are particularly pointing to, we have
    had now more than 300 allegations that have been brought to us
    about sexual harassment in our grantee institutions; others
    within our own intramural program. Of those 300, about 30
    percent of them have turned out to be actually entirely
    validated. That has resulted in a hundred different changes in
    grants that--particularly, removal of principal investigators
    and replacement of those with other individuals.
        One hundred and twenty-five individuals have been taken out
    of our pool of peer reviewers because of this kind of concern
    about the bias that they bring to that experience.
        And we have made it very clear to our institutions that we
    expect them to report any circumstance----
        Senator Murray. Well, expecting them does not require them
    to.
        Dr. Collins. And, Senator, you and I are in an interesting
    discussion here that I agree--I wish we were able to simply say
    require. At the present time, legally, we are told we do not
    have that authority. We would have to go through a 2-year
    rulemaking effort, or we would need statutory assistance.
        Senator Murray. Well, okay. This is really important, and
    whatever we need to do, I do not--you know, I know you have
    worked on it, I know you have focused on it, but I know of
    women who have left our scientific research institutes because
    of this. We cannot afford to have that happen for a thousand
    reasons. So, whatever it is we need to do here, we need to know
    what it is so we can do it.
        Dr. Collins. I am so with you. And if there is another
    iteration we can take at this to try to figure out--I will say
    that what we have said in terms of the expecting response from
    our institutions has gotten their attention in a pretty
    remarkable way. Even without requiring it, we are seeing
    reporting coming through.
        Senator Murray. Well, to every one of them that is
    listening, I am not done with this.
        Dr. Collins. Okay.
        Senator Murray. Senator Blunt.
        Senator Blunt. Thank you, Chair.
        I have three or four questions. Let me eliminate a couple
    of other topics by just making a couple of comments on some
    things that have already been said, one, and one thing that has
    not been, I do not believe, brought up today.
        One is on the CTSA awards. None of the people talking to us
    that are current recipients think that this simplifying the
    process makes it more likely that they will get the research
    bench-to-bedside result that they think you want and they think
    is the key to this award.
        And, you have heard a number of schools mentioned, and
    University of Washington would be one of them that Senator
    Murray would be very familiar with. Washington University in
    St. Louis collaborates through this program with Saint Louis
    University and the University of Missouri to get to more rural
    hospital settings and do things. So, I suspect you have heard a
    number of concerns about that today.
        I have not heard brought up one of my concerns, which I am
    just going to mention. I do not think you need to respond to
    it. I do think that waiving the intellectual property rights on
    COVID-19 vaccines is a problem. I think it is a problem because
    I do not think it actually would increase the number of
    vaccines, the capacity to produce a vaccine that has efficacy,
    in the timeframe we need to make it. It probably is not
    benefitted much by waiving the rights to the research. The WTO
    (World Trade Organization) has to unanimously agree, which I do
    not think they do. But, if they do, we give our research to
    everybody.
        And third, when this comes up again, companies would have
    less willingness, I think, to step forward. At least one of the
    companies, Dr. Collins that we dealt with in Warp Speed, there
    was no agreement at all that if they were not successful--we
    had a contract. We would buy 100,000 doses, but only if they
    were FDA authorized. So, they were out there totally on their
    own, as these companies you would expect to be.
        I do not think this is likely to happen because of the WTO,
    but I have some concerns that I suspect are shared by others at
    NIH.

              IMPACT OF COVID-19 PANDEMIC ON CHILDHOOD DEVELOPMENT

        Dr. Bianchi, just the title--let's just take the title of
    your Institute and look at COVID. What do you think the impact
    on child health and development of COVID and the COVID
    environment, the pandemic environment, the quarantine
    environment, has been? And how are we going to be looking at
    what the long-term ramifications of that might be and what
    advice we may be able to give to schools and moms and dads and
    behavioral health and other health providers as it relates to
    child development impacted by this?
        Dr. Bianchi. Thank you so much for that question, Senator
    Blunt, because children, you know, have not--I think they are
    so important in terms of our Nation's future, first of all.
    But, the fact that children have been home from school has
    affected the entire family, has affected the workforce, et
    cetera.
        But, because children in general have been asymptomatic or
    mildly symptomatic, they have not gotten as much attention, and
    yet being at home, being away from in-person schooling, I think
    may have significant impact for years to come. And, for that
    reason, we are trying to get the kids back to school as soon as
    possible.
        And as part of the RADx Underserved Population program, we
    are also leading an initiative to really develop, evaluate, and
    implement testing, along with mitigation, of, you know, hand
    washing, social distancing, et cetera, to get evidence to
    reassure people to get kids back to school. Two of the sites
    are actually in Missouri, and one is in Washington State. There
    is a program in Yakima, and there is a special program in
    Missouri that is looking at how you deal with kids who have
    intellectual disabilities and cannot mitigate in the same way.
        So, to answer your question, I think there will be long-
    term effects. I think the answer is to get kids back to school
    safely, with evidence. And, this program is based on a funded
    project that was very successful in North Carolina that showed
    with all the mitigation, with the work with the superintendents
    of schools, that the secondary infection rate in schools was
    extremely low compared to the community.
        Senator Blunt. Yes. I would think here that some of the
    developmental issues, and they will be different with 4 and 5
    year olds and kindergarten and first grade than they will
    people in seventh grade, and those may be different than
    people----
        Dr. Bianchi. Absolutely.
        Senator Blunt [continuing]. In the eleventh and twelfth
    grade and how--you know, I think we are going to have to watch
    this carefully and try to get data and then share that data.

                           FUTURE OF MRNA TECHNOLOGY

        On vaccines--actually, on--maybe more on mRNA than
    vaccines, what do we think the impact may be as it relates to
    cancer, to HIV? We will start, Dr. Fauci, with you. Can we look
    at the flu shot in a different way? And what do we think the
    mRNA impact, now that we know this different use for it, may
    have on other healthcare settings? And Dr. Sharpless, I am
    going to come to you second on this.
        Dr. Fauci. It is going to--I believe, and many of my
    colleagues believe, that the mRNA technology, as it has been so
    spectacularly successful with SARS-CoV-2 to develop a vaccine
    against COVID-19, is already being pursued for other
    infections, including HIV and including influenza. So, there
    are a couple of things that are going on now. Even as we see
    the successes with COVID-19 in using the mRNA technology for
    the development, for example, of universal flu vaccines, as
    well as now having HIV vaccine researchers now looking at the
    possibility of an mRNA platform technology to use for HIV. So,
    it is already happening.
        Senator Blunt. Dr. Sharpless, on mRNA, I mean, we know the
    impact in just the last half dozen years of immunotherapy on
    cancer treatment. What about this mRNA intervention and how it
    might impact the way we look at fighting cancer?
        Dr. Sharpless. Yes, this is a very exciting topic. You
    know, people interested in this space have been working on
    this, you know, long before the pandemic. So, using mRNA for
    cancer therapy has many potential applications because you can
    really get the body to make a protein, and that protein could
    have a desirable effect against cancer, for cancer therapy, in
    a lot of ways.
        The furthest advance, as you mentioned, is the use of mRNA
    vaccines, you know, cancer vaccines. And clearly, they tend to
    be highly personalized, the ideas that you can sequence
    someone's own tumor and then make the vaccine to their very own
    tumor in a way that will not cause them autoimmune side
    effects, and this is an idea to augment other kinds of
    autoimmune cancer--or anti-immune cancer therapies.
        So, it is a very promising area. It is in clinical trials,
    and we just need to see how this develops.
        Senator Blunt. Thank you. My last question, Chair.

            IMPACT OF COVID-19 PANDEMIC ON RESEARCH AND RESEARCHERS

        Dr. Collins, in the pandemic, particularly with lab
    closings, we obviously lost some time, and lost research that
    is going to take a long time to recreate. Are the lab
    reopenings happening in the way they need to? And, do you have
    the flexibility to extend a grant to overcome the disruption?
    And probably just not this disruption of the time closed, but
    the research lost by closing, as well.
        Dr. Collins. I am glad you are asking because this is yet
    another of the terrible casualties of this terrible pandemic.
    It has been very hard on researchers, especially those who need
    a laboratory to do their work or who were running a clinical
    trial that was very hard to enroll participants. And, yes, we
    did have to have many of those folks staying away from the
    workplace for their own safety.
        They are coming back. Our own program at NIH, our
    intramural program, now is up to about 50 percent occupancy,
    but it is not anywhere near where it was pre-pandemic. We have
    done everything we can with our flexibilities to try to make
    sure, particularly, that trainees and early-stage investigators
    do not get further injured by this by extending the periods of
    their training; or by allowing grants if they are able to put
    forward a special request to be extended for an extra year,
    either without extra funds, or with, if the case is strong.
        And yes, I also think we need to be cognizant of the way in
    which this is affecting people in other ways. We have now come
    up with a way to provide childcare support for our trainees who
    otherwise have not had that, and that has been one additional
    burden on their shoulders.
        Our estimates are that it is about a $16 billion loss that
    has occurred because of the way in which this has affected
    research in our extramural institutions; that they are in a
    tough place to try to make up. So, I appreciate your asking the
    question.
        We are going to have a really big challenge getting
    ourselves back into the place that we were before this
    happened.
        Senator Blunt. Well, let us know what we need to be
    thinking about as we think about the rest of this bill on that
    topic. And thank you, Chair.
        Senator Murray. Thank you very much. And I want to thank
    all of our witnesses today for their really--for a really
    productive hearing. I think we all learned a lot. So, thank you
    very much.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due one week after the
    President's budget is delivered at 5 p.m. The hearing record
    will also remain open until then for members who wish to submit
    additional materials for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted to Dr. Francis Collins
                  Questions Submitted by Senator Patty Murray
        Question. The President's fiscal year 2022 skinny budget proposed a
    major new biomedical research effort by establishing ARPA-H. While the
    skinny budget was light on details regarding the structure of the
    program, the Administration's statement indicated that the initial
    focus of ARPA-H would be `on cancer and other diseases such as diabetes
    and Alzheimer's.'
        Assuming Congress and the Administration work together to establish
    ARPA-H, how would you envision ARPA-H setting priorities for research
    into additional diseases?
        Answer. Over the long term, the proposed structure for the Advanced
    Research Projects Agency for Health (ARPA-H) is intended to empower the
    ARPA-H leadership and staff to set and execute on research priorities
    for a variety of high-risk, high-reward, milestone-driven projects that
    can lead to novel capabilities, platforms, and resources that are
    applicable to a range of diseases.
        For the initial direction, the Administration is working to set up
    multiple pathways, both within the government and the broader
    stakeholder community, for priority setting and for exploring new areas
    ripe for research at ARPA-H. At the time of this hearing, the White
    House Office of Science and Technology Policy (OSTP) and the National
    Institutes of Health (NIH) are in the planning phases of convening
    multiple listening sessions with key stakeholder groups including
    patient organizations, industry, venture capitalists and
    philanthropists, and others from the academic and research communities.
    During these sessions, stakeholders will be asked to offer their
    perspective on what they see as the greatest research challenges and
    opportunities that could be addressed using the ARPA-H model. This
    input will help refine the scope and provide a wealth of ideas for the
    first ARPA-H director to consider as they develop the agency's vision.
        In mid-July, the Administration established a Joint Fast Track
    Action Committee (FTAC) to help steer the creation of ARPA-H and lay
    the groundwork for strong interagency coordination. OSTP and NIH serve
    as co-chairs of this committee that includes representatives from
    Department of Agriculture, DARPA, Office of the Under Secretary of
    Defense for Research & Engineering, ARPA-E, BARDA, CDC, CMS, FDA, VA,
    EPA, NSF, and the Smithsonian Institution, among others.
        Question. Some of the greatest advances in medical innovation in
    the last decade have been brought on through genetic analyses and use
    of sophisticated computer programs that can shorten the time taking
    drug candidates through clinical studies. In fact, the development of
    COVID-19 vaccines benefited from the use of 21st century technology
    like cloud computing and AI to help stop the virus' spread and save
    lives.
        How will the President's budget build on the use of modern tools
    like cloud computing, AI, and genetic analyses to further accelerate
    the delivery of cures to patients?
        Answer. Over the last decade, pharmacogenetics has advanced the
    frontier of personalized medicine such that drug therapeutics are
    developed based on the genetic aberrations of disease. This approach is
    most notably applied for cancer treatments and also other diseases.
    Cancers of various types are treated by first knowing the genetic
    mutations and/or deletion of genes. Then drug candidates are screened
    and developed by computer modeling of the target sites along with
    potential drug candidates. Such modeling requires various large
    datasets and analytics that, if stored in the cloud and interoperable,
    can be mined to find the best drug candidates that bind to the target
    sites for treatment. Storing large datasets in the cloud is only the
    first requirement for cloud computing. Such computation requires new
    tools, and support for tool development is essential to realize the
    opportunities for cloud computing.
        Artificial intelligence (AI) has advanced the pace of drug
    discovery and development via predictive models of drug/target
    interactions and also facilitates clinical trial design based on
    algorithms for go/no go decisions during the trials.
        The President's Budget Request supports the application of AI to
    improve diagnostics for diseases as diverse as coronavirus disease 2019
    (COVID-19) and cancer. In each case, information-rich data sources that
    are stored, aggregated together, and analyzed in the cloud are used to
    rapidly train and test these new capabilities. New programs like the
    Artificial Intelligence/Machine Learning Consortium to Advance Health
    Equity and Researcher Diversity program, or AIM-AHEAD, and Bridge2AI
    will harness AI for health by generating AI-ready datasets and best
    practices for machine learning. This will allow researchers to
    accelerate data-driven discovery for grand challenges in biomedicine
    using AI-based technologies. Additionally, NIH's partnership with cloud
    services providers--Google, AWS and now Microsoft Azure--further
    enhances researchers' abilities to leverage industry technologies and
    utilize AI-ready data for drug discoveries and therapeutic treatments.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        Question. I have worked with the Subcommittee Chair and Ranking
    Member for years on sustained, predictable increases to the NIH
    budget--with the goal of providing at least 5 percent real growth year-
    over-year. We have had success, leading to a 42 percent increase over
    the past 6 years, along with supplemental funding in COVID-19 relief
    packages. The President's fiscal year 22 budget calls for a 19 percent
    increase to the NIH overall budget. The vast majority of that comes
    from the proposed creation of a new advanced research effort, called
    ARPA-H. When I toured the NIH campus recently with many members of this
    Subcommittee, you discussed how innovative efforts during the
    pandemic--such as with the RADx testing program or Warp Speed vaccine
    development--align with the ARPA-H proposal, incorporation closer
    partnerships with industry and coordination at different stages in the
    research and development of promising breakthroughs. Your testimony
    discusses application of this nimble ARPA-H proposal for cancer,
    infectious diseases, and autoimmune diseases.
        As we evaluate this proposal, what are the core aspects of this
    ARPA-H policy that you want us to keep in mind?
        Answer. We envision that the Advanced Research Projects Agency for
    Health (ARPA-H) will be able to tackle large-scale challenges using a
    proven high-risk, high-reward approach that embraces nimbleness and
    flexibility with the broader goal of delivering rapid breakthroughs
    that serve all patients. Being successful in this endeavor requires
    close communication and collaboration across government and with key
    stakeholders in the external biomedical community. This could include
    undertaking projects with Federal agencies, private companies,
    independent research institutes, medical centers, as well as academic
    institutions--all collaborating to advance innovative health research.
    NIH deployed similar approaches in response to the COVID-19 pandemic
    (Accelerating COVID-19 Therapeutic Interventions and Vaccines, or ACTIV
    and Rapid Acceleration of Diagnostics, or RADx)--which yielded life-
    saving results for Americans, and also served as a learning opportunity
    to appreciate further the value of employing a DARPA--like model to
    support research. With Congressional support, we believe we can
    leverage these models in other areas of health research to drive
    transformative change and impact.
        Question. We have spoken in the past about two seemingly divergent
    issues. On one hand, we talk about the need to invest in medical
    research to find breakthroughs and cures for patients, so we rightfully
    appropriate billions into NIH-funded research--sign me up for that. But
    then these drugs come to market--the vast majority of them benefitting
    from NIH research (e.g. a study finding that all 210 drugs approved by
    FDA between 2010 and 2016 benefitted from NIH-funded research in some
    form)--and too many of them with exorbitant price tags. Recent studies
    show that high costs contribute to poor medication adherence, including
    with one-quarter of cancer patients choosing not to fill a prescription
    due to cost. I know Dr. Sharpless has talked about the ``financial
    toxicity'' for cancer patients. Americans pay the highest prices for
    medications in the world, with a recent GAO report finding that the
    U.S. pays two- to four-times more for certain medications than other
    developed countries. It is counterintuitive and an outrage that
    taxpayers fund cutting-edge research, which leads to drugs, that we
    often cannot afford once they hit the market. I understand NIH does not
    set drug prices and does not want to limit the handoff or development
    of its research to stakeholders that commercialize the discoveries. But
    the current system does not maximize the benefits for patients.
        Given the role of NIH research in contributing to FDA-approved
    medications, many of which come with extremely high price tags, what
    specific steps can NIH take to ensure that patients are able to afford
    the incredible discoveries made at NIH?
        The NIH has received several petitions to exercise march-in rights
    (35 U.S.C. Sec. 203), but has never done so.
      --Under what circumstances would NIH consider doing so?
      --Under that statutory authority, how does NIH define and evaluate
            the term ``practical application'' for the purposes of how a
            contractor or assignee makes a subject invention funded by NIH
            available to the public on reasonable terms?
      --What are the factors used in such definition and evaluation?
      --Can you provide an example of the analysis undertaken in evaluation
            of a previously filed march-in-petition?
        Answer. The National Institutes of Health (NIH) shares your concern
    about the high price of drugs and the impact on public health. The
    article you reference shows that all of the 210 drugs approved by U.S.
    Food and Drug Administration from 2010 to 2016 were based on at least
    one scientific publication reporting on research funded by the NIH.\1\
    The researchers reported that 96 percent of the NIH funded projects
    were identified based on a search for the ``target'' rather than the
    drug itself. Identifying a drug target, meaning a protein in a cell
    that has a function in a disease process, opens the door for any
    researcher in industry or academia to screen for drugs that bind to the
    target to slow or arrest disease processes. This research is key to a
    vibrant drug discovery process in the United States and does not limit
    discovery to one drug for each target. The development of multiple
    drugs for a particular disease allows the patient and physician to
    choose the best one for them and can lead to price competition in the
    market. Drug pricing is a complex problem that involves various
    segments of the market, much of which NIH has no control over. A
    smaller number of important drugs utilize patented inventions funded by
    the NIH. When NIH has been asked to consider march-in under the Bayh-
    Dole Act based on the price of such drugs, NIH has stated that the
    issue of drug pricing is one that should be address by Congress, as it
    considers these matters in a larger context.\2\
    ---------------------------------------------------------------------------
        \1\ Cleary et al., 2018, www.ncbi.nlm.nih.gov/pmc/articles/
    PMC5878010/.
        \2\ NIH march-in responses from 1997-2013 at ott.nih.gov/policy/
    policies-reports under ``NIH March-In Response''.
    ---------------------------------------------------------------------------
        The Bayh-Dole march-in provision (See 35 U.S.C. 203) allows a
    government funding agency to require a grantee to grant a license to a
    patent of an invention made under that agency's awarded grants or
    contracts and allows other ``responsible applicants'' to obtain the
    license if one of four circumstances are met:
        1. the contractor or assignee has not taken, or is not expected to
    take within a reasonable time, effective steps to achieve practical
    application of the subject invention in such field of use
        2. to alleviate health or safety needs which are not reasonably
    satisfied by the contractor, assignee, or their licensees
        3. to meet requirements for public use specified by Federal
    regulations and such requirements are not reasonably satisfied by the
    contractor, assignee, or licensees
        4. the agreement required by section 204 [a requirement that
    patented products be manufactured substantially in the United States
    unless a waiver is granted]
        The first two criteria are typically cited in petitions to consider
    a march-in by the National Institutes of Health (NIH). For example, if
    a company has rights to a government funded patent for a drug candidate
    but is not making reasonable efforts to bring it to market, the company
    may be failing to meet the requirements to achieve practical
    application of the invention. These criteria are considered on a case-
    by-case basis by the agency in view of the facts presented in each
    case.
        If NIH were to march-in, the grantee could appeal that decision
    through the Federal courts. Only after the company had lost all legal
    appeals could NIH grant a license to a second company, should there be
    one interested in developing a new version. Additionally, the drug
    could be covered by other patents that cover certain aspects of the
    drug, such as methods of making and administering it. In such
    instances, the march-in could be ineffective, because the original
    company could stop a new company from making the generic until the
    other patents expire.
        After the court appeals and expiration of any other patents, a
    company would typically have to conduct clinical trials or otherwise
    establish equivalency with the brand drug to obtain U.S. Food and Drug
    Administration approval. The entire process, including administrative
    hearings, court appeals and new clinical trials, could take years
    before the new product reached the market. In the meantime, alternative
    therapies may have become available or the patent subject to march-in
    may have expired.
        NIH has considered march-in on several occasions and was either
    able to work with parties to reach an agreement to address the issues
    raised, such as the case with CellPro and Fabrazyme, or decided that
    the march-in legal requirements were not met to march-in to address the
    public health and safety issues raised, such as was the case with
    Norvir.\3\
    ---------------------------------------------------------------------------
        \3\ See ott.nih.gov/policy/policies-reports under NIH March-In
    Response.
    ---------------------------------------------------------------------------
        Question. The COVID-19 pandemic has impacted every major sector of
    the economy of the United States, including our nation's biomedical
    research. I have heard from countless universities across the state of
    Illinois about the impact that this pandemic has had on the medical
    research pipeline. From shuttered labs, to interrupted or delayed
    clinical trials, to unforeseen pandemic-related costs, they have
    estimated that this pandemic has caused over $10 billion in lost
    research. Last year, Senator Moran and I sent a bipartisan letter to
    Senate leadership, requesting at least $10 billion in additional
    funding to help make-up for the unforeseen disruptions and costs to
    medical research nationwide.
        Dr. Collins, I am wondering if you can speak to the toll that the
    pandemic has taken on medical research nationwide and what Congress
    might be able to do to help.
        Answer. The National Institutes of Health (NIH) remains deeply
    concerned and mindful about how the spread of coronavirus disease 2019
    (COVID-19) has negatively affected the biomedical research
    enterprise.\4\ Last summer, the NIH estimated it would cost at least
    $10 billion to restart labs which were forced to rapidly close. That
    original estimate proved overly optimistic as the pandemic subsequently
    continued, and as such, the NIH now estimates the financial impacts to
    be approximately $16 billion on the biomedical and behavioral research
    enterprise.
    ---------------------------------------------------------------------------
        \4\ https://nexus.od.nih.gov/all/2020/11/04/continued-impact-of-
    covid-19-on-biomedical-research/.
    ---------------------------------------------------------------------------
        The estimates considered many factors:
      --Key resources, such as animal colonies, cell lines and expired
            reagents that need to be re-established.
      --Access to core facilities that was limited due to a backlog of
            requests.
      --Delicate and complicated equipment that required recalibration and
            quality control testing prior to returning to routine use.
      --Requirements for social distancing to protect staff and clinical
            trial participants coupled with anticipated reluctance by
            participants to travel, which slowed the rate of clinical trial
            accrual and progress and increased the cost of conducting
            trials.
        In addition to the financial estimates, the NIH fielded two online
    surveys to objectively document COVID-19's impact on the extramural
    research workforce.\5\ The main finding from the surveys was that the
    majority of respondents noted concerns about research functions,
    research productivity, and financial status.\6\ Well into the pandemic,
    many NIH-supported research labs enforced social distancing, inherently
    restricting access and severely limiting the ability to generate
    research results and preliminary data at a crucial time in career
    development of early stage investigators and trainees. Junior faculty,
    often with only a single NIH award and unable to access their labs to
    generate additional data, are at risk of losing all funding and may
    have insufficient data to write papers while working from home. Some
    investigators, especially women with dependent care responsibilities,
    are more negatively affected. Investigators supported by training or
    career development awards are experiencing hiring freezes and job
    revocations, jeopardizing the ability of early-stage career
    investigators to transition to independence, particularly as they come
    to the end of their current funding. Clinical investigators have been
    diverted from their research labs to meet the clinical demands of
    COVID-19 patient care.
    ---------------------------------------------------------------------------
        \5\ https://nexus.od.nih.gov/all/2020/10/05/encouraging-
    participation-in-upcoming-nih-surveys-to-identify-impacts- of-covid-19-
    on-extramural-research/.
        \6\ https://nexus.od.nih.gov/all/2021/03/25/the-impact-of-the-
    covid-19-pandemic-on-the-extramural-scientific-workforce-outcomes-from-
    an-nih-led-survey/.
    ---------------------------------------------------------------------------
        Considering these effects, the NIH is concerned about potential
    pandemic-related losses of scientists exiting the biomedical research
    workforce and abandoning scientific careers to seek alternative
    employment. In an effort to address the unanticipated impacts of the
    pandemic on the career trajectories of early career scientists, the NIH
    has provided several policy flexibilities, including grant award
    extensions (both funded and un-funded), opportunities for investigators
    to extend the timeline for early career status, provided administrative
    supplements, and more.
                                     ______

                  Questions Submitted by Senator Brian Schatz
        Question. At the hearing, we discussed psychedelic drug research
    and the potential of these drugs to treat mental health illness. You
    stated that the NIH would consider having a workshop on this subject.
        What is the current status of NIH-funded clinical trials involving
    human subjects on the potential benefits of psychedelics combined with
    psychotherapy?
        Are there statutory or regulatory barriers to NIH pursuing or
    funding human subject research on psychedelic drugs?
        When does NIH plan to convene a workshop on psychedelic drug
    research?
        Answer. The National Institutes of Health (NIH) supports research
    on the development and testing of pharmacological interventions--
    including the use of hallucinogens such as ketamine, and psychedelic
    drugs such as psilocybin--for the treatment of illnesses. In
    particular, the National Institute of Mental Health (NIMH) requires an
    experimental therapeutic approach for the development and testing of
    therapeutic interventions for mental illnesses, in which the studies
    not only evaluate the clinical effect of an intervention, but also
    generate information about the mechanisms underlying a disorder or an
    intervention response. Research on psychedelic drugs holds promise for
    uncovering mechanisms of mental illnesses and possible interventions,
    ultimately leading to novel treatments with fewer side effects and
    lower abuse potential. Further research is needed to examine the
    efficacy and long-term safety of psychedelic drugs, including with
    repeated exposure and potential interactions with existing treatments.
        The dissociative anesthetic ketamine has recently emerged as an
    effective fast-acting antidepressant.\7\ The NIMH Director's Message,
    ``New Hope for Treatment-Resistant Depression: Guessing Right on
    Ketamine,'' describes the role of NIMH and other researchers in the
    development of esketamine, a U.S. Food and Drug Administration-
    approved, rapid-acting medication that targets treatment-resistant
    depression.\8\ Within the NIMH Intramural Research Program, Dr. Carlos
    Zarate is now conducting clinical trials to better understand how
    ketamine rapidly reduces depressive symptoms in people with treatment-
    resistant depression or bipolar depression.\9,10\
    ---------------------------------------------------------------------------
        \7\ pubmed.ncbi.nlm.nih.gov/27839782/.
        \8\ www.nimh.nih.gov/about/director/messages/2019/new-hope-for-
    treatment-resistant-depression-guessing-right-on- ketamine.
        \9\ clinicaltrials.gov/ct2/show/NCT03065335.
        \10\ clinicaltrials.gov/ct2/show/NCT03973268.
    ---------------------------------------------------------------------------
        The National Institute on Drug Abuse (NIDA) currently supports a
    clinical trial which aims to assess the efficacy of ketamine, in
    combination with behavioral therapy, in the treatment of cocaine use
    disorders.\11\
    ---------------------------------------------------------------------------
        \11\ clinicaltrials.gov/ct2/show/NCT03344419.
    ---------------------------------------------------------------------------
        Additionally, a privately funded clinical trial is assessing the
    potential efficacy of the psychedelic drug psilocybin for the treatment
    of obsessive-compulsive disorder.\12\ While the NIH is not directly
    funding this trial, NIMH does support the trial's principal
    investigator through a Mentored Patient-Oriented Career Development
    Award.\13\
    ---------------------------------------------------------------------------
        \12\ clinicaltrials.gov/ct2/show/NCT03356483.
        \13\ reporter.nih.gov/project-details/10127338.
    ---------------------------------------------------------------------------
        Further, a number of NIH-funded researchers are conducting basic
    and preclinical research to investigate the use of psychedelic drugs as
    potential therapeutic interventions for mental illnesses. For example,
    NIMH-funded researchers are examining the mechanisms underlying the
    antidepressant effects of psychedelic drugs in an effort to develop
    novel, non-hallucinogenic treatment strategies that are both safer and
    more effective than existing treatment options.\14\
    ---------------------------------------------------------------------------
        \14\ reporter.nih.gov/project-details/10003396.
    ---------------------------------------------------------------------------
        As with all human subjects research, clinical research on
    psychedelic drugs is governed by several statutes, regulations, and
    policies intended to protect the rights and welfare of research
    participants. For example, NIH has specific requirements for research
    staff and policies regarding research conduct, safety monitoring, and
    reporting of information about research progress.\15\ In accepting an
    award that supports human subjects research, the recipient institution
    assumes responsibility for all research conducted under the award,
    including protection of human subjects at all participating and
    consortium sites.\16\ All human subjects research must also be
    reviewed, approved, and monitored by an Institutional Review Board.\17\
    ---------------------------------------------------------------------------
        \15\ grants.nih.gov/policy/humansubjects/policies-and-
    regulations.htm.
        \16\ grants.nih.gov/grants/policy/nihgps/html5/section_4/
    4.1.15_human_subjects_
    protections.htm.
        \17\ www.fda.gov/regulatory-information/search-fda-guidance-
    documents/institutional-review-boards-frequently-asked-questions.
    ---------------------------------------------------------------------------
        Because psychedelic drugs are controlled substances, clinical
    research using psychedelic drugs must also follow Drug Enforcement
    Administration requirements, including registration, inspection, and
    certification of the drugs.\18\
    ---------------------------------------------------------------------------
        \18\ grants.nih.gov/grants/policy/nihgps/html5/section_4/
    4.1.5_controlled_substances.htm.
    ---------------------------------------------------------------------------
        From April through June 2021, the Trans-NIH Integrative Medicine
    Course Organizing Committee hosted a series of research talks on
    psychedelic drugs.\19\ Building on these research talks, NIMH and NIDA
    are now working together to convene a scientific workshop in winter
    2021. This workshop will bring together leading researchers to examine
    the state of the evidence for the use of psychedelics in the treatment
    of mental illnesses.
    ---------------------------------------------------------------------------
        \19\ events.cancer.gov/nci/psilocybinresearch/agenda.
    ---------------------------------------------------------------------------
        Question. The United States shares a unique political relationship
    with the Native Hawaiian community. Different Federal agencies within
    HHS are responsible for the administration of Native healthcare
    programs, but the same Federal trust responsibility requires the
    provision of comprehensive, quality healthcare to Native Hawaiians,
    Alaska Natives and American Indians. In 2015, NIH established the
    Tribal Health Research Office within the Office of the Director to
    coordinate tribal health research activities across NIH. However, no
    such research office exists for Native Hawaiians.
        Would you consider expanding the scope of the Tribal Health
    Research Office to include Native Hawaiians? Would this help to
    increase the number of Native Hawaiian researchers and the amount of
    Native Hawaiian research being conducted across the country?
        Has NIH set any goals for the Tribal Health Research Office, and
    how will you measure its success and impact across NIH's Institutes and
    Centers?
        Some funding opportunities at NIH, such as the Native American
    Research Centers for Health program, do not permit entities serving
    Native Hawaiian communities to apply. Why are these entities excluded,
    and would NIH consider including these entities in the eligibility for
    these grant opportunities?
        Answer. The National Institutes of Health (NIH) Tribal Health
    Research Office (THRO) does not conduct disparity research on Native
    American populations. THRO ensures that the NIH fulfills its
    obligations to Indian Tribes as federally recognized sovereign nations,
    conducts government to government interactions appropriately, and holds
    formal Consultations with Tribal governments on policy, regulatory, and
    legislative issues that have a significant direct impact on Indian
    Tribes.
        The National Institutes of Health (NIH) published the NIH Strategic
    Plan for Tribal Health Research with input from American Indian/Alaska
    Native (AI/AN) Communities and the NIH Tribal Advisory Committee (TAC).
    The plan includes four agency-wide strategic goals: enhancing
    communication and collaboration; building research capacity for AI/AN
    communities; expanding research; and enhancing cultural competency and
    community engagement. The Tribal Health Research Office (THRO), along
    with the NIH Institutes and Centers (ICs), developed processes and
    metrics for evaluating progress on the strategic objectives and their
    supporting action items to achieve these goals. THRO regularly collects
    data on AI/AN health research activities from all ICs through an
    automated process to analyze the NIH research portfolio, assess
    progress towards the strategic goals, and measure impact across NIH.
        The National Institute of General Medical Sciences in conjunction
    with multiple NIH Institutes, Centers, and Offices (ICOs) partner with
    Indian Health Service (IHS) to support the Native American Research
    Centers for Health (NARCH). NARCH grant applications are submitted by
    and awarded to a tribe or tribal organization, who are sovereign
    nations with distinct governing bodies. Awarding the grant directly to
    the tribe or tribal organization allows for the community to dictate
    and oversee research priorities, while drawing upon necessary expertise
    from the research community to accomplish its scientific goals.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. West Virginia is consistently ranked last in the nation
    for health outcomes. In 2020, the America's Health Rankings Report
    ranked West Virginia 50th for premature deaths, frequent mental
    distress, and multiple chronic conditions. We also rank last in life
    expectancy. West Virginia has, in many ways, been left behind as
    medical advances have saved lives in other places.
        What is NIH doing to bridge this gap in health outcomes?
        How do you ensure that the medical research that you do benefits
    people in poor, rural communities?
        How can we better expand the access rural Americans have to
    successful medical treatments, particularly in states like mine where
    the disease burden is so high?
        Answer. The National Institutes of Health (NIH) recognizes the
    unique health disparities that rural communities face, and as such,
    rural health is an important area of research for the agency.
        Through diverse collaborations and partnerships with communities,
    academic institutions, and state agencies, NIH supports and conducts
    rural health research to improve health outcomes and reduce rural
    health disparities with a special emphasis on the poor in rural
    communities. In fiscal year 2020, NIH supported more than 1,000 rural
    health-related grants for approximately $728 million. In 2020, West
    Virginia received approximately $45.7 million in funding from NIH, of
    which about $6.4 million supported research and research capacity-
    building activities related to rural health.
        In 2019, NIH held the Inaugural NIH Rural Health Seminar, a
    collaboration of several NIH Institutes and Centers to explore topics
    in rural health and opportunities for research collaborations to
    improve rural health outcomes. In 2020, NIH hosted a virtual rural
    health conference entitled, NIH Rural Health Seminar: Challenges in the
    Era of COVID-19. In October 2021, NIH will host the Pathways to
    Prevention Workshop: Improving Rural Health Through Telehealth-Guided
    Provider-to-Provider Communication, a virtual event to identify
    research gaps, explore barriers, and facilitate successful, sustainable
    implementation of provider-to-provider telehealth in rural settings.
        NIH's rural health research focuses on key areas aimed at
    addressing health disparities that rural populations in West Virginia
    and around the United States experience. In fiscal year 2020, in
    response to the disproportionate impact of coronavirus disease 2019
    (COVID-19) on racial and ethnic minority, and other vulnerable
    communities including rural populations, NIH established the Rapid
    Acceleration of Diagnostics for Underserved Populations (RADx-UP)
    initiative. The overreaching goal of the RADx-UP initiative is to
    understand the factors associated with disparities in COVID-19
    morbidity and mortality and to lay the foundation to reduce disparities
    for those underserved and vulnerable populations more impacted by
    COVID-19. One example of a RADx-UP project in your state, is the
    Developing Novel Strategies to Increase COVID-19 Testing among
    Underserved and Vulnerable Populations in West Virginia through
    Community and State Partnerships. This project will implement
    collaborative strategies to increase availability and uptake of severe
    acute respiratory syndrome coronavirus 2 (SARS CoV-2) testing among the
    medically underserved, rural West Virginia population that includes
    multiple vulnerable groups at risk for severe COVID-19 and death. This
    initiative will test whether those implemented strategies, including
    home test kit and mobile unit mechanisms, successfully increase
    testing, and if not, determine why the interventions did not work to
    inform future sustainable testing policy.
        In addition, NIH supports the West Virginia University Health
    Sciences TME CoBRE project, which focuses on the microenvironment of
    different tumor types, including cancers initiating in the bone marrow,
    head and neck, breast, and brain. This project will increase
    understanding of the constant interaction between the tumor and its
    environment, provide diverse training opportunities and mentoring
    strategies for junior faculty, and develop critical infrastructure and
    recruit additional tumor microenvironment focused scientists to West
    Virginia. Another project, the West Virginia Clinical and Translational
    Science Institute: Improving Health through Partnerships and
    Transformative Research (WVCTSI), leads statewide collaborations and
    innovation in clinical and translational research. This project will
    build sustainable research infrastructure, recruit clinician scientists
    and translational researchers that excel in team science, and actively
    engage with multiple stakeholders that include communities, medical
    providers, and policy makers to improve the health of West Virginians.
        NIH is committed to ensuring that there are opportunities for poor
    rural Americans to access the benefits of research and that research
    addresses the unique strengths and challenges of rural communities by
    supporting several initiatives focused on human immunodeficiency virus
    (HIV), cardiovascular disease, cancer, drug addiction, and other
    chronic diseases disproportionately affecting rural communities. First
    announced in April 2018, the NIH Helping to End Addiction Longterm\SM\
    Initiative, or NIH HEAL\SM\ Initiative, is an expansive agency-wide
    effort. It spans basic, translational, clinical, and implementation
    science and promotes collaborations of all types of research to address
    the crises of opioid misuse, addiction, and overdose in the United
    States. Launched in fiscal year 2020, Strategies to Improve Health
    Outcomes and Reduce Disparities in Rural Populations supports research
    to promote a greater understanding of the challenges faced by rural
    populations in developing or adapting evidence-based interventions that
    can reduce health risks faced by rural Americans. A total of eight
    awards were funded including: Harnessing the Power of Peer Navigation
    and mHealth to Reduce Health Disparities in Appalachia which is using a
    community-based approach to integrate peer navigation and mobile health
    strategies to develop a culturally congruent, bilingual intervention to
    increase the use of HIV, sexually transmitted infection, and Hepatitis
    C prevention and care services among individuals with health
    disparities living in rural Appalachia. Another study, Heart of the
    Family: A Cardiovascular Disease and Type 2 Diabetes Risk Reduction
    Intervention in High-Risk Rural Families is examining the effects of a
    family focused, lifestyle intervention that is culturally tailored for
    use with rural Hispanic or Latino and non-Hispanic or Latino adults. In
    2020, the National Institute on Minority Health and Health Disparities
    (NIMHD) funded four rural Resource Hubs to focus on rural health
    research. These hubs will involve coalitions of researchers and
    community partners to build research capacity in an identified rural
    catchment area and offer opportunities to share resources and data
    across collaborators.
        NIH continues to support the Accelerating Colorectal Cancer
    Screening and Follow-Up Through Implementation Science (ACCSIS)
    Program, a Cancer Moonshot? Initiative, designed to reduce cancer
    screening disparities. The aim is to identify evidence-based
    interventions and identify promising approaches for bringing these
    interventions to unscreened populations. Researchers test interventions
    such as mailing programs for home testing, provider education, and
    clinic-based patient navigation among Medicaid, rural, and racial and
    ethnic minority groups. In fiscal year 2020, NIH reissued and released
    the Pragmatic Research in Healthcare Settings to Improve Diabetes and
    Obesity Prevention and Care funding opportunity announcement. This
    initiative aims to improve diabetes and obesity prevention and/or
    treatment that are adapted for implementation in healthcare settings
    where individuals receive routine medical care. One of the funded
    grants, Telemedicine for Reach, Education, Access, Treatment and
    Ongoing Support (TREAT-ON), is a diabetes educator-driven, primary
    care-based telemedicine model that redesigns primary care practice to
    provide access to real-time ongoing support and help high risk
    participants in an underserved rural community to achieve and sustain
    improvements in clinical, psychosocial and behavioral outcomes. The NIH
    Minority Health and Health Disparities Strategic Plan 2021-2025 aims to
    test best practices for dissemination and implementation of minority
    health and health disparities research in diverse diseases and
    conditions into rural communities.
        Continued collaborations and partnerships with scientists and
    organizations from rural communities, such as West Virginia, will
    contribute to NIH's reach in rural communities and support our work to
    combat rural health disparities.
        Question. The NIH funds the WV Clinical and Translational Science
    Institute at West Virginia University through a 5-year $20 million
    grant. The Institute provides critical health research across West
    Virginia and has successfully mentored early career investigators,
    established pilot project funding, and created a research network
    across 27 primary care sites. Their research has focused on important
    health issues in my state including lung disease in coal miners, opioid
    addiction, and the hepatitis C epidemic, as well as cancer, heart
    disease, and stroke. Most recently, the Institute has been on the front
    line of COVID-19 research, having received a $1.5 million NIH Grant to
    lead an 8-state effort so that data from COVID-19 patients could be
    analyzed to develop the most impactful COVID-19 research. They're also
    responsible for utilizing the NIH RADx grant to scale up COVID-19
    testing in WV Communities.
        Can you comment on the importance of continued collaboration
    between the NIH and research institutions like the WV Clinical and
    Translational Science Institute at West Virginia University?
        What more can we be doing to support young researchers, such as
    those mentored through this Institute?
        Answer. One of the core programs supported by the National
    Institute of General Medical Sciences (NIGMS) Institutional Development
    Award (IDeA) is the IDeA Networks for Clinical and Translational
    Research (IDeA-CTRs), which includes the West Virginia Clinical and
    Translational Science Institute (WV CTSI). The IDeA-CTR network aims
    to:
      --Support the development and/or enhancement of infrastructure and
            human resources required to address clinical and translational
            research needs in IDeA-eligible states and jurisdictions;
      --Strengthen clinical and translational research that addresses the
            broad spectrum of health challenges faced by populations in
            IDeA-eligible regions; and
      --Foster and coordinate collaboration in clinical and translational
            research within an IDeA-CTR network and with other
            institutions.
        Strengthening and expanding the capacity for clinical and
    translational research in IDeA-eligible states is a pressing need,
    since health conditions such as obesity, diabetes, cardiovascular
    diseases, cancer, infectious diseases, chronic obstructive pulmonary
    disease, maternal health issues, and substance use disorders are
    disproportionally present in and borne by communities in these states.
    The IDeA-CTR networks support health research professionals who have
    first-hand knowledge of these challenges in order to understand and
    improve the health outcomes of residents in affected jurisdictions.
    Having the WV CTSI in place during the coronavirus disease 2019 (COVID-
    19) pandemic, for instance, has allowed it to act as a springboard for
    West-Virginia-based research aimed at studying and addressing the
    virus. The $1.5 million supplemental award referenced in this question
    facilitated the development of an eight-state consortium that created
    an IDeA State COVID-19 Patient Registry. Through the collaboration
    between the NIH and WVU, the Registry has become a key component of the
    National COVID Cohort Collaborative, making important contributions in
    addressing the unique challenges brought by COVID-19 to traditionally
    underserved groups such as rural populations. Another supplement to the
    WV CTSI supports a network for conducting COVID-19 testing in West
    Virginia that includes the state health department, the national guard,
    and rural clinics. This collaborative effort is playing a major role in
    facilitating the state's testing efforts. Finally, the WV CTSI is also
    a key participant of an NIH-sponsored multi-site Post-Acute Sequelae of
    SARS-CoV-2 (PASC) study of ``Long COVID'' patients who continue to
    experience symptoms long after initial infection.
        Both NIGMS and NIH remain committed to supporting IDeA-CTR networks
    like the WV CTSI, given the very important role that such networks play
    in developing research infrastructure and improving health outcomes
    within IDeA states.
        The National Institutes of Health (NIH) believes that supporting
    early career researchers is crucial to maintaining a productive,
    innovative, and diverse biomedical research workforce that can continue
    to advance the vitality of the scientific research enterprise. NIH's
    Next Generation Researchers Initiative (NGRI) is developing and
    implementing strategies to identify, support and retain investigators
    across early career stages.
        As part of the NGRI, NIGMS has prioritized and included several
    strategies for supporting trainees and early-stage investigators (ESIs)
    within its 2021-2025 Strategic Plan, along with targets for
    implementing those strategies that provide accountability and the
    ability to measure progress. Career development initiatives such as the
    recently launched Maximizing Opportunities for Scientific and Academic
    Independent Careers (MOSAIC) program focus on retaining and supporting
    postdoctoral scholars from diverse backgrounds through the critical
    point of transitioning them into independent faculty careers.
    Cooperative agreements with professional organizations support
    educational activities that equip MOSAIC scholars with professional
    skills, mentoring, and career networks. At the individual level, grants
    such as NIGMS' Maximizing Investigators' Research Award (MIRA) offer
    support to early-stage investigators (ESIs) by providing them both the
    opportunity to perform creative and ambitious research as well as the
    flexibility to follow important new research directions and scientific
    insights. Since launching this award mechanism in 2015, MIRA has
    supported 628 early-stage investigators (ESIs), at least two of whom
    were in West Virginia. In fiscal year 2020 alone, NIGMS funded 200 ESIs
    through MIRA. As these examples illustrate, both the NIGMS and NIH
    remain committed to supporting promising early career investigators in
    every state in the nation.
                                     ______

                    Questions Submitted by Senator Roy Blunt
        Question. Dr. Collins, I am a big supporter of the Clinical and
    Translational Science Award (CTSA) program. I believe we should look
    for ways to strengthen the CTSA program and reinforce the hubs around
    the country. That is why I am troubled to hear about a possible CTSA
    reorganization that will be announced in June. This reorganization
    comes with limited discussion and consultation with the CTSA directors.
    I am concerned, specifically, with the proposal to break up hub awards
    into smaller pieces, requiring CTSAs to write several grant
    applications instead of just one. Dr. Collins, I have two questions.
    First, as you know, this Committee pays a lot of attention to CTSAs and
    has been concerned in the past about communication between NCATS and
    the CTSA community. For example, NCATS emailed relevant stakeholders to
    combat the rumors about changes to the CTSAs, but did not provide any
    relevant data to explain what they want to do and why they want to do
    it. That did nothing but add to the concerns and speculation in the
    community.
        Why haven't these specific changes been discussed broadly within
    the CTSA community? I believe if there was open dialogue and a stronger
    partnership between NCATS and CTSAs, there would likely be more buy-in
    from the community.
        Two, how does cutting the hub award and requiring CTSAs to compete
    for multiple awards strengthen the program? It appears to me that this
    change would bring uncertainty to the program and jeopardize the
    stability of the hubs.
        Answer. The Clinical and Translational Sciences Award (CTSA)
    program is indeed a very valuable and important program for the
    National Center for Advancing Translational Sciences (NCATS), NIH, and
    the nation. NCATS understands that there are often concerns when there
    are planned updates to a program, particularly one as large and
    impactful as the CTSA Program. The planned updates are part of the
    regular NIH business process for reissuing Funding Opportunity
    Announcements (FOAs), which is required because FOAs expire after 3-4
    years. The planned updates will maintain the structure of the program
    and reflect the public input received--much of which was provided by
    the CTSA hub institutions and investigators. The planned updates are
    designed to strengthen the program, by prioritizing hub strengths,
    streamlining the overall application process, emphasizing clinical
    partnerships which are critical to achieving the objectives of this
    national program, and stabilizing the funding provided to the hub
    institutions by allowing up to 7 years of funding (rather than the
    typical five-year award period for NIH awards).
        How NCATS Engages with the CTSA Community: NCATS agrees that a
    strong partnership is extremely important and works closely with the
    CTSA community on a regular basis.
      --Regular Meetings: A CTSA Steering Committee \20\ including
            leadership from NCATS and the CTSA Principal Investigator
            community, meets monthly. A monthly webinar for all CTSA
            Program investigators also shares information about the
            program. NCATS CTSA leadership and program officers also
            routinely engage with investigators and institutional
            leadership across the CTSA Program as part of their regular
            duties for implementing a program of this size and complexity.
            In addition, there are yearly multi-day conferences where the
            CTSA investigators and NCATS staff engage deeply on important
            issues related to the CTSA program.
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        \20\ clic-ctsa.org/groups/steering-committee.
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      --Engaging the Community on Updates to the Planned FOA: To maintain
            fair and open competition for funding opportunities, NCATS
            cannot discuss specific details about a draft FOA with select
            groups of the public, particularly those who already have
            funding and would be re-competing for the funds. The level of
            engagement must be framed to ensure that all investigators and
            institutions, not only the current awardees, have an equal
            opportunity to compete for the program funds and that NCATS
            officials act impartially and not give preferential treatment
            to any organization or individual.\21\ In following these NIH
            policies, NCATS provided multiple opportunities to ask for and
            receive input from the broader public, including the CTSA
            community, on how to improve the CTSA Program.
    ---------------------------------------------------------------------------
        \21\ ethics.od.nih.gov/principles-ethical-conduct-government-
    officers-and-employees.
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        --A key approach for input was a Request for Information (RFI)
                released in the Fall of 2019. The comments received, many
                from the CTSA community, significantly influenced the
                updates to the CTSA Program that NCATS is planning. (RFI;
                NOT-TR-19-027 \22\)
    ---------------------------------------------------------------------------
        \22\ grants.nih.gov/grants/guide/notice-files/NOT-TR-19-027.html;
    (see this video,www.youtube.
    com/watch?v=LDBJSl-_QbQ, for an overview presentation of feedback
    received).
    ---------------------------------------------------------------------------
        --General feedback was sought from CTSA application peer reviewers
                over multiple study sections; many of whom are also CTSA
                investigators.
        --Informal discussions occurred with CTSA Program consortium
                members, individually and in small group settings, over the
                course of typical program oversight and interactions.
        --Often the first public discussion about a future FOA occurs when
                NCATS, like other NIH Institutes and Centers, seeks concept
                approval from its Advisory Council during a session open to
                the public. This occurs on June 11, 2021. Of note, the
                NCATS Advisory Council includes three members that are
                Principal Investigators from the CTSA Program.
        --In addition, NCATS has built in additional time after the release
                of the new FOA--6 months, instead of 2-4 months, prior to
                the first application receipt date--to familiarize all
                potential applicants with the new FOA, including hosting of
                webinars to provide technical assistance to the applicant
                community.
        --NCATS widely shared a communication to address inaccuracies and
                rumors about changes to the CTSA Program FOA. The letter
                did not discuss planned changes to the CTSA Program nor
                provide data, as sharing details about the FOA in a non-
                public manner prior to its posting is not permissible.
        --Summary of Stakeholder Feedback: From the input received through
                the multiple approaches described above, stakeholder
                feedback centered around four distinct areas: (1)
                decreasing application administrative burden, (2)
                increasing Hub flexibility and Hub specialization
                opportunities, (3) expanding Hub funding options, and (4)
                preserving partnerships and collaborations. Three
                additional areas were identified by NCATS for improvement:
                (1) ensuring the CTSA Program's sustainability (in terms of
                avoiding the need to reduce the number of hubs or cut
                budgets), which requires updates to budget formulas and
                calculations; (2) increased emphasis towards addressing
                health disparities; and (3) strengthening clinical research
                capabilities, which have been critical to the national
                responses to the opioid epidemic and the coronavirus
                disease 2019 (COVID-19) pandemic.
        Hub Budgeting: NCATS takes the proper stewardship of taxpayer funds
    very seriously. NCATS does not intend to change the number of hubs or
    the amount of funding dedicated to the hub core awards. Future award
    amounts will be based on the amount requested by each applicant and
    will follow a revised formula for classifying the size of awards from
    what is currently used. In addition to incorporating feedback from
    different stakeholders, one of NCATS' objectives is to ensure the long-
    term sustainability of the program while avoiding a reduction in the
    number of hubs or reducing hub budgets to stay within the appropriated
    budget for the program. Requested budgets for CTSA awardees have been
    increasing to the highest award size under the CTSA graduated award
    structure, which is not sustainable under current funding for the
    program, so a restructured award calculation is needed. The total award
    size of future hubs is anticipated to be similar to the current awards
    for the vast majority of awardees.
        Structure of the Program Applications: NCATS considered extensive
    public feedback, outlined above, in updating the CTSA Program FOA,
    including how these updates could contribute to stabilization for the
    awardees and to sustainability of the program. To date, the application
    process for institutions applying for CTSA hub awards has been
    complicated and burdensome, linking up to three separate activities
    together into one package, the U54 application. Linking the Hub, Career
    Development, and Training activities together for application
    submission and peer review is primarily for the benefit of NIH in being
    able to track these activities. However, based on feedback, it places
    substantial burden on the applying institution in the form of
    developing large, complex applications, often containing several areas
    of duplicate information. The review of three separate activities in
    one application risks pulling an institution out of funding range, due
    to one of the activities not faring well in peer review. Applicants
    that do not successfully compete face a prolonged period of uncertainty
    for funding, while having to address, revise, and resubmit the entire
    U54 application package for a subsequent review cycle. These factors
    combined with the duration of the awards--five years --raises the
    stakes of each application and contributes to an environment where
    applying and awarded institutions are in a constant state of
    application preparation.
        Stakeholder concerns about the complexity of the current
    application are an important and consistent piece of feedback NCATS
    received. Separating the applications will streamline the submission
    process for each component, will reduce duplication of information in
    an application, will result in less reliance on the success of one part
    of the application, will avoid the risk of significant delays in
    awarding a hub if the Training or Career Development components are not
    strong, and may allow better alignment of Training and Career
    Development awards with the clinical training calendar. Separating the
    Hub application from the training and career development applications
    will also allow the Hub application, which is the key institutional
    award, to be awarded for up to 7 years, more than the standard 5 years.
    With this strategy, NCATS intends to provide further stability to an
    institution's funding by extending the Hub award. Combining all
    applications together does not allow for that seven-year Hub award
    option, as NIH limits training and career development awards to 5
    years. Separating the applications and providing the additional planned
    funding opportunities will also give the institutions more control over
    where they place their priorities based on their own strengths, another
    key piece of feedback received through stakeholder input.
        In closing, we hope that these responses have addressed your
    concerns. If not, NCATS is happy to provide additional information.
    NCATS recognizes the significance of the CTSA Program. The pandemic has
    further served to highlight the importance of this program in
    responding to emerging clinical and translational needs at local,
    regional, and national levels. NCATS' intent with the proposed updates
    to the CTSA FOA is to strengthen the program, provide additional
    funding stability, and continue to incorporate research to tackle
    health disparities through this program. NCATS also wants to address
    important concerns raised by the CTSA community to streamline
    application and award preparation processes, continue to emphasize the
    importance of partnerships, and allow institutions more flexibility to
    leverage their strengths in contributing to this important national
    resource.
        Question. Dr. Collins, the impact of COVID-19 has been
    significant--both to Americans physical health, but also to their
    mental health. The fiscal year 2022 budget includes $25 million for
    focused research on the impact of the pandemic on mental health.
        Can you discuss what research areas this funding will be focused on
    and how the All of Us research initiative will play a role in
    understanding the full impact of the pandemic?
        Answer. The All of Us Research Program's participants come from
    diverse communities across the United States and generously donate
    their data and time to drive a wide range of biomedical discoveries,
    which are vital for informing public health strategies and
    preparedness. Due to the diverse nature of the program, the All of Us
    Research Program will play a vital role in understanding the mental and
    physical impact of the pandemic across the United States and within
    some of the hardest-hit communities. All of Us began to address the
    challenge of the coronavirus disease 2019 (COVID-19) pandemic in May
    2020 by leveraging its significant and diverse participant base to seek
    new insights into COVID-19 and its impact through an online COVID-19
    Participant Experience (COPE) survey.\23,24\ The COPE surveys focused
    on understanding the mental and physical impacts of the COVID-19
    pandemic on participants and included questions on symptoms, stress,
    social distancing, social determinants of health, and economic impacts.
    Participants were invited to take the survey in May, June, July,
    November, and December 2020, and February 2021. This multi-pronged
    assessment will enable researchers to study the effects of COVID-19
    over time and better understand how COVID-19 affects people's mental
    and physical health differently. To date, over 10,000 participants
    completed all six COPE surveys and over 100,000 completed at least one
    COPE survey during the pandemic, with 70 percent of those participants
    coming from a community that is historically underrepresented in
    biomedical research.
    ---------------------------------------------------------------------------
        \23\ allofus.nih.gov/news-events-and-media/announcements/all-us-
    research-program-launches-covid-19-research- initiatives.
        \24\ www.nlm.nih.gov/dr2/
    COPE_Survey_NIH_All_of_Us_Clean_4.27.20.pdf.
    ---------------------------------------------------------------------------
        In addition to COPE, All of Us tested blood samples from over
    24,000 participants collected between January 2 and March 18, 2020, for
    the presence of SARS-CoV-2 antibodies, which provided evidence of
    infection in five states prior to initial reports. The program
    anticipates making the full results of this study available in June
    2021.\25\ Additionally, All of Us is collecting relevant electronic
    health record (EHR) information from more than 246,000 participants,
    some of whom have been diagnosed with COVID-19 or sought healthcare for
    related symptoms, to help researchers look for patterns and learn more
    about the physical and mental health impacts of COVID-19 and the
    effects of different medicines and treatment. As data are made
    available from all of these efforts, researchers will look for new
    leads that may bring greater precision to the diagnosis, treatment, and
    prevention of COVID-19, including those communities that have been hit
    the hardest. The program will make data gathered through these
    activities broadly accessible to approved researchers on a rolling
    basis, in future releases of its secure data platform, the Researcher
    Workbench.\26\ The program will continue to explore additional ways it
    can leverage its unique and diverse dataset to answer critical research
    questions to enhance our understanding about the full impact of the
    pandemic, especially with a focus on mental health.
    ---------------------------------------------------------------------------
        \25\ The results of this study were announced on June 15, 2021;
    complete details at: allofus.nih.gov/news-events-and-media/
    announcements/nih-study-offers-new-evidence-early-sars-cov-2-
    infections-us.
        \26\ www.researchallofus.org/.
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        Question. Dr. Collins, the COVID-19 pandemic highlighted the need
    to use non-human primates (NSP) in research. The budget requests $30
    million for NSP infrastructure.
        Can you provide further details to the Committee on the need for
    this funding and details on how this funding would be allocated and to
    whom?
        What types of research would be at jeopardy if NSPs were not
    replaced or expanded?
        Answer. The National Institutes of Health (NIH) remains committed
    to protecting animal welfare while, at the same time, advancing
    biomedical research and human health. The budget request for $30
    million for nonhuman primate infrastructure would cover facilities used
    to house nonhuman primates which require continual updates and
    maintenance to ensure responsible stewardship over these invaluable
    resources. The funds in the budget request would be distributed by
    soliciting applications from NIH grantees to improve existing
    facilities, not to establish new nonhuman primate facilities. Several
    nonhuman primate facilities have existed for over 60 years and housing
    enclosures require frequent repair and replacement. New construction
    for research facilities would include animal holding rooms, necessary
    equipment such as surgical tables, centrifuge, ultrasound, clinical
    analyzer, procedure, and veterinary clinical support in order to meet
    or exceed the current high-level care of the nonhuman primates.
    Additionally, the COVID-19 pandemic highlighted the need for new
    construction to expand animal biosafety level 3 areas in order to have
    biocontainment facilities associated with nonhuman primate facilities.
    In addition to ethically appropriate housing, nonhuman primates require
    a proper diet, clinical/veterinary care as well as psychological and
    environmental enrichment, which necessitates skilled staff and
    additional resources including supplemental produce, various enrichment
    devices such as foraging devices for food, various toys, and puzzles.
        NIH would support expansion at existing NIH-supported facilities to
    leverage the investment. The NIH Office of Research Infrastructure and
    Programs (ORIP) supports a well-coordinated national consortium of
    seven National Primate Research Centers (NPRCs) and other breeding
    colonies that collectively address research needs and trends, best
    husbandry practices, maintenance of genetic diversity, standardization
    of models, ethics, rigor, and reproducibility. NPRCs are national
    resources serving not only NIH-funded investigators but other federally
    funded investigators, foundations, and industry, including many SARS-
    CoV-2 projects in the last year.
        Research with animal species, including nonhuman primates, remains
    critical for modeling human physiology and is essential for developing
    new prevention strategies, treatments, and cures for disease beyond the
    need for responding to emerging infectious diseases. Nonhuman primates
    have been essential for understanding human biology and developing
    treatments for diseases, mostly because of our shared anatomy,
    physiology, and behavior. Importantly, the genetic sequence
    similarities between nonhuman primates and humans can reach up to 98.77
    percent, which has made nonhuman primates models critical for studying
    neurobiology, transplant tolerance and rejection, infectious diseases,
    reproductive biology, and regenerative medicine. More recent
    applications have been in regenerative medicine and gene therapy and
    editing. There is a rapidly emerging need for marmosets in the
    neurosciences where recent National Academies of Sciences, Engineering,
    and Medicine (NASEM) reports and the Brain Research Through Advancing
    Innovative Neurotechnologies (BRAIN) Initiative community have pointed
    out that demand far exceeds supply.\27\ Another critical area of
    intense need and research development is nonhuman primate models of
    Alzheimer's disease to develop therapies. Nonhuman primate models are
    commonly used for studies of visual systems, auditory systems,
    cognitive function, and brain connectivity. The single largest
    application of nonhuman primates continues to be in developing vaccines
    and therapies for HIV/AIDS.
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        \27\ www.nap.edu/read/25356/chapter/7.
    ---------------------------------------------------------------------------
        Research using animal models, including nonhuman primate models,
    has led to tremendous advances critical for saving countless lives and
    extending human life expectancy around the world. Until suitable non-
    animal models are developed, the complexity of human systems, both in
    health and in disease, can only be truly understood through
    complementary model systems with sufficient complexity, and nonhuman
    primates remain invaluable for this effort. When animal models are
    required, NIH will only conduct and support research in accordance with
    the highest scientific and ethical principles. To uphold these
    principles, the NIH budget includes investments in nonhuman primate
    facilities, resources, and enrichment.
        Question. Dr. Collins, how much funding, broken down by Institute
    or Center, has NIH repurposed for COVID-19 related lab reopenings or
    lost research activities?
        Answer. To support our recipients affected by the pandemic, the
    National Institutes of Health (NIH) provided extensions, both funded
    and unfunded, as well as administrative supplements, to address the
    unanticipated impacts of the pandemic. The NIH has also issued multiple
    funding opportunities for current recipients to repurpose existing
    awards and expand the scope of ongoing research to include coronavirus
    disease 2019 (COVID-19) research activities.\28\ Continued support for
    these projects is contingent on satisfactory progress, the availability
    of funds, and NIH Institute and Center (IC) funding priorities, which
    continue to change as the pandemic, and research on COVID-19
    progresses.
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        \28\ grants.nih.gov/grants/guide/COVID-Related.cfm.
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        Decisions related to individual awards are made by the funding NIH
    IC on a case-by-case basis, taking into account those critical factors.
    All requests to change the scope of an NIH grant award require prior
    approval from the awarding NIH IC, as stipulated in the NIH Grants
    Policy Statement, section 8.1.2.5.\29\
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        \29\ grants.nih.gov/grants/policy/nihgps/HTML5/section_8/
    8.1.2_prior_approval_
    requirements.htm#Change4.
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        The NIH continues to analyze the data on the impact of COVID-19 on
    the biomedical research community, and its potential impact on NIH
    budget and grant activities.
        Question. It is my understanding that one of the main issues NIH
    faced related to COVID-19 expenses was for post-doctoral candidates
    finishing their training, research, or fellowship.
        How has this issue been addressed and do you expect to see a
    funding issue related to the extension of some of these grant awards
    into fiscal year 2022?
        Answer. The coronavirus disease 2019 (COVID-19) pandemic, along
    with extensive mitigation measures, has adversely affected progress in
    many biomedical research settings. Evidence from multiple sources,
    including results from a survey during the fall of 2020, indicates
    legitimate concerns about career trajectory for early career
    scientists.\30\ Hearing these concerns, the National Institutes of
    Health (NIH) issued a Guide Notice detailing our approach to support
    early career scientists whose career trajectories may have been
    significantly affected by the pandemic.\31\ Specifically, NIH is
    providing an opportunity for recipients in their last year of NIH
    Fellowship (F) and NIH Career Development (K) awards who have been
    impacted by COVID-19 to request extensions.\32\ Such extensions will be
    considered on a case-by-case basis, within the existing availability of
    funds.
    ---------------------------------------------------------------------------
        \30\ nexus.od.nih.gov/all/2021/03/25/the-impact-of-the-covid-19-
    pandemic-on-the-extramural-scientific-workforce-outcomes-from-an-nih-
    led-survey/.
        \31\ grants.nih.gov/grants/guide/notice-files/NOT-OD-21-052.html.
        \32\ https://nexus.od.nih.gov/all/2021/02/08/extensions-for-early-
    career-scientists-whose-career-trajectories-have-been-significantly-
    impacted-by-covid-19/.
    ---------------------------------------------------------------------------
        Generally speaking, the NIH typically makes between 500 to 600 F
    and K extensions per year, the vast majority (more than 95 percent) of
    which are no-cost extensions. Only seven funded extensions were awarded
    in fiscal year 2019. In fiscal year 2020, the NIH awarded 548
    extensions, with 75 (14 percent) of these being funded extensions. Thus
    far in fiscal year 2021, 15 funded extensions are linked to NOT-OD-21-
    052, but we will have a much better sense of uptake as the fiscal year
    concludes. Though there appears to be a relative increase in the number
    of funded extensions commensurate with the pandemic, the absolute
    numbers remain low.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. What is the fully intended scope of ARPA-H? Will it
    address diseases beyond cancer, diabetes, and Alzheimer's, such as ones
    with more challenging markets? Do you have examples?
        Answer. The scope of the Advanced Research Projects Agency for
    Health (ARPA-H) is intended to be broad and, indeed, stretch beyond the
    areas initially identified by the President. There are a number of
    areas with substantial unmet needs--some examples include emerging
    infectious disease, rare and ultra-rare disease, and antimicrobial
    resistance--and, with targeted investments over time, breakthrough
    progress could be made. In addition to specific disease areas, ARPA-H
    intends to build capabilities and explore various platform
    technological approaches which may have broad applicability across a
    range of diseases and conditions. A recent commentary in Science \33\
    outlined some exciting concepts such as developing mRNA vaccines to
    prevent most cancers; creating molecular ``zip codes'' to more
    precisely target tissues and cell types while minimizing side effects;
    deploying holistic interventions that identify those at high-risk and
    leverage new telehealth approaches to eliminate racial disparities in
    maternal morbidity and mortality rates and premature births; and
    developing small, highly accurate, inexpensive, non-intrusive, wearable
    24/7 monitors for blood pressure and blood sugar. While these examples
    are meant to illustrate the breadth of potential projects that ARPA-H
    could support, we believe it is projects like these that can have a
    significant impact for patients who are relying on biomedical research
    and innovation to live longer, healthier lives.
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        \33\ science.sciencemag.org/content/373/6551/165.
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        Question. Additionally, how will ARPA-H fit into the larger health
    focused R&D structure? How will its role be defined as unique among the
    various funding programs, and will there be coordination with other
    entities such as BARDA to ensure cooperation and avoid duplication?
        Answer. The Advanced Research Projects Agency for Health (ARPA-H)
    is meant to become an integral component of the constellation of
    agencies focused on promoting health and research and development--both
    within and beyond NIH and HHS. As described in a recently published
    commentary in Science,\34\ ARPA-H should be housed as a new entity
    within NIH. The rationale for this organizing principle is two-fold.
    First, the goals of ARPA-H fall squarely within the mission of the NIH,
    which is ``to seek fundamental knowledge about the nature and behavior
    of living systems and the application of that knowledge to enhance
    health, lengthen life, and reduce illness and disability.'' Second, the
    NIH offers a rich source of fundamental health research that will be
    foundational for a constructive, collaborative, and productive
    relationship with ARPA-H. We envision robust collaborations on
    synergistic topics with the existing NIH Institutes and Centers, along
    with organizations both outside and within the government. The added
    benefit of housing ARPA-H within NIH is that it will create
    administrative efficiencies so that more resources can be directed
    toward the mission and help avert duplication of effort.
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        \34\ science.sciencemag.org/content/373/6551/165.
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        In mid-July, the Administration launched a Federal Joint Fast Track
    Action Committee (FTAC) intended to help steer the creation of ARPA-H
    and lay the groundwork for strong interagency coordination. OSTP and
    NIH serve as co-chairs of this committee that includes representatives
    from the Department of Agriculture, DARPA, Office of the Under
    Secretary of Defense for Research & Engineering, ARPA-E, BARDA, CDC,
    CMS, FDA, VA, EPA, NSF, and the Smithsonian Institution, among others.
    Bringing these entities together at an early stage will help ensure
    strong collaboration and coordination among the various research-
    focused organizations throughout the Federal Government. The agency
    personnel who sit on the FTAC will also be a valuable source of insight
    and advice as ARPA-H is launched.
                                     ______

                Questions Submitted by Senator Patrick J. Leahy
        Question. I strongly support the Administration's renewed approach
    to innovation in medical research through the establishment of the
    Advanced Research Projects Agency for Health (ARPA-H). COVID-19 has
    shown that a commitment to breakthrough innovation, directed allocation
    of resources, and collaborative approaches can accelerate how
    scientific breakthroughs can be transitioned to treatments and cures.
    The administration has proposed that the agency will focus on
    innovative treatments in cancer, Alzheimer's disease, and opioid
    disorders. Several institutions in Vermont are national leaders in
    these stated research fields despite their smaller and more rural
    nature. While I strongly support any efforts to accelerate innovation,
    I am concerned that valuable collaborators could be left out or lose
    out on Federal funding, particularly if there is no traditional grant
    application process.
        What role will smaller and more rural research institutes play in
    ARPA-H? If projects are funded outside a grant application process,
    will there be established guidelines to include collaborators from
    rural or traditionally underrepresented areas?
        Answer. Over the long term, the proposed structure for the Advanced
    Research Projects Agency for Health (ARPA-H) is intended to empower the
    ARPA-H leadership and staff to set and execute on research priorities
    for a variety of high-risk, high-reward, milestone-driven projects that
    can lead to novel capabilities, platforms, and resources that are
    applicable to a range of diseases. These priorities include the
    opportunity to fund smaller and more rural research institutes.
        For the initial direction, the Administration is working to set up
    multiple pathways, both within the government and the broader
    stakeholder community, for priority setting and for exploring new areas
    ripe for research at ARPA-H. At the time of this hearing, the White
    House Office of Science and Technology Policy (OSTP) and the National
    Institutes of Health (NIH) are in the planning phases of convening
    multiple listening sessions with key stakeholder groups including
    patient organizations, industry, venture capitalists and
    philanthropists, and others from the academic and research communities.
    During these sessions, stakeholders will be asked to offer their
    perspective on what they see as the greatest research challenges and
    opportunities that could be addressed using the ARPA-H model. This
    input will help refine the scope and provide a wealth of ideas for the
    first ARPA-H director to consider as they develop the agency's vision.
        In mid-July, the Administration established a Joint Fast Track
    Action Committee (FTAC) to help steer the creation of ARPA-H and lay
    the groundwork for strong interagency coordination. OSTP and NIH serve
    as co-chairs of this committee that includes representatives from
    Department of Agriculture, DARPA, Office of the Under Secretary of
    Defense for Research & Engineering, ARPA-E, BARDA, CDC, CMS, FDA, VA,
    EPA, NSF, and the Smithsonian Institution, among others.
        Soliciting a diversity of perspectives and approaches will be a key
    tenet of the Advanced Research Projects Agency for Health (ARPA-H).
    Much like DARPA and ARPA-E, it will do so by supporting the best
    strategies to solve an identified challenge and by pursuing multiple
    approaches. Program managers will also have the authority to combine
    proposals from different institutions to assemble the boldest, most
    innovative portfolio, allowing each team to build on their strengths
    while benefiting from the knowledge, expertise, and resources from
    other institutions. ARPA-H will also provide awards that range in size
    and mechanism--from smaller, pilot projects to develop a prototype, to
    complex multi-site trials, to prizes that stimulate healthy competition
    and ingenuity. Further, ARPA-H will support a Small Business Innovation
    Research (SBIR) and Small Business Technology Transfer (STTR) program
    with business development, commercialization, and other resources to
    provide small businesses with the tools they need to be successful.
    These approaches are examples of mechanisms that ARPA-H will utilize to
    support a range of organizations across the country which may include
    small and/or rural institutions, and its portfolio will be regularly
    evaluated to ensure there is diversity of perspective. Because ARPA-H
    will be a nimble, dynamic organization, it will be able to readily
    pivot to experiment with new approaches.
        Question. Chronic pain is a significant public health issue
    affecting an estimated 50.2 million Americans each year. Based on data
    from the National Health Interview Survey (NHIS), the total value of
    lost productivity due to chronic pain is estimated to be nearly $300
    billion annually. With little known about alternatives for treating and
    managing relief from pain, medical providers are often limited to
    prescribing highly addictive opioids or muscle relaxants to help
    patients mitigate symptoms from pain. Scientific research suggests that
    long term use of such medications can result in the body's reduction of
    its own ability to fight pain. Even for patients who do not experience
    direct abuse or addiction with long term use, scientists have found
    that withdrawal symptoms are present when patients stop taking these
    medications. Unfortunately, research into addiction and alternatives to
    treatment has historically lagged at NIH. Enhanced research on chronic
    pain management and treatment, other than through the use of highly
    addictive opioid painkillers, has the potential to reduce substance
    abuse and promote better methods for addressing pain.
        I strongly support the NIH Heal Initiative to find solutions to
    curb the national opioid public health crisis by understanding,
    managing, and treating pain. Please describe any progress made by the
    HEAL Initiative on medication development to alleviate pain and to
    treat addiction. What remains the biggest barrier to research to
    investigate new and alternative options to treat chronic pain?
        Answer. The National Institutes of Health (NIH) recognizes the need
    to improve pain management without risk of addiction and other serious
    side effects. NIH is taking a multi-pronged approach to develop safe
    and effective therapies to reduce our reliance on opioids and treat
    addiction. The NIH Helping to End Addiction Long-term (HEAL) Initiative
    launched in 2018 has awarded over $1.5 billion for research to discover
    and accelerate development of non-addictive pharmacological and non-
    pharmacological pain treatments, as well as treatments for opioid use
    disorder (OUD) and overdose.
        Through the HEAL Initiative, NIH supports over 70 targeted studies
    to accelerate the development of treatments for OUD, including novel
    medications and biologic agents, as well as novel formulations of
    approved medications to treat OUD and prevent opioid overdose. To date,
    16 Investigational New Drug Applications were filed with the U.S. Food
    and Drug Administration and authorized to proceed for human studies.
    These studies focus on a variety of drug targets, as well as vaccines
    that could prevent opioids from entering the brain. HEAL currently
    funds nine opioid vaccine projects including vaccine candidates
    targeting oxycodone,\35\ fentanyl \36\ and heroin.\37\ This strategy
    could offer more accessible, manageable treatment through longer-
    lasting vaccines to reduce the risk of relapse.
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        \35\ reporter.nih.gov/search/Pcd2IghkPU6lnJkOT7FlFQ/project-
    details/9778811.
        \36\ reporter.nih.gov/search/Wp_sHzUhIUuYqDimSa90iw/project-
    details/9737173.
        \37\ reporter.nih.gov/search/GNnJWbYvQUeIlbwhgFofXA/project-
    details/9734921.
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        HEAL-supported work also includes studies to identify, optimize and
    test promising molecules, biologics, and devices for treating pain that
    target non-opioid pathways in the nervous system. Biomarker studies to
    enhance clinical trials and improve best practices are moving forward.
    In addition, non-pharmacological approaches to manage many different
    pain conditions are being evaluated through effectiveness and
    implementation research approaches.
        In these ways, HEAL is providing much needed resources to advance
    research on new and safe alternatives to opioids for chronic pain. The
    complexity and diverse nature of chronic pain itself along with a high
    prevalence of other co-occurring chronic conditions such as diabetes,
    depression, and autoimmune disorders create an enormous challenge for
    advancing research.
        Mechanisms for the causes of different pain conditions vary,
    biomarkers for patient response to treatment and likelihood for
    progression of disease also are characteristic of the disease
    condition. In addition, treatments for co-morbidities require careful
    balancing and often long- term multidisciplinary care. These and other
    factors require an expanded breadth and scope of pain research to
    better provide personalized care for those with chronic pain. The
    Federal Pain Research Strategy \38\ describes research priorities to
    relieve the burden of pain. The NIH HEAL initiative provided support to
    move many of the report's recommendations forward.
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        \38\ www.iprcc.nih.gov/federal-pain-research-strategy-overview.
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        Specifically, the NIH HEAL initiative established essential pain
    research infrastructure to accelerate development of new medications
    and devices to treat pain. An analgesic screening platform uses animal
    and human cell-based models such as neural tissue chips for rapid
    screening of molecules or devices for analgesic-relevant biological and
    pain behavioral activity. HEAL, with input from academic and industry
    partners, established an Early Phase Pain Investigation Clinical
    research network (phase 2 studies) to test safety and efficacy of novel
    therapeutics and a later stage pain management Effectiveness Research
    Network (ERN) to compare effectiveness of pharmacological and non-
    pharmacological approaches in many different pain conditions. The
    Pragmatic and Implementation Studies for the Management of Pain to
    Reduce Opioid Prescribing (PRISM) network focuses on clinical trials of
    non- pharmacologic pain therapies in healthcare systems. The Phase 2
    network will launch trials on two new analgesics in late 2021. The ERN
    is supporting eight large trials for various pain management
    strategies. PRISM is supporting six large trials in healthcare systems.
    In addition, HEAL established an analgesic development pipeline to
    accelerate the development and testing of novel drugs and devices. This
    comprehensive program uses team-based science coupled with a
    comprehensive set of research resources to bring new therapeutics
    rapidly to the clinic. To advance the discovery and validation of new
    drug targets, HEAL has funded over 30 projects to discover and verify a
    diverse set of drug target types across multiple pain conditions, six
    drug optimization studies on new safe and effective pain treatments,
    and 11 projects to test the effectiveness of implanted devices and
    noninvasive stimulation of nerves in the brain or throughout the body
    to reduce perception of pain. In addition, to improve the efficacy of
    clinical trials for pain treatments, and to increase the chance that
    new therapeutics will advance along the regulatory path to approval,
    HEAL tests the development of biomarkers to objectively measure pain,
    including pain associated with sickle cell disease, musculoskeletal
    disease, nerve pain and headache. Promising biomarkers identified
    through this program may advance to clinical validation through the
    Early Phase Pain Investigation Clinical Network (EPPIC-Net). Findings
    from these studies could improve quality of life for millions of people
    in the United States who experience pain daily. Recent HEAL
    accomplishments toward new therapeutics include two patent filings for
    small molecule modulators of pain receptors involved in chronic pain
    and migraine.
        New directions for HEAL will also continue to pursue goals laid out
    in the Federal Pain Research Strategy,\39\ including demonstration
    projects to aid in the development of a coordinated approach to pain
    management in healthcare systems. This effort would assess multi-
    disciplinary and multimodal approaches to pain management embedded in
    healthcare systems. Research within systems of pain care would allow
    for effective interventions to be adopted into the healthcare system
    and improve access for patients. Focused discussion with select
    healthcare program leadership would identify pain conditions of
    greatest opportunity, with an emphasis on effectiveness research,
    quality management and team-based care. This effort would seek to
    leverage existing infrastructure through ongoing collaborative and
    interagency efforts.
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        \39\ www.iprcc.nih.gov/federal-pain-research-strategy-overview.
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        Another specific effort in development aims to advance health
    equity to address the wide disparities in care and treatment for pain
    and addiction, known to result in both the undertreatment and
    overtreatment with opioids, increased risk of addiction and overdose,
    lack of access to effective non-pharmacological options for pain
    treatment, and lack of access to evidence-based addiction care.
    Disparities in pain management exist across multiple levels: pain
    assessment, treatment, and management at the patient, provider,
    community, and healthcare system levels. Planned expansion to HEAL
    includes the development and implementation of culturally appropriate
    interventions for the prevention and management of pain and addiction
    in diverse populations, with a focus on sustainable and scalable
    interventions that can be rapidly implemented by healthcare systems.
        In addition, recent discoveries in human genetics and molecular
    biology will be incorporated into the development of a novel team-based
    platform to rapidly test targets and candidate therapeutics for diverse
    human pain conditions and share findings with the wider pain research
    community. This research will address pain systems and allow for a
    variety of research questions including conditions of chronic analgesic
    use, other drug use, substance use disorders (SUDs) and other co-morbid
    conditions, and will enable and accelerate human gene- and cell- based
    validation of pain therapeutic targets through the HEAL initiative and
    other pipelines. This will build on existing HEAL research on
    preclinical and translational research in pain, and ongoing efforts to
    accelerate the development of novel treatments for pain. Through these
    and other efforts at HEAL and across the NIH, we aim to continue to
    improve our understanding of pain and develop non-addictive, effective
    therapies.
        Question. Migraine is currently the second leading cause of all
    global disability. Unfortunately, due in part to limited research and
    treatment, inappropriate opioid prescriptions for migraine present
    Americans with ongoing risks of opioid use disorders and have worsened
    outcomes in patients. Overall, 6 million Americans living with
    migraines are active opioid users. I strongly support the NIH Heal
    Initiative to find solutions to curb the national opioid public health
    crisis by understanding, managing, and treating pain. While migraine
    grant proposals are eligible for consideration under the HEAL request
    for applications (RFAs) issued for pain research, less than 1 percent
    of HEAL Initiative appropriations have funded headache disorders
    research--the least funded NIH area among all the nation's burdensome
    diseases. I am very concerned about the failure to attract enough
    investigators to this historically under-funded research area.
        Does NIH have plans to issue specific RFA programs for headache
    disorders research, comparable in scope to the Back Pain Consortium
    (BACPAC) group of RFAs for research on back pain?
        Answer. The National Institutes of Health (NIH) recognizes the
    burden of pain at the individual and population levels and that
    headache disorders are prevalent and disabling conditions which affect
    millions of Americans. The NIH launched the HEAL Initiative (Helping to
    End Addiction Long-term) to improve pain care and better prevent and
    treat opioid use disorder. Priorities of the HEAL initiative, developed
    with our stakeholders with expertise in pain research and care, include
    enhanced understanding of pain, discovery and validation of novel pain
    therapeutic targets, testing therapies in clinical settings, and
    accelerating the process to bring new therapies to patients. The
    initiatives are, or were, open to all pain conditions. The HEAL
    initiative also established much needed research infrastructure to
    support innovative science. Headache research fits within the scope of
    all these initiatives and will benefit from the enhanced
    infrastructure.
        HEAL funding solicitations call for proposals across all pain
    conditions. NIH staff recognizes the low submission rate of headache
    applications and broadly disseminates information on HEAL and other
    funding announcements to the research community to encourage
    submissions. Most funding announcements specifically cite headache as
    an area of interest and others are inclusive of headache. Low back pain
    is an exception among pain conditions in that it has unique research
    gaps such as lack of diagnostic tools and technologies, no accepted
    common data elements, poor diagnostic criteria, complex etiology, and
    lack of an adequate evidence base for effective practice guidelines.
    The HEAL Back Pain Consortium (BACPAC) initiative was launched to fill
    these extensive gaps to improve pain care across the spectrum of low
    back pain.
        Migraine and other headache disorders have good classification
    schemas, a range of effective treatment therapies whose development was
    supported by NIH research, and evidence-based diagnostic categories and
    treatment protocols (International Headache Society). Our understanding
    of migraine etiology is more advanced than that for back pain. NIH has
    supported transformative basic research that advanced our knowledge of
    migraine mechanisms, causes, and predictors, biomarker identification,
    and new therapy development. For example, NIH supported investigators
    provided the foundation for development of CGRP antibodies now used
    widely for migraine therapy. NIH sponsored research also contributed to
    understanding how migraine auras activate nociceptors and initiate a
    migraine, and the mechanism of action for new migraine therapies such
    as vagus nerve stimulation. Basic research on potassium channels,
    delta, or kappa opioid receptors, and TRP channels fundamentally
    increased our understanding of trigeminal nociceptors and their
    involvement in initiating a migraine, giving us new targets for
    potential treatments. An NIH sponsored pivotal pediatric migraine
    clinical trial changed clinical practice for children with chronic
    daily headaches.
        NIH and HEAL leadership recognize that far too many headache
    sufferers are prescribed opioids despite clear clinical practice
    guidelines that call for non-opioid effective alternatives rather than
    opioids. This practice reflects the sparsity of headache specialists
    and the lack of and education of our primary care providers who are
    often the first to treat those with disabling migraines. NIH also
    recognizes the need to expand the headache research workforce. The HEAL
    initiative recently released funding announcements to support training
    and mentorship of early and mid- career researchers in the field of
    basic, translational, and clinical pain research. We encourage those
    interested in headache research to benefit from these opportunities.
                                     ______

                    Questions Submitted to Dr. Anthony Fauci
                Questions Submitted by Senator Richard J. Durbin
        Question. I have received a lot of questions from Illinois
    families, who are hoping for more clarity on the CDC's most recent mask
    guidelines. Many vaccinated parents--with unvaccinated children at
    home--are wondering if they should be wearing masks when out in public.
        What advice would you give to vaccinated parents who have
    unvaccinated children at home?
        When do you think we will have a COVID vaccine approved for
    children younger than 12 years of age?
        Answer. Currently authorized coronavirus disease 2019 (COVID-19)
    vaccines meet the U.S. Food and Drug Administration's (FDA's) rigorous
    standards for safety and effectiveness, and current data suggest that
    fully vaccinated people are less likely to transmit severe acute
    respiratory syndrome coronavirus 2 (SARS-CoV-2) to others. According to
    the Centers for Disease Control and Prevention (CDC), fully vaccinated
    people--including those living with unvaccinated children or
    adolescents--can resume activities without wearing masks or physically
    distancing, except where required by Federal, state, local, tribal, or
    territorial laws, rules, and regulations. Individuals ages 2 and older
    who are unvaccinated, however, should continue to wear masks in public
    and when around people who do not live in their household, except when
    eating or sleeping. CDC will continue to evaluate and update public
    health recommendations for fully vaccinated people as more information,
    including on Delta and other new variants, becomes available.
        Efforts to evaluate COVID-19 vaccines in children under age 12
    currently are underway, and a COVID-19 vaccine may be available for
    this age group by the end of 2021. On March 16, 2021, Moderna, in
    collaboration with the National Institute of Allergy and Infectious
    Diseases (NIAID) and the Biomedical Advanced Research and Development
    Authority (BARDA), launched KidCOVE, a Phase 2/3 study to evaluate the
    safety and efficacy of the Moderna COVID-19 vaccine in children ages 6
    months to less than 12 years. Pfizer also is conducting a Phase 1/2/3
    trial to evaluate its COVID-19 vaccine in this age group. In addition,
    other vaccine developers are planning to begin trials to test their
    vaccine candidates in children. Until a COVID-19 vaccine is available
    for children under age 12, it will be important for all individuals,
    especially children and other unvaccinated individuals, to continue to
    follow all public health measures for COVID-19 advised by the CDC,
    including frequent hand washing and the use of masks and social
    distancing in certain settings.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. My home state of West Virginia is battling an epidemic
    during the middle of a pandemic. My state has been devastated by the
    drug epidemic, COVID-19, and we now lead the nation in new HIV
    infection rates. You have spent much of your career focused on the
    prevention, diagnosis, and treatment of HIV/AIDS. Your research has
    been instrumental in saving countless lives in the United States and
    around the world. The National Institute of Allergy and Infectious
    Diseases supports initiatives focused on diagnosing, treating,
    preventing and responding to the HIV epidemic in the United States.
    These efforts represent steps in the right direction, but will not
    alone end West Virginia's increasing numbers of new HIV infections and
    other opioid-related infectious diseases.
        What is being done to replicate testing and surveillance efforts we
    saw put into place for COVID-19 for other infectious diseases, like
    HIV/AIDS?
        What public health infrastructure would be required to bring better
    infectious disease testing and surveillance to fruition?
        Answer. The Federal response to coronavirus disease 2019 (COVID-19)
    relied heavily on the utilization and expansion of existing resources
    for human immunodeficiency virus (HIV) and other infectious diseases.
    By leveraging available resources, we have been able to accelerate the
    development of diagnostic tests and other medical countermeasures, as
    well as surveillance and community engagement efforts. In turn,
    knowledge gained from the COVID-19 response may inform strategies to
    address other infectious diseases such as HIV. This includes efforts
    undertaken by the U.S. Department of Health and Human Services (HHS) to
    end HIV in the United States by 2030 through the Ending the HIV
    Epidemic in the U.S. (EHE) initiative. EHE is coordinating across HHS
    agencies and with patient, community, academic, and other partners to
    plan, design, and deliver local HIV prevention and care services. This
    ``whole-of-society'' approach is a model for ending both the HIV
    epidemic as well as the COVID-19 pandemic. Proper diagnosis and
    treatment of HIV are key components of this initiative, and efforts to
    improve testing and surveillance for HIV are ongoing.
        An important aspect of the response to the COVID-19 pandemic as
    well as the HIV epidemic is community engagement. The National
    Institute of Allergy and Infectious Diseases (NIAID), in cooperation
    with the Department of Defense, established the COVID-19 Prevention
    Network (CoVPN) by leveraging existing NIAID-funded clinical trials
    networks, including networks focused on HIV treatment and prevention.
    The CoVPN built on existing community relationships to enhance trust
    and meaningful engagement in key racial and ethnic minority communities
    throughout the United States to promote diverse participation in
    clinical trials for COVID-19. The community relationships enhanced by
    the CoVPN may be further leveraged to advance efforts, including
    testing and surveillance, for HIV and other infectious diseases.
        The National Institutes of Health (NIH) also anticipates that the
    rapid establishment of COVID-19 testing and surveillance may help to
    address HIV and other infectious diseases. NIH launched the Rapid
    Acceleration of Diagnostics (RADx) initiative to speed innovation in
    technologies to test for severe acute respiratory syndrome coronavirus
    2 (SARS-CoV-2), in partnership with the Biomedical Advanced Research
    and Development Agency (BARDA), the Centers for Disease Control and
    Prevention (CDC), the U.S. Food and Drug Administration (FDA), and the
    Defense Advanced Research Projects Agency (DARPA). As part of RADx, NIH
    and CDC are evaluating whether frequent self-administered, at-home
    SARS-CoV-2 testing helps reduce community transmission of SARS-CoV-2.
    Efforts to develop and deploy rapid, point-of- need diagnostics for
    SARS-CoV-2--including at-home testing kits--may inform community-based
    testing and surveillance strategies for other infectious diseases,
    including HIV.
        NIH and NIAID will continue to build on investments in improved
    diagnostic tests for SARS- CoV-2 to support the development of novel
    diagnostic tests for other infectious diseases such as HIV. In
    addition, lessons learned on the best way to integrate and expand on
    existing research efforts and infrastructure will be invaluable as we
    continue to prepare for--and respond to-- other existing and emerging
    infectious disease threats.
        As discussed in response to part a of this question, the Federal
    response to the COVID-19 pandemic has strengthened existing
    partnerships and coordination mechanisms, as well as established new
    partnerships that will inform the response to future infectious disease
    pandemics and existing epidemics, such as the HIV/AIDS epidemic in the
    United States. The coordinated efforts through RADx and the CoVPN
    allowed us to leverage the intrinsic strengths from public and private
    sector partners to achieve an unprecedented level of scientific
    achievement and community engagement. When the COVID-19 pandemic ends,
    lessons learned from our experiences with RADx and the CoVPN will
    continue to help inform efforts to address other infectious disease
    threats.
        NIH and NIAID will continue to work with HHS Operating Divisions
    and other Federal agencies to identify the actions that were most
    effective in responding to the COVID-19 pandemic. This information may
    result in new initiatives, strategic plans, and/or formal assessments
    of pandemic preparedness.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
        Question. As America begins to assist the world to vaccinate all
    who want it, the current vaccine options can be problematic for
    countries without the infrastructure to store vials in a cooled or
    frozen environment.
        How beneficial could an effective, intranasal vaccine option be for
    developing countries that cannot store the current vaccines at frigid
    temperatures or produce the healthcare workers to give the shot?
        Do you see this option benefitting Americans who may be hesitant to
    receive the current vaccine dosage in a shot?
        Answer. Global access to safe, effective vaccines will be critical
    to address the coronavirus disease 2019 (COVID-19) pandemic. Limiting
    the spread of the severe acute respiratory syndrome coronavirus 2
    (SARS-CoV-2) virus in foreign countries helps to control the pandemic
    in those countries while also limiting the development and spread of
    variants that could eventually be introduced into the United States. To
    enhance vaccine availability in foreign countries, the Biden
    Administration has supported and contributed to COVAX, a global
    mechanism for equitable access to COVID-19 vaccines. COVAX has
    delivered COVID-19 vaccines to more than 100 countries, the majority of
    which have lower-income economies. The United States also has made
    millions of doses of COVID-19 vaccines available to other countries to
    support vaccination campaigns around the world.
        Existing COVID-19 vaccines are being successfully administered
    globally, and several COVID-19 vaccines authorized for emergency use or
    in clinical testing in the United States can be shipped and stored at
    refrigerator temperatures (2-8 degrees Celsius). Still, the development
    of vaccines that can be administered with less skill and/or stored at
    warmer temperatures have the potential to expand vaccination efforts
    both in the United States and abroad. The National Institute of Allergy
    and Infectious Diseases (NIAID) is supporting the development of
    vaccine candidates and platforms that may be more accessible and
    convenient than currently available COVID-19 vaccines, including a
    single-dose intranasal SARS-CoV-2 vaccine candidate called ChAd-SARS-
    CoV-2-S. NIAID scientists and collaborators recently showed that the
    intranasal ChAd-SARS-CoV-2-S vaccine candidate limited infection in
    non-human primates. Novel vaccines with alternative administration
    strategies, such as intranasal vaccines, may reduce barriers to
    transporting and administering vaccines in developing countries. It is
    important to note, however, that these vaccines may still need to be
    kept at low temperatures or may require administration by a healthcare
    provider with specialized training to ensure accurate dosing and
    administration. For example, FluMist Quadrivalent--a U.S. Food and Drug
    Administration-approved intranasal vaccine against influenza--must be
    administered by a healthcare provider in the United States.
        In addition, National Institutes of Health (NIH) scientists and
    NIH-supported researchers are studying additional vaccine delivery
    technologies, including vaccines that can be orally administered or
    that utilize microneedles in patches placed on the skin to deliver the
    vaccine. For example, NIH scientists have begun preclinical evaluation
    of a virus-like-particle-based vaccine candidate for SARS-CoV-2 that
    can be administered orally, and NIH-supported researchers are
    evaluating a patch-based vaccine for SARS-CoV-2. An NIH-supported Phase
    I trial of a patch-based vaccine candidate for influenza showed that
    individuals that received the vaccine had a similar immune response to
    those receiving the influenza vaccine via intramuscular injection. NIH
    also is supporting the development of another promising patch-based
    vaccine candidate for influenza that uses biodegradable microneedles
    originally developed through NIH-supported research to stabilize
    vaccines and antibiotics outside of the cold chain. Although additional
    testing will be necessary, orally administered and patch-based vaccines
    may prove to be an invaluable tool in resource-limited settings as they
    may require little to no refrigeration, as well as less training to
    administer correctly.
        As we work to address the COVID-19 pandemic, as well as other
    infectious disease threats, recent innovations in vaccine technology
    will help make it easier to get vaccines to areas that can be difficult
    to serve with traditional vaccines. NIH continues to support research
    on intranasal, oral, and patch-based vaccine platforms, all of which
    could be highly adaptable for use against a number of infectious
    pathogens.
        Vaccines that can be administered intranasally may be considered
    less invasive than those that require an injection. Such an option may
    encourage individuals who are hesitant to receive the COVID-19 vaccines
    currently authorized for emergency use in the United States, which are
    all administered via intramuscular injection, to become vaccinated.
    Additional vaccine delivery technologies, such as oral or patch-based
    vaccines may also provide additional flexibilities when trying to reach
    individuals in resource-limited areas or who are vaccine hesitant or
    needle adverse. As noted in the response to part a of this question,
    NIAID is supporting and will continue to support the development of
    vaccine candidates with different delivery technologies to reduce
    vaccine hesitancy as well as barriers to vaccine access.
                                     ______

      Questions Submitted to Dr. Diana Bianchi and Dr. Eliseo Perez-Stable
                Questions Submitted by Senator Richard J. Durbin
        Question. Our nation continues to struggle with racial disparities,
    especially in maternal health. The U.S. is one of only 13 countries
    where our nation's maternal mortality rates are worse now than they
    were 25 years ago. Every year, 700 women in the U.S. die as a result of
    their pregnancy--and more than 60 percent of these deaths are
    preventable. Tragically, African American and Hispanic women are three
    times as likely as White women to die from pregnancy-related issues.
    For years, I have introduced the MOMMA's Act with Rep. Robin Kelly, and
    I'm so pleased that a major component of our bill was recently signed
    into law as part of the American Rescue Plan. Now states can follow in
    Illinois' footsteps by allowing new moms to keep their Medicaid
    coverage for a full year, versus just 60 days.
        What research NIH is doing in this space?
        How is NIH working to actually improve maternal and infant
    healthcare?
        Answer. Maternal health is a priority for the National Institutes
    of Health (NIH) and multiple NIH institutes have heavily invested in
    research to prevent maternal morbidity and mortality (MMM) and improve
    health for women, before, during, and after pregnancy. In fiscal year
    2020 NIH supported $407 million in research on maternal health and $224
    million in research on MMM.
        In a year that was dominated by both the coronavirus disease 2019
    (COVID-19) pandemic and renewed calls to combat health disparities and
    inequities, NIH ensured these challenges were integrated into efforts
    to reduce MMM. In March 2020, researchers in the Eunice Kennedy Shriver
    National Institute of Child Health and Human Development's (NICHD)
    Maternal-Fetal Medicine Units Network designed the Gestational Research
    Assessments for COVID-19 (GRAVID) study, which evaluated data from more
    than 1,200 pregnant women at 33 hospitals across the country and found
    that pregnant COVID-19 patients with severe disease are at higher risk
    for cesarean delivery, postpartum hemorrhage, hypertensive disorders of
    pregnancy, and preterm birth. Data from the study is being shared with
    a larger registry to inform future studies of COVID-19's effects on
    pregnancy and maternal health.
        Tackling the challenge of reducing maternal MMM requires strong
    partnerships with and among local communities and resources,
    particularly with racial and ethnic minority populations that
    experience stark health disparities. To that end, several NIH
    Institutes, Centers, and Offices (ICOs) held community engagement
    activities to hear first-hand how patient communities can inform future
    research and what engagement strategies might enhance local efforts to
    improve maternal health. A common refrain was that research conducted
    in a community should be developed with and vetted by the community to
    ensure success and improved outcomes. These engagement activities
    informed the development of the IMPROVE (Implementing a Maternal health
    and PRegnancy Outcomes Vision for Everyone) Initiative, which aims to
    build an evidence base that will improve maternal care and outcomes
    from pregnancy through 1 year postpartum. IMPROVE is co-led by NICHD
    and the NIH Office of Research on Women's Health and engages over 30
    ICOs to research the leading causes of maternal mortality in the United
    States--cardiovascular disease, infection, and immunity--as well as
    contributing health conditions or social factors, such as mental health
    disorders, diabetes, obesity, substance use disorders, and structural
    and healthcare system issues that disproportionately affect Black
    pregnant and postpartum women. IMPROVE prioritizes comprehensive,
    interdisciplinary research that engages communities with high rates of
    maternal deaths and complications. This work will help create tailored,
    evidence-based solutions for pregnant and postpartum women.
        NIH research on MMM generates evidence that improves outcomes and
    clinical care, and several NIH Institutes have strong investments in
    this space. For example, an NICHD-funded study demonstrated that when
    hospitals implemented evidence-based recommendations for clinical
    practice there was a reduction in the risk of severe maternal morbidity
    from obstetric hemorrhage, a common complication of childbirth. The
    reduction was more dramatic for Black women more than for White women,
    reducing disparities and improving outcomes. NICHD is also supporting a
    machine learning framework to predict severe maternal morbidity.
    Researchers aim to analyze population-based data from Maryland state
    databases and hospital surveys to develop techniques that can predict
    maternal risks early. Identifying key predictors of severe maternal
    morbidity can help ascertain health disparities, strengths and
    weaknesses in obstetric care, and prevent adverse maternal and neonatal
    outcomes.
        In fiscal year 2020, the National Institute on Minority Health and
    Health Disparities (NIMHD) started an initiative entitled Addressing
    Racial Disparities in Maternal Mortality. This initiative supports
    multidisciplinary research projects that examine the clinical, social,
    behavioral, and healthcare system interventions to address racial
    disparities in MMM in the United States. Additionally, NIMHD funded the
    Maternal and Developmental Risks from Environmental and Social
    Stressors (MADRES) project in collaboration with the National Institute
    on Environmental Health Sciences, to examine prenatal environmental
    exposures and social stressors in relation to depression and
    cardiovascular risk factors postpartum.
        The National Heart, Lung, and Blood Institute (NHLBI) is weaving
    together a network of community-engaged researchers who will not only
    work to improve women's heart health and reduce maternal mortality, but
    will also address other health disparities. For example, NHLBI's new
    Maternal Health Community Implementation Program, will fund three or
    four regional coalitions to pilot test community-based strategies in
    areas where maternal death rates are high, particularly in the
    southeast. Additionally, NHLBI's Early Intervention to Promote
    Cardiovascular Health of Mothers and Children (ENRICH) will tap into
    existing Federal home health/wellness programs that serve at-risk
    families to determine if adding a cardiovascular intervention will
    enhance maternal and early childhood outcomes. Approximately 3,000
    mother- child pairs across various sites will be reached as part of
    this effort.
        These are just a few examples of how NIH's broad investment in
    addressing MMM is improving maternal and infant care.
                                     ______

                 Questions Submitted by Senator Jeanne Shaheen
        Question. I am hopeful that our continued investment in the Special
    Diabetes Program, and diabetes research at NIH as a whole, can help
    spur a new wave of breakthroughs, and maybe one day a cure for
    diabetes.
        Now that Congress has secured longer-term funding for the Special
    Diabetes Program, can you please provide information on NIH's priority
    areas for Special Diabetes Program research in the years to come?
        Answer. The National Institutes of Health (NIH) appreciates the
    recent extension of the Special Diabetes Program, which will allow us
    to continue critical ongoing research programs and to support new
    research to improve the health and quality of life of people with or at
    risk for type 1 diabetes and its complications. For example, the recent
    extension will allow the National Institute of Diabetes and Digestive
    and Kidney Diseases (NIDDK) to continue the Human Islet Research
    Network, which is working to better understand how insulin-producing
    cells are lost in type 1 diabetes and to find strategies to replace or
    protect them in people, toward curing the disease. NIDDK plans to begin
    new clinical trials through the Type 1 Diabetes TrialNet network,
    testing agents to prevent onset of clinical type 1 diabetes. Such
    research will build on the landmark success of previous TrialNet
    research demonstrating for the first time ever that early preventive
    treatment can delay onset of clinical type 1 diabetes in high-risk
    individuals. NIDDK also plans to support research building on the
    tremendous recent progress in developing transformative diabetes
    management technologies, such as artificial pancreas devices. For
    example, future research is needed to improve components of artificial
    pancreas devices (e.g., glucose sensors, hormone formulations), develop
    simpler and more user-friendly devices, and test devices in
    understudied populations (e.g., older adults, pregnant women, people
    with poorly controlled blood glucose levels). This type of research
    will move us closer to our goal of developing multiple different
    artificial pancreas technologies for people of all ages so that they
    can choose the technology best suited to their clinical needs. NIDDK
    also plans to support new research to identify novel ways to detect and
    monitor type 1 diabetes onset and progression, such as by determining
    whether ``extracellular vesicles'' that originate from pancreatic
    tissue may be useful to detect earlier stages of type 1 diabetes than
    currently possible. NIDDK is collaborating with the National Heart,
    Lung, and Blood Institute on new research toward reducing
    cardiovascular disease in people with type 1 diabetes, as very little
    is known about how best to prevent and treat this life-threatening
    complication. To inform other future research directions, NIDDK is
    spearheading a planning meeting in spring 2022 under the auspices of
    the statutory Diabetes Mellitus Interagency Coordinating Committee to
    obtain input from external scientific and lay experts on critical new
    and emerging research opportunities that could be supported by the
    Special Diabetes Program.
        Question. New Hampshire continues to be one of the hardest-hit
    states in the substance use disorder epidemic, with one of the highest
    overdose death rates in the country. I am very supportive of the
    ongoing work at the National Institute on Drug Abuse (NIDA) to research
    potential non-addictive alternatives to opioids for pain management.
        Could you discuss progress on any research within NIDA to study
    these types of alternatives?
        Answer. The National Institutes of Health (NIH) recognizes the need
    to improve pain management without risk of addiction and other serious
    side effects. NIH is taking a multi-pronged approach to develop safe
    and effective therapies to reduce our reliance on opioids.
        To avoid replay of the spike in opioid deaths related to over-use
    of medical opioids for pain management we need more effective, non-
    addictive pain medications and data that can inform best practices in
    pain care. The NIH Helping to End Addiction Long-term (HEAL) Initiative
    was launched in 2018 and significantly expanded research to discover
    and accelerate development of non-addictive pharmacological and non-
    pharmacological pain treatments. HEAL has awarded over $1.5 billion for
    research to improve pain management and address opioid use disorder and
    overdose. Studies supported by HEAL, the Blueprint Neurotherapeutics
    Program, and multiple NIH Institutes, in particular the National
    Institute for Neurological Disorders and Stroke (NINDS), are underway
    to identify, optimize and test promising molecules, biologics, and
    devices that target non-opioid pain pathways in the nervous system.
    Biomarker studies to help with diagnosis of pain conditions and to
    identify patients most likely to respond to a particular treatment will
    enhance pain clinical trials and improve best practices are moving
    forward. In addition, non-pharmacological approaches to manage many
    different pain conditions are being evaluated through effectiveness and
    implementation research approaches.
        The NIH HEAL initiative established essential pain research
    infrastructure to accelerate development of new medications and devices
    to treat pain. An analgesic screening platform uses animal- and human
    cell-based models such as neural tissue chips for rapid screening of
    molecules or devices for analgesic relevant biological and pain
    behavioral activity. HEAL, with input from academic and industry
    partners, established an Early Phase Pain Investigation Clinical
    research network (phase 2 studies) to test safety and efficacy of novel
    therapeutics and a later stage pain management Effectiveness Research
    Network (ERN) to compare effectiveness of pharmacological and non-
    pharmacological approaches in many different pain conditions. The ERN
    is supporting eight large trials for various pain management
    strategies. The Pragmatic and Implementation Studies for the Management
    of Pain to Reduce Opioid Prescribing (PRISM) network focuses on
    clinical trials of non-pharmacologic pain therapies in healthcare
    systems.
        The Phase 2 network will launch trials on two new analgesics in
    2021. The ERN is supporting eight large trials for various pain
    management strategies. PRISM is supporting six large trials in
    healthcare systems. In addition, HEAL established an analgesic
    development pipeline to accelerate the development and testing of novel
    drugs and devices. This program uses team-based science coupled with a
    comprehensive set of research resources to bring new therapeutics
    rapidly to the clinic. To advance the discovery and validation of new
    drug targets, HEAL has funded over 30 projects to discover and verify a
    diverse set of drug target types across multiple pain conditions, six
    drug optimization studies on new safe and effective pain treatments,
    and 11 projects to test the effectiveness of implanted devices and
    noninvasive stimulation of nerves in the brain or throughout the body
    to reduce perception of pain. This effort greatly expands on NINDS
    supported studies in these areas.
        Recent HEAL accomplishments toward new therapeutics include two
    patent filings for small molecule modulators of pain receptors involved
    in chronic pain and migraine. One ongoing study received
    Investigational New Drug (IND) approval for use of buprenorphine with
    nonpharmacological treatment to relieve pain in patients undergoing
    kidney dialysis. Through the NIH Blueprint Neurotherapeutics Program
    researchers are developing non-addictive kappa opioid receptor
    antagonists for treatment of migraine and a safe, non-opioid epoxide
    hydrolase inhibitor to reduce diabetic nerve pain. Earlier, NIH
    supported basic science research led to calcitonin gene-related peptide
    therapy for migraine and nerve growth factor therapy for inflammatory
    pain. Drugs that target these molecules are now approved by the U.S.
    Food and Drug Administration to treat migraine and osteoarthritis pain.
    Through the Brain Research through Advancing Innovative
    Neurotechnologies (BRAIN) Initiative, which is a major effort to
    develop tools to map, monitor, and modulate neural circuits, NIH has
    supported studies that will enhance diagnostics and therapies for
    chronic pain and other neural circuit disorders.
        Question. The Institutional Development Award (IDeA) program at NIH
    has proven critical in funding New Hampshire researchers, including
    especially the innovative work at Dartmouth College and Dartmouth-
    Hitchcock Health. I am hopeful that Congress can continue to support
    funding for this program.
        Can you provide any insight into how NIH is currently making use of
    Institutional Development Award funds and whether more funding for the
    program would be helpful?
        Answer. The Institutional Development Award (IDeA) supports basic,
    clinical, and translational research, faculty development, and
    infrastructure improvements at institutions in states and territories
    that have historically received a lower aggregate level of NIH funding.
    The program aims to strengthen biomedical research capacity, enhance
    the competitiveness of investigators in securing research funding, and
    enable clinical and translational research that addresses the specific
    needs of rural and medically underserved communities. Currently,
    institutions in 23 States and Puerto Rico are eligible for funding
    through the IDeA Program, the various components of which include:
      --IDeA Networks of Biomedical Research Excellence (INBRE). INBRE
            enhances, extends, and strengthens the research capabilities of
            biomedical research faculty in IDeA states through a statewide
            program that links a research-intensive institution with
            primarily undergraduate institutions. INBRE supports
            institutional research and infrastructure development; research
            by faculty, postdoctoral scientists, and students at
            participating institutions; and targeted outreach to build
            science and technology knowledge within a state's workforce.
            Only one INBRE award is made per IDeA-eligible state. The New
            Hampshire INBRE, which is led by Dartmouth and co-led by the
            University of New Hampshire, is in its twelfth year of
            operation and has used the program's support to improve and
            expand research capacity at all eight of its partner
            institutions, including adding additional labs, cores and
            instrumentation/infrastructure; establishing fully functional
            Office of Sponsored Programs for faculty members to
            competitively seek extramural grants; training and mentoring of
            both faculty and students; and enhancing a vibrant
            institutional research culture. In fiscal year 2020, the
            National Institute of General Medical Sciences (NIGMS)
            supported 24 INBRE awards.
      --Centers of Biomedical Research Excellence (COBRE--Phases I, II, and
            III). COBRE supports the establishment and development of
            innovative, state-of-the-art biomedical and behavioral research
            centers at institutions in IDeA-eligible states that: (a)
            galvanize multidisciplinary research to develop a critical mass
            of investigators that are competitive for peer-reviewed
            research funding; (b) provide improvements to research
            infrastructure; and (c) maintain research cores to sustain a
            collaborative, multidisciplinary research environment that
            includes pilot project programs, mentoring, and workforce
            training. In fiscal year 2020, NIGMS supported 112 COBRE
            awards. One such example, a Phase I COBRE at Dartmouth's Geisel
            School of Medicine called iTarget (Institute for Biomolecular
            Targeting), aims to catalyze the development of new therapeutic
            approaches to address cancer, chronic obstructive pulmonary
            disease, and respiratory syncytial virus, a common viral
            infection that can be dangerous to young children and the
            elderly. This COBRE is providing unique resources to
            investigators at Dartmouth and its IDeA partners, thus
            enhancing research productivity and funding competitiveness
            across the region.
      --IDeA Networks for Clinical and Translational Research (IDeA-CTR).
            IDeA-CTRs develop a network infrastructure and capacity in
            IDeA-eligible states to conduct clinical and translational
            research focused on health concerns that disproportionately
            affect rural and medically underserved populations and/or that
            are prevalent in IDeA states. IDeA-CTR awards support mentoring
            and career development activities in clinical and translational
            research. In fiscal year 2020, NIGMS supported 12 IDeA-CTR
            awards.
      --Regional Technology Transfer Accelerator Hubs. NIGMS established
            the Regional Technology Transfer Accelerator Hubs for IDeA
            states in each of the four IDeA regions (central, northeast,
            southeast, and western regions). The hubs provide both
            consulting services and skills development in entrepreneurship,
            technology transfer, small business finance, and other areas
            needed to transform important discoveries made in the
            laboratory into potentially viable commercial products that
            address human health. In fiscal year 2020, NIGMS supported four
            accelerator hubs. The northeast hub is located at Celdara
            Medical in Lebanon, New Hampshire.
      --Research Co-Funding. NIGMS provides co-funding for applications
            from IDeA state institutions that have been judged meritorious
            by NIH peer-review committees and national advisory councils
            but that may also fall outside the usual range of support by a
            given NIH Institute or Center (IC). In fiscal year 2020, NIGMS
            co-funded 42 research project grants at 20 NIH ICs; one of
            these was at Dartmouth College.
                                     ______

                    Questions Submitted to Dr. Ned Sharpless
                  Questions Submitted by Senator Patty Murray
        Question. The American Cancer Society's Annual Report to the Nation
    on the Status of Cancer highlighted that we are making good progress in
    the battle against cancer, with the incidence and mortality rates for
    most cancers have dropped significantly. However, among the 20 most
    common cancers, relative survival for patients significantly improved
    since the mid-1970s except for those with uterine cancer.
        What plans does the NCI have in fiscal year 2022 to develop a
    paradigm of increased research to improve hope for survival for
    patients with uterine cancer?
        Answer. The National Cancer Institute (NCI) shares the committee's
    commitment to research on uterine cancers, including endometrial cancer
    (cancer of the inner lining of the uterus), and improving outcomes for
    patients.
        Today, nearly 40 percent of adults are obese, and without
    intervention, the obesity epidemic will result in more cancers. Uterine
    cancer incidence and mortality have increased in recent years,\40\
    believed to be partially associated with rising rates of obesity.\41\
    Women who are obese or overweight are approximately two to four times
    as likely as normal weight women to develop uterine cancer, including
    endometrial cancer, making interventions to address weight and obesity
    vital to combatting uterine cancer incidence and mortality. Examples of
    NCI-supported research on this topic include a study of how changes in
    body composition following weight loss impact inflammatory biomarkers
    in biopsy-collected endometrial tissue and blood samples and whether
    these processes differ between Black and White women; \42\ the
    development of a weight loss intervention among Appalachian residents;
    \43\ and a study of the Deep South Interactive Voice Response (IVR)-
    supported Active Lifestyle (DIAL) Intervention to increase physical
    activity levels among residents of the Deep South.\44\
    ---------------------------------------------------------------------------
        \40\ pubmed.ncbi.nlm.nih.gov/30521505/,seer.cancer.gov/
    report_to_nation/statistics.html#
    factors.
        \41\ www.cancer.gov/about-cancer/causes-prevention/risk/obesity/
    obesity-fact-sheet.
        \42\ reporter.nih.gov/project-details/10129305.
        \43\ reporter.nih.gov/project-details/10065366.
        \44\ reporter.nih.gov/project-details/10163139.
    ---------------------------------------------------------------------------
        Researchers at the University of North Carolina Lineberger
    Comprehensive Cancer Center are directly examining the metabolic and
    molecular differences of endometrial tumors in obese and non-obese
    women. In addition, this research team is exploring how metformin,
    widely used to treat type II diabetes, may also exhibit anti-tumor
    activity through its effects on a patient's metabolism.\45\
    ---------------------------------------------------------------------------
        \45\ reporter.nih.gov/project-details/10104456.
    ---------------------------------------------------------------------------
        Translational research to bridge the gap between basic research on
    endometrial cancer and potential therapies is also essential to
    improving outcomes for patients. NCI supports a Specialized Program of
    Research Excellence (SPORE) focused on translational research for
    endometrial cancer at the University of Texas/MD Anderson Cancer
    Center. This SPORE is conducting research aimed at developing
    therapeutic strategies for advanced/recurrent endometrial cancer and
    aggressive subtypes, addressing unmet clinical needs in prevention and
    conservative therapy of high-risk precancerous lesions and low-grade
    endometrial cancer, and incorporating molecular diagnostics into
    clinical decisionmaking.\46\
    ---------------------------------------------------------------------------
        \46\ trp.cancer.gov/spores/endometrial.htm.
    ---------------------------------------------------------------------------
        As of July 2021, NCI is supporting over 150 clinical trials with a
    primary focus on uterine (including endometrial) cancer. Examples of
    these projects include studies of the use of an immunotherapy agent, in
    combination with other cancer therapies, to treat high risk endometrial
    cancer; \47,48\ a trial examining a combination therapy to treat
    endometrial cancers that express the HER2 protein; \49\ and a study
    evaluating the use of the experimental therapy triapine to treat
    endometrial serous adenocarcinoma, a difficult to treat subtype of
    uterine cancer.\50\ Clinical trials are an integral part of advancing
    research in this important topic area, and NCI is committed to reaching
    out to disparate, at-risk communities to explain, educate, and
    encourage clinical trial participation.
    ---------------------------------------------------------------------------
        \47\ clinicaltrials.gov/ct2/show/NCT04214067.
        \48\ clinicaltrials.gov/ct2/show/NCT03914612.
        \49\ clinicaltrials.gov/ct2/show/NCT04585958.
        \50\ clinicaltrials.gov/ct2/show/NCT04494113.
    ---------------------------------------------------------------------------
        As part of the National Institutes of Health (NIH) efforts to
    identify future research directions, NCI and the Eunice Kennedy Shriver
    National Institute of Child Health and Human Development (NICHD)
    explored research opportunities into the progression of benign
    gynecologic conditions to cancers through a collaborative workshop in
    April 2019. Currently, NICHD funds research on benign gynecologic
    conditions such as endometriosis and uterine fibroids, while NCI funds
    research on women's cancers. The workshop sought to bridge the two
    research areas and identify gaps in the biologic, epidemiologic, and
    clinical understanding of progression from benign conditions to cancer.
    The workshop addressed three gynecologic disease types: (1)
    endometriosis or endometrial cancer and endometrial-associated ovarian
    cancer, (2) uterine fibroids (leiomyoma) or leiomyosarcoma, and (3)
    denomyosis or adenocarcinoma. Working groups were formed for each
    disease type, and key questions and current challenges that emerged
    from the discussions, along with potential research opportunities to
    advance understanding of progression of gynecologic benign conditions
    to cancer, were published. Specific research questions and gaps were
    identified in all three focus areas, and several cross-cutting topics
    emerged. The results of this workshop, as well as ongoing horizon-
    scanning activities, will continue to inform NIH's next steps to
    address uterine cancer.
        Question. Non-Hispanic Black women are two time as likely as non-
    Hispanic White women to die from uterine or cervical cancer (https://
    www.ajog.org/article/S0002-9378(16)46212- 5/pdf).
        Can NIH/NCI please share with the Committee the research activities
    the NCI is supporting to address this disparity, particularly with
    regards to access to care, prevention, early diagnosis, treatment
    completion and developmental therapeutics?
        Answer. The National Cancer Institute (NCI) shares the Committee's
    concern regarding cervical and uterine/endometrial cancer disparities
    and is working to support research to eliminate these disparities, as
    well as cancer disparities more broadly. Examples of research aimed at
    addressing disparities in uterine and cervical cancer outcomes are
    provided below.
        NCI is a leader in developing and supporting definitive, practice-
    changing gynecologic (GYN) clinical trials, as well as responding to
    areas of scientific inquiry that are unaddressed by private industry.
    The NCI GYN Cancers Steering Committee sets clinical trials strategic
    priorities that address areas of unmet clinical need, important
    unanswered clinical questions, and potential new approaches to disease
    treatment.\51\ The Institute has supported and advanced GYN cancer
    research that will provide greater insight into these cancers,
    additional options for drug therapies, and improved surgical techniques
    with the intent of increasing survivorship and quality of life. As of
    July 2021, NCI is supporting over 150 interventional clinical trials
    with a primary focus on uterine (including endometrial) cancer, two
    trials on the rare uterine sarcoma, and nearly 100 trials for cervical
    cancer patients. NCI also has several trials that are ``disease
    agnostic,'' meaning that they are open to patients with certain genetic
    alterations rather than traditional cancer types, creating
    opportunities for patients to potentially benefit from precision
    medicine and targeted therapy.
    ---------------------------------------------------------------------------
        \51\ www.cancer.gov/about-nci/organization/ccct/steering-
    committees/nctn/gynecologic.
    ---------------------------------------------------------------------------
        A recent study led by NCI intramural researchers used population
    data from NCI's Surveillance, Epidemiology, and End Results (SEER)
    database to evaluate trends of hysterectomy-corrected uterine cancer
    incidence rates for women overall and by race and ethnicity, geographic
    region, and histologic subtype. Correct estimation of these rates
    requires accounting for hysterectomy prevalence, which varies by race,
    ethnicity, and region. The researchers found that incidence rates of
    common subtypes of uterine cancer were stable in non-Hispanic White
    women over the study period and increased in women of other racial/
    ethnic groups. By contrast, incidence rates of aggressive subtypes have
    been increasing dramatically over time in all racial/ethnic groups; in
    particular, much higher rates of these aggressive subtypes were
    observed in Black women than in other racial/ethnic groups. The
    researchers also observed that survival rates were lower among all
    women with aggressive subtypes than among women with common subtypes,
    and Black women had the lowest survival rates within each stage at
    diagnosis or histologic subtype.
        Uterine serous carcinoma (USC) is a rare but aggressive type of
    endometrial cancer. In about one-third of women with USC, their tumor
    cells overproduce a protein called HER2 (human epidermal growth factor
    receptor 2), which is associated with poor prognosis in women with
    endometrial cancer. Black women with endometrial cancer are more likely
    than White women to be diagnosed with UCS and are more likely than
    women of other races/ethnicities to have HER2 overproducing UCS tumors.
    NCI clinical studies for patients with HER2 overproducing uterine
    serous cancer and carcinosarcoma are currently in development.
        NCI-supported researchers are working to describe additional
    differences in subtypes of uterine and endometrial cancers, with the
    eventual goal of targeting therapies to treat each disease subtype. For
    example, investigators at Brigham and Women's Hospital, using data from
    the NCI-supported Epidemiology of Endometrial Cancer Consortium
    (E2C2),\52\ are studying genomic variation across the full spectrum of
    endometrial tumors, distinct risk factor profiles across tumor types,
    and the role of underlying tumor biology to better understand the
    disparities in outcomes between African-American and non-African-
    American women.\53\ NCI-supported investigators at Wayne State
    University are examining aggressive subtypes of high-grade endometrial
    tumors, including endometrioid, serous, clear cell and mixed
    carcinomas, by analyzing both clinical and genetic data in 500 women
    (250 African-American, 250 White) diagnosed with these cancers.\54\ In
    addition, NCI is supporting a planning grant to establish a Specialized
    Program of Research Excellence (SPORE) at Northwestern University
    focused on gynecologic cancer disparities. One of the pilot projects
    will focus on the tumor genomics of endometrial cancer.\55\
    ---------------------------------------------------------------------------
        \52\ epi.grants.cancer.gov/eecc/.
        \53\ reporter.nih.gov/search/o5KPkwNzZUavBogOfHXfCgproject-details/
    10156374.
        \54\ reporter.nih.gov/search/frdhnx_EQkONjxE8GPyxvQ/project-
    details/9916725.
        \55\ reporter.nih.gov/search/-UP_KUgEu0G9_0Zt655Nsg/project-
    details/9961257.
    ---------------------------------------------------------------------------
        To more accurately evaluate the risk of cervical precancer and
    study novel biomarkers in women undergoing cervical cancer screening,
    intramural researchers in NCI's Division of Cancer Epidemiology and
    Genetics have partnered with the University of Mississippi Medical
    Center and the Mississippi State Department of Health in the STRIDES
    Study (Studying Risks to Improve Disparities of cervical cancer in
    Mississippi). This study, based in one of the top five states for
    cervical cancer incidence and mortality, combines the expertise of
    clinicians, laboratory scientists, epidemiologists, and implementation
    scientists to address all aspects of cervical cancer prevention and
    control.\56\
    ---------------------------------------------------------------------------
        \56\ dceg.cancer.gov/research/cancer-types/cervix/cervix-
    mississippi.
    ---------------------------------------------------------------------------
        In 2020, NCI launched the ``Last Mile Initiative,'' with the goal
    of improving cervical cancer screening coverage to underserved, never
    screened, and under-screened women. This initiative will evaluate an
    alternative cervical cancer screening approach: self-collection of
    samples (self- sampling) by women, which are then sent to labs for
    human papillomavirus (HPV) testing. This approach aims to identify
    cervical cancer cases in these groups of women, which account for over
    half of cervical cancer cases in the United States each year. Self-
    sampling offers several benefits, including ease of collection at the
    time and place of the patient's choosing, without the need for a clinic
    appointment or speculum exam. To conduct this assessment, NCI
    established a public-private partnership between Federal agencies,
    industry partners, and professional societies/clinical guidelines
    organizations, and will support a nationwide, multicentric screening
    trial in diverse settings, the Last Mile Initiative Self-sampling for
    HPV Testing to Improve Cervical Cancer Prevention Trial (LMI-SHIP
    Trial).\57\
    ---------------------------------------------------------------------------
        \57\ prevention.cancer.gov/major-programs/nci-cervical-cancer-last-
    mile-initiative.
    ---------------------------------------------------------------------------
        Additionally, NCI is collaborating with the NIH Office of Research
    on Women's Health (ORWH) and other NIH Institutes and Centers to
    participate in an ORWH Advisory Committee on Research on Women's Health
    Consensus Conference to be held in October 2021. The conference will
    include a focus on cervical cancer disparities and research
    opportunities to continue to address disparities in incidence and
    mortality.
        NCI will continue to identify opportunities to better understand
    and address cancer health disparities, including for cervical and
    uterine/endometrial cancers.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        Question. Approximately 20,000 people in the United States have
    germline mutations in the gene RUNX1. Patients with RUNX1-familial
    platelet disorder are at a heightened risk for developing blood
    cancers. NCI supports a longitudinal natural history study of patients
    with such germline mutations and their families. While germline RUNX1
    mutations are rare, I understand that NIH-funded research in this area
    holds promise for the fields of hematology and oncology.
        How can deepening our understanding of, and ultimately developing
    cancer prevention strategies for, inherited blood cancer predisposition
    syndromes like RUNX1 familiar platelet disorder advance the entire
    cancer research field forward?
        Answer. The RUNX1 gene regulates the development of blood cells
    (hematopoiesis), controlling other genes that help determine the fate
    of hematopoietic stem cells, which have the potential to develop into
    all types of mature blood cells, including platelets. Platelets are
    cells that help blood to clot. Inherited mutations in the RUNX1 gene
    cause familial platelet disorder with associated myeloid malignancies
    (RUNX1-FPDMM) and predispose individuals to some types of blood
    cancers. Although genetic predisposition to solid tumors such as breast
    and colon cancers has been widely recognized over the past several
    decades, the contribution of inherited genetic disorders related to
    blood cancer is a more recent field of study.
        There are many instances where understanding the molecular basis
    for a rare inherited disease has provided insight into more common
    forms of a particular disease. For example, BRCA1 and BRCA2 mutations
    were discovered as hereditary breast cancer genes but are also relevant
    to sporadic (non-hereditary) breast cancers, ovarian cancers, and some
    hereditary forms of colon cancer. Similarly, understanding the blood
    cancers associated with RUNX1-FPDMM may lead to improved understanding
    of other types of blood cancers as well.
        Research efforts across the National Institutes of Health (NIH) are
    underway to better understand RUNX1-FPDMM. Investigators funded by the
    National Heart, Lung, and Blood Institute (NHLBI) are studying cells
    from people with this disorder to better understand key target genes
    regulated by RUNX1 and their role in hematopoiesis.\58\ This work could
    also yield a better understanding of genetic pathways that lead to
    blood cancers, as well as the blood clotting mechanisms that contribute
    to cardiovascular disease. Investigators at the National Human Genome
    Research Institute (NHGRI), along with intramural scientists at the
    National Cancer Institute (NCI), are conducting a natural history study
    at the NIH Clinical Center that is intended to identify and follow
    patients with RUNX1 mutations to hopefully identify biomarkers that can
    predict which patients will develop cancers.\59\ To date, the study has
    enrolled 198 patients from 55 families, representing the largest FPDMM
    cohort being followed prospectively at a single institution in the
    world.
    ---------------------------------------------------------------------------
        \58\ reporter.nih.gov/project-details/10083753.
        \59\ www.genome.gov/Current-NHGRI-Clinical-Studies/hematologic-and-
    premalignant-conditions-associated-with-RUNX1-
    mutation;clinicalstudies.info.nih.gov/ProtocolDetails.
    aspx?id=2019-HG-0059; clinicaltrials.gov/ct2/show/NCT03854318.
    ---------------------------------------------------------------------------
        Studying RUNX1-FPDMM will have broader significance than just this
    rare disease. Germline (inherited) predisposition to hematopoietic
    malignancies is often under-diagnosed, with recent studies indicating
    that 10-30 percent of RUNX1 mutations detected in acute myeloid
    leukemias are inherited, which is much more common than previously
    appreciated.\60\ In addition, FPDMM can serve as a model to study the
    development of leukemia, since researchers can monitor individuals with
    the RUNX1 mutation before they develop leukemia to identify factors
    associated with cancer risk and to map tumor evolution.
    ---------------------------------------------------------------------------
        \60\ pubmed.ncbi.nlm.nih.gov/32315381/.
    ---------------------------------------------------------------------------
                                     ______

                    Questions Submitted by Senator Jack Reed
        Question. The fiscal year 2021 Appropriations law included full
    funding--$30 million--for the Childhood Cancer STAR Act, which I
    authored.
        Could you provide an update on how that funding will be spent in
    the coming year?
        How will that work be coordinated with the childhood cancer data
    initiative?
        Answer. NCI is supporting several new and ongoing Childhood Cancer
    STAR Act research projects in fiscal year 2021, for a total planned
    investment of $28 million. The Centers for Disease Control and
    Prevention continues to support enhancements to expand capacity within
    the National Program of Cancer Registries (NPCR) to help cancer
    registries collect and make the data on pediatric cancer cases
    available more rapidly, a $2 million effort in fiscal year 2021.
        Consistent with provisions in Section 101 of the STAR Act, NCI's
    fiscal year 2021 appropriation for STAR Act activities is supporting
    new and expanded projects focused on the collection and storage of
    biospecimens for future research. Several projects are conducted
    through the NCI-supported Children's Oncology Group (COG) to focus
    additional attention to rare cancer subtypes that are currently
    underrepresented in NCI-supported biorepositories, as well as tumor
    types with a high risk of treatment failure. For example, particularly
    rare subtypes of pediatric cancers for which COG does not have open
    clinical trials, tumor tissue collection options are limited. STAR Act
    appropriations are supporting the COG Rare and Under-Represented Cancer
    Tissue Banking project to enable tumor tissue and associated germline
    (e.g., blood) sample collection for specific groups of patients for
    which current tumor tissue collection is lacking or inadequate, with
    priority for tumor types such as sarcomas and brain and central nervous
    system (CNS) tumors, which have high risk of treatment failure.
        The COG Rare and Under-Represented Cancer Tissue Banking project
    was launched in fiscal year 2020 and is expanding in scope in fiscal
    year 2021. This initiative is collaborating closely with CCDI, and with
    the use of fiscal year 2021 CCDI funds, tumor tissue will undergo
    clinically-relevant molecular profiling through the CCDI Molecular
    Characterization Protocol. The data generated will be returned to
    treating physicians to help guide the diagnosis and treatment of
    patients, and the data will additionally be stored and made available
    to the research community through CCDI data platforms. In addition to
    rare cancer populations, the CCDI Molecular Characterization Protocol
    will initially support characterization of tumors from children with
    CNS tumors and from children with soft tissue sarcomas. The Protocol
    aims to collect, store, and make available detailed clinical and
    molecular information for each child participating in the study,
    including data that will help a pediatric oncologist treat that patient
    and help researchers learn more about childhood cancers.
        NCI is continuing support in fiscal year 2021 for other STAR Act
    biobanking projects launched in fiscal year 2020. Through the COG Rapid
    Autopsy Specimen Collection project, NCI and COG are working with
    patient organizations to support rapid autopsy collection of tumor
    samples from children and adolescents and young adults (AYAs) who have
    died of their disease. Foundations and families within the pediatric
    brain tumor community have been leaders in such programs, and NCI
    continues to learn from their experiences to expand this model to other
    childhood cancers. We are incredibly grateful to these parents and
    caregivers, who amidst unimaginable grief and loss, contribute to
    future research to advance science and help other families.
        NCI is also supporting the COG to continue to expand the collection
    of specimens taken at the time of relapse, as well as collecting
    diagnostic samples for children and AYAs who have already submitted
    samples at relapse through NCI's Pediatric Molecular Analysis for
    Therapy and Choice (MATCH) Precision Medicine Trial. An important
    impediment to understanding mechanisms of treatment failure for
    childhood solid tumors is the limited numbers of paired specimens from
    both diagnosis and relapse that are available for researchers to study.
    Specimens at relapse are critical for evaluating biological changes
    between diagnosis and relapse that can lead to the identification of
    mechanisms of treatment failure and to the development of strategies
    for circumventing these mechanisms. Through CCDI, Pediatric MATCH tumor
    specimens from diagnosis and from relapse are being molecularly
    characterized to identify the changes in gene mutations and gene
    expression that occur between diagnosis and relapse, which could inform
    better treatments.
        Consistent with Section 202 of the STAR Act, in fiscal year 2021,
    NCI will continue to conduct and support childhood cancer survivorship
    research. NCI has supported two new Requests for Applications (RFAs)
    since fiscal year 2019 that are directly aligned with survivorship
    research areas emphasized in the STAR Act. Issued in fiscal year 2019,
    RFA CA-19-033: \61\ Improving Outcomes for Pediatric, Adolescent and
    Young Adult Cancer Survivors focused on projects to develop and test
    interventions that prevent, mitigate or manage adverse outcomes in
    pediatric and/or AYA cancer survivors and/or evaluate models of care
    that strengthen coordination, continuity, and quality, or that reduce
    access barriers to needed services including follow-up care, and that
    improve outcomes across the survivor's lifespan. Development of
    interventions to address disparities in outcomes and/or access to
    needed care, and to address the needs of minority or medically
    underserved pediatric and/or AYA populations were also prioritized. NCI
    is supporting seven awards in response to this RFA, and the awards will
    focus on various patient sub-populations (e.g. disease site),
    developmental groups, specific late and long-term effects, and the
    types of interventions (both preventive and supportive care).
    ---------------------------------------------------------------------------
        \61\ grants.nih.gov/grants/guide/rfa-files/RFA-ca-19-033.html.
    ---------------------------------------------------------------------------
        Issued in fiscal year 2020, RFA CA-20-027 \62\ and RFA CA-20-028:
    \63\ Research to Reduce Morbidity and Improve Care for Pediatric, and
    Adolescent and Young Adult (AYA) Cancer Survivors invite applications
    for research projects to improve care and health-related quality of
    life for childhood and AYA cancer survivors, with a focus on six key
    domains that align with research priorities emphasized in the STAR Act:
    (1) disparities in survivor outcomes; (2) barriers to follow-up care
    (e.g. access, adherence); (3) impact of familial, socioeconomic, and
    other environmental factors on survivor outcomes; (4) indicators for
    long-term follow-up needs related to risk for late effects, recurrence,
    and subsequent cancers; (5) risk factors and predictors of late/long-
    term effects of cancer treatment; and (6) development of targeted
    interventions to reduce the burden of cancer for pediatric/AYA
    survivors.
    ---------------------------------------------------------------------------
        \62\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-20-027.html.
        \63\ grants.nih.gov/grants/guide/rfa-files/rfa-ca-20-028.html.
    ---------------------------------------------------------------------------
        In fiscal year 2021, NCI will support subsequent years for grants
    initially awarded in fiscal year 2019 and fiscal year 2020, as awards
    were made for five-year terms, and the Institute will be making several
    new grant awards through the RFA launched in fiscal year 2020. The
    first round of applications is in the final stages of review, and
    awards will be made before the close of fiscal year 2021. The second
    round of applications are due on July 30, 2021, and awards are
    anticipated to be made in fiscal year 2022.
        NCI also continues to make additional investments in childhood
    cancer survivorship research beyond the STAR Act appropriation, funding
    several notable initiatives and projects with resources provided
    through the Institute's general appropriation. For example, NCI
    continues to fund long-standing investments in the Childhood Cancer
    Survivor Study (CCSS),\64\ which the Institute has supported
    continuously since establishing CCSS in 1994. This cohort of more than
    38,000 childhood cancer survivors diagnosed between 1970 and 1999 (and
    5,000 siblings of survivors who serve as the comparison group for the
    study) serves as a foundational resource for the survivorship research
    community.
    ---------------------------------------------------------------------------
        \64\ cancer.gov/types/childhood-cancers/ccss.
    ---------------------------------------------------------------------------
        Additionally, NCI continues to support research projects that
    investigators develop and submit independent of specific childhood and
    AYA cancer survivorship funding opportunities such as the STAR Act RFAs
    described above. These investigator-initiated research projects provide
    critical contributions to this field, and awards made to date in fiscal
    year 2021 include a project to compare symptom burdens (toxicity),
    neurocognitive change, and functional outcomes in children with
    pediatric brain tumors treated with proton versus photon radiotherapy.
    Proton beam radiotherapy (PBRT) is often thought to be a promising
    treatment for children with brain tumors as it may preserve cognitive
    functioning without sacrificing disease control. This will be the first
    large-scale study to prospectively compare the two therapies to assess
    important measures of daily functioning that will quantify the clinical
    significance of any differences identified between groups in
    survivorship. This project aims to help physicians and families better
    understand the relative effect of PBRT on symptoms and neurocognitive
    functioning to inform treatment decisions.\65\ Another award is
    supporting further study of psychosocial risk in young survivors of
    pediatric cancer diagnosed in early childhood, including the role of
    both physical and neurocognitive late effects. This project aims to
    identify specific medical and neurocognitive late effects that increase
    psychosocial morbidity, as well as protective factors, to inform more
    effective interventions to optimize quality of life in children
    affected by cancers diagnosed in early childhood.\66\ In addition, the
    NCI-supported ASPIRES (Activating cancer Survivors and their Primary
    care providers to Increase coloREctal cancer Screening) study aims to
    prevent the development of subsequent cancers among childhood cancer
    survivors treated with abdominal or pelvic radiotherapy, who are almost
    four times more likely to develop colorectal cancer (CRC) compared to
    the general population. The study will test a remote intervention aimed
    at promoting early CRC screening and detection.\67\
    ---------------------------------------------------------------------------
        \65\ reporter.nih.gov/search/kPIDddsyREmcoShhVEYN4Q/project-
    details/10146799.
        \66\ reporter.nih.gov/search/5Nb7PgFn7kyHJnjYOFzMQA/project-
    details/10122486.
        \67\ reporter.nih.gov/search/5Nb7PgFn7kyHJnjYOFzMQA/project-
    details/10096080.
    ---------------------------------------------------------------------------
        NCI remains committed to implementing the research sections of the
    STAR Act directed toward the Institute, and to ensuring that these
    efforts continue to complement the Institute's broader portfolio of
    childhood and AYA cancer research. This includes CCDI, the COG, the
    CCSS, and many other research programs and projects working together to
    support much needed progress for children with cancer and their
    families, including survivors and caregivers facing the challenges of
    managing the late effects of cancer and its treatments.
                                     ______

                    Questions Submitted by Senator Roy Blunt
        Question. Dr. Sharpless, one of the goals I had when I was Chairman
    of this Subcommittee was to increase NIH funding, in an effort to
    increase the success rates of grants--meaning more research grants
    would be funded. This is important because the NIH peer review system
    does not always reward high-risk science or young researchers' grant
    applications. But, if you have additional funding, you can fund more
    than just the `safest' science grants from the most established
    researchers. NCI has seen an increase of more than 50 percent in the
    number of grant applications since 2013, keeping your success rates and
    paylines lower than most NIH Institutes. While the positive aspect of
    this statistic is that the cancer research community is energized and
    applying for NCI funding, you can only fund a certain amount of
    applications because of the significant increase in grant applications.
    The last two LHHS bills have included specific funding for NCI to
    increase their Research Project Grants.
        How has this allowed you to increase success rates, raise the
    payline, and make more awards?
        Answer. The intense competition and demand for NCI funding reflects
    incredible scientific opportunities in cancer research and presents a
    major challenge for the NCI to carefully balance increasing demand for
    competing grant funding while sustaining previous years' commitments to
    multi-year grants.
        Investigator-initiated research has proven itself to be one of the
    biggest drivers of progress in cancer research, and accordingly is the
    biggest driver of NCI's budget, with long-term investments into funding
    new and continuing awards constituting more than 40 percent of NCI's
    annual budget. These awards have been the source of some of the most
    innovative and transformative ideas in cancer research, leading to
    direct benefits for patients in the form of new oncology drug
    approvals, the development of immune checkpoint inhibitor therapy
    (Nobel Laureate Jim Allison), CAR-T (chimeric antigen receptor-T) cell
    immunotherapy (Carl June), and novel drug design strategies such as
    PROTACs (proteolysis targeting chimeras) \68\ that use normal cellular
    processes to identify and destroy proteins in cancer cells that drive
    cancer growth (Raymond DeShais and Craig Crews).
    ---------------------------------------------------------------------------
        \68\ www.cancer.gov/research/annual-plan/scientific-topics/protac-
    infographic.
    ---------------------------------------------------------------------------
        Considering all funding mechanisms, NCI supported 109 additional
    awards in fiscal year 2020 as compared to fiscal year 2019 (from 6,053
    in fiscal year 2019 \69\ to 6,162 in fiscal year 2020 \70\). Across
    fiscal year 2020 and 2021, the successive funding increases allowed NCI
    to increase the R01 payline from the 8th percentile in fiscal year 2019
    to the 11th percentile in fiscal year 2021. With the fiscal year 2020
    budget increase, NCI increased R01 paylines by 25 percent compared to
    fiscal year 2019 and restored continuing grants to 100 percent of their
    committed level, providing researchers the full fiscal year 2020 budget
    approved during the initial grant award. Funding increases in fiscal
    year 2021 allowed NCI to further raise the payline for R01 research
    awards, for an overall 35 percent increase compared to 2019, as well as
    to keep funding continuing awards at 100 percent. In addition, for
    those two consecutive years (fiscal year 2020 and fiscal year 2021),
    NCI also raised the payline for Early-Stage Investigators, reflecting
    NCI's commitment to developing and supporting early career scientists
    to build the next generation of cancer researchers.
    ---------------------------------------------------------------------------
        \69\ www.cancer.gov/about-nci/budget/congressional-justification/
    fy2021-nci-congressional-justification.pdf.
        \70\ www.cancer.gov/about-nci/budget/congressional-justification/
    fy2022-nci-congressional-justification.pdf.
    ---------------------------------------------------------------------------
        We have the final success rate and total number of awards results
    for fiscal year 2020, the year when Congress targeted an additional
    $212.5 million for new and continuing grants, but we will not have
    final results for fiscal year 2021 until after the first quarter of
    fiscal year 2022. Our fiscal year 2020 results show that NCI increased
    the number of competing R01s we issued within the payline by more than
    100 awards, a jump of more than 15 percent from the prior year. The
    funding increase also allowed us to pay other meritorious R01
    applications that scored just outside the payline. Overall, our success
    rate for fiscal year 2020 rose to 12.7 percent, from 11.6 percent in
    the prior year.
        The targeted increases that Congress has provided allows NCI to
    increase paylines, achieve a corresponding increase in the overall NCI
    application success rate, and issue more grant awards. This funding has
    been critical to awarding new grants, while also allowing NCI to
    support ongoing research and the breadth of core NCI research
    investments, such as NCI's designated cancer centers, Specialized
    Programs of Research Excellence (SPOREs), and large national networks
    of clinical trials. All of these awards and programs will continue to
    fuel broad, sustained progress that serves the needs of individuals
    with cancer and those at risk of cancer, leading to a deeper
    understanding of the biology of cancer and new strategies to prevent,
    screen, diagnose, and treat cancer, in all its forms.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. The NCI is doing tremendous work in implementing the new
    Childhood Cancer Data Initiative, which holds the promise of vastly
    improving the treatment of childhood cancer and the quality of life for
    survivors. The Childhood Cancer STAR Act calls for a major investment
    in biorepository and bio-specimen collection.
        Can you tell us how these two vital initiatives are working
    together? NIH Response:
        Answer. The National Cancer Institute (NCI) agrees that it is vital
    for biospecimen collection and storage efforts supported through the
    STAR Act and data generation, analysis, and sharing supported through
    Childhood Cancer Data Initiative (CCDI) to continue to contribute to
    and enhance each initiative's progress in a complementary manner. To
    that end, NCI is utilizing STAR Act appropriations to support the
    Children's Oncology Group (COG) Rare Tumor Populations Biobanking
    project, which enables tumor tissue and germline (e.g., blood)
    collection for specific groups of patients for which current tumor
    tissue collection is lacking or inadequate, with priority for tumor
    types such as sarcomas and brain and central nervous system tumors,
    which often have the highest risk of treatment failure.
        The COG Rare Tumor Populations Biobank was launched in fiscal year
    2020 and is expanding in scope in fiscal year 2021. This initiative is
    collaborating closely with CCDI, and with the use of fiscal year 2021
    CCDI funds, tumor tissue will undergo clinically-relevant molecular
    profiling through the CCDI Molecular Characterization Protocol. The COG
    Rare Tumor Populations Biobank provides a critical foundation for these
    characterization efforts within CCDI. The data generated will be
    returned to treating physicians to help guide the diagnosis and
    treatment of patients, and the data will be stored and made available
    to the research community through CCDI data platforms. In addition to
    rare cancer populations, the CCDI Molecular Characterization Protocol
    will initially support characterization of tumors from children with
    Central Nervous System (CNS) tumors and from children with soft tissue
    sarcomas. The Protocol aims to collect, store, and make available
    detailed clinical and molecular information for each child
    participating in the study, including data that will help a pediatric
    oncologist treat that patient and help researchers learn more about
    childhood cancers.
        NCI is also supporting a STAR Act biobanking project through the
    COG to continue to expand the collection of specimens taken at the time
    of relapse, as well as collecting diagnostic samples for children and
    adolescents and young adults (AYAs) who have already submitted samples
    at relapse through NCI's Pediatric Molecular Analysis for Therapy and
    Choice (MATCH) Precision Medicine Trial. An important impediment to
    understanding mechanisms of treatment failure for childhood solid
    tumors is the limited numbers of paired specimens from both diagnosis
    and relapse that are available for researchers to study. Specimens at
    relapse are critical for evaluating biological changes between
    diagnosis and relapse that can lead to the identification of mechanisms
    of treatment failure and to the development of strategies for
    circumventing these mechanisms. Through CCDI, Pediatric MATCH tumor
    specimens from diagnosis and from relapse are being molecularly
    characterized to identify the changes in gene mutations and gene
    expression that occur between diagnosis and relapse, which could inform
    better treatments.
        These are specific examples of early and ongoing collaboration
    between STAR Act and CCDI- supported projects, and more broadly, there
    will be additional opportunities for data generated through STAR Act
    specimen collection and survivorship research efforts to contribute to
    the CCDI data ecosystem. For example, other STAR Act biobanking
    projects have supported additional biospecimen collection within the
    NCI-supported Childhood Cancer Survivor Study (CCSS), focused on
    subsequent cancers and chronic health conditions. CCDI funds were used
    to molecularly characterize specimens from patients who developed
    second cancers to enhance understanding of the genetic factors that
    lead to increased risk of second malignant tumors. Additionally, CCDI
    funds have supported submission and management of CCSS data to NCI and
    other NIH repositories so that they can be linked within the CCDI data
    ecosystem and more easily shared with the broader research community.
        As NCI's CCDI continues to link data resources across the childhood
    cancer research field, we envision these linkages and the data
    ecosystem they create serving as a resource for continued research, and
    as a growing repository for all types of data generated through NCI and
    other funded childhood and AYA cancer research. Similar to the CCSS,
    individual research projects, including preclinical studies and
    clinical trials, will have the opportunity to contribute data to CCDI,
    linking this additional data to CCDI resources such as the Molecular
    Characterization Protocol and the National Childhood Cancer Registry,
    two foundational CCDI initiatives.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. I, along with many members of the committee remain
    concerned with the lack of targeted therapies for rare cancer patients.
    It is my understanding that rare cancers account for 380 of 400
    distinct forms of cancer and almost 1/3 of all diagnoses and include
    all pediatric cancers. A recent analysis showed that 80 percent of all
    patients who lacked an FDA-targeted therapy were rare cancer patients.
    In addition, of the 3,994 clinical trials in phases 1, 2, and 3 from
    January 1, 2012 to January 1, 2017, almost 75 percent did not include a
    rare cancer by name. While rare cancer affects every population,
    translational research and commercial drug development has
    traditionally neglected small patient populations. Each subtype of
    cancer requires a targeted therapy in order to save a life or to
    significantly improve lifespan.
        What is NIH's plan to ensure there are adequate investments for
    treatments for rare cancer patients and what can Congress and this
    committee do to help?
        Answer. The National Institutes of Health (NIH) remains committed
    to supporting research to advance the understanding of all cancers,
    including rare cancers, and to inform the development of targeted
    cancer therapies for rare cancers and rare subtypes of cancers,
    including pediatric cancers (all types and subtypes of pediatric
    cancers are considered ``rare'' by definition).
        The cancer research community--thanks to NIH-supported developments
    in understanding the specific genes, proteins, and other unique
    molecular characteristics driving certain cancer subtypes--continues to
    recognize that cancer is made up of a collection of hundreds, if not
    thousands, of subtypes defined by these characteristics. As a result of
    National Cancer Institute (NCI)-supported efforts and other relevant
    research, ``cancer'' is increasingly becoming a collection of rare
    cancer subtypes.
        This evolved understanding of cancer is reflected in NCI's current
    clinical trials portfolio and investments in translational and basic
    research, including several initiatives in the intramural Center for
    Cancer Research (CCR).
        Increasingly, clinical trials are examining targeted therapies
    based on molecular subtypes. For example, NCI's National Clinical
    Trials Network (NCTN) is currently supporting trials assessing
    therapies to treat gliomas with certain genetic alterations \71\ and
    pancreatic cancers with specific gene alterations.\72,73\ NCI also
    supports trials that are dedicated to patients with rare tumors,
    including the NCTN-supported Dual Anti-CTLA-4 and Anti-PD1-Blockade in
    Rare Tumors (DART) Trial \74\ and the Rapid Analysis and Response
    Evaluation of Combination Anti-Neoplastic Agents in Rare Tumors (RARE
    CANCER) Trial,\75\ which is supported by NCI's Experimental
    Therapeutics Clinical Trials Network.
    ---------------------------------------------------------------------------
        \71\ www.clinicaltrials.gov/ct2/show/NCT00887146.
        \72\ www.clinicaltrials.gov/ct2/show/NCT04858334.
        \73\ www.clinicaltrials.gov/ct2/show/NCT04548752.
        \74\ www.clinicaltrials.gov/ct2/show/NCT02834013.
        \75\ www.clinicaltrials.gov/ct2/show/NCT04449549.
    ---------------------------------------------------------------------------
        To ensure that researchers have a strong pipeline of therapy
    candidates to consider for use in clinical trials, NCI supports several
    initiatives to support the preclinical stage of development of
    therapeutics to treat rare cancers, including the NCI Experimental
    Therapeutics (NeXT) Program and the Pediatric Preclinical Testing
    Consortium (PPTC). The mission of NeXT is to advance clinical practice
    and bring improved therapies to patients with cancer by supporting the
    most promising new drug discovery and development projects. The PPTC
    addresses key challenges associated with the development of new
    therapies for children with cancer by developing reliable preclinical
    testing data for pediatric drug candidates that can be used to inform
    new agent prioritization decisions.
        The first step in identifying new therapeutic targets, however, is
    elucidating the basic biological mechanisms that give rise to cancers.
    To further these research efforts, NCI supports the development of
    resources for broad use across the cancer research community. These
    resources include cell lines, organoid models, patient derived
    xenograft (PDX) models, biospecimens, and other biological samples. NCI
    makes drug information summaries available on its website, along with
    extensive cancer treatment summaries. Additional resources include the
    Developmental Therapeutics Program, the National Clinical Trials
    Network (NCTN) Navigator, Patient-Derived Xenograft (PDX) Centers, PDX
    Finder, the NCI Mouse Repository, and the Physician Data Query (PDQ)
    Database.\76\
    ---------------------------------------------------------------------------
        \76\ A more extensive list is available at www.cancer.gov/research/
    resources/.
    ---------------------------------------------------------------------------
        The Rare Tumor Patient Engagement Network, launched in fiscal year
    2018 and part of NCI's CCR, leverages the resources of the NCI
    intramural research program and the NIH Clinical Center to bring
    together investigators, patients, and advocacy groups to study rare
    tumors. Under the umbrella of this effort, NCI launched the My
    Pediatric, Adolescent, and Adult Rare Tumor (MyPART) Network, a
    collaboration of scientists, patients, family members, advocates, and
    healthcare providers to find treatments for rare cancers. The MyPART
    Network collects samples like blood, saliva, and archived biopsy tissue
    from people with rare solid tumors as part of the Natural History Study
    of Rare Solid Tumors. The purpose of the study is to engage rare tumor
    patients and their families in the research process, study how rare
    tumors grow, track participants' health history over a long period of
    time, share data with other scientists, build new ways of testing new
    treatments, and design new clinical trials for rare cancers. MyPART
    scientists also hold clinics on rare tumors to facilitate
    collaborations between researchers, patients, and advocacy
    organizations; to date, MyPART has hosted clinics on chordomas, SDH-
    deficient gastrointestinal stromal tumors, and medullary thyroid
    cancer, and more clinics are in the planning stages. Additionally, the
    NCI Comprehensive Oncology Network Evaluating Rare CNS Tumors (NCI-
    CONNECT) program aims to advance the understanding of rare adult
    central nervous system (CNS) cancers by establishing and fostering
    patient-advocacy-provider partnerships and networks to improve
    approaches to care and treatment; seven clinical studies and trials are
    currently open through NCI-CONNECT.\77\
    ---------------------------------------------------------------------------
        \77\ www.cancer.gov/rare-brain-spine-tumor/refer-participate/
    clinical-studies.
    ---------------------------------------------------------------------------
        Because of these and similar investments, the U.S. Food and Drug
    Administration (FDA) has approved a number of therapies in recent years
    for patients with rare cancer subtypes and related conditions. For
    example, in May 2021, the FDA granted accelerated approval to sotorasib
    (Lumakras) for patients with locally advanced or metastatic non-small
    cell lung cancer (NSCLC) with alterations in the KRAS G12-C gene, a
    mutation which is present in only 13.8 percentsa of NSCLC patients.
    Similarly, the FDA approved selumetinib (Koselugo) in 2020 for the rare
    tumor condition neurofibromatosis type 1, in patients over the age of
    two, as the first approved treatment for this condition. In 2018, the
    FDA granted accelerated approval to larotrectinib (Vitrakvi) for adult
    and pediatric patients with solid tumors with a neurotrophic receptor
    tyrosine kinase (NTRK) gene fusion. NTRK gene fusions are prevalent in
    nearly all cases of certain rare cancer subtypes, including secretory
    carcinoma of the breast or salivary gland and infantile fibrosarcoma;
    they have also been observed in some patients with more common types of
    cancer, such as glioma, melanoma, and carcinomas of the thyroid, lung,
    and colon.\78\
    ---------------------------------------------------------------------------
        \78\ www.ncbi.nlm.nih.gov/pmc/articles/PMC6859817/.
    ---------------------------------------------------------------------------
        NIH will continue to support research efforts that reflect the
    scientific understanding of the many subtypes of cancers, including
    work that will enable the development of therapies for rare tumor
    subtypes.
                                     ______

                    Questions Submitted to Dr. Gary Gibbons
                    Questions Submitted by Senator Roy Blunt
        Question. Dr. Gibbons, we have all heard about the plight of COVID-
    19 ``long-haulers'' who have symptoms after their acute COVID-19
    infection has subsided. A growing number of studies suggest that many
    patients experience some type of heart damage after contracting the
    infection, even in those not sick enough to be hospitalized. According
    to the American Heart Association, nearly one-fourth of those
    hospitalized with COVID-19 have been diagnosed with cardiovascular
    complications. A study in the Journal of the American Medical
    Association stated that researchers found abnormalities in the hearts
    of 79 percent of recovered patients and ``ongoing myocardial
    inflammation'' in 60 percent.
        Who is most at-risk of this type of heart damage, and is there
    indication that this damage is permanent?
        With heart damage appearing to be widespread, will screenings to
    detect cardiovascular damage be included as routine follow-up care for
    COVID-19 patients?
        Do you have any sense of how long longitudinal studies should last
    to follow long-haulers?
        Answer. While severe acute respiratory syndrome coronavirus 2
    (SARS-CoV-2) enters the body through the respiratory tract, the virus
    also infects many other cell types and can damage multiple organs and
    tissues, including the heart and blood vessels. In rare cases, acute
    infection has been associated with cardiovascular complications
    including acute myocardial injury, myocarditis (heart inflammation),
    and arrhythmias (irregular heartbeat). This is not surprising given
    that viruses frequently trigger inflammation, and as the body's immune
    system fights off the virus, the inflammatory process can damage
    healthy tissues, including the heart. Many different viruses are known
    to cause myocardial injury and myocarditis.
        Many patients with coronavirus disease 2019 (COVID-19) experience
    damage to their blood vessels, leading to the formation of blood clots
    (thrombosis) that can develop in or travel to vital organs, including
    the heart. Blood clots in the coronary arteries can starve the heart of
    oxygen and damage the heart muscle. NIH's ACTIV-4 Antithrombotics
    adaptive master protocols have made progress in evaluating the safety
    and effectiveness of various types of blood thinners (e.g., aspirin,
    heparin, apixaban) for treating adults with signs of blood vessel
    damage and thrombosis from COVID-19, known as COVID-19-associated
    coagulopathy.\79\ Clinical trials are ongoing across three patient
    populations (inpatient, outpatient, and convalescent or patients
    recovering from COVID-19). These trials are providing valuable
    information about how to help prevent moderately ill patients with
    COVID-19 from progressing to intensive care, and could perhaps help
    mitigate future cardiac complications. For example, ACTIV-4 has shown
    that full-dose heparin is safe and effective at preventing blood clots
    in moderately ill hospitalized patients and reduced the need for life
    support.
    ---------------------------------------------------------------------------
        \79\ www.nih.gov/research-training/medical-research-initiatives/
    activ/covid-19-therapeutics-prioritized-testing-clinical-trials#activ4.
    ---------------------------------------------------------------------------
        Studies have shown that patients with COVID-19 may show signs of
    cardiac injury, detected by a release of the cardiac muscle protein
    troponin into the bloodstream.\80\ Such injury is associated with worse
    short-term outcomes and higher mortality. An analysis of more than 40
    studies involving more than 8,000 COVID-19 patients found that venous
    thromboembolism (VTE; blood clots originating in a vein) occurred in
    approximately 21 percent of patients.\81\ Among COVID-19 patients
    admitted to intensive care, the VTE rate was as high as 31 percent. A
    review of myocarditis associated with acute COVID-19 estimated that the
    incidence is less than five percent; although less than previously
    thought, this could still mean a large number of patients with acute
    myocarditis given that COVID-19 cases in the United States have
    surpassed 33 million.
    ---------------------------------------------------------------------------
        \80\ www.heartrhythmjournal.com/article/S1547-5271(20)30625-1/
    fulltext#tbl1.
        \81\ pubmed.ncbi.nlm.nih.gov/33251499/.
    ---------------------------------------------------------------------------
        The incidence of continuing or new cardiac problems after COVID-19
    or asymptomatic SARS-CoV-2 infection remains unknown. Although most
    people with COVID-19 get better within weeks of illness, some people
    experience post-acute sequelae, including chest pains, shortness of
    breath, exhaustion, heart palpitations, and chest pain. In addition,
    patients diagnosed with cardiac injury, thrombosis, or myocarditis
    during acute COVID-19 could sustain damage to the heart that persists
    long after the acute illness has passed. There is still much to be
    learned about the long-term cardiovascular consequences of SARS-CoV-2
    infection.
        NIH's Researching COVID to Enhance Recovery (RECOVER) initiative
    seeks to understand, and ultimately to prevent and treat, long COVID
    and other post-acute sequelae of SARS-CoV-2 (PASC) across the
    lifespan.\82\ At the center of the Initiative is an observational study
    that will include adults and children recruited from ongoing studies of
    COVID-19, long COVID clinics, and other cohorts. RECOVER is designed to
    significantly expand both our knowledge about the full clinical
    spectrum, long term outcomes, and underlying biology of PASC; as well
    as our ability to provide safe and effective therapeutic interventions.
    ---------------------------------------------------------------------------
        \82\ recovercovid.org/.
    ---------------------------------------------------------------------------
        Current diagnostic protocols generally include physical, cognitive,
    and psychological assessments. The evaluation of patients hospitalized
    with COVID-19 includes elements of a cardiovascular evaluation,
    including assessment of known cardiovascular disease and risk factors
    for cardiovascular disease, assessment of symptoms that may be caused
    by respiratory or cardiac disease, laboratory testing (including a
    complete blood count and complete metabolic panel), chest radiograph,
    electrocardiogram (ECG), and troponin testing (which is followed if
    elevated). A more targeted cardiac evaluation may be needed depending
    on the patient's symptoms. Patients who develop new onset heart
    failure, for example, may need an echocardiogram (echo) to determine
    the best course of action. One of the goals of the RECOVER meta-cohort
    study is to develop core defining characteristics and diagnostic
    criteria for long COVID and other forms of post-acute sequelae of SARS-
    CoV-2 infection (PASC), including understanding the impact the virus
    has on the cardiovascular system.
        NIH plans to, and has support to follow the RECOVER meta-cohort for
    at least 3 years. In addition to addressing the public health impact of
    SARS-CoV-2 infection, RECOVER also has the potential to enhance our
    understanding of other chronic syndromes theorized to have a viral
    origin, at least in some individuals, such as chronic fatigue syndrome
    and postural orthostatic tachycardia syndrome (POTS).
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. Pulmonary fibrosis (PF) means scarring in the lungs. Over
    time, the scar tissue can destroy the normal lung and make it hard for
    oxygen to pass through the walls of the air sacs into the bloodstream.
    PF is not just one disease--it is a group of more than 200 different
    lung diseases that all look very much alike.
        The most recent studies show that more than 200,000 Americans are
    living with PF today. Approximately 50,000 new cases are diagnosed each
    year and as many as 40,000 Americans die each year. With no known cure,
    certain forms of PF, such as idiopathic pulmonary fibrosis, (IPF), may
    take the lives of patients within three to 5 years from diagnosis.
        PRECISIONS is the first-ever clinical trial to apply the principles
    of precision medicine to the diagnosis and treatment of idiopathic
    pulmonary fibrosis. PRECISIONS is supported by a $22 million grant from
    the National Institutes of Health (NHLBI grant number HL145266) and
    Three Lakes Foundation, a philanthropic organization.
        PRECISIONS is designed as a double-blind, multi-center, randomized,
    placebo-controlled trial investigating the safety and efficacy of NAC
    in patients with IPF who have a specific genetic variant which is
    present in 25 percent of IPF patients. The trial will enroll 200
    patients from approximately 20 PFF Care Center Network (CCN) sites.
    Initial recruitment into the study is being facilitated by looking at
    phenotypic data from patients that are enrolled in the PFF Registry.
        Can you provide an update on the NHLBI-funded PRECISIONS grant,
    which seeks to shed more light on the role of genetics in pulmonary
    fibrosis?
        How has the COVID pandemic affected this study?
        Answer. The National Heart, Lung, and Blood Institute (NHLBI) is
    committed to supporting research on pulmonary fibrosis, which leads to
    progressive scarring of the lungs that makes it increasingly more
    difficult to breathe. PRECISIONS \83\ is a five-year study that aims to
    enroll 200 patients with idiopathic pulmonary fibrosis (IPF) and use
    genetic testing to identify those patients most likely to respond to an
    experimental treatment, an antioxidant known as N-acetylcysteine or
    NAC. This first-of-its-kind precision medicine trial builds on an
    earlier study suggesting that a gene called TOLLIP influences how
    patients respond to NAC, such that it might be helpful only for a
    subgroup of patients who have a particular version of the gene. The
    trial will enroll only that subgroup, in order to increase the
    likelihood of detecting a benefit.
    ---------------------------------------------------------------------------
        \83\ reporter.nih.gov/project-details/9822535.
    ---------------------------------------------------------------------------
        PRECISIONS is co-funded by the Three Lakes Foundation, a non-profit
    philanthropy that supports education and research efforts to improve
    the time to diagnosis and accelerate new therapies for IPF. The study
    also involves a partnership with the Pulmonary Fibrosis Foundation,
    whose patient registry is being leveraged to perform molecular analyses
    on biospecimens obtained from patients with IPF. These analyses are
    intended to uncover novel genetic risk factors that will improve IPF
    diagnosis, predict its clinical course, and understand its underlying
    disease mechanisms--all of which could yield further insight into
    potential targeted therapies.
        The study was delayed in the latter half of fiscal year 2020 due to
    COVID-19-related institutional research restrictions, which led to
    NHLBI approval of a six-month interim no-cost extension. By December
    2020, the investigators had successfully completed all pre-specified
    project milestones for the first phase of their biphasic research plan,
    including enrollment of the first study participant. NHLBI approved the
    transition to the second phase of the project in March 2021. To date,
    six study sites have been activated, the percentage of eligible
    participants who meet the study's genotype inclusion criteria has been
    exactly as expected, and recruitment has proceeded on target.
        During COVID-19-related delays and uncertainty regarding the
    feasibility of in-person lung function assessments (spirometry),
    PRECISIONS initiated an ancillary study to understand the utility of
    home spirometry to monitor patients with IPF. The study also intends to
    add a COVID-19--specific questionnaire to baseline and follow-up visits
    in the clinical trial as a means of leveraging this existing patient
    cohort to capture additional data on the epidemiological and clinical
    characteristics of COVID-19.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. Concerned about other countries' ability to obtain
    vaccines quickly for their populations, the Administration recently
    announced that it will support a waiver of the World Trade Organization
    TRIPS Agreement, which would waive intellectual property protections
    for COVID-19 vaccines. It is my understanding, however, that there are
    no guarantees that the companies or countries who seek to use vaccine
    manufacturer's intellectual property to make copies will be able to
    deliver safe and effective vaccines, or that their manufacturing
    processes will meet the strict regulatory standards necessary for
    authorization. Furthermore, there are already reports of counterfeit
    vaccines being used to exploit vulnerable populations in the U.S. and
    around the world.
        Are you concerned that giving away intellectual property via a
    TRIPS waiver could make worse the problem of counterfeit and low-
    quality vaccines in the market? What effect could this have on
    endangering lives and undermining public confidence in the vaccines
    that have been proven safe and effective?
        Answer. The National Institutes of Health (NIH) is concerned about
    counterfeit and low-quality vaccines; however, NIH does not have the
    expertise or authority to investigate these matters. The degree to
    which any TRIPS waiver addresses these issues of concern will not be
    known unless and until the terms are agreed upon.
        Question. The Administration recently endorsed the idea of waiving
    intellectual property (IP) protections for COVID-19 vaccines, in the
    hopes that it will speed up manufacturing of the vaccines around world.
    However, it is my understanding that some vaccine developers are
    already experiencing constraints in everything from raw materials to
    fill-finish capacity critical to producing and administering vaccines.
        Are you concerned that diverting critical supplies from
    manufacturers with proven track records for delivering high-quality,
    safe and effective vaccines could actually worsen the supply chain
    constraints we're currently seeing, and not just for COVID vaccines,
    but also non-COVID-19 medicines such as oncology and other infectious
    diseases?
        Answer. The National Institutes of Health (NIH) fully supports
    efforts to ensure reliable supply chains for vaccines and other
    medicines; however, NIH is not directly involved in these efforts.
                                     ______

                    Questions Submitted to Dr. Perez-Stable
                    Questions Submitted by Senator Roy Blunt
        Question. Dr. Perez-Stable, we typically talk about getting
    researchers into the NIH field and staying there as a pipeline.
    However, when we look at the pipeline for minority researchers, it can
    easily be called a funnel. We have a lot of work to do in increasing
    the diversity of NIH researchers. And as the COVID-19 pandemic has
    highlighted, NIH must also focus on health disparities research. The
    problems to these two solutions may go hand-in-hand. I know that Dr.
    Collins has started the UNITE program to look at racial inequities
    within the NIH community and has started a Common Fund program to fund
    transformative research into health disparities. While I commend these
    steps, many of the fundamental issues these programs are trying to
    address are reasons we started the Institute you fund--the National
    Institute for Minority Health and Health Disparities.
        Can you provide your perspective on how we get more minority
    scientists into the NIH community?
        And, specifically, what role should NIH take in making sure
    minorities have the educational background necessary to go into STEM
    fields--which often starts at the high school level, if not earlier?
        Answer. The National Institutes of Health (NIH) is committed to
    diversifying the research workforce and will continue to identify
    opportunities to increase its focus on building and supporting a
    diverse scientific workforce. The NIH UNITE initiative was developed to
    address inequity in biomedical research and will help NIH to identify
    more strategies and opportunities to strengthen its efforts to
    diversify the research workforce and attract and prepare more students
    from underrepresented backgrounds for STEM careers. The NIH already has
    several efforts to diversify the STEM pipeline and to train students at
    all levels of education as described below.
        NIH supports several initiatives to attract and recruit more
    minority scientists into the NIH intramural community. For example, the
    NIH Equity Committee systematically tracks and evaluates diversity,
    inclusion, and equity metrics in the intramural research program. In
    addition, the Distinguished Scholars Program (DSP) enhances the
    diversity of principal investigators in the NIH Intramural Research
    Program (IRP) by supporting first year tenure-track investigators with
    supplemental funds to start their research lab and engaging in
    activities designed to foster a sense of belonging and to promote
    research and career success. Moreover, the IRP provides a diverse
    environment for NIH-wide scientific recruitments through the Stadtman
    Tenure-Track Investigators, Lasker Clinical Research Scholars, and
    Early Independent Scientists recruitment programs. This approach has
    led to a greater proportion of women and scientists from
    underrepresented backgrounds recruited to NIH. The 2019 DSP cohort was
    comprised of approximately 7 percent Hispanics or Latinos, 27 percent
    African Americans or Blacks, 27 percent Asians, 40 percent White, and
    73 percent female. Among the fiscal year 2020 cohort, 21 percent was
    African American or Black, 21 percent Hispanic or Latino, 21 percent
    Asian, 36 percent White, and 50 percent female. Of the 15 Distinguished
    Scholars selected in the 2019 cohort, nine were Stadtman Tenure-Track
    Investigators, and two were Lasker Clinical Research Scholars. Of the
    14 Distinguished Scholars selected in the 2020 cohort, 10 were Stadtman
    Investigators, and three were Lasker Scholars.
        Extramurally, NIH has dedicated efforts to recruit diverse
    scientists from underrepresented groups to prepare successful NIH
    grants. NIH provides Diversity Research Supplements to enhance the
    diversity of the research workforce by recruiting and supporting
    graduate students, post-doctoral fellows, and eligible investigators
    from diverse backgrounds, including those from groups that have been
    shown to be underrepresented in health-related research. These
    supplements to existing grants provide a pathway to career success for
    scientists from diverse backgrounds and remains relatively
    underutilized. There are several other NIH programs that promote
    diversifying the research workforce and some are highlighted below.
    First, the NIH/National Institute on Minority Health and Health
    Disparities Loan Repayment Program (NIMHD LRP), which aims to increase
    the pool of qualified researchers who conduct health disparities
    research. Over a 15-year period, recipients of an LRP award from NIMHD
    are more likely to be awarded a subsequent NIH grant than their
    counterparts who were not successful. The LRP Health Disparities
    applications have now been extended to all NIH Institutes as of 2019.
    Second, the Native American Research Centers for Health promote a cadre
    of scientists and health research professionals interested in American
    Indian/Alaska Native health research. Third, NIMHD established the
    NIMHD Health Disparities Research Institute to support the research
    career development of promising early-career minority health and health
    disparities research scientists. Fourth, the NIH's Faculty
    Institutional Recruitment for Sustainable Transformation (FIRST)
    program, announced in 2020, will increase the participation of
    researchers dedicated to inclusive excellence, including minority
    researchers, in biomedical research at NIH-funded institutions. The aim
    of the program is to enhance institutional inclusive excellence, with
    diversity and equity at its core enabling biomedical research
    institutions to hire a diverse cohort of early-stage research faculty
    committed to inclusive excellence and diversity. The current pipeline
    of underrepresented scientists is not empty with about 14 percent of
    new U.S.-granted Science, Technology, Engineering and Math (STEM) PhDs
    awarded to underrepresented groups and similarly 14 percent of current
    medical students are from these groups.Lastly, the Science Education
    Partnership Award (SEPA) Program funds innovative pre-kindergarten to
    grade 12 science, technology, engineering, and mathematics (STEM) and
    Informal Science Education (ISE) educational projects. SEPA projects
    create partnerships among biomedical and clinical researchers and
    teachers and schools, museums and science centers, media experts, and
    other educational organizations. The NIH will continue to identify
    opportunities to increase its focus on building and supporting a
    diverse scientific workforce.

                              SUBCOMMITTEE RECESS

        Senator Murray. The meeting is adjourned. Thank you.
        [Whereupon, at 12:08 p.m., Wednesday, May 26, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2022

                                  ----------

                            WEDNESDAY, JUNE 9, 2021

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:02 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Reed, Shaheen, Schatz, Baldwin,
    Murphy, Manchin, Blunt, Capito, Hyde-Smith, Braun, and Leahy.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                            Office of the Secretary

    STATEMENT OF HON. XAVIER BECERRA, SECRETARY

                   OPENING STATEMENT OF SENATOR PATTY MURRAY

        Senator Murray. Good morning. The Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies will come to order. Today, we are having a
    hearing on the Biden administration's fiscal year 2022 budget
    request for the Department of Health and Human Services.
    Senator Blunt and I will each have an opening statement, then I
    will introduce our witness, Secretary Becerra. After his
    testimony, Senators will each have 5 minutes for a round of
    questions, and before we begin, I do want to walk through the
    COVID-19 safety protocols in place today, and I want to thank
    all of our clerks and everyone who has worked really hard to
    get this set up and help everyone stay safe and healthy.
        As I mentioned before the break, with the change in
    guidance from the Office of the Attending Physician, the
    committee is now returning to requiring in-person attendance by
    witnesses and members who wish to make statements or ask
    questions. However, social distancing remains in effect, and
    those who have not been fully vaccinated are strongly
    encouraged to wear masks.
        While we are unable to have the hearing fully open to the
    public or media for in-person attendance, live video is
    available on our committee website, and if you are in need of
    accommodations, including closed captioning, you can reach out
    to the committee or the Office of Congressional Accessibility
    Services.
        Secretary Becerra, I am pleased to say this budget
    represents a world of change from the past few years on
    healthcare, and a road map on progress for years to come. It
    proposes increasing the Centers for Disease Control and
    Prevention's budget by nearly a quarter, which, as we discussed
    in our hearings with Director Walensky, will not only help see
    our Nation through this pandemic, but help us rebuild our
    public health system, and better prepare for the next one.
        It also proposes serious investments to tackle other
    ongoing public health crises. Healthcare providers across my
    State have reported a sharp uptick in youth mental health
    emergencies during this pandemic, and the national suicide rate
    has been climbing for years. This budget builds on the
    resources we've provided for mental health and substance use
    services in our COVID-19 bills with an additional $9.7 billion
    for the Substance Abuse and Mental Health Services
    Administration, and an increase of $3.7 billion over fiscal
    year 2021 levels.
        Washington State also saw drug overdoses increase by 38
    percent over the first half of 2020, and our Nation saw a
    record-breaking number of overdose deaths last year. President
    Biden is proposing an historic investment of $10.7 billion
    across HHS (Department of Health and Human Services) programs
    to end the opioid epidemic, and he is proposing we continue the
    progress we've seen towards ending another epidemic by
    investing $670 million in the HIV/AIDS elimination initiative.
        And to aid the fight against cancer, Alzheimer's, long-term
    COVID-19, and countless other diseases, President Biden is
    calling for the largest budget increase for the National
    Institutes of Health in the agency's history.
        In the fight against systemic racism, he has proposed new
    investments across the department to reduce health disparities,
    and after years of relentless attacks on women's healthcare and
    reproductive rights, President Biden is charting a clear path
    in a new direction, one that puts women's health first, and
    puts patients, not politicians, in charge of their own
    healthcare decisions.
        I am pleased to see this budget call for $340 million for
    the Title X Family Planning Program, which helps so many
    patients, particularly women of color, get birth control,
    cancer screening, STD screenings, and other essential care.
    This funding will build on the administration's recent progress
    to restore the Title X Family Planning Program with a new
    proposed rule.
        The budget would also eliminate the Hyde Amendment, which
    is a critical step towards ensuring every person is trusted to
    make their own individual choices about their life and future,
    based on their own values, no matter who they are, where they
    live, or how much money they make. I do recognize that is an
    area of strong disagreement among members of this committee,
    but for too long, Hyde has made abortion accessible only to
    those with means, while women of color and women who are paid
    low incomes struggle to get care.
        This budget also takes other important steps to prioritize
    women's health. Our maternal death rate is the highest in the
    developed world, and two in three of those deaths is
    preventable. The death rate for rural mothers is 50 percent
    higher, and black and native women are two to three times more
    likely to die from a pregnancy-related cause than white women.
    This budget will invest $220 million to combat our maternal
    mortality crisis.
        Domestic violence is another longstanding and urgent
    problem, and one made more challenging by a pandemic that makes
    it even harder for people to get away from their abusers. This
    budget proposes doubling Federal funding for programs that
    provide shelter and support for survivors of domestic violence.
        We've also seen throughout this pandemic how the childcare
    crisis has grown worse, and been particularly hard on women,
    and hardest of all on women of color, and women who are paid
    low wages. This budget acknowledges the importance of investing
    in a bright future for every child in our Nation, and proposes
    to increase funding for childcare and development block grants
    by $1.5 billion in addition to the bold investments proposed in
    the American Families Plan, and provide an increase of over $1
    billion for Head Start and pre-school development grants.
        It also acknowledges our moral obligation to provide relief
    to some of the world's most vulnerable populations, including
    making sure the children in our Nation's custody are treated
    with decency, humanity, and kindness by calling for $1 billion
    in funding for refugee programs, and $3.3 billion for the
    unaccompanied children program, which has been stretched thin
    by this pandemic. These funds will help ensure children in HHS
    custody are quickly and safely placed in appropriate homes,
    provide care and services for them while they are in HHS
    custody, and provide social and legal services after they leave
    HHS custody.
        Secretary Becerra, I look forward to hearing more from you
    on how the department is prioritizing the health and well-being
    of these children, and how this funding will help that work.
        I always say a budget is a reflection of your values, and
    all-in-all, this budget paints a clear, encouraging picture of
    President Biden's values on healthcare. It shows he values
    public health, science, equity, women, children, families, and
    critically, the health and well-being of every single American,
    and that he believes healthcare must truly be a right in this
    country, not a privilege. I look forward to working with him
    and Secretary Becerra and my Senate colleagues to pass
    investments like those outlined in this budget into law to take
    bold steps to lower healthcare costs, and expand coverage, and
    apply lessons learned from the COVID-19 pandemic. With that, I
    will turn it over to Senator Blunt for his remarks.

                         STATEMENT OF SENATOR ROY BLUNT

        Senator Blunt. Thank you, Senator Murray. Appreciate
    Secretary Becerra being here today. We spent several years
    working together in the House before I came to the Senate, and
    you went home to become the Attorney General of California, and
    I look forward to what we can do together over the next couple
    of years.
        Certainly, over the past year, we've faced a global
    pandemic that nobody would have anticipated, and nobody was
    trained for. You said in the House hearing in May that the
    fight against COVID-19 isn't over yet, and certainly, I agree
    with that. While the vaccination rates are going up, and the
    cases are going down, we still have a lot to finish to win this
    fight.
        Many public experts have stated, and that includes those
    within the administration, that we really do have to achieve a
    certain vaccination level necessary to reach the kind of
    immunity where the virus ceases to spread, and we would hope,
    when it had no opportunity to spread, it would then cease to be
    something we need to be concerned about right now.
        But we also are going to be looking carefully to see if a
    booster is going to be required, and, of course, if a booster
    is required to maintain that level of immunity, it's going to
    be a great obligation on you, and the administration, and the
    Congress to see that we have a plan that makes that work.
        We also really need to have a clear strategy to provide
    vaccines to developing nations. We've seen in the past that
    outbreaks like Ebola, the one thing we know is that the next
    sick patient is only a plane ride away from here, and so, what
    we can do to help there ultimately protects us, as well.
        I'm particularly concerned about what we're doing and the
    strategy we have for unaccompanied alien children. You and I
    have talked about that even yesterday, and I look forward to
    chances to talk about that more. Many people think that this
    unaccompanied children issue has nothing to do with COVID, but,
    of course, how you deal with individuals coming in from another
    country does have something to do with COVID, and it also has
    something to do with COVID when you're taking money from our
    COVID-19 funds to deal with this problem that has to be dealt
    with.
        So far, the department's transferred $2.98 billion to the
    unaccompanied children account to deal with the fallout of
    border policies that just simply aren't working. This includes
    funding specifically that came out of COVID-19 relief, out of
    the American Rescue Plan. I want to remind the committee than
    only a few short months ago, President Biden felt it was so
    imperative to pass a COVID-19 supplemental bill that the
    administration pushed a $1.9 trillion bill through on a totally
    partisan vote, with no real input from my side of the aisle,
    and then, immediately, almost immediately, transferred $850
    million of that funding that was going to go for COVID-19
    relief to this fund for unaccompanied children.
        Just last week, the administration transferred another $846
    million to the unaccompanied children program from COVID-19
    funding. That money in the bill was intended to fund community
    health centers, behavioral health centers, workforce training,
    public health workforce, and other programs. Well, you know, $3
    billion of that money won't be allowed to do that because we're
    having to deal with a policy at the border that has to be dealt
    with, with even the vice president, in the last week, trying to
    do things to tell people to stop coming to the border. We have
    to have a policy that works better there.
        The supplemental passed in December that was written by
    this committee included, and it was a bipartisan vote, included
    critical resources for the Strategic National Stockpile. We saw
    the problems during the pandemic of what happened if the
    Stockpile wasn't there. The department already has taken $850
    million from the Stockpile fund to, again, the unaccompanied
    children program. I will remind all of us that we've all had
    questions over the last year of why didn't we do a better job
    having the Stockpile money being used for the Stockpile. We
    don't want to see the Stockpile again become a fund that is
    easily transferred.
        Finally, the department transferred $426 million from
    fiscal year Labor/HHS funds for programs like--children's
    hospitals, graduate medical education, the Ryan White HIV/AIDS
    Program, medical research, childcare. One of the problems in
    this last bill that was passed--I hope we don't repeat this in
    a bill that comes through our committee.--I don't believe we
    will, but unlike language we had normally had, there was no
    real restraint on transfers, no restriction on those transfers,
    no requirement to justify to the committee the transfers, no
    notification of the transfers.
        Those things were in every other bill we passed last year.
    They were not in the first bill that was passed this year, and
    so, the department hasn't given us notice on all of those
    transfers in a timely way, but the bill didn't require them to
    give us notice in a timely way. The members on my side of the
    aisle want to have discussions about how we deal with this
    ongoing in a better way.
        Without a dialogue with this committee, I would hope again
    that we don't have the flexibility next year that we have
    insisted on, like reporting and things, in the past. While we
    may disagree, and I may disagree with the Department's
    transfers, or even the way the Unaccompanied Children Program
    has been managed, there are certainly significant areas where I
    do agree.
        I support the National Institutes of Health increases. I
    think the new research institute at NIH (National Institutes of
    Health), ARPA-H (Advanced Research Projects Agency for Health),
    is in the right place at the right time with the right focus,
    and I announced in our hearing last week, you remember, Chair,
    that I intend to be supportive of that, and I believe we can
    make it work in a way we wouldn't have envisioned before the
    last couple of years, and the new things we did to step up to
    the pandemic.
        I certainly agree with the expansion of the Certified
    Community Behavioral Health Clinics to help address the mental
    health crisis. I agree with efforts to end the HIV pandemic and
    bring additional resources to bear on the opioid epidemic. The
    devil's always in the details, but I hope we can move forward
    on those things and others, but the administration is obviously
    requesting a huge increase in nondefense discretionary funding.
    In the Department of Health and Human Services alone, a 23
    percent increase, or an increase of $23 billion. That's
    compared to a defense department budget that the increase of
    1.6 percent doesn't even keep up with inflation.
        For the last several years, our friends on the other side
    of this dais have pushed for parity between defense and
    nondefense when Republicans were in charge and were advocating
    defense spending. I hope we can have, and I expect, frankly,
    will have a similar discussion this year.
        Finally, I wholeheartedly disagree with the
    administration's removal of the longstanding Hyde Amendment.
    One of things I've had a chance to do in both House and Senate
    is count, and I don't believe we can get a bill out of this
    committee without having the Hyde Amendment in that bill. It's
    been in the Appropriations Bill for 40 years. Every person on
    this committee who has ever voted for a final Labor/HHS bill
    has voted for Hyde since it first appeared in 1976. I don't
    think this year should be or, frankly, at the end of the day,
    will be different, but it is clearly, as the chair's already
    pointed out, going to be an issue we're going to vigorously
    discuss.
        This committee, Mr. Secretary and Chair, have been
    successful over the past 6 years with passing the bill, because
    we've really done things that, while they move things in a
    great direction, in the right direction, I think, didn't do it
    in a way that made drastic policy changes. I look forward to
    that same kind of incremental approach, and look forward to
    working with you, Mr. Secretary, as we move forward to continue
    to head your critically important department in the right
    direction, because it serves the American people, and in many
    ways, serves people all over the world. Thank you, Chairman.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Thank you, Chair Murray. I appreciate Secretary Becerra
    (pronounced: ba-serra) for being here today to discuss the
    Administration's fiscal year 2022 budget request.
        Over the past year, we have faced the challenges of a global
    pandemic. At a hearing in the House in May, you testified that, ``The
    fight against COVID-19 is not yet over.'' I agree. While vaccination
    rates are going up and cases are going down, we're still not finished
    with the fight. First, as many public health experts have stated, even
    those within the Administration, there is a certain vaccination level
    necessary to reach herd immunity and we're not there quite yet. Second,
    we may or may not need COVID-19 boosters at some point in the future
    and if we do, that will require further outreach and vaccination
    campaigns. Finally, we need to have a clear strategy to provide
    vaccines to developing nations. As we have seen with past infectious
    disease outbreaks like Ebola, the next sick patient is only a plane
    ride away.
        That is why I have been particularly concerned with the
    Administration's strategy on Unaccompanied Alien Children. Many may
    think that one issue has nothing to do with the other. But when the
    Administration is robbing Peter to pay Paul, they become inextricably
    linked.
        Mr. Secretary, over the past three months the Department has
    transferred $2.98 billion to the Unaccompanied Children account to deal
    with the fallout of the Administration's failed border policies. This
    includes funding specifically for COVID-19 relief from the American
    Rescue Plan. I want to remind the Committee that only a few short
    months ago, President Biden felt it was so imperative to pass a COVID-
    19 supplemental bill that the Administration pushed through a $1.9
    trillion partisan bill, with no input from Republicans, and then almost
    immediately transferred $850 million from funding that should have gone
    to additional COVID-19 testing to fund additional unlicensed shelter
    beds for Unaccompanied Alien Children. And just last week, the
    Administration transferred an additional $846.5 million to the
    Unaccompanied Children program from their partisan COVID-19 bill
    intended to fund Community Health Centers, behavioral health workforce
    training, public health workforce, among other programs.
        Second, the bipartisan COVID-19 supplemental passed in December
    that was written by this Committee included critical resources for the
    Strategic National Stockpile--which has proven essential during this
    pandemic, and for future crises. The Department took $850 million from
    this vital stockpile under the guise that the Unaccompanied Children
    program needed money due to COVID-19 and not failed border policies.
        Finally, the Department transferred $426 million from fiscal year
    2021 Labor/HHS funds, from programs like Children's Hospitals Graduate
    Medical Education, Ryan White HIV/AIDS, medical research, and child
    care. Prior to making these choices, none of these decisions were
    discussed with this Committee. In fact, Members on my side of the aisle
    have had no substantive discussions with you about the crisis at the
    border, even though the Administration has transferred or reprogrammed
    almost $3 billion of funding to address it.
        I understand that the Department is not in charge of our
    immigration laws and that the Department has to care for unaccompanied
    children that cross the border, regardless of where they come from or
    how they arrive. But without a dialogue with this Committee on how to
    do so, I suspect you will not have the flexibility to run this program
    next year as you have had this year. The Appropriations Committee
    appropriates funding based on the budget request, through arduous
    negotiations between the Senate and House, between Republicans and
    Democrats. I do not think the Administration should simply ignore that.
        While we may disagree on the Department's management of the
    Unaccompanied Children program, there are significant places where we
    agree. I support the increase to the National Institutes of Health and
    think that the new research Institute at NIH is coming at the right
    time with the right focus. I agree with expansion of Certified
    Community Behavioral Health Clinics to help address the mental health
    crisis, efforts to end the HIV epidemic, and bringing additional
    resources to bear to end the opioid epidemic.
        However, this is going to be a difficult year and the devil is
    always in the details. For example, the Administration is requesting a
    15.9% increase for non-defense discretionary funding, and the
    Department of Health and Human Services is requesting a 23% increase or
    an increase of $23 billion. That is significant, especially when
    compared to the Defense Department's budget request doesn't even keep
    up with inflation. Over the last several years, the other side of the
    aisle has pushed for parity between defense and non-defense funding and
    that is where we have ended up. I would expect a similar outcome this
    year.
        Finally, I wholeheartedly disagree with the Administration's
    removal of the longstanding Hyde Amendment. The Hyde Amendment prevents
    the Department from using federal taxpayer dollars to fund elective
    abortions. Hyde has been included in every government funding bill for
    more than 40 years. Every person on this Committee who has ever voted
    for a final Labor/HHS bill has voted for Hyde since its first
    appearance in 1976. And I do not think this year should be any
    different.
        Mr. Secretary, this Committee has been successful over the last six
    years with passing a bill because we haven't made fundamental, drastic
    policy changes. That is the position I took as Chairman and it will
    continue to be my position this year. I hope the Department will set
    aside its partisan policies to support programs that benefit all
    Americans instead.
        Thank you, again, for being here today.

        Senator Murray. Thank you very much, Senator Blunt. I will
    now introduce our witness today. It's Xavier Becerra, the
    Secretary of the Department of Health and Human Services. Thank
    you for joining us today. And at this point, I'm going to turn
    the gavel over to Senator Reed. Thank you for being here. I
    have to go introduce three constituents at another committee
    meeting. I will return, but until that time, Senator Reed will
    hold the gavel, and Secretary Becerra, you can begin your
    testimony. Thank you.

                    SUMMARY STATEMENT OF HON. XAVIER BECERRA

        Secretary Becerra. Madam Chair, thank you. Ranking member
    Blunt, members of the committee, thank you again. The
    Department of Health and Human Services is at the center of
    many challenges facing our country today. The COVID-19 pandemic
    has shed light on how inequities and inefficient Federal
    funding can leave communities vulnerable to crisis. Now, more
    than ever, we must ensure that the Department has the resources
    to achieve its mission, and to build a strong public health
    system, and a healthier America.
        For HHS, the budget proposes $131 billion in discretionary
    budget authority, and $1.5 trillion in mandatory funding. This
    budget underscores the administration's commitment to prepare
    the Nation for the next public health crisis, to expand access
    to affordable healthcare, to address health disparities, to
    tackle the opioid and other drug crises, and to invest in other
    priority areas, like maternal health, Tribal health, and early
    childhood education.
        We know the fight against COVID-19 is not yet over, but
    even as HHS works to beat the pandemic, we must also prepare
    for the next public health challenge. To start, the budget
    makes significant investments in our preparedness and response
    capabilities, including by investing in the Strategic National
    Stockpile, and the public health workforce. It provides a new
    mandatory funding stream for the manufacture of medical
    countermeasures here at home, to protect Americans from future
    pandemics, and create U.S. jobs.
        The budget includes the largest fiscal year investment in
    the CDC (Centers for Disease Control and Prevention) in almost
    two decades. The budget reflects the president's commitment to
    expand access to quality, affordable healthcare for all
    Americans. It builds on the groundbreaking reforms introduced
    in the American Rescue Plan by permanently extending the
    enhanced premium subsidies that put affordable healthcare
    coverage within reach for millions more Americans.
        The budget also expands access to home and community-based
    services under Medicaid, critical services that allow older
    Americans and our loved ones with disabilities to live
    independently in their homes and communities. And the budget
    calls for Congress to take additional steps this year to lower
    the costs of prescription drugs, and further expand and improve
    health coverage through additional benefits and public coverage
    options.
        Healthcare must be a right, not a privilege, and I will
    work hard to ensure that families across the Nation are able to
    secure the healthcare that they need. And as we work to expand
    access to affordable healthcare and address the challenges of
    COVID-19 and future pandemics, we need to address public health
    crises that are already here. Like violence in our communities
    and climate change.
        The President's budget increases funding to support
    domestic violence survivors. It addresses gun violence by
    doubling funding for firearm violence prevention research and
    allows HHS to play a major role in the administration's
    government-wide effort to tackle the climate crisis, by
    supporting research and programs identifying the human health
    impacts of the climate change and establishing an Office of
    Climate Change and Health Equity.
        To ensure that HHS is equitably serving all Americans, the
    budget invests in reducing maternal mortality and morbidity
    that disproportionately impacts women of color. It builds on
    the American Rescue Plan's State option to extend Medicaid
    postpartum coverage, it funds a range of rural healthcare
    programs, and expands the pipeline for rural health providers.
    It includes a dramatic funding increase in advance
    appropriations for the Indian Health Services, and it invests
    in improving access to vital reproductive and preventative care
    services through Title X.
        To support families and build the best possible future for
    our children, the budget makes major investments to ensure high
    quality childcare is affordable for low- and middle-income
    families, and to provide high-quality pre-K for all 3- and 4-
    year-olds. We know our experiences as children shape the adults
    we become. Support in childhood leads to success in the future.
        To address COVID-19's unprecedented acceleration of
    substance use and mental health disorders, the budget makes
    historic investments in SAMHSA (Substance Abuse and Mental
    Health Services Administration) to support research,
    prevention, treatment, and recovery services. To support
    innovation in research, the budget increases funding for NIH by
    $9 billion, $6.5 billion of which will go to establish the
    advanced research project agency for health, ARPA-H, with an
    initial focus on cancer and other diseases such as diabetes and
    Alzheimer's.
        This major investment in Federal research and development
    will leverage ambitious ideas to build transformational
    innovation through health research and the application and
    implementation of health breakthroughs.
        Finally, to ensure our funds are used appropriately, the
    budget invests in program integrity, including efforts to
    combat fraud, waste and abuse in Medicare, Medicaid, and
    private insurance.
        Madam Chair, I'd like--and Mr. Chairman, I'd like to close
    by recognizing the women and men at HHS for their outstanding
    and tireless work fighting COVID-19 to protect the health of
    their fellow Americans. To build back a prosperous America, we
    need a healthy America. We've taken important steps over the
    past few months to expand access to quality, affordable
    healthcare, to lower healthcare premiums, and to protect
    women's health at home and abroad. President Biden's budget
    request builds on that progress. Thank you.
        [The statement follows:]
                   Prepared Statement of Hon. Xavier Becerra
        Chair Murray, Ranking Member Blunt, and Members of the Committee,
    thank you for the opportunity to discuss the President's Fiscal Year
    (FY) 2022 Budget for the Department of Health and Human Services (HHS).
    I am pleased to appear before you, and I look forward to continuing to
    work with you.
        HHS is at the center of many challenges facing our country today--
    the COVID-19 pandemic, safely caring for unaccompanied children at our
    southern border, the overdose and the addiction epidemic gun violence,
    racial inequality, and more--and we are rising to meet those
    challenges. I am honored to be given the responsibility to lead HHS at
    this time.
        COVID-19 has shed light on how health inequities and insufficient
    Federal funding can leave communities vulnerable to crises. The
    President's Budget invests in America, demonstrates a conscious effort
    to address racial disparities in health care, tackles the opioid and
    other drug crises, and puts us on a better footing to take on the next
    public health crisis.
        Now more than ever, we must ensure that HHS has the resources to
    achieve its mission and tackle these challenges after years of
    underfunding. The President has put forward a budget that does just
    that. The FY 2022 budget proposes $131.8 billion in discretionary
    budget authority and $1.5 trillion in mandatory funding. The Labor-HHS
    total is $119.5 billion, an increase of $23 billion. Investments in the
    budget support families in areas such as behavioral health (mental
    health and substance use), maternal health, emerging health threats,
    science, data and research, tribal health, early child care and
    learning, and child welfare.
        To build back a prosperous America, we need a healthy America, and
    President Biden's budget builds on that vision while investing in the
    many programs housed at HHS to save lives.
              preparing for and responding to public health crises
        The fight against COVID-19 is not yet over. Even as HHS works to
    beat this pandemic, we are also preparing for the next public health
    crisis. The FY 2022 budget makes significant investments in our
    preparedness and response capabilities.
        The Strategic National Stockpile, within the HHS Office of the
    Assistant Secretary for Preparedness and Response, has served a
    critical role in the COVID-19 response, permitting rapid deployment of
    personal protective equipment, ventilators, and medical supplies to
    states, cities, tribes, and territories across the country. The budget
    provides $905 million for the stockpile, $200 million above FY 2021, to
    ensure that the stockpile is ready to respond to future pandemic events
    and any other public health threats while maintaining a robust
    inventory of critical medical supplies, enhancing visibility of the
    domestic supply chain, and modernizing the stockpile's distribution
    model. In addition, the budget provides $823 million, $227 million
    above FY 2021, for the Biomedical Advanced Research and Development
    Authority, which has supported the development of new vaccines,
    therapeutics, and diagnostics for the COVID-19 response. Additional
    resources will support improved medical countermeasure platforms that
    will enable quicker, more effective detection and public health and
    medical responses to health security threats. The budget also supports
    a strong public health workforce, and addresses gaps in the existing
    public health infrastructure, including at the state and local levels.
    In addition to discretionary investments, the budget includes $30
    billion over four years in mandatory funding for HHS, the Department of
    Defense, and the Department of Energy to protect Americans from future
    pandemics and create U.S. jobs through major new investments in medical
    countermeasures manufacturing; research and development; and related
    biopreparedness and biosecurity investments.
        During this pandemic, we have seen the critical role of the Centers
    for Disease Control and Prevention (CDC). To ensure that CDC is well
    positioned to address current and emerging public health threats, the
    budget restores capacity to the world's preeminent public health agency
    by investing an additional $1.6 billion over the FY 2021 level for a
    discretionary funding total of $8.7 billion. This is the largest budget
    authority increase for CDC in almost two decades. A core function of
    CDC is partnering with state, tribal, local, and territorial entities,
    and this funding will enhance those partnerships. The budget will also
    provide CDC with additional resources to further develop and expand
    teams of highly trained and deployable public health experts to support
    preparedness at the local level.
        The COVID-19 pandemic has also shown the importance of producing
    reliable data. Bad inputs lead to bad outputs, and without good data,
    CDC cannot effectively prepare for, or respond to, public health
    threats and make well-informed decisions to protect the American
    people. With funding provided in the FY 2022 budget, CDC will build
    upon previous investments in the data infrastructure to date and
    continue efforts to modernize public health data collection and
    analysis nationwide.
        Public health threats know no borders, and CDC is working to
    prevent, detect, and respond to epidemic threats at home and abroad.
    With CDC experts embedded in countries around the world, CDC is
    supporting global COVID-19 response by leveraging core public health
    capacities and relationships built through decades of CDC global health
    activities. As we continue to confront new and emerging COVID-19
    variants, as well as a surge of cases in India, support for CDC's work
    is even more important. CDC is working closely with U.S. government
    agencies, ministries of health, and other partners to assist countries
    in responding to COVID-19, while simultaneously developing and
    implementing adaptations to interventions for malaria, HIV, and
    vaccine-preventable diseases. With the President's proposed FY 2022
    investments, CDC will not only address preparedness within the United
    States, but will also support core public health capacity improvements
    overseas and strengthen global health security by improving our ability
    to deploy experts internationally and support efforts to prevent,
    detect, and respond to emerging global biological threats. CDC will
    invest in global health security and continue to fight health threats
    worldwide while simultaneously enhancing domestic preparedness to
    address threats here at home. Domestic health is increasingly impacted
    by global factors and CDC's global health security efforts include
    conducting research to ensure efficient disease response.
        The Assistant Secretary for Preparedness and Response (ASPR) and
    CDC investments complement preparedness activities across HHS including
    basic and clinical research within National Institutes of Health (NIH)
    and activities within the Food and Drug Administration (FDA) to advance
    regulatory science and mitigate potential supply or drug shortages.
        While we prepare for future pandemic threats, we are also facing a
    public health crisis that is already here: violence in our communities.
    The current public health emergency has shone a light on the issue of
    domestic and gender-based violence. More than 1 in 4 women and more
    than 1 in 10 men have experienced contact sexual violence, physical
    violence, or stalking by an intimate partner and reported significant
    impacts. The budget provides $489 million for the Administration for
    Children and Families (ACF) to support and protect domestic violence
    survivors, which is more than double the FY 2021 enacted levels. The
    budget also provides $66 million for victims of human trafficking and
    survivors of torture, more than 45 percent above FY 2021 enacted
    levels.
        We have also seen the devastating impact of gun violence in
    communities across the country. Almost 40,000 people die as a result of
    firearm injuries in the United States every year, while homicide is the
    third leading cause of death for people ages 10-24. This is a public
    health issue, and one that disproportionately impacts communities of
    color. The budget addresses this crisis by doubling CDC and NIH funding
    for firearm violence prevention research. The budget provides $100
    million in discretionary funding to CDC to start a new Community
    Violence Intervention initiative, in collaboration with the Department
    of Justice, to implement evidence- based community violence
    interventions at the local level. In addition to the discretionary
    investment for the Community Violence Intervention initiative, the
    budget includes a total of $5 billion in mandatory funding for CDC and
    the Department of Justice, beginning in FY 2023 and continuing through
    FY 2029.
        The climate crisis has real public health impacts, and the HHS'
    mission depends on healthy and sustainable environments. HHS thus has a
    major role to play in the Administration's government-wide effort to
    tackle this crisis. HHS' investments to combat climate change in the FY
    2022 Budget will advance health equity, lay the foundations for
    economic growth, and ensure that benefits from tackling the climate
    crisis accrue to tribal communities, communities of color, low-income
    households, and disadvantaged communities that have been marginalized
    or overburdened. The budget includes a $100 million increase in NIH
    funding to support research aimed at understanding the health impacts
    of climate change, as well as an additional $100 million investment in
    CDC's Climate and Health program to support efforts to understand and
    identify potential health effects, including children's environmental
    health considerations associated with climate change and implement
    plans to adapt to a changing environment. The American Jobs Plan also
    would invest $1.5 billion to increase the resilience of hospitals and
    critical infrastructure, fund health emergency preparedness cooperative
    agreements, and build resilience including in relation to the effects
    of a changing climate.
           caring for all americans through health and human services
        Central to the HHS mission is the charge to enhance the health and
    well-being of all Americans. The budget invests in areas across HHS to
    ensure that we are equitably serving the American people. As Secretary,
    I will ensure that this focus is fundamental to all of our work.
        A critical part of this is investing in civil rights enforcement to
    ensure that all people receiving services from HHS-conducted or HHS-
    funded programs, no matter who they are, or where they live, can
    receive health care free from discrimination.
        The FY 2022 Budget makes expanding affordable health care access a
    priority across Centers for Medicare & Medicaid Services programs. A
    recently released report titled ``Health Coverage Under the Affordable
    Care Act: Enrollment Trends and State Estimates'' shows that the
    Affordable Care Act (ACA) has expanded health insurance coverage to
    millions of Americans, and the budget goes even further. It builds on
    the groundbreaking reforms introduced in the American Rescue Plan Act
    by extending the enhanced premium subsidies that put affordable health
    care coverage within reach of millions more Americans. These
    improvements in the American Rescue Plan Act are lowering premiums for
    more than nine million current enrollees by an average of $50 per
    person per month. In addition, due to the COVID-19 pandemic, an ongoing
    opportunity to apply for enrollment in Marketplace health care coverage
    is available on HealthCare.gov through August 15. This extension
    provides individuals and families a desperately needed opportunity to
    get quality, affordable health insurance coverage. As of May 10, over 1
    million additional Americans have signed up for health insurance
    through the Marketplace, and an additional 2 million obtained improved
    benefits through the Marketplace, benefitting from both reduced
    premiums and more affordable cost sharing.
        The FY 2022 Budget also expands access to critical home- and
    community-based services (HCBS) under Medicaid, critical health care
    services that allow older people and people with disabilities to live
    independently in their homes and communities. The budget builds on the
    additional Medicaid funding included in the American Rescue Plan that
    not only expands access to these important services but also
    strengthens state HCBS programs by allowing states to use the
    additional money to, for example, provide additional benefits, like
    mental health and substance use services, to beneficiaries, as well as
    to raise wages and provide paid leave for home care workers.
        I look forward to working with the Congress to achieve the
    Administration's goal of lower costs and expanded and improved coverage
    for all Americans. This includes reforms to lower the costs of
    prescription drugs, such as allowing Medicare to negotiate payment for
    certain high-cost drugs, and requiring manufacturers to pay rebates
    when drug prices rise faster than inflation. We will also work to
    improve Medicare, Medicaid, CHIP, and private insurance coverage, by
    pursuing changes such as improving access to dental, hearing, and
    vision coverage in Medicare, making it easier for eligible people to
    get and stay covered in Medicaid, promoting Early and Periodic
    Screening, Diagnostic and Treatment (EPSDT) requirements for eligible
    youth, and reducing out-of-pocket costs for individuals in private
    insurance coverage obtained through the Marketplace. The Administration
    also supports additional public coverage options, including a public
    option that would be available through the insurance marketplaces.
    Health care is a right, not a privilege, and I will work to ensure that
    families across the nation are able to secure this right.
        The United States has the highest maternal mortality rate among
    developed nations, with an unacceptably high mortality rate for Black
    and American Indian/Alaska Native women. Addressing this critical
    public health issue is a major priority of this Administration, as
    evidenced by the American Rescue Plan's state option to extend Medicaid
    postpartum coverage. Building on HHS's longstanding efforts to improve
    maternal health, including the Department's recent Medicaid postpartum
    waiver approvals, the budget provides more than $220 million in
    discretionary funding to reduce maternal mortality and morbidity by
    implementing evidence-based interventions to address critical gaps in
    maternity care service delivery and improve maternal health outcomes.
    This includes increased funding to CDC's Maternal Mortality Review
    Committees and the Health Resources and Services Administration's
    (HRSA) Rural Maternity and Obstetrics Management Strategies program.
    HRSA also prioritizes maternal health through its Title V Maternal and
    Child Health Block Grant and Alliance for Innovation on Maternal Health
    programs. As with all our public health work, collecting good data will
    be critical. In addition to these discretionary resources, the budget
    includes $3 billion in mandatory funding over five years, to invest in
    maternal health and reduce the maternal mortality rate and end race-
    based disparities in maternal mortality.
        HRSA's work is central to our focus on serving all Americans, given
    their mission to improve health outcomes and address health
    disparities. HRSA-funded Health Centers provide access to care for low-
    income and marginalized populations, and they serve 1 in 11 people in
    the nation. The President's Budget increase to workforce diversity
    programs, highlights HRSA's commitment to supporting health care
    providers dedicated to working in underserved areas and building toward
    a workforce that reflects the communities it serves and is able to
    provide culturally relevant care.
        The budget provides $670 million across HHS to continue efforts to
    end the HIV epidemic in the United States by working closely with
    communities that have high rates of HIV transmission to implement
    effective prevention, diagnosis, and treatment strategies, including
    ones that address the disproportionate impact of HIV and Hepatitis C
    infections in Tribal communities. HHS programs have already made major
    progress in combating the HIV epidemic. HRSA ensures equitable access
    to services and supports for low-income people with HIV through Health
    Centers as well as the Ryan White HIV/AIDS Program. In 2019, 88.1
    percent of those served under the Ryan White HIV/AIDS Program had
    achieved viral suppression, a record level that exceeds the national
    average of 64.7 percent. HHS will build on this work to end the
    epidemic once and for all.
        Also, directly connected to the HHS mission is the need to provide
    access to high-quality care, no matter where you live. HHS will
    continue to focus on the unique needs of rural communities. HHS
    administers a range of programs that address rural health, from those
    that serve large populations such as Health Centers, to those serving
    targeted populations such as the Black Lung Clinics Program. The FY
    2022 budget serves active, inactive, retired, and disabled coal miners
    and their families through high-quality medical, outreach, educational,
    and benefits counseling services. It also provides funding to increase
    the number of individuals receiving training and serving in health
    professions in rural communities, as research has shown that providers
    are likely to remain in the communities where they train as residents.
        HHS will also address the stark health disparities that persist in
    Tribal communities by investing in the Indian Health Service (IHS),
    which serves over 2.6 million American Indians and Alaska Natives. The
    COVID-19 pandemic's devastating impact on Tribal communities has
    demonstrated the real human toll of these disparities. The budget
    provides a $2.2 billion, or 36 percent, increase for IHS in order to
    take a historic step to address chronic underfunding, expand access to
    high-quality health care, and address critical facilities and
    information technology infrastructure deficiencies across Indian
    Country. For the first time, the budget also proposes advance
    appropriations for IHS to provide stability for the Indian Health
    system and parity with how other Federal health agencies are funded. I
    am committed to strengthening the Nation-to-Nation relationship between
    the United States and Indian Tribes. To this end, the budget supports
    self-determination through a consultative process to consider long-term
    solutions, including mandatory funding, to ensure adequate and stable
    funding for IHS.
        The budget also provides an 18.7 percent increase to the Title X
    Family Planning program to improve access to vital reproductive and
    preventive care and to advance gender equity. Over the last two years,
    nearly half of the programs supported by Title X lost providers as a
    result of the 2019 regulation which added burdensome restrictions
    inconsistent with quality care guidelines and ultimately resulted in
    many highly qualified, longstanding healthcare entities to exit Title
    X. The budget allows Title X to not only restore highly qualified
    providers, but also to expand its essential services to meet increased
    demand as a result of the global pandemic and resulting recession. In
    2019, Title X-funded clinics served almost 3.1 million Americans, 66
    percent of whom had incomes at or below the federal poverty level and
    41 percent of whom were uninsured. This is nearly 1 million fewer
    people served than in 2018.
                        investing in children's futures
        Our experiences as children shape the adults we become, and support
    in childhood can mean success in the future. As Frederick Douglass
    wrote, ``It is easier to build strong children than to repair broken
    men.'' High-quality early care and education lay a strong foundation so
    that children can take full advantage of education and training
    opportunities later in life. The American Jobs Plan and the American
    Families Plan invest in school and child care infrastructure and
    workforce training, and ensure that low and middle-income families pay
    no more than 7 percent of their income on high-quality child care.
    These investments include $200 billion over ten years for a national
    partnership with states to offer free, high-quality, accessible, and
    inclusive preschool to all three- and four-year-olds, benefitting five
    million children. The budget also invests $250 billion over ten years
    to make child care affordable.
        The budget also provides $19.8 billion in discretionary funding for
    the Department's early care and education programs in ACF, $2.8 billion
    over FY 2021 enacted. This includes $11.9 billion for Head Start, which
    helps young children enter kindergarten ready to learn. Head Start
    programs deliver services through 1,600 agencies in local communities,
    and they provide services to more than a million children and pregnant
    women every year, in every U.S. state and territory. In addition, the
    budget provides $7.4 billion for the Child Care and Development Block
    Grant, $1.5 billion over FY 2021 enacted, to expand access to high-
    quality child care for families in all corners of the country. Over a
    million children receive child care subsidies every month funded by the
    Child Care and Development Fund, and nearly half of the families
    receiving child care subsidies reported income below the Federal
    Poverty Level. These investments will improve outcomes for children
    across the country.
        The budget also invests in improvements to the child welfare
    system, particularly to address its racial inequity. The budget
    provides $100 million in new competitive grants for states and
    localities to advance reforms that would reduce the overrepresentation
    of children and families of color in the child welfare system and
    address the disparate experiences and outcomes of these families. This
    funding will also give more families the support they need to remain
    safely together. The budget also provides $200 million for states and
    community-based organizations to respond to, and prevent, child abuse,
    over 30 percent above FY 2021 enacted.
                combating mental health and substance use crises
        HHS must address the public health crises associated with mental
    health and substance use disorders. This need is especially urgent
    given that both crises have accelerated during the COVID-19 pandemic.
    Calls to mental health helplines have increased across the country as
    Americans struggle with increased anxiety, depression, risk of suicide,
    and trauma-related disorders resulting from the pandemic. Younger
    adults, racial minorities, essential workers, and unpaid adult
    caregivers are particularly impacted. Similarly, preliminary data from
    2020 suggests that overdose deaths, which were already increasing,
    accelerated at an unprecedented rate during the pandemic. Provisional
    data suggest that over 90,000 drug overdose deaths occurred in the
    United States in the 12 months ending in September 2020. That
    represents a year-over-year increase of close to 29 percent.\1\ This
    crisis is also evolving--overdose deaths involving substances other
    than opioids are also increasing. HHS will ensure that our work is
    responsive to the needs of communities across the country.
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention. (2021). Vital
    Statistics Rapid Release: Provisional Drug Overdose Death Counts.
    Retrieved May 6, 2021 at https://www.cdc.gov/nchs/nvss/vsrr/drug-
    overdose-data.htm.
    ---------------------------------------------------------------------------
        The budget addresses these crises through investments in the
    Substance Abuse and Mental Health Services Administration.
        In a historic investment, the budget provides $1.6 billion to the
    Community Mental Health Services Block Grant to respond to the systemic
    strain on our country's mental health care system--more than double the
    FY 2021 level. To address the undeniable connection between the
    criminal justice system and mental health, the discretionary request
    will also invest in programs for people involved in the criminal
    justice system. HHS will also focus on the behavioral impact of COVID-
    19, including on children. When children and young people face Adverse
    Childhood Experiences (ACEs) such as trauma, it can continue to affect
    them across their lifespan, so it is critical we intervene now to
    support their social, emotional, and mental well-being.
        The budget also takes action to address addiction and the overdose
    epidemic, investing $11.2 billion across HHS, $3.9 billion more than in
    FY 2021, including $3.5 billion for the Substance Abuse Prevention and
    Treatment Block Grant, which has historically failed to keep up with
    increases in the cost of providing substance use care to America's
    neediest citizens. For the first time, the budget includes a 10 percent
    set aside for recovery support services, a critical step for building
    and sustaining the nation's recovery support services infrastructure.
    The Block Grant remains a critical source of funding for states,
    tribes, and territories to provide prevention, treatment, and recovery
    support services to their citizens. The impact of this epidemic is felt
    in our communities, and the budget will direct funding to states and
    Tribes to increase community-level response. The budget will also
    increase access to medications for opioid use disorder and expand the
    behavioral health provider workforce, particularly in underserved
    areas. I greatly appreciate the investments the American Rescue Plan
    Act provided to the Substance Abuse Prevention and Treatment Block
    Grant, Mental Health Block Grant, and Certified Community Behavioral
    Health Centers, and HHS will continue to build on these efforts.
                         promoting biomedical research
        HHS' work is responsible for major scientific breakthroughs, and we
    are committed to supporting innovative science and research in order to
    advance the health and well-being of our nation. As the world's premier
    biomedical research agency, NIH will continue to be at the forefront of
    scientific advancements. The budget includes $52 billion for NIH, a $9
    billion increase or 21 percent increase over FY 2021 enacted. Included
    in this increase is $6.5 billion to establish the Advanced Research
    Projects Agency for Health (ARPA-H). With an initial focus on cancer
    and other diseases such as diabetes and Alzheimer's, this major
    investment in Federal research and development will leverage ambitious
    ideas to build transformational platforms, capabilities, and resources
    to speed the application and implementation of health breakthroughs and
    shape the future of health and medicine in the U.S.
        This bold new approach will complement NIH's existing research
    portfolio, which is a vital contributor to longer and healthier lives,
    supports and trains world-class scientists, and drives economic growth.
    Outside of ARPA-H, the remaining $2.5 billion increase will allow NIH
    to continue investing in basic research and translating research into
    clinical practice to address the most urgent challenges, such as HIV/
    AIDS and ending the opioid crisis.
                    restoring america's promise to refugees
        HHS plays a critical role in promoting the wellbeing of those
    seeking refuge or relief in the U.S. The FY 2022 budget provides over
    $4.4 billion to the Office of Refugee Resettlement (ORR)--an increase
    of over $2.5 billion above FY 2021 enacted. This funding would allow
    ORR to support an increase in the refugee admissions ceiling to 62,500
    this fiscal year and to continue to rebuild the resettlement
    infrastructure in order to resettle up to 125,000 refugees in FY 2022.
        This funding increase also reflects a commitment to ensuring that
    unaccompanied children are provided with care and services that align
    with child welfare best practices while they are in ORR's custody, and
    unified with relatives and sponsors as safely and quickly as possible.
    Despite significant challenges posed by COVID-19 and policies from the
    previous administration, HHS is humanely caring for unaccompanied
    children while working to unite them with a vetted sponsor. Working
    across government and in close partnership with the Department of
    Homeland Security, we have substantially increased our ability to
    quickly facilitate the transfer of children out of U.S. Customs and
    Border Patrol custody and into child-appropriate settings, including
    with fully vetted sponsors.
                        funding core program operations
        It is simply not possible to meet the HHS mission and address all
    these key changes without sufficient funding to cover our operational
    needs. The FY 2022 budget invests to bolster operations. It strengthens
    administrative and operational resources throughout the Department
    needed to ensure proper stewardship of resources entrusted to HHS by
    Congress.
                   providing oversight and program integrity
        Given the magnitude of HHS's work-and the taxpayer dollars used to
    fund it-it is critical that we ensure that our funds are used
    appropriately. The budget invests in program integrity, including
    efforts to combat fraud, waste, and abuse in Medicare, Medicaid, and
    Private Insurance.
                                   conclusion
        I want to thank the Committee again for inviting me to discuss the
    President's FY 2022 Budget for HHS, which offers a comprehensive fiscal
    vision for the nation that reinvests in America's health, supports
    future growth and prosperity, and meets U.S. commitments in a fiscally
    sustainable way. I look forward to continuing to show how HHS helps
    fulfill that vision.

        Senator Reed [presiding]. Thank you very much, Mr.
    Secretary. Chairwoman Murray has allowed me to go first, and
    then I'll recognize Senator Blunt. Like Senator Blunt, one of
    the privileges of my life in public service is having served
    with you in the House of Representatives, and congratulations,
    Mr. Secretary, on your well-deserved position.

                      NATIONAL SUICIDE PREVENTION LIFELINE

        One of the legislative initiatives that I was involved with
    was the National Suicide Prevention Lifeline. I worked together
    with Senators Gardner, Baldwin, and Moran. We've changed the
    ten-digit number to a three-digit number, and several States
    have already adopted the number. Everyone has to adopt it by
    next year, but the reality is we'll need more funding, because,
    as more people use this number, we'll need more counselors and
    more capacity.
        We asked that SAMHSA provide a cost estimate to Congress on
    Lifeline in early April. Could you give us an update on the
    cost estimate, Mr. Secretary?
        Secretary Becerra. Senator, thank you for the question,
    because this one is important. Even though it's not one of the
    bigger items, it is crucial for a lot of people. Just as 911
    has become indispensable, 988, I believe, will become
    indispensable for those who need some help in crisis.
        And where we are right now, Senator, is we have had some
    briefings with members on the Hill. We're trying to follow up
    with those. We're hoping to move as quickly as possible. You
    may have seen in the budget, the President has quadrupled the
    amount of money that he would allocate for this particular 988
    program and so, we would hope to receive funding for--about a
    year's worth of funding of about $102 million over the 24 or so
    million that there was before.
        We're hoping to move quickly, but I think you're right. To
    do this well, and to do it throughout the country, we may need
    to come back to you.
        Senator Reed. Well, thank you, Mr. Secretary, but I think
    we all recognize there's been an incredible increase in
    suicides, and particularly disturbing, among young people, also
    among service members, and so, I appreciate your efforts to get
    this thing done.

                   LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

        Turning to another issue, LIHEAP (Low Income Home Energy
    Assistance Program). It's a critical program, long supportive
    of it. The resources in the budget are impressive, and I
    appreciate it, but one of the issues we have is getting the
    word out, if you will. There are many individuals who could
    participate, but they're not aware of the program. Can you
    share the steps the agency is taking to conduct outreach and
    make sure that eligible individuals get their LIHEAP?
        Secretary Becerra. Senator, on top of increasing the budget
    for the LIHEAP program, because, like you, I have been a
    fighter for this program for quite some time, and we're also
    reaching out. We're reaching out to the utility companies,
    we're reaching out to local governments, we're trying to have
    them help us reach out to people who qualify for these
    services, and so, we don't want to just wait and believe that
    people will hear that we're increasing the funding for LIHEAP.
        We're going to try to work with our local partners, private
    sector and public, to try to reach those families that really
    need this funding to help them survive, and make sure, monthly-
    wise they're covered.
        Senator Reed. Well, thank you, Mr. Secretary. One of the
    agencies that has been very effective are the community action
    agencies. They have roots in the community, so, I'm sure
    they're on your list, but I just wanted to mention that for the
    record.

                  PERSONAL PROTECTIVE EQUIPMENT MANUFACTURERS

        We all are concerned about PPE (Personal Protective
    Equipment). We had a wake-up call during the pandemic, and we
    are concerned about how you're stockpiling it in terms of
    prioritizing U.S. manufacturers, or at least manufacturers that
    are consistent allies of the United States, and not potential
    competitors. But can you comment?
        Secretary Becerra. Here I have to thank you all for the
    work you did to help us stand up a sizeable pot of money, $10
    billion, that will help us make sure that we're doing all we
    can to increase domestic manufacturing of that. Not just the
    PPE, but the types of material, and the types of product that
    we need in the event of a future pandemic, or a future crisis.
        And so, we're trying to adapt. The stockpile has to enter
    the 21st century. We have to make sure that what we do have
    stored actually will work once we need it, and we have to make
    sure that what we are storing is what we need to be equipped
    for the crises of the 21st century. But thank you for that
    support.
        Senator Reed. Well, thank you very much, Mr. Secretary, and
    again, thank you for your service, and I'm extremely pleased
    that you're the Secretary. Thank you.
        Secretary Becerra. Thank you, Senator.
        Senator Reed. Senator Blunt, please.
        Senator Blunt. Thank you, Senator. Secretary, the Congress
    has provided $178 billion over the course of the last year for
    the Provider Relief Fund. There's another $8.5 billion in
    addition to that for rural hospitals in the American Rescue
    Plan that passed in January. I think most of that money has to
    be spent by June 30.
        You answered some questions on that at the Ways and Means
    Hearing yesterday. You said we're trying to make sure we don't
    make the mistakes of the past. What are a couple of those
    mistakes, and how are you trying to move forward without
    continuing what you think was a mistake?
        Secretary Becerra. Senator, I think we would all agree that
    we want to know where and why taxpayer dollars are going to
    particular item or cause, and I think most people will tell
    you--at least the comments that we're seeing are that there
    wasn't enough transparency in the process. How the money was
    allocated. Why was one provider provided dollars, in some
    cases, quite a bit of money, and in other cases, other
    providers who were also in need, didn't?
        And so, what we want to do is provide that transparency. At
    the same time, we understand that there were a number of
    providers who were left behind because of the formula that was
    used to disperse the dollars, based on Medicare claims.
        And in many cases, if you happened to be a provider that
    relied a lot on, say, Medicaid or other sources, or you
    provided a lot of charity care, you might not have had the same
    level of claims. That doesn't mean you didn't have the COVID
    patients. So, we're trying to provide the transparency, make
    sure we direct the money where it's needed, and with the money
    that's still left, we want to make sure that you all can look
    at this and say, we get it.
        Senator Blunt. So, I think there's approximately $50
    billion left. I also believe that money, most of it, needs to
    be spent by June 30. What are you doing to get that money out,
    and when you do get it out, what are you doing to make it more
    likely that the hospitals will be able to spend that money
    before the deadline?
        Secretary Becerra. Senator, there's a tranche of money that
    has not yet been allocated, and so the deadline for spending
    that has not yet been determined, but there is money that did
    go out that does have a deadline, and what we're trying to do
    is, over the next few weeks, make sure we provide some guidance
    so people understand how we can make sure that everyone
    fulfills their commitments in getting these dollars.
        We want to make sure we provide some flexibility. We also
    want accountability. We want to make sure folks understand that
    when they got these taxpayers dollars to help Americans in
    need, that taxpayers expect that it went to help those families
    in need. And so, what we'll try to do is--understand that we
    can't change the process that began before, but what we can try
    to do is make sure we get the accountability while trying to
    provide some flexibility.
        Senator Blunt. So, advice I gave the previous
    administration on this in a letter I wrote last fall was, don't
    make it needlessly difficult by continuing to change the
    guidelines that you've giving hospitals on how they can spend
    the money. So, I hope as you allocate this last amount of
    money, or put out whatever guidance you need, that it doesn't
    suddenly restrict what they were earlier told they could do,
    but more importantly, it does let them know that you're going
    to have guidelines out there that they can rely on if they
    spend the money that way, that it meets the guidelines.

                             UNACCOMPANIED CHILDREN

        On the unaccompanied children issue, Secretary, I think you
    have an average of about 400 children coming in every day. You
    can verify that, if you know, and how many children do you have
    leaving the program every day?
        Secretary Becerra. It's a number, Senator, as you know,
    that fluctuates. A couple months ago, the average was probably
    closer to 600, maybe above that. Today, you're probably right.
    It hovers somewhere between 3 to 5 hundred a day, but we can't
    predict it.
        Senator Blunt. Well, the average is kind of what I'm
    wondering about, both on children coming in and then children
    leaving the program.
        Secretary Becerra. Yes, again, right now, and what we do at
    the department, my team, we try to use a week average. We go
    week by week to see the trends, but I'd say you're probably
    accurate. Somewhere between 3 to 5 hundred a day, over the last
    week, two weeks coming in.
        Those that we are discharging to a responsible sponsor,
    after checking the background of those individuals, somewhere
    between, probably between 4 to 6 hundred, probably closer to
    the higher range of 600 than 400.
        Senator Blunt. And who checks the background on the
    individuals that these children are given responsibility for?
        Secretary Becerra. We have a dedicated team of people
    who've been trained to do background checks.
        Senator Blunt. And they work for you? HHS team, or a----
        Secretary Becerra. It's an HHS team. We pay for all the
    services that are provided. In many cases, we've been
    fortunate, the Department of Homeland Security has been very
    generous in providing us with some of their personnel who have
    been trained in doing intake work and processing. We have
    others within the Federal Government who have volunteered, and
    certainly we have folks from within HHS who are doing this.
        We had to substantially increase the number of caseworkers
    that we use so we could make sure we process in a timely
    fashion those children's record to see if they could be
    discharged to a responsible custodian.
        Senator Blunt. Well, when 400 are coming in, or 500 or
    coming in, but more importantly, when say, 500-600 are going
    out, I know you don't want, and I don't want any of those
    children to go to a place where they're less safe, where
    they're going to be exploited or taken advantage of, and I
    would hope you're doing everything you can dealing with those
    big numbers to be sure that that does not happen.
        Secretary Becerra. Senator, I can assure you, the reason
    back in March and April we were looking at this and really
    seeing it as a major challenge in CBP, that's Customs and
    Border Protection, was having these large number of children in
    their adult detention facilities, where they should not be, is
    because we wanted to make sure before we took that child, we
    could provide exactly what you just said.
        The safety, the health requirements, wherever we are going
    to place that child. We ran out of the licensed care facilities
    that we typically would send these kids to a substantial time
    ago. We've had to stand up a number of emergency shelters to be
    able to properly house these children, and where possible, we
    try to move them as quickly as we can to a safe home once we've
    gone through the vetting process.
        It is tough, it's challenging, and it's expensive, but
    we're going to do it right.
        Senator Blunt. Thank you, Mr. Secretary, thanks.
        Senator Reed. Thank you very much, Senator Blunt. And now,
    on behalf of Chairwoman Murray, let me recognize Senator
    Schatz.

                                   TELEHEALTH

        Senator Schatz. Thank you Mr. Chairman, Ranking Member.
    Thank you, Secretary. Last month, Mr. Secretary, you said that
    telehealth can be a godsend. I agree. 55 senators on a
    bipartisan basis who cosponsored my telehealth bill agree, but
    we're facing a telehealth cliff, because your current authority
    to expand Medicare's coverage of telehealth expires when the
    public health emergency ends.
        Unless Congress acts, we will go back to the Dark Ages,
    with very limited access to telehealth. So, Secretary, do you
    believe that Medicare beneficiaries should have access to
    telehealth, no matter whether they live in rural or urban
    areas?
        Secretary Becerra. Absolutely. Telehealth is something that
    we have to move towards. We learned lessons from COVID, and I
    hope that you all are able to agree on legislation that gives
    us more authority.
        Senator Schatz. Do you think that it's important that
    Medicare beneficiaries are able to use telehealth in their
    homes?
        Secretary Becerra. We want to make sure telehealth reaches
    every part of the beneficiaries' surroundings. I want to be
    careful here, because we want to make sure there's
    accountability, and there are some proposals that would show
    that accountability. But we want to make sure that, in fact, if
    we're going to provide reimbursement for that service, that
    those beneficiaries are receiving real service.
        Senator Schatz. Are you satisfied that the current law that
    we're utilizing under this public health emergency is working,
    and that there's sufficient accountability?
        Secretary Becerra. Thank you for asking it that way. I
    think we need better authority.
        Senator Schatz. Thank you. Do you believe that federally
    qualified health centers and rural health clinics should be
    able to provide telehealth services to their patients?
        Secretary Becerra. Again, with accountability, yes.
        Senator Schatz. Do I have your commitment to work with
    Congress to provide the necessary data and technical assistance
    that we need to enact these telehealth policies this year?
        Secretary Becerra. You have me at hello on that one.

                             NATIVE HAWAIIAN HEALTH

        Senator Schatz. All right. Great. Let me just talk to you a
    little bit about issues of native Hawaiian health. The U.S.
    shares a unique political relationship with the native Hawaiian
    community. Different Federal agencies within HHS are
    responsible for the administration of native healthcare
    programs, but the same Federal trust responsibility requires
    the provision of comprehensive, quality healthcare to native
    Hawaiians, Alaska natives, and American Indians.
        But native Hawaiians are often overlooked or left out of
    HHS initiatives, and it does not always seem that HHS staff
    understand the Federal trust responsibility to native
    Hawaiians, and I don't think this is anybody's fault. We do
    oftentimes fall under a different statutory architecture
    because there's not a treaty relationship, there's a trust
    relationship, and so, what I'm really asking is if you would
    lay eyes on this particular relationship.
        The way the statutory architecture works is sort of, in my
    view, immaterial to whether or not we're going to recognize
    this trust responsibility, and then in its implementation as we
    do native Hawaiian health programs, and other dollars that flow
    through HHS, we want to make sure that we are on equal footing
    with all native people. Do I have your commitment for that?
        Secretary Becerra. Absolutely.

                          PUBLIC HEALTH EMERGENCY FUND

        Senator Schatz. Thank you very much. We have seen a--I want
    to talk to you about one final thing, and this is the Public
    Health Emergency Fund. We've seen a pattern where every few
    years, when an infectious disease outbreak or public health
    emergency occurs, we're taken by surprise, totally flat-footed.
    The Federal Government cobbles together funding, and then
    Congress appropriates.
        But often, these are delayed, and they're delayed for
    idiosyncratic reasons, whether the particular disease resonates
    with the public, whether or not Congress is in session, and so,
    you know, the idea here is to establish a reserve fund so that
    you don't have to come back to Congress in order to respond to
    a public health emergency.
        Do you think it would be helpful for Federal response
    agencies such as CDC, FDA (Food and Drug Administration), and
    NIH to be able to respond proactively and get ahead of these
    public health emergencies before they get out of control, and
    then you have to come to Congress and ask for not a few
    billion, but a few hundred billion?
        Secretary Becerra. Senator, I think I have to hire you, but
    yes, the answer is yes.
        Senator Schatz. Well, I'm often told if this doesn't work
    out, I'd be an okay staffer.
        [Laughter.]
        Senator Schatz. Thanks very much.
        Secretary Becerra. Thank you.
        Senator Murray [presiding]. Senator Manchin is next, I
    believe. He is not down there? Okay, we'll turn to Senator
    Baldwin.

                                SHORT TERM PLANS

        Senator Baldwin. Thank you, Madam Chair. A record 31
    million Americans have obtained coverage through the Affordable
    Care Act, and that's in part thanks to this administration's
    efforts to stand up a special enrollment period, and increase
    funding for the Navigator Program, which assists people in
    searching for a plan that's right for them. These are two of my
    top priorities that I called for at the very beginning of the
    pandemic, but obviously didn't occur until this year.
        I know that these actions have made a huge difference in
    people's lives. Unfortunately, under the previous
    administration, there were rules changes that allowed the
    proliferation of plans that I would refer to as junk insurance
    plans, that don't have to provide the same protections based on
    pre-existing conditions, et cetera.
        Secretary Becerra, does the administration have any way of
    knowing how many Americans have signed up for these junk
    insurance plans?
        Secretary Becerra. Senator, I don't know if we can give a
    precise number, but we do know that the number of people who've
    signed up for these plans has increased, and it is very
    troublesome, because now we see the consequences when you think
    you have insurance, and you go and use services, and lo and
    behold, you're going to pay out-of-pocket a whole lot of money.
        Senator Baldwin. Yes. We also know that many of these plans
    engage in deceptive or misleading marketing practices kind of
    aimed at confusing customers during both special enrollment
    periods and open enrollment. At a time when comprehensive
    coverage is more affordable than ever, and the administration
    is working to get more Americans covered, why hasn't there been
    any sort of action taken to combat these junk plans and their
    practices?
        Secretary Becerra. Probably the best answer there, Senator,
    is stay tuned. We are looking to do some things. We want to
    make sure whatever we do withstands any legal challenge, but we
    are taking a close look at these plans that are really offering
    no real benefit or service to the people who are paying money.
    And so, I'd look forward to working with you on that, because
    it is a development that is alarming, especially during this
    time of pandemic when everyone needs to know what they actually
    have access to.

                              MEDICAID REENTRY ACT

        Senator Baldwin. Exactly. I look forward to working with
    you on that. Incarcerated and newly released individuals who
    have substance use disorder are at significant risk of overdose
    and death, as well as recidivism. And during the pandemic,
    these individuals have been at a substantially higher risk of
    contracting and dying from COVID-19. I was proud to introduce a
    bipartisan measure called the Medicaid Reentry Act, which would
    allow States to restart Medicaid coverage for eligible
    individuals 30 days prior to their release from a jail or
    prison. This coverage is really vital to facilitating what we
    might call a warm hand-off to addiction treatment and other
    healthcare services. Mr. Secretary, can you speak to the
    importance of providing comprehensive care for reentering
    individuals, and will you commit to working with me to pass and
    implement the Medicaid Reentry Act?
        Secretary Becerra. Senator, not only do I want to be
    supportive, we want to help get this through quicker than you
    think, because so many people are falling through the cracks,
    and we know that there is a way to help many of these folks.
        We just put out, about 2 or 3 weeks ago, we announced $3
    billion that we were putting out as a result of your good work
    on the American Rescue Plan. $3 billion, half of which is going
    to go towards substance use disorder services, and the other
    half for mental health issues, and so, we want to get out there
    quickly, and so, we look forward to working with you on this,
    because this is a major endeavor.
        We have money in the budget to help us deal with folks who
    are reintegrating back into the community, and so, very much
    prepared to do that work with you.

                          STRATEGIC NATIONAL STOCKPILE

        Senator Baldwin. Yes. I believe you've been asked some
    questions, significant questions, on the Strategic National
    Stockpile already in this hearing. I just wanted to note that I
    spent much of last year writing letters to the previous
    administration to ensure that my State, the State of Wisconsin,
    received the supplies that it needed from the Strategic
    National Stockpile to combat COVID-19. And unfortunately, it
    often took you know, public pleas from governors and Senators,
    and letters from congressional delegations as a whole for
    States to obtain the supplies that they needed during this
    crisis in its early days.
        And that's unacceptable. The President's fiscal year 2022
    budget calls for an increase of $200 million for the Strategic
    National Stockpile, including for modernizing the Stockpile's
    distribution model, and increasing visibility of the domestic
    supply chain to improve our response capabilities.
        So, can you describe how HHS has worked to increase the
    supplies available in the Stockpile? And why it's important for
    us to prioritize this funding for distribution and oversight
    improvements.
        Secretary Becerra. Senator, first I want to thank you for
    the good work that you've done here. This probably looks very
    familiar, what you see in the budget, because it really follows
    much of what you were proposing and calling for. And so, we do
    want to increase the transport of supplies, the capabilities.
    We want to refine and modernize our inventory. We want to be
    able to track our supplies better. We want to be able to expand
    domestic manufacturing. The $10 billion that was made available
    for us to really focus on domestic manufacturing will be
    critical.
        All that's going to get underway. More will be done if we
    get a budget that reflects those priorities. If we can move the
    budget from $900 million to $1.1 billion, that's significant.
    And if that is included, then we can really launch in ways that
    really let us make sure that we tell the American people we're
    stockpiling for what you need to get ready for in the future,
    and not say, ``Oops, we didn't realize we'd need that,'' when
    it finally hits us.
        Senator Baldwin. Thank you.
        Senator Murray. Thank you. Senator Shaheen.
        Senator Shaheen. Thank you, Madam Chairman. Mr. Secretary,
    we're delighted to have you in front of us this morning, and
    congratulations on your new role. You are in a position that
    touches the lives of the majority of Americans, and so, we
    appreciate your good work.

                                EXCESS VACCINES

        I wanted to first ask you about a news report I heard this
    morning on the number of States that have excess vaccines,
    coronavirus vaccines that are going to expire if we don't
    figure out some way to use them. Estimates I've seen say that
    as many as 500 million excess vaccines could be available by
    fall.
        I just came back from a trip to Eastern Europe, where they
    are desperate for vaccines. While I was there, we were able to
    announce the decision to provide vaccines to the country of
    Georgia, and they were very pleased to hear that.
        Are we considering doing more to make those excess vaccines
    available to countries that are really in need?
        Secretary Becerra. Senator, thank you for the question.
    Obviously troubling if we do see vaccines expire, but we are
    working with our state partners. The difficulty is we have to
    make sure there's a process that's orderly, that we could
    ensure the utility of the vaccine, and that people can have
    confidence that it is still a viable vaccine.
        And so, there are a number of things that we have to do if
    we're going to move that vaccine, because you need to have that
    chain of custody in place. And so, we're absolutely working
    with our state partners on this.
        We want to make sure our state partners understand that, as
    much as they may want to just get out there and help somebody,
    we have to do it the right way, because we have to have the
    confidence that the vaccines still work.
        Senator Shaheen. Well, I appreciate that. I agree that's
    very important, but we know that China is doing this very well.
    In fact, when I was at a dinner in Georgia, I sat next to a
    woman who had just had her second vaccine from China. And so,
    if they can do it, we ought to be able to do it, and we should
    make this a priority. So, I hope you will agree to do your part
    to help make that happen.
        Secretary Becerra. We'll make it a priority, but we'll do
    it our way, not China's way.

                          STATE OPIOID RESPONSE GRANTS

        Senator Shaheen. That's appropriate. New Hampshire's one of
    those States that's been very hard hit by the substance misuse,
    and the opioid epidemic has hit us very hard. The decision by
    the previous administration to provide set-aside funding to
    help the hardest hit States was very helpful to us, those State
    opioid response grants that came to us, and the support in so
    many other ways.
        We have gotten much better at saving people's lives through
    Narcan and other means, but we're seeing people migrate to
    other substances, methamphetamines, cocaine, heroin, and I hope
    that you will commit to work with our office and some of those
    other States that have been so hard hit so that even though our
    overdose death rate may be flat, we don't see a dramatic drop
    in funding because of that.
        Secretary Becerra. Senator, as you probably saw in our
    budget, we actually try to increase the amount of money there
    is----
        Senator Shaheen. Which I appreciate.
        Secretary Becerra. Yes, the State opioid response grants
    that are out there. And so, we hope to work with New Hampshire
    and all the States. Quite honestly, there's not a State in the
    country that isn't being impacted by opioids. Some, however,
    like your State, more impacted than others.
        And so, definitely looking forward to working with you.
    This is one issue where I did a lot of work as State AG
    (Attorney General). I would have thought by now we might have
    heard, but I know there is a settlement in the making that will
    help supplement what the Federal Government is doing, and I
    hope together, with what the States acquire through a
    settlement, and what we're able to do working with you, we can
    actually tackle this in a meaningful way.
        Senator Shaheen. Well, now that we are seeing COVID in our
    rear-view mirror, it will really be important to get back to
    some of those programs so that we can reach people, so that we
    can make progress, and I appreciate the commitment that you
    have.

                              CHILDCARE PROVIDERS

        One of the other areas that has been heavily impacted
    because of the coronavirus has been childcare. We've seen the
    reports of what's happened to women because they can't get
    childcare anymore. In meeting with childcare providers in New
    Hampshire, they have had a very difficult time, and continue to
    have, as people try and come back, and they try and provide
    coverage for families. But one challenge has been expediting
    the funds that are going out to States, and it's an issue for
    us at the State level, as well, because of the challenge of
    making sure people understand the guidance and are very clear.
        What I heard from childcare providers is that they don't
    want to spend money and then find out later that they haven't
    complied with the rules and have to give it back. So, will you
    work with New Hampshire and other States to make sure that that
    guidance and assistance is there for our childcare providers,
    who are really struggling at this time?
        Secretary Becerra. Absolutely. Absolutely, and I look for
    your guidance, and any member who wishes to make sure that we
    are working closely with your state partners.

                           HEALTH INSURANCE SUBSIDIES

        Senator Shaheen. Thank you. Finally, I've only got a few
    seconds left, but if I could, Madam Chair, just ask a final
    question about health insurance, because we have a chart here
    that shows what would happen if we are able to address
    deductibles in a way that does what the American Rescue Plan
    did to help expand coverage. And what this shows is--I have
    legislation that would tie the plans and deductibles to the
    Gold plan rather than the Silver plan. And so, this shows what
    happens for a family making $25,000 or less, in terms of the
    impact of expanding the help so that they could get additional
    assistance with their deductibles if we peg it to the Gold plan
    rather than the Silver plan.
        And you can see the numbers behind me for medium cost-
    sharing assistance is $800. For the highest cost-sharing
    assistance right now, it's $177. So, it would be really helpful
    to families to be able to expand, thus, to help with those
    deductible costs, and I hope we can work with you to do that.
        Secretary Becerra. Senator, I'd only add--I know time has
    expired--I'd only add that President Biden made a very strong
    commitment here, and the fact that we are trying to extend
    permanently the increase in subsidies that families get would
    be tremendously important, because all those families who
    you're pointing to who fall off that cliff, that fiscal cliff,
    when they hit that point in their income, where they no longer
    get the subsidies.
        Senator Shaheen. Right.
        Secretary Becerra. Wow. All of a sudden, they can't afford
    the care, and President Biden wants to extend the good work
    that you all did to provide additional subsidies for those
    middle-class families. So, we want to work with you.
        Senator Shaheen. Thank you, I appreciate it. Thank you,
    Madam Chair.
        Senator Murray. Thank you. Thank you. We have been honored
    to be joined by the Chair of the full committee, Senator Leahy.
    Thank you for being here. Turn to you.
        Senator Leahy. Thank you very, very much. Thank you and
    Senator Blunt for having this hearing. I appreciate having the
    Secretary here. I should note for the record, the Secretary and
    I have known each other for years. We've worked together at the
    Smithsonian as regents, and he knows that I'm a huge fan of
    his, and I look forward to working with him on this.
        I was glad to see a large increase in funding to support
    research and prevention treatment. Recovery support services,
    as you can tell from Senator Shaheen's question and others, and
    your own experience, really concerns all of us. We see the
    fatalities in opioid overdoses going up. We tried a lot of
    innovative, community-based approaches in my State of Vermont,
    and with your own experience in the Congress, you know that
    it's not unusual for local issues to come up among the members
    of the Appropriations Committee.

             ALTERNATIVES TO OPIOIDS FOR TREATMENT OF CHRONIC PAIN

        But I think that research to addiction alternatives has
    lagged at the Federal level. I think we have to have more
    research on chronic pain management and treatment, other than
    through the use of opioid painkillers, and I think that is
    extremely important, because we're going to need to help people
    with the chronic pains. Will your budget support funding for
    alternatives to opioids for treatment of chronic pain?
        Secretary Becerra. Mr. Chairman, first, great to see you,
    and thank you for your concern and the work that you've done.
    We're going to try to be as flexible as we can, because the
    solutions to opioids will not come from Washington, D.C., the
    support will, and we can provide some resources, so there are
    any number of ways to tackle substance abuse disorders, and,
    quite honestly, and one of the things I found when I was the
    attorney general of California is that even the medications
    differ in their utility State by State.
        And so, we have to be able to provide our state partners,
    local partners the flexibility. They're the ones that are going
    to do the work. They're the ones who have the know-how. We want
    to provide the support and be a partner.
        Senator Leahy. I know that the University of Vermont, their
    Center of Rural Addiction helps rural counties, and the budget
    includes a request increase of $55 million for rural
    communities' opioid response programs. And I hope we can use
    that to train, recruit, retain addiction specialists to serve
    in rural areas, because obviously, a State like mine, and
    actually every State here, has rural areas, and I would hope
    that you could look at what they're doing in the Center of
    Rural Addiction that we have. There could be similar ones in
    other States, and I just want you to think about how we can
    most effectively use that funding.
        Secretary Becerra. And Senator, again, having come from a
    position as a leader in my State of California, I want to now,
    as Secretary at the Federal level, make sure that I'm listening
    as closely as I can to the local leaders. And so, what we try
    to do should be to try to support the innovation, the best
    practices locally.
        Opioids is going to be very difficult, and even with all
    the resources that we're providing, and that this future
    settlement may provide with the attorneys general, it's still a
    bear. And we've learned many things about how to deal with
    opioids, but it's still going to be a bear, and so, whether
    it's rural or inner city urban, there are people doing this on
    the ground, and we should go with the most effective best
    practices that are out there.

                                   TELEHEALTH

        Senator Leahy. Well, and I will make sure I get to you some
    of the things that we're doing, because the rural health
    programs are much needed. Telehealth is very needed, but then
    you have the problem that many of us find in rural areas,
    broadband connectivity and all these others, it's not the
    medication, it's getting the telehealth there in the first
    place. So, I hope your budget will address some of these
    issues.
        Secretary Becerra. Yes. And Senator, we spoke a little
    earlier about telehealth, and one of the things you want to do
    with telehealth as you learn from what COVID has taught us is
    to make sure that we expand access to that Internet service, to
    that technology. And it would be a shame, especially in rural
    communities that you just mentioned, and its poor rural and
    urban communities, if we expand telehealth but forget them
    because they can't get it because they lack good broadband.
        Senator Leahy. Thank you. Thank you, Madam Chairman.
        Senator Murray. Thank you, Mr. Chairman. Senator Capito.
        Senator Capito. Thank you, Chair Murray. I appreciate the
    hearing, and thank you, Secretary Becerra, who we served
    together, and congratulations on your new position. Before I
    begin to ask questions, I just wanted to echo the theme that I
    know Ranking Member Blunt had conveyed, and I share.
        I am the ranking member on Homeland Security, and so I have
    a particular interest in this, and I am, Mr. Secretary, I can't
    decide if I'm frustrated or grateful, but you have overseen the
    transfer and reprogramming of almost $3 billion within your
    department from COVID-related purposes. I believe testing and
    strategic reserve is where those dollars came from, to address
    the migrant crisis at the border.
        So, I'm frustrated you ignored the intent of the funds, but
    I appreciate that your action signals to your own
    administration something that we have been calling for months,
    and that is that billions of unspent COVID funds can and should
    be used for a more pressing need.
        My question is--I'm very interested, obviously, as a
    citizen and a representative from West Virginia, on the opioid
    and overdose issue, but I think you've answered that, and we
    certainly want to be a partner. When you mentioned that the
    answers are local, can be found locally, I think our State in
    many sections of our State, and Senator Manchin I think would
    agree here, have come forth with some tremendous ideas to be
    solutions to the problem that are community based, that are
    widespread within the community, and that lift those
    communities.
        Unfortunately, the pandemic--there's a lot of backsliding,
    as you know, so we've got to get this right back on the screen.
    And we also have along with that an increase in my own home
    county of HIV, which is very concerning to me, and I'm hoping
    that the CDC, while they're in our State right now on this
    issue, can be a bit more aggressive there.

                              ALZHEIMER'S DISEASE

        What I wanted to ask, then, I'll move to another area of
    passion for me, and that's the Alzheimer's disease. We saw most
    recently that a new treatment that emerged and was approved,
    tentatively, I think, is targeted for people at early stages of
    Alzheimer's disease. And it is the only drug on the market that
    aims to slow the brain's deterioration instead of just treating
    the symptoms.
        But along with this comes an effort that we've had,
    bipartisan here in the Senate, which is this new--not new, but
    the existing welcome to Medicare initial exam, where we are
    empowering and trying to empower our medical professionals to
    begin asking questions early to try to meet the challenges that
    not just that particular Medicare patient could have, but also
    the family. As you know, caring for the folks afflicted with
    Alzheimer's is very intense, and very, very difficult for
    families. And expensive.
        But in those visits, we encourage screen detection,
    diagnosis, and other things of related dementia. I think what
    we have here is, if we have this progression of a possibility
    of a drug that can help, we need to merge this with the welcome
    to Medicare exam so that we are expanding the possibilities
    that a welcome to Medicare exam could do, and sort of heading
    off what could be the later ravages of Alzheimer's.
        I don't know if you all have thought about that, in terms
    of Medicare, what your perspectives might be there.
        Secretary Becerra. Senator, you've hit on something that's
    crucial as we continue to see innovation in new medicines, and
    that is how do we incorporate them, because these are not
    inexpensive medicines.
        Senator Capito. Right.
        Secretary Becerra. And so, to your point, the earlier we
    start in the process of trying to detect conditions that a
    person might present with, the sooner we'll know if we have to
    provide these types of medicines. And it's going to save us a
    lot of money if we get them upfront versus later stages when
    it's extremely expensive to treat some of these very difficult,
    devastating diseases.
        So, I think you're absolutely right. It's the preventative
    model. It's approaching folks early. It's trying to do the
    intervention while you can, and maybe have a chance to either
    slow, or maybe in some cases cure the condition. But certainly,
    we should not be waiting until it's at its worst point.
        Senator Capito. Right. I agree with that. This one is a
    particular challenge, as you know, because it's not something
    that maybe is apparent in your blood count, or you know, you
    can physically see it. It's something that those of us who have
    experienced, and comes on very gradually in some cases, and
    before you know it, you can't ask that last question. So, I
    thank you for your dedication here. I want to work with your
    department to see if we can enhance that welcome to Medicare
    wellness check so we can prevent on the front end. Thank you.
        Secretary Becerra. Thank you.
        Senator Murray. Senator Manchin.

                             DOMESTIC MANUFACTURING

        Senator Manchin. Thank you, Madam Chairman. Secretary, the
    Food and Drug Administration reports that nearly 40 percent of
    finished drugs, and roughly 80 percent of active pharmaceutical
    ingredients are manufactured abroad. Widespread shortages of
    personal protective equipment, the PPEs as we know, and other
    medical equipment at the beginning of the COVID-19 had a
    disastrous impact on all of us, in hospitals and consumers
    especially.
        While global shortages of semiconductors in recent months
    forced U.S. manufacturers to slow or halt production lines.
    Just yesterday, President Biden directed Federal agencies to
    institute whole of government efforts to strengthen domestic
    competitiveness, and supply chain resilience, important to
    supporting domestic manufacturing of generic essential
    medicines.
        So, how is HHS responding to this directive to strengthen
    our domestic supply chain?
        Secretary Becerra. Senator, we've had conversations on
    this. And thank you, first, for providing us with some
    resources. The American Rescue Plan does provide us several
    billion dollars to try to move towards more domestic
    manufacturing. We've also seen as a result of COVID and the
    Strategic Stockpile how we lack the kinds of product and
    medicines that we needed.
        And so, what we're trying to do is, working within ASPR,
    (Assistant Secretary for Preparedness and Response) the agency
    within HHS that would deal with this, we're trying to move as
    quickly as we can to start having a stockpile that really will
    have us ready for the 21st century. We know COVID's not the
    last pandemic, and so we want to be ready. This report that was
    just issued yesterday that speaks to these issues on domestic
    manufacturing will go a long way in directing all of us in how
    we do this. But, no doubt, when it comes to anything related to
    health, HHS has to be on top of it.
        Senator Manchin. Has HHS done any type of an inventory,
    looking at what manufacturing facilities might be able to be
    restarted if or if not, or basically put into production for
    the needs of our country?
        Secretary Becerra. I'd say that's underway----
        Senator Manchin. Okay.
        Secretary Becerra [continuing]. Nowhere near completion.
        Senator Manchin. If you can, whenever you can have your
    people working on that, or we can work with them or something--
    --
        Secretary Becerra. Yes.
        Senator Manchin [continuing]. Identifying those facilities.
        Secretary Becerra. Absolutely.

                                    OPIOIDS

        Senator Manchin. Sir, also, we had 90,000 Americans die
    from overdose last year. My State's been hit the hardest. We
    have an average of about 70 to 75 thousand every year. We had a
    spike because of the COVID. The problem that I have seen is
    that basically they're putting more and more products on the
    market. Manufacturers are producing larger and larger volumes.
    It just doesn't stop, and I've never seen any of us being able
    to stop that or thwart that, so, if we know that these opioids
    are causing the problem, we need treatment centers, and we have
    not enough.
        I look at domestic shelters we have. When we identified
    domestic violence as really an epidemic in our country, we put
    domestic shelters in about every neighborhood. This is an
    epidemic. Overdose. So, I've had a piece of legislation called
    Lifeboat, and all we're doing is saying you will pay one penny
    per milligram production fee if you're going to make opioids.
        We never had opioids when you and I were growing up in it,
    okay? So, if this is what they think that they need, and that's
    their model business model, then you're going to pay for one
    penny per milligram, and every penny of that goes into
    treatment centers. So, every part of our Nation, any part of
    our Nation will have treatment centers to help people. Is it
    something you all think you could support, or have you heard
    much about it, or can we set with yours?
        Secretary Becerra. We look forward to working with you on
    that because we agree. In fact, just two or three weeks ago--I
    already mentioned this earlier--we put out grant funding of $3
    billion, half of which----
        Senator Manchin. You went $3.7. I applaud you all on the
    three and a half billion.
        Secretary Becerra. Yes. We're still----
        Senator Manchin. But still yet, it kind of goes you know,
    we hit these ebbs. This would be consistent. $2 billion a year.
    One penny is $2 billion a year.
        Secretary Becerra. Yes.
        Senator Manchin. Unbelievable. It doesn't hurt anybody.
        Secretary Becerra. Go to it. We'll offer you whatever
    technical assistance and whatever else we can, because what
    we're putting in our budget and we've already done through the
    American Rescue Plan, what you all have been working on, we're
    still not keeping pace with this epidemic.

                                      340B

        Senator Manchin. With the need. I agree with you. Thank
    you. And then also, my final question. The 340B program is
    essential for providing access to safe and affordable
    medications for low-income West Virginians, and low-income all
    over our country. Recently, HHS determined that six
    pharmaceutical companies have violated the program by
    restricting access to contract pharmacies.
        The undermining of the 340B program by pharmaceutical
    companies and pharmacies' benefit managers has taken its toll
    on my West Virginia hospitals, community health centers, and
    their contract pharmacy partners, and I'm sure in every State
    every one of us have been hit with this. What are the next
    steps that you will take as the head of HHS to ensure the
    integrity of the 340B program?
        Secretary Becerra. Well, Senator, as you just said, we just
    put out, in writing, we didn't just say it verbally, we put
    out, in writing, a clear message to these six manufacturers
    that we believe that they're violating the law. You violate the
    law, you pay the consequences, and so----
        Senator Manchin. Has it been turned over to DOJ (Department
    of Justice)?
        Secretary Becerra. We're waiting for responses.
        Senator Manchin. Okay.
        Secretary Becerra. Some have responded, but we're waiting
    for full responses. By the way, our budget also does increase
    funding in this area. I think we provide almost a doubling, not
    quite a doubling of the money that is available to make sure
    that we can do the grant rule-making that we need. I hope what
    you'll do is you'll give us more authority to actually give
    clear guidance on what can be done and can't be done on 340B
    because----
        Senator Manchin. And I really think we could do that in a
    bipartisan way, because I tell you, we're all being affected.
    Every one of us.
        Secretary Becerra. That would be helpful, because this way
    the manufacturers can't sort of play this shell game with us.
        Senator Manchin. Okay.
        Secretary Becerra. They'd know what their responsibility
    is.
        Senator Manchin. Well, I look forward to working with you,
    and thank you for your service, Secretary.
        Secretary Becerra. Thank you.
        Senator Manchin. Thank you, Madam Chairman.
        Senator Murray. Thank you. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Madam Chairman. Mr.
    Secretary, I recently visited the border with several of my
    colleagues a few months ago, and we just saw how many children
    were down there. The issue that's going on. The possibility of
    thousands of illegal immigrants crossing the Southern border
    and being transported to our State and housed in facilities in
    Mississippi is what the concern is.

                             UNACCOMPANIED CHILDREN

        But I understand that your department reached out to many
    States, including Mississippi, to identify potential housing
    locations for these unaccompanied migrant children, and when
    Mississippi declined to participate, your office sidestepped
    State and local governments by asking private organizations and
    nonprofits to house the immigrant children.
        And I've been getting several calls on this. I mean, from a
    friend who said the local caterer just had a called asking,
    ``can you put in a bid of feeding 200 seven days a week, three
    times a day?'' Where is this coming from, Mr. Secretary? What
    do you know about this? Do we need to get our local resources
    ramped up for these children coming in? And I said, I know
    nothing about this.
        But this action, you know, just ignored the elected
    officials, who said that they were not going to participate,
    and they're not being notified or given up-to-date information.
    We just have to rely on these calls that we get. But you know,
    there's just no transparency whatsoever in the last few weeks,
    other than calls from my local sheriff saying, ``I heard this
    is happening,'' because of the inquiries being made in the
    community.
        It is of great concern to me and my constituents that HHS
    would send distressed children to States without the
    involvement or approval of those States and communities and
    without the resources and security that we would need to care
    for such a large influx of migrants.
        But I firmly believe this administration's misguided
    actions have created a humanitarian crisis on the Southern
    border, and you know, they're looking for the States to pick up
    the pieces, to make this happen if those children get
    transported without our knowledge into our State.
        Does your department plan to continue on this path and to
    circumvent the will of the State governments? Do they plan to
    continue that if we know best what the capabilities of us
    serving those children are, and how do you plan to improve
    communications with the States and provide up-to-date
    transparent information on the UC (unaccompanied children)
    program?
        Secretary Becerra. Senator, thank you for the question.
    Very important. And by the way, I hope in the future you feel
    comfortable reaching out to me. I'd like to develop that
    relationship with you so that your team and my team can work
    together on some of these issues. On this particular matter, my
    sense is that some of the information that you've been given is
    not only incorrect, but it's disturbing.
        We never make any approach into a State without talking to
    the State's leadership, and local leadership. As you just
    mentioned yourself that some of the State officials said that
    they were approached and they rejected the opportunity to have
    some of these migrant kids go into their State.
        We have an obligation to provide a safe place for these
    children. We typically look for licensed care facilities,
    people who are licensed and trained to do this. They're
    children. And so, we go wherever we can. We do reach out to the
    State leadership to see if they will help us, but if the State
    leadership doesn't want to help us with children who are in
    distress, we still have an obligation to find a place for these
    kids.
        We do nothing behind anyone's back, because all these
    facilities are licensed by the very State. And so, whoever is
    telling you that they don't know anything about this is either
    being disingenuous or they're not interested in helping us make
    sure we take care of children. We don't offer them luxury, we
    try to provide them with the basics. And we look for licensed
    care facilities. We're not going to put them in a facility
    where we don't have people who are trained to care for kids,
    and we have to search far and wide throughout the United
    States, because we don't just use facilities that are near the
    borders where these kids cross.
        And so, I would hope to be able to work with you and your
    team to show you how we do this, because we're not hiding
    anything. What I can guarantee you is that we're going to
    provide a safe place for these kids while they're in our care.
    However temporary it is, while they're in our care, we're going
    to do this the right way. I suspect you have kids or grandkids.
    I have children. No grandkids yet. I would expect whoever has
    my child to take the best care they can with what they've got.
        Senator Hyde-Smith. But you do understand the concerns of
    the local medical facilities and law enforcement if we were to
    overnight get 200 children in a small area.
        Secretary Becerra. Certainly, if that were the case. But
    that never happens, because we don't do something overnight.
    You can't, not with 200 kids. There's nothing you can do with
    200 kids that is just done overnight. We have to go through the
    process of establishing the relationship. Remember, most of
    these licensed facilities can't accommodate more than just a
    handful of kids.
        The emergency intake sites that we have stood up,
    principally in places like Texas and in California, those are
    large. But those take months. In some cases, maybe weeks, but
    months to stand up. And there's no way to hide when you have a
    facility that's holding maybe three or 400 kids, or more from
    the sight of any official.
        But the licensed care facilities are typically 10, 12, 20
    kids, and the State knows about it because these folks, these
    facilities have to seek a license from the State in order to
    operate. These are facilities that operate for these migrant
    children, unaccompanied migrant children. We don't take money
    from the foster care program to do this. It is a separate
    stand-alone program, because there are special circumstances.
        These kids are here under temporary--not even status--they
    are requesting asylum, and so we have to process them. That's
    done by DOJ and DHS (Department of Homeland Security), but we
    have the responsibility, HHS, to provide them with the care,
    either under our custody, or if we're able to find a
    responsible custodian, temporarily in that custodian's care.
        And the only activity that might occur in your State is
    only the result of having worked with that licensed care
    facility to reach an arrangement to have some of these kids
    housed temporarily there.
        Senator Hyde-Smith. Well, we may be contacting you, because
    it was a large number of calls. It was a couple hundred all in
    one, and the locals--and, of course we called everybody we knew
    in Mississippi, and no one knew anything about it. So, we may
    be contacting you on that, because----
        Secretary Becerra. Please do so.
        Senator Hyde-Smith [continuing]. You know, we just
    definitely want to be prepared and know those things.
        Secretary Becerra. Please, I invite you to.

                             FETAL TISSUE RESEARCH

        Senator Hyde-Smith. Another concern I have is funding
    research that uses fetal tissue from unborn children who have
    been aborted, I believe that science is best when it's ethical
    and respects the dignity of life. I also believe that the
    Americans who object to abortion should not have their taxpayer
    dollars going toward purchasing fetal tissue from abortionists
    like Planned Parenthood.
        Furthermore, even the American Medical Association has
    raised concerns regarding the serious ethical problems created
    by the financial benefits to those involved in the sale of
    fetal tissue. And I'm over my time, but I just want to make a
    couple of points here. Is----
        Senator Murray. If the Senator could be concise, we've got
    another Senator waiting quite a bit of time, and you are way
    over time.
        Senator Hyde-Smith [continuing]. We are concerned about
    that, and that the justification rule from 1995 is still being
    used, and we know that science has changed a lot since 1995,
    and so we may want to have another discussion about that. Thank
    you, Madam Chairman.
        Secretary Becerra. Look forward to it.
        Senator Murray. Thank you. Senator Murphy.
        Senator Murphy. Thank you very much, Madam Chair. Let me
    just underscore the Secretary's remarks about these kids and
    the facilities they're in. These are State-licensed facilities,
    as the Secretary said repeatedly. These are not federally
    licensed facilities. And so every State knows where these kids
    are, and they all have the opportunity, if they want to, to
    pull the license, modify the license, do whatever they need to
    do.
        But, let's be honest, these kids are not security concerns.
    I mean, I understand there's a logistical effort necessary to
    care for these kids, and I would hope that notwithstanding
    folks' political opposition to the President, we would all
    agree that if these kids are here applying for asylum, we
    should you know, all be in the business of trying to you know,
    make sure that they have a roof over their head. But they're
    not a security concern. These are you know, 13-, 14-, 15-year-
    old kids who you know, fled destitute poverty and violence to
    come to a better life, and are temporarily in our care until
    they get connected with a relative. So, I just don't want to
    overstate the danger or the impact that these young people
    have.
        Let me just, Mr. Secretary, associate myself with the
    remarks of Senator Baldwin on the short-term, limited duration
    plans. I wasn't here for your answer, but I heard that you said
    we should wait and stay put for additional announcements. I
    hope that that is coming shortly. These plans you know, they're
    just frauds. They're sold a bill of goods, these folks who pick
    them up, and then find out that they actually have no
    insurance, and I hope that we can get those out of the
    marketplace as quickly as possible.
        My question to you is around the proposal for additional
    ACA (Affordable Care Act) premium subsidies, about $60 billion
    in the President's budget over the next 4 years to continue the
    increased subsidies, and I thank Senator Shaheen for her
    advocacy and her leadership on this. I'm very supportive of
    that proposal, but I just want to point out that that is $60
    billion not necessarily going to consumers. That's $60 billion
    that's going to the for-profit healthcare industry. That's $60
    billion that's going to end up in the pockets of insurance
    companies, and drug companies, medical device companies, for-
    profit hospitals. You know, all sorts of entities that are just
    making a king's ransom off of our healthcare system today.
        I'm very glad that Senator Murray and Chairman Pallone have
    kicked off a process by which we're going to, I gather, start
    to come up with a path forward on a public option. The ability
    to put a Medicare, Medicare-like plan on these exchanges that
    does not have the kind of profit motive that private insurance
    plans do, and, if done right, will provide some real price
    pressure on the private sector.

                                 PUBLIC OPTION

        For instance, Senator Merkley and I have introduced what we
    believe to be the sort of most aggressive public option, and in
    it would be included bulk purchasing authority for you or for
    CMS (Centers for Medicare and Medicaid Services) that would
    result in a lower price for the Medicare-like plan. But it
    would also create pressure that would have benefits to private
    sector plans, as well.
        What do you think of the process that has been announced in
    the Senate and the House to begin conversations about public
    option legislation? Do you see this as part of the answer on
    price moving forward? Because my only worry about a strategy on
    affordability that is predicated mostly on subsidy for the
    exchanges is that that ends up just feeding the for-profit
    health insurance and medical industry machine, which you know,
    ends up doing very well for them, ends up in increased coverage
    for Americans, but doesn't get at the price question.
        Secretary Becerra. So, Senator, having served with you as
    we were going through the process of passing the Affordable
    Care Act, and having pushed for many of the things that you're
    discussing, what I can tell is now, in this position, I just
    want you all to get something done, because, give me some
    authority to do something to lower costs, give me the ability
    to try to drive down the cost of those services, and to expand
    coverage.
        Any number of good ideas, but I know that you all have to
    go through this process and figure out how to get to the right
    number to get something passed. The President has publicly
    stated he is supportive of the public option, we have dollars
    in this budget to try to support movement towards getting more
    Americans onto coverage, and I would simply tell you, we're
    ripe to get something done. The American public wants to see us
    do something, and so, it's almost--yes to all of the above.
    Just let's see something cross over the finish line.
        Senator Murphy. I appreciate that the administration and
    you have a lot on your plate right now, but at some point, some
    leadership to point us and others in the right direction on
    this question on how we construct a public option would
    probably be helpful, but I thank the Chair for her leadership
    on this. Thank you.
        Senator Murray. Thank you. Senator Braun.
        Senator Braun. Thank you, Madam Chair. Good to be talking
    to you again----
        Secretary Becerra. Thank you.

                            PARTIAL-BIRTH ABORTIONS

        Senator Braun. February 23, in your nomination hearing, I
    asked will you follow the law, and it was in reference to the
    Hyde Amendment back then and some other things. Recently, you
    were testifying in a House committee, and the subject of
    partial-birth abortions came up, and I think there was some
    confusion as to whether there was a law on the books or not,
    and I assume that you of course now know there is.
        I think what I'm interested in is not so much what you're
    going to do to enforce existing law, what you might be
    proposing or pushing when it comes to, you know, the issue of
    abortion, sanctity of life. So, is there any interest in your
    office pushing or trying to get legislation out there that
    would overturn the ban on partial-birth abortions?
        Secretary Becerra. Senator, thanks for the question, and
    thanks for following up from our previous discussion on this. I
    think the President has been fairly clear, and maybe if I
    wasn't so clear in my previous testimony, I could try to
    elaborate a bit. We're going to do what the law permits us to
    do. We're going to follow the law. This is a subject that,
    obviously, people differ on. These issues usually are premised
    on very deeply held beliefs. But what I can tell you is that if
    I'm doing my job, I'm following the law, and right now, Roe v.
    Wade is the law of the land.
        We're going to do everything we can to protect a woman's
    reproductive rights, to have healthcare. We want everyone to
    have access equitably to healthcare, and so, we're going to do
    everything we can to make sure that whether you're rich, poor,
    young, old, tall, short, you're going to have access to the
    care you need.

                                 HYDE AMENDMENT

        Senator Braun. So, the current law incorporates the Hyde
    Amendment, and in the President's budget, that is a clear
    omission. So, does that mean that, and were you part of the
    formulation of the budget you know, that would have that not as
    part of it? And that's been around since 1977. So, when you
    hear statements that would be unclear about an existing law of
    partial-birth abortions, which you actually voted against that
    law, the one banning it, it would give many of us pause in
    terms of what might be done.
        You're clear that you're going to respect the law, but I
    think I'm more interested in what you might be interested in
    doing to change the law. And the fact that the Hyde Amendment
    is not part of the budget, is that something more ominous on
    the horizon that it would be incorporated into law, at least
    it's reflected in the proposed budget, and were you part of
    crafting that omission?
        Secretary Becerra. Remember, Senator that President Biden,
    before he became president, said that he would be against
    maintaining the Hyde Amendment, and so, the budget is a
    reflection of what the President has said in the past. I have
    thousands of votes in my 24 years in the House of
    Representatives. I think my record's pretty clear where I stand
    on this issue, as well.
        But, as you just said, my obligation is to respect the law,
    and the law is not established by the executive, it is
    established by Congress. And so, we will respect and follow
    whatever the law is that you all pass.
        Senator Braun. Well, I'm glad to hear you're going to
    respect the law. I think that would be the minimum that we'd
    require out of anyone here in any capacity, and I think that
    what you're saying is that you may be trying to change the law,
    and President Biden has been clear, according to you, that he
    does not want the Hyde Amendment to be part of what ideally
    would be part of law in that area.
        And then, what would worry some of us is that then the next
    step might be taken to where partial-birth abortions come into
    play, and I think it just good to be honest about what one's
    intentions are, and we're in a climate right now when it looks
    like there's a lot out there legislatively, and for any of us
    that are passionate about the sanctity of life, it is
    something--obviously, we would love to know clearly you know,
    what the intentions of the administration would be. Your
    intentions and lawmakers, as well. So, I think that we're not
    going to get any further on that topic here today, but I
    thought it was definitely worth mentioning.
        Secretary Becerra. Senator, I look forward to working with
    you. The art of compromise and the ability to come together is
    what makes this democracy work, and so, we don't have to have
    the exact same views to be able to get things done for the
    country.
        Senator Braun. Thank you.
        Secretary Becerra. Thank you.

                               MATERNAL MORTALITY

        Senator Murray. Thank you. Mr. Secretary, the U.S. is the
    only industrialized nation where the maternal death rate is
    rising. Each year, 700 women die due to pregnancy, childbirth,
    or subsequent complications, according to the CDC, and the vast
    majority of those deaths are preventable. Black, Tribal, and
    women who live in rural areas are at much greater risk, so we
    need to address the gaps in care for pregnant and postpartum
    women and root out bias and discrimination in maternity care
    settings.
        So, I was really pleased to see your budget build on some
    of our bipartisan investments that we've been making in recent
    years to combat this crisis with $220 million across several
    agencies within HHS. I want you to talk to us about how this
    new funding will address the problems driving these disparities
    for women of color and women who live in rural areas, and maybe
    what lessons you've learned from the committee's initial
    investments.
        Secretary Becerra. Senator, thank you. This one is
    important, not only because it's the right thing to do, but, as
    you said, we as a country, as a Nation, a leading Nation are
    doing something totally wrong when it comes to protecting
    women, women who are going to help us move the next generation
    of leaders. And so, it's time, and I'm thrilled that the
    President saw the need to make a substantial investment here.
        Not only is it the $3 billion to improve the maternal
    health programs that we have under the American Families Plan
    that he has proposed, but it's the $223 million that I hope we
    get in funding, that's in this budget for a program that he
    wants to start to help improve maternal health programs around
    the country.
        It is the challenge to States to say, under Medicaid, we
    right now provide a woman 60 days of postpartum care after
    she's delivered. We're saying, guess what? You join in, and
    we'll give you--we'll help you pay for a full year's, 12
    months' worth of care for that woman. Because it's not just the
    delivery and the recuperation from the delivery, it's making
    sure the woman is ready to move forward in that first year of
    life of that child.
        And so, this one's critical, and, as I've always mentioned,
    this is something my wife, as an OBGYN has always talked so
    much about. How we don't really care too much except for making
    sure that we see the delivery go well. There's so much that
    goes on before the delivery, and so much that has to go on
    after. And to have in our own country, pockets of America where
    women are still dying, or their children are dying at birth,
    it's just incredible.
        So, these are the investments that we need to make, and
    it's unacceptable to not do otherwise.
        Senator Murray. Well, thank you. I look forward to working
    with you on that. Mr. Secretary, the number of migrant children
    referred to HHS's care began steadily increasing last year,
    including after courts enjoined the prior administration's
    policy of applying Title 42 restrictions to unaccompanied
    children. And at the same time, as you well know, COVID-related
    limitations significantly reduced HHS's capacity in its entire
    network of State licensed shelters.

                 UNACCOMPANIED CHILDREN EMERGENCY INTAKE SITES

        And as a result of that, this administration inherited a
    system already approaching a breaking point, and the use of
    emergency intake sites has, thankfully, gotten a lot of our
    kids out of CBP facilities, and the department has made some
    progress in a very short period of time, I know, to reduce the
    number of kids at these emergency sites.
        But those sites do not provide the same level of care or
    services that HHS's other facilities, and their extended use
    really raises concerns. I wanted to ask you what is HHS doing
    to phase out of these emergency sites as quickly as possible by
    placing more kids into these State licensed facilities, and
    with appropriate families and sponsors as soon and safely as
    possible?
        Secretary Becerra. Well, Senator, as you may have heard in
    my discussion with Senator Hyde-Smith, we reach out to every
    facility we can, in any part of the country. Because you're
    right, while these emergency intake sites have done the job of
    providing these kids with the care that you would expect, far
    more than the Custom and Border Protection Service could, we
    know that it's better to have them in a facility that is
    licensed to provide that care.
        There are any number of licensed facilities, but very few
    of them we haven't already approached, and so, we're going
    everywhere we can, and we have been able to expand the number
    of licensed beds that have been available. There was a point
    where we had more kids in emergency intake centers than we had
    in licensed care facilities, when our census numbers were
    really high. But we have now flipped that, and there are more
    kids today in licensed care facilities than we have in these
    emergency intake sites.
        Senator Murray. Okay, and are you addressing the emergency
    intake sites, and what are we doing there to improve the level
    of care? Because they still do exist and will for a time.
        Secretary Becerra. Substantial amount. Today, those intake
    sites offer behavioral health services to kids, which we know
    that is important for so many of these kids because they come--
    --
        Senator Murray. At all of the emergency intake sites?
        Secretary Becerra. I think we have it at all of the sites
    now. We do have behavioral health specialists who are there to
    provide for their needs. We've always provided the medical
    care. We were never sure when we first started standing up
    these sites how long they would be around, and so, we made sure
    we had the medical services. But getting behavioral health
    specialists is obviously a little bit extra. It's a tougher
    thing. But now, we do, because we've seen how we've had to open
    a number of them.
        We also now do discharge work. We actually do the process
    of doing the intake, getting the information, doing the
    background checks on potential custodians, sponsors. And that
    wasn't done at the beginning either, because they were just
    emergency intake sites to help us deal with the overflow.
        But we've seen that so many of these kids would end up
    staying in these sites for weeks, and so, we decided, no, let's
    start doing the work now of finding a responsible sponsor that
    can hold them, versus keeping them in one of these sites.
        So, it's almost a full service--it is a full service. If
    you go to Long Beach, California, not only is it a full-service
    site, several hundred kids, but the community has so much
    gotten involved that they ended up getting, and this was about
    a month or so ago, 70,000 toys and books donated by the
    community. Several hundred kids, but they got 70,000 gifts from
    the community, which now is making it possible for us to send
    some of these things to some of the other kids in some of these
    other sites.
        And so, it's a whole of agency approach, because we want to
    make sure that we provide the right service. Again, I have to
    acknowledge, this is expensive stuff. It is not easy. And we
    are not going to let a child go to someone unless we feel
    confident that they're going to be responsible caregivers. And
    so, it's very difficult, but these are kids.
        Senator Murray. Yes. Okay, thank you. Senator Blunt.

                             COVID-19 VACCINE GOALS

        Senator Blunt. Thank you, Chair. Mr. Secretary, are we
    going to reach the White House goal of 70 percent of all U.S.
    adults with at least one shot by July 4, and for 160 million
    Americans to be fully vaccinated by that date?
        Secretary Becerra. I would not bet against this President,
    Senator, because he's so far done a pretty good job of hitting
    his marks, and I know he's determined, and we're working with
    him to get to that 70 percent. But, quite honestly, it
    shouldn't be just a goal of the President. It should be a goal
    of every American to try to help us get to that 70 percent
    threshold and beyond, because it's for the good of the people,
    not just for the President.
        Senator Blunt. Well, I agree with that. I guess we'll see
    if there are enough donuts, and enough cans of beer, and
    whatever else is being offered as the incentive to get people
    to take that vaccine. It's really important to get this done,
    and I hope we meet that goal. I'd be pleased if we exceeded it.
    Who's taking principal responsibility for that?
        Secretary Becerra. The President has thought it so
    important that he established, even before he came into office,
    this working group. Jeffrey Zients has been leading that group
    for some time, and over the course, it's gone mostly from
    trying to address to combat the pandemic and COVID-19, to now
    making sure folks are getting vaccinated.
        We're still doing all of the other things. But the major
    focus has been now getting that vaccine out as best we can, and
    I'm waiting for the invite, Senator, so that we can go to your
    State and see the pockets that still have to get vaccinated,
    and we'll do what we can.
        Senator Blunt. Well, good. We'd be glad to have you, and
    we're trying to do that. I think one of the lessons we learned
    early on in this is you don't want to make it too complicated.
    Hopefully, we won't face this situation again in a hurry, but
    we might with the booster shots and, you know, the more people
    that can, without wondering if they qualify, can line up and
    get their vaccination, the better off we are, I think.

                           GRADUATE MEDICAL EDUCATION

        I noticed in your budget submission that there is no
    increase in children's hospitals graduate medical education. As
    you know, that's the one part of medical education that's not
    funded out of Medicare. We've made an increase every year in
    the last 6 years. I hope you'll help us look at that again and
    find an increase. There are accounts really close to that that
    have increases. You know, if you don't have the opportunities
    to go into children's hospitals and get your specialty that
    way, you wind up going somewhere else, and I think we'd all
    agree that we don't benefit from having a lack of people
    focused on children's healthcare.
        Secretary Becerra. GME (graduate medical education)
    programs are critical. When I was in the House, I fought very
    hard. LA obviously has a number of facilities, and at one
    point, we almost lost MLK hospital in Los Angeles, which was
    one of the safety net providers, and we fought really hard to
    preserve the GME slots that we had for MLK, so that once it got
    back into business, we'd still be able to bring in graduate
    medical students, and so, I absolutely agree with you. We have
    to do everything we can to try to increase the number of, and
    supply of these doctors. Especially because, as you know, we
    lack those physicians and in those specialties for children.
        Senator Blunt. I'd like to figure out some way we could do
    with children's medical education what we've done with all
    other medical education for all other specialties. Maybe we can
    work together and figure out if there is a way in some other
    fund we could fund this like we fund everything else.

                              ACA/UNINSURED NUMBER

        How many people--I know it was mentioned earlier that I
    think 31 million people have insurance through the Affordable
    Care Act. How many people do we believe don't have insurance
    now?
        Secretary Becerra. There are still probably tens of
    millions. I don't want to give you a number off the top of my
    head.
        Senator Blunt. Will you get back to us with a number on
    that?
        Secretary Becerra. Absolutely.
        Senator Blunt. I think when we started down this road a
    decade ago, it was 30 million we thought didn't have insurance.
    I'm afraid it's still about 30 million, but I'll let you take
    that for the record.
        Secretary Becerra. Will do, Senator.
        Senator Blunt. Okay. Thank you, Chair.
        Secretary Becerra. Thank you.

                                   CHILDCARE

        Senator Murray. Thank you. Mr. Secretary, the pandemic
    really exposed what many of us have known for a very long time
    that the childcare system in our country is really broken. And
    childcare is just such an essential of our infrastructure. It's
    really key to our economy, and during the pandemic, we saw four
    times as many women leave the labor force as men, in large part
    due to increased caregiving and distance learning
    responsibilities. And the problem was even worse for Black and
    Latina mothers.
        So, I'm really glad to see your budget propose large
    investments in childcare, including a $1.5 billion increase to
    the Child Care and Development Block Grant. Prior to the
    pandemic, CCDBG (Child Care and Development Block Grant)
    programs served just one in seven eligible children, and the
    need for the services is now expected to rise significantly
    given the economic turmoil that's been created by this
    pandemic.
        So, talk to us about how this funding will improve access
    to childcare.
        Secretary Becerra. Madam Chair, you've said it. I mean, our
    economy will not fully recover until we address the childcare
    needs, especially for women, single women. And so, it is
    important for us to make these kinds of investments. But it
    still doesn't take us where we need to go. As you just
    mentioned, just for those who were eligible, we were only
    providing services to one in seven.
        It's unfortunate that we look at it this way. Maybe it's
    our tradition that we think that we could take care of our kids
    ourselves, but today, that's not the reality. More often than
    not, even if it's a two-parent household, both parents have to
    work. And no one wants to see a scenario--I grew up being a
    latchkey kid. No one wants to see a scenario where we damage
    our future because we didn't think of investing in our kids.
        The President's proposals to provide full-time pre-K for 3-
    and 4-year-olds would be a tremendous help for a lot of
    families. Providing the childcare tax credit that I know is
    before you, a tremendous help. But investments in these block
    grants that help those families is critical, especially for
    middle and low-income families.
        Senator Murray. Well, you know, there's a recent report
    that showed nationwide the cost of childcare jumped, on
    average, 47 percent during the pandemic. We now have people
    trying to go back to work, and they're going, I couldn't afford
    this before, now what am I going to do?
        And another problem we're seeing is the wages for childcare
    providers and early educators is abysmal, and yet these
    operators are now trying to operate on extremely thin margins,
    like everyone else. They can accept fewer kids, they have to
    have all of the sanitation equipment. It is much harder to run
    these businesses. So, I wanted to ask you how the budget
    requests address the funding gap that now exists between what
    parents can afford to pay and what high-quality childcare
    providers need so they can operate?
        Secretary Becerra. Madam Chair, probably the best way to
    say it is this is what happens when you fail to invest for a
    long time. It all starts to come at you, it hits you in your
    face, and what we're finding is that the costs will continue to
    increase, families will have a harder time, but quite honestly,
    we should not be paying the dirt low wages that so many of
    these childcare workers have been receiving. They deserve to be
    paid for the work they do. They're taking care of our most
    precious assets.
        And so, we need to see them receive a decent wage and
    salary, which will cost more in terms of the service for the
    parents, but we have failed for so long to really invest in
    taking care of our kids and helping our brothers and sisters in
    America care for their kids that things are coming home to
    roost. We have to make the investments. Fortunately, President
    Biden wants to make those investments. I know that there's a
    great deal of support in the House and in the Senate to do
    something serious when it comes to childcare, whether it's the
    tax credit or major direct investments, we need to do it,
    because----
        Senator Murray. Well, this is a top priority for me, and I
    know it is for pretty much every working parent out there so,
    we will work with you on that.
        Secretary Becerra. Amen.

                               HEALTH DISPARITIES

        Senator Murray. I wanted to ask you one last question. The
    pandemic's deadly impact on communities of color really shows
    that we have a long way to go to address systemic racism and
    health inequities, and there's factors from housing to food
    deserts to access to health services that can really have an
    impact on somebody's health. So, I was really pleased to see
    the budget focus on addressing those problems, including an
    increase of $150 million for CDC's social determinates of
    health activities. Can you talk a little bit about what those
    initiatives will do to reduce health disparities?
        Secretary Becerra. Madam Chair, the most important things
    is that we're now recognizing--the fact that we're using the
    words social determinants of health show how far we've come as
    a Nation and as a policy-making body that we recognize that, in
    so many ways, your health is determined by your background, too
    often by your ZIP code, and we have to change those things,
    because there are people in America who are left out. There are
    places, the pockets in America where the services don't reach
    them, whether it's rural America or whether it's inner-city
    America.
        And the President has made equity one of the prominent
    features of his administration, and we will do the same at HHS.
        Senator Murray. Well, thank you very much, and that will
    end our hearing today. I do want to thank all of our fellow
    committee members and Secretary Becerra for a very thoughtful
    discussion today about the President's budget request and how
    we can work together to really address some of these really
    critical issues of lowering healthcare costs, and helping
    families across the country get covered, address inequities,
    respond to public health crisis, childcare. So much more that
    is within your jurisdiction. So, really appreciate your
    testimony today.
        Secretary Becerra. Thank you.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Murray. For any Senators who wish to ask additional
    questions, questions for the record will be due June 18 at 5
    p.m. The hearing record will also remain open until then for
    members who wish to submit additional material for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                Questions Submitted to Secretary Xavier Becerra
                  Questions Submitted by Senator Patty Murray
        Question. The past year has been particularly devastating for
    children and young adults' mental health. The CDC found the proportion
    of emergency room mental health visits increased by a quarter from
    April to October last year for children ages 5 and 11, and by nearly a
    third for those between ages 12 and 17. Suicide attempts and
    psychiatric help calls for children are also on the rise. Seattle
    Children's Hospital in Washington is seeing 170 children with mental
    health emergencies a week--compared to 50 before the pandemic. Sacred
    Heart Children's Hospital in Spokane saw admissions to its adolescent
    psychiatric unit and its pediatric floor for behavioral health issues
    both rise by around 70 percent.
        How does the budget request target mental health services
    specifically to children and young adults?
        How does the request address the ability for children to access
    mental health services within their communities?
        Answer. HHS is committed to providing mental health services that
    address the needs of children and young adults. SAMHSA supports school-
    based programming in part through Project AWARE (Advancing Wellness and
    Resilience in Education). The purpose of this program is to build or
    expand the capacity of State Educational Agencies, in partnership with
    State Mental Health Agencies (SMHAs), to increase awareness, provide
    training and promote connection to services for youth with behavioral
    health needs. From October, 2016 to September, 2020, Project AWARE
    trained over 56,000 providers and ensured that more than half a million
    school-aged youth had access to and were referred to mental health
    services.
        School-based health centers (SBHC) are typically funded by U.S
    DHHS-Health Resources and Services Administration (HRSA; https://
    www.hrsa.gov/our-stories/school-health-centers/index.html) and/or by
    individual State Departments of Health. SBHCs provide students with a
    variety of age-appropriate health services, including, but not limited
    to, primary medical care, health education, and nutrition education.
    SBHCs are increasingly offering behavioral healthcare services such as
    mental health and substance use screening, counseling, and case
    management/referral services. SBHCs are often operated as a partnership
    between the school and a community health organization, such as a
    community health center (FQHC) or local health department; and for
    behavioral health services, SBHCs often partner with local community
    mental health centers.
        SAMHSA has continued to expand the Certified Community Behavioral
    Health Clinics (CCBHCs) through expansion grants, awarding 134 grants
    in early 2021 through recent emergency funding, with up to 74
    additional grants being awarded in summer of 2021 as part of the
    regular appropriations process. 166 CCBHC grantees were awarded in
    fiscal year 2020. SAMHSA is also planning a formal technical assistance
    arrangement to support organizations in implementation and
    sustainability. The CCBHC programs provide an array of critical,
    integrated services to meet the behavioral health needs of communities.
    CCBHCs provide a full continuum of timely, person and family-centered
    services, including access to crisis services 24/7, and are
    particularly focused on the needs of individuals with serious mental
    illness (SMI), serious emotional disturbance (SED) and/or substance use
    disorder (SUD). The program is designed to support individuals and
    families who are uninsured or underinsured and who may otherwise lack
    access to effective screening and treatment. The program encourages use
    of telehealth and other modalities to increase reach of services and to
    address barriers to care access.
        Question. The fiscal year 2021 Labor-HHS bill included a new, 5
    percent set aside in the Mental Health Block Grant for states to
    develop crisis systems to improve their ability to respond to
    individuals experiencing a mental health crisis. These systems are
    intended to connect people with appropriate services, rather than
    referring them to law enforcement or emergency rooms.
        How does the request build on the crisis response set aside created
    in the fiscal year 2021 bill and how does HHS plan to work with states
    to ensure these systems are fully accessible with adequate coordination
    between mental health and law enforcement?
        Answer. The Community Mental Health Services Block Grant received
    an increase of $825 million in the fiscal year 2022 President's Budget,
    for a total of $1.6 billion, to expand access to behavioral healthcare.
    Within the total, $75 million is directed to the crisis services set-
    aside. This investment in crisis services will direct funding to states
    to build much needed crisis systems that will provide high quality,
    expeditious mental healthcare. This funding also will support the
    partnering of behavioral health providers with law enforcement.
        SAMHSA has been actively engaging with states on the use of MHBG
    funds, including this crisis set-aside ($75 million in fiscal year 2022
    President's Budget). This coordination has included technical
    assistance on the use of funds, requests for information on specific
    allocations of funding across the crisis continuum of care, and
    recommended changes to the data reporting system. States are at
    different stages in their implementation of core crisis services and
    currently use the funds to expand existing core services or develop new
    services. Funding regional or statewide crisis centers is an allowable,
    but not required, use of the funds. There is significant variation in
    the degree to which states are using MHBG funds to support activities
    such as the Lifeline crisis call centers. The fiscal year 2022
    President's Budget includes funds for SAMHSA to further expand the
    capacity of the call centers to ensure they can respond to the expected
    increase in call volume accompanying the transition to 988.
        Beyond the current Lifeline functionality, it is critical that
    individuals experiencing a behavioral health emergency have access to a
    coordinated crisis system of care. Effectively responding to people in
    crisis who are experiencing a behavioral health emergency has three
    main components as outlined in SAMHSA's National Guidelines for
    Behavioral Health Crisis Care: providing someone to talk to, providing
    in-person response, and providing a place to go. Implementing 988
    successfully will be a critical first step in the crisis response.
    Current research suggests that many crises can be effectively addressed
    through a call alone. In addition, call centers that have follow-along
    capacity and/or access to local outpatient treatment resources can
    provide enhanced crisis care. A robust crisis system, including 988
    access through the Lifeline network, will decrease suicides, reduce
    arrests and criminal justice involvement for individuals with
    behavioral health needs, and will facilitate linkages to care to reduce
    unnecessary emergency department boarding and hospitalization.
    Implementation of the Lifeline, partnered with the development of a
    coordinated and comprehensive behavioral health crisis services system
    across the United States, will save lives.
        The fiscal year 2022 President's Budget further supports local
    communities in meeting the mental health needs of people who are
    incarcerated by investing $45 million more in these programs for a
    total of $51 million to support the needs of those who are involved in
    the criminal and juvenile justice system(s) providing funding for
    partnerships between mental health providers and law enforcement.
    SAMHSA will award a new cohort of grants to community-based behavioral
    health providers that focus specifically on the delivery of mental
    disorder treatment while in jail and provide linkages to care post-
    incarceration.
        Question. The President's budget request includes a $77.6 million
    increase for the National Suicide Prevention Lifeline in order to help
    build the infrastructure necessary to make a smooth transition to the
    new three-digit code (9-8-8) as required by the National Suicide
    Hotline Designation Act.
        Please describe how this funding will strengthen the existing
    infrastructure of the Lifeline and better prepare local centers to
    respond to the increase in calls expected once the transition to 9-8-8
    occurs.
        Answer. The creation of 988 is a once-in-a-lifetime opportunity to
    strengthen and expand the Lifeline and transform America's behavioral
    health crisis care system to one that saves lives by serving anyone, at
    any time, from anywhere across the nation. Preparing the Lifeline for
    full 988 operational readiness will require a bold vision for a system
    that provides direct, life-saving services to all in need and links to
    community-based providers uniquely positioned to deliver a full range
    of crisis care services. SAMHSA sees 988 as the linchpin and catalyst
    for a transformed behavioral health crisis system in much the same way
    that, over time, 911 spurred the growth of emergency medical services
    in the United States.
        SAMHSA envisions a multi-phase approach to making 988 operational
    and effective. SAMHSA is committed to using this investment to
    strengthen the existing infrastructure and prepare for the launch of
    988. The first phase is focused on increasing the capacity and
    operational readiness for the National Suicide Prevention Lifeline to
    accept 988 calls, chats, and texts by July of 2022. This includes
    support to ensure a national back-up system or safety net. SAMHSA has
    reviewed modeling estimates to anticipate the expected call volumes
    with 988 rollout. The President's Budget includes funds to support the
    resources needed for network and telephony infrastructure expansion,
    training to harmonize protocols across all local centers, and staffing
    to increase the capacity of the Lifeline to respond to the anticipated
    increase in calls expected with the 988 transition.
        An ideal crisis system would include state and regional crisis
    hubs, which can be fully integrated with mobile crisis response, crisis
    receiving facilities and follow up care. SAMHSA believes that the
    crisis system will be critical to make 988 optimally effective in
    addressing behavioral health crisis needs and reducing unnecessary
    hospitalizations and law enforcement involvement.
        Question. The budget request notes that this funding will be used
    to increase the capacity to respond to text messages and to those who
    need specialized services. Does the Department plan on leveraging
    existing infrastructure rather than recreating these capabilities?
        Answer. Yes, leveraging existing infrastructure will be
    instrumental in the success of 988. Initially established by Congress
    in 2005, the Lifeline is a national network of over 180 independently
    operated crisis call centers, three Spanish language centers, and the
    Veterans Crisis Line (VCL). The network is currently linked by the
    toll-free telephone number, 1-800-273-TALK, which is available 24 hours
    a day, 7 days a week. The Lifeline network also consists of 9 national
    backup and 38 chat/text centers. The backup and chat/text core network
    centers operate under contractual obligations through the Lifeline
    Administrator, who oversees the current Lifeline cooperative agreement
    from SAMHSA.
        Until recently, funding for the National Suicide Prevention
    Lifeline was only $7 million. This funding along with limited state
    investments has been insufficient to pay local centers to answer
    Lifeline calls. With the President's Budget request, as well current
    state investments in the answering of Lifeline calls, important
    progress is being made.
        It is critical to invest in strengthening Lifeline network
    operations. While further system transformation will require additional
    capacities (e.g., substance use integration, coordination across the
    crisis continuum, etc.), the immediate priority is ensuring the
    Lifeline has sufficient resources to address the scope of contacts
    addressed directly in the National Suicide Hotline Designation Act,
    including individuals in suicidal or mental health crisis. In the near
    term, efforts should be made to map available local resources so that
    facilitated transfers and referrals can be made to support individuals
    with additional needs.
        SAMHSA recognizes the need for a multi-pronged approach to address
    the needs of populations at higher risk of suicide. This includes both
    leveraging existing technologies as well as piloting and developing
    novel approaches to enhance access to crisis care.
        Question. When does the Department intend to provide the
    Subcommittee with the report on the costs associated with a transition
    to 9-8-8?
        Answer. SAMHSA has been working diligently on three important
    reports to Congress--the 988 Appropriations Report, the Report on
    Training and Access to 988 for High Risk Populations, and the Report on
    988 Resources. SAMHSA worked collaboratively with the VA to develop the
    Resources report to Congress. All three reports are in the final stages
    and will be submitted to the respective Committees and your
    Subcommittee shortly.
        Question. The pandemic's impact on child-care has been especially
    hard on communities of color, undermining parents' economic stability
    and children's school readiness. Virtually all child-care workers are
    women, disproportionately women of color and immigrant women who do not
    receive adequate wages or benefits. COVID has only made these
    inequities worse. Additionally, even before the pandemic, children of
    color were less likely to attend a high- quality early learning program
    than their white peers, and entered kindergarten 9 months behind their
    white non-Hispanic peers in math and almost 7 months behind in reading,
    on average. Furthermore, Center closures because of the pandemic have
    threatened an already limited supply of care for infants and toddlers
    and made it even harder for families of color to get quality,
    affordable child-care. I am concerned these closures will deepen racial
    and socioeconomic inequities in access to high-quality early learning
    opportunities that promote kindergarten readiness for children.
        What role is HHS playing in addressing the racial inequities in
    child-care for families and providers?
        Answer. The HHS Office of Child Care (OCC) is providing guidance,
    technical assistance, and oversight to assist states, tribes, and
    territories with administering the multiple rounds of COVID-19 child
    care supplemental funding, including the $39 billion in child care
    funding provided by the American Rescue Plan Act consisting of $24
    billion in child care stabilization funds and $15 billion in
    supplemental Child Care and Development Fund (CCDF) awards. This
    funding is helping to stabilize and improve the child care sector and
    improve access for all children and families, including addressing
    racial and ethnic inequities.
        The American Rescue Plan Act child care stabilization funds are
    providing immediate financial relief to child care providers facing
    increased costs and declining revenue. Our guidance on these funds
    (Information Memorandum CCDF-ACF-IM-2021-02) indicates that
    applications, technical assistance, and written resources should be
    available in multiple languages, and that states are encouraged to work
    with culturally relevant organizations to meet the ongoing needs of
    providers receiving grants. We are also collecting data on the race,
    ethnicity, and location of child care providers to track the equitable
    distribution of resources.
        The CCDF supplemental funds in the American Rescue Plan Act are an
    unprecedented opportunity to expand access to high-quality child care
    and move toward a more equitable child care system by assisting many
    families and providers who have not previously participated in the
    child care subsidy system--including families and providers from
    communities of color. Our guidance (Information Memorandum CCDF-ACF-IM-
    2021-03) strongly recommends that states prioritize increasing provider
    payment rates and workforce compensation so that child care providers
    can retain a skilled workforce and deliver higher-quality care to
    children receiving subsidies. These steps will advance equity for
    women, particularly women of color, lift families out of poverty, boost
    the broader economy, increase women's labor force participation, and
    improve outcomes for children. Our guidance also encourages states to
    pursue opportunities to build the supply of child care--including the
    use of grants and contracts--for historically-underserved populations.
    The guidance also encourages states to use some of the funds for
    outreach activities to underserved populations, including to
    disseminate materials in multiple languages, and to fund partners and
    organizations trusted by families and child care providers--including
    culturally relevant organizations.
        OCC has developed a number of technical assistance (TA) resources
    to help state, territory, and tribal CCDF administrators and other
    systems-level professionals assess and ensure equitable child care
    service delivery to racially disadvantaged communities. These resources
    encompass all child care settings, e.g., center-based care, family
    child care, and family, friend, and neighbor care; as well as the range
    of age groups served by CCDF. Our TA system embeds racial equity
    considerations in the planning, development, and evaluation of new
    resources to ensure they are inclusive of diverse perspectives and
    responsive to disadvantaged community's needs.
      --The National Center on Early Childhood Quality Assurance (ECQA) has
            developed resources on considerations for leadership in early
            childhood systems development and for child care licensing
            systems, as well as other health equity resources to help
            grantees develop integrated strategies to support the social
            and emotional wellness of children by highlighting promising
            strategies used by CCDF grantees. See for example Kickoff:
            Office of Child Care Initiative to Improve the Social-Emotional
            Wellness of Children and A Resource Guide for Developing
            Integrated Strategies to Support the Social and Emotional
            Wellness of Children.
      --Our TA Center for the Preschool Development Grants, Birth to Five
            (PDG B-5)--which supports early childhood systems development,
            including child care--recently delivered a webinar on building
            state capacity to consider equity in data collection,
            specifically administrative data, to improve equitable access
            and outcomes through data collection and analysis. The Center
            also developed a research to practice brief that highlights
            current research trends and implications for racial and ethnic
            disparities related to early childhood, including policy
            choices to reduce disparities and set children and families on
            more favorable trajectories. TA website users have demonstrated
            a strong interest in this equity content and it is among the
            PDG B-5 TA Center's most popular links: https://
            childcareta.acf.hhs.gov/improving-equity-services.
      --In recognition of the disproportionate impact of the COVID-19
            pandemic on indigenous communities, OCC has made a focused
            effort over the last year to identify ways to support Tribal
            CCDF programs' response and recovery. Understanding that
            cultural connection is a strength and resiliency factor in
            tribal children and families, the National Center on Tribal
            Early Childhood Development (NCTECD) has developed a number of
            resources to support grantees with culturally relevant quality
            improvement activities, including resources focused on CCDF
            quality requirements; ideas and innovations for quality
            improvement activities that meet community needs; support with
            planning, including prioritization and budgeting; and
            developing clear and strong policies and procedures. See
            https://childcareta.acf.hhs.gov/quality-improvement- resource-
            page.
        In addition, our TA providers regularly refer states and other TA
    recipients to resources published by national organizations (such as
    the Annie Casey Foundation and Child Trends) that center racial equity
    in the development and implementation of child care policies and
    practices. These resources are used in the provision of intensive/
    individualized, targeted/group, and universal TA strategies depending
    on grantee need and readiness.
        Looking ahead, the Biden-Harris Administration's Build Back Better
    vision for early childhood would add substantial ongoing investments to
    early learning services and infrastructure and continue the momentum
    created by the American Rescue Plan Act--to benefit all children,
    families and providers--including in communities of color. The
    President's fiscal year 2022 Budget includes $250 billion over 10 years
    to make child care affordable and to modernize and expand child care
    facilities. High-quality early care and education opportunities lay a
    strong foundation so that children can take full advantage of education
    and training opportunities later in life. The President's Build Back
    Better invests in child care infrastructure and workforce training and
    ensures that low and middle-income families pay no more than 7 percent
    of their income on high-quality child care. The Build Back Better also
    proposes $200 billion for a national partnership with states to offer
    free, high-quality, accessible, and inclusive prekindergarten to all
    three- and four-year-olds. The proposed universal prekindergarten
    program is designed to give states incentives to build out their
    existing pre-k programs to reach more 3- and 4 -year-olds and to
    increase program quality by building on what has already been
    established in states. The Budget also proposes increased funding
    levels for existing early care and education programs, including nearly
    $11 billion for CCDF and a total of $11.9 billion for Head Start.
        Question. Title X is the only Federal program dedicated to
    providing family planning services for people who are paid low incomes.
    It disproportionately serves communities of color, where the pandemic
    has hit the hardest and exposed sharp disparities in access to care.
    Sadly, this critical program has been chronically underfunded for too
    long. The President's Budget proposes to increase the program by $54
    million, its first increase in nearly a decade. Yet, research shows
    Title X would need hundreds of millions more annually to provide family
    planning services to all women without insurance and who are paid low
    incomes in the United States.
        Please explain how HHS plans to use this increase to help increase
    access for women of color and women who are paid low incomes?
        Answer. HHS agrees the nation must take swift action to prevent and
    remedy stark racial and ethnic disparities in health and healthcare
    delivery in America, including advancing equity and reducing health
    disparities in all healthcare programs. As you noted, the budget
    provides a 19 percent increase to the Title X Family Planning program
    for a total of $340 million to support family planning services for
    approximately 3.5 million persons, with approximately 90 percent having
    family incomes at or below 200 percent of the Federal poverty level and
    a disproportionate number of clients served identify as a person of
    color. The Office of Population Affairs (OPA), part of the Office of
    the Assistant Secretary for Health (OASH), advises the HHS Secretary on
    a range of public health priorities including quality family planning
    and adolescent health and serves as a key stakeholder on HHS' effort to
    advance health equity.
        OPA administers the Title X family planning program, the only
    Federal program devoted solely to the provision of family planning and
    related preventive healthcare. By law, under the Title X program,
    priority is given to individuals from low-income families, which
    include many communities of color. On January 28, 2021, President Biden
    issued a ``Memorandum on Protecting Women's Health at Home and Abroad''
    directing the Department to review the 2019 Title X Final Rule and
    ``consider, as soon as practicable, whether to suspend, revise, or
    rescind, or publish for notice and comment proposed rules suspending,
    revising, or rescinding, those regulations, consistent with applicable
    law, including the Administrative Procedure Act.'' The memorandum
    specifically directed the Department to ensure that undue restrictions
    are not put on the use of Federal funds or on women's access to medical
    information. After reviewing the 2019 rule, the Department went through
    notice-and-comment rulemaking and finalized a regulation to revoke the
    2019 rules and restore the 2000s regulation that successfully guided
    the program for decades with several modifications needed to strengthen
    the program and ensure access to equitable, affordable, client-
    centered, quality family planning services for all clients.
        Question. Chairman Pallone and I recently wrote a letter to
    interested parties requesting input on how best to write legislation
    establishing a public health insurance option. The objective is to
    create a strong Federal public option that makes healthcare more
    accessible, more affordable, and simpler for patients and families. In
    addition to policies like permanently extending the increased premium
    tax credits in the American Rescue Plan, a public option would go a
    long way towards ensuring every person has quality, affordable coverage
    regardless of income, age, race, disability, or zip code. We were
    pleased that the budget expressed the President's support for a public
    option available through the ACA marketplaces.
        How would a public option help expand coverage, bring down
    healthcare costs, and make healthcare easier to access for patients and
    families?
        Answer. The President supports providing Americans with additional,
    lower-cost coverage choices by creating a public option that would be
    available through the ACA marketplaces and giving people age 60 and
    older the option to enroll in the Medicare program with the same
    premiums and benefits as current beneficiaries, but with financing
    separate from the Medicare Trust Fund. . President Biden has been clear
    that his goals for improving the American healthcare system begin with
    building on the successes of the Affordable Care Act, and HHS is
    committed to working toward that goal.
        Question. The Affordable Care Act (ACA) authorized $30 million for
    Consumer Assistance Programs (CAPs) to provide a dedicated Federal
    funding stream to help health insurance consumers effectively steer
    their way through our nation's complex health insurance system and to
    avail themselves of new consumer protections in the ACA. In 2010, HHS
    awarded nearly $30 million in CAP grants to 40 states, territories, and
    the District of Columbia. Regrettably, efforts to overturn and then
    weaken the ACA resulted in blocking additional funding after the first
    year. Many states--including New York, Massachusetts, Maine,
    Connecticut, Rhode Island, Vermont, the District of Columbia, Maryland
    and more--maintained CAPs with limited state funds, but others closed
    altogether for lack of funding. These programs help consumers
    understand and use their insurance plans, resolve medical billing
    problems, and appeal insurance denials. As the Biden Administration
    joins Congress to provide support to individuals who are underinsured
    or who have lost their jobs and healthcare coverage due to the economic
    downturn caused by the COVID-19 pandemic, assistance is needed to help
    consumers navigate and understand their healthcare options.
        Does the Administration support the resumption of the ACA CAP
    programs to sufficiently meet the demand for such assistance?
        How does the Administration plan to prioritize the provision of
    services provided in the CAP programs to people across the nation?
        Answer. HHS is committed to using all available tools to strengthen
    the ACA Marketplaces, making it easier for people to get and keep
    health insurance, and making sure more Americans know about their
    options and are supported in their enrollment.
        Question. In December 2018, the bipartisan 21st Century IDEA (PL
    115-336) was signed into law. It requires agencies to modernize their
    websites, intranets and digitize their paper-based forms with the goal
    of improving the Federal Government's customer experience and digital
    service delivery. Since Congress passed the 21st Century IDEA, the
    nature of how individuals engage with the government has fundamentally
    changed--in large part because of the COVID- 19 pandemic. These changes
    underscore an even stronger need to implement the 21st Century IDEA and
    allow Federal agencies to deliver an excellent customer experience from
    anywhere, to anyone, on any device.
        Has CMS fully implemented the 21st Century IDEA Act (Public Law No:
    115-336)? What barriers has CMS faced in implementing this law and
    modernizing its digital services?
        The law required each executive agency to digitize and ensure any
    paper- based form was made available to the public in a fully usable
    mobile friendly option. Where does CMS stand in ensuring its forms can
    be filled out and submitted electronically on all digital devices?
        Who is responsible inside CMS for ensuring the agency fully
    implements PL 115-336?
        Answer. CMS is committed to making sure beneficiaries, enrollees,
    providers, and other stakeholders have access to the information they
    need to make important decisions about their healthcare. The 21st
    Century IDEA provided CMS with valuable resources and guidance that
    bolstered its ongoing efforts to modernize its websites. CMS has
    implemented the 21st Century IDEA for all of its public websites, and
    many CMS forms are available for beneficiaries, enrollees, providers,
    and other stakeholders to fill out and submit online. The CMS Office of
    Communications continues to make updates that make it easier to access
    and submit these forms from a mobile device.
        Question. HRSA's C.W. Bill Young Cell Transplantation Program,
    along with its nonprofit partner the National Marrow Donor Program
    (NMDP), provides support and access for patients who need lifesaving
    bone marrow transplants. The President's budget request proposes to
    combine the Cell Transplantation/National Registry Program with the
    National Cord Blood Inventory (NCBI) Program. It also appears to
    request an increase of $7 million for the Cell Transplantation/National
    Registry Program.
        Please provide greater detail than what was included in the HRSA
    Congressional Justification (CJ) on the proposed consolidation and how
    HHS plans to spend the proposed increase.
        Answer. In fiscal year 2022, HHS will use approximately $49.2
    million in consolidated funds from the C.W. Bill Young Cell
    Transplantation Program (CWBYCTP) and the National Cord Blood Inventory
    (NCBI) to support the common legislative and therapeutic functions of
    both programs (i.e. bone marrow functions, cord blood functions, single
    point of searching access, stem cell therapeutic outcomes database, and
    patient advocacy) outlined in the TRANSPLANT ACT of 2021.
        In fiscal year 2022, HHS expects to award approximately $10 million
    to licensed cord blood banks to continue banking high-quality, diverse
    cord blood units. HHS also plans to provide approximately $7 million to
    examine ways to optimize cord blood utilization. The remaining $32.2
    million will support the five legislative functions described above
    through one or more contracts. HHS will obligate these funds primarily
    for contract-supported initiatives (i.e. adult donor recruitment and
    tissue typing, searches for stem cell sources through a single point of
    electronic access, patient education, case management, donor advocacy,
    public outreach, professional development, and data collection). HHS
    will use a small portion for administrative costs.
        Question. In addition, this Committee provided increases for this
    program in both fiscal year 2200 and fiscal year 2021, yet the CJ
    includes little detail on how HRSA plans to use these resources. Please
    provide execution detail for each of these fiscal year increases and
    the total amount that was obligated and applied to HRSA's partners who
    run the program.
        Answer. In fiscal year 2020, HRSA provided an increase in funding
    to support new and existing activities under the Single Point of
    Access-Coordinating Center contract. The activities for the Office of
    Patient Advocacy and Stem Cell Therapeutic Outcomes Database contracts
    remained unchanged. The funding provided for each CWBYCTP contractor is
    outlined below:
      --National Marrow Donor Program--
        --Single Point of Access-Coordinating Center (SPA-CC)--$21.8
                million used to support the SPA-CC contract, which carries
                out three legislative functions (i.e., bone marrow, cord
                blood, single point of access);
          -- This funding included an additional $5.4 million, which
                increased existing support for adult donor recruitment and
                tissue typing; high-resolution tissue typing of cord blood
                units and collaboration with cord blood banks to enhance
                cord blood operations. The funding also supported new
                activities under the contract, including: cytomegalovirus
                testing of adult donors; COVID-19 related increases
                including donor and courier costs; and cryopreservation of
                blood stem cell products.
        --Office of Patient Advocacy (OPA)--$877,000 used to support the
                Office of Patient Advocacy; and
      --Medical College of Wisconsin's Center for International Blood and
            Marrow Transplant Research--
        --Stem Cell Therapeutic Outcomes Database--$4.6 million used to
                collect outcomes data on blood stem cell transplants using
                bone marrow and cord blood.
        In fiscal year 2021, HRSA plans to fund existing and enhanced
    activities carried out by the following CWBYCTP contractors:
      --Single Point of Access-Coordinating Center (SPA-CC)--$29.8 million
            used to support the SPA-CC contract.
      --HHS will fund many of the same activities, including adult donor
            recruitment and tissue typing, high-resolution tissue typing of
            cord blood units, and collaboration with cord blood banks.
            Also, HHS will fund donor advocacy and contingency planning
            activities.
        --The additional $7 million will support existing NCBI cord blood
                banks; raise physician awareness of all cellular therapy
                treatment options, including cord blood; and support
                engagement with the cord blood community.
      --Office of Patient Advocacy (OPA)--$903,000 used to support the
            patient advocacy and case management. The scope for this
            contract has not increased in recent years.
      --Stem Cell Therapeutic Outcomes Database--$4.7 million used to
            collect outcomes data on blood stem cell transplants using bone
            marrow and cord blood. The scope for this contract has not
            increased in recent years.
        Question. The Committee included language in the fiscal year 2021
    Conference Agreement that encouraged HHS to ``review the accreditation
    and eligibility requirements for the Public Health Service Corps and
    behavioral health workforce programs to allow access to the best
    qualified applicants, including those who graduate from Psychological
    Clinical Science Accreditation System (PCSAS) programs''. This review
    and these changes are necessary to update Department policy that was
    adopted prior to the establishment of PCSAS to permit the graduates of
    the current 44 PCSAS University accredited doctoral programs in
    psychological clinical science to be eligible to compete.
        Please provide an update on progress to update these Department
    policy and regulation.
        Answer. As of December 2020, the Public Health Service Commissioned
    Corps includes the Psychological Clinical Science Accreditation System
    programs in the Category Specific Appointment Standards. This means
    that individuals with such accreditation are permitted into the Corps.
        HRSA is currently exploring options to include PCSAS doctoral
    programs as eligible entities in the upcoming fiscal year 2022 Graduate
    Psychology Education competition. HRSA will continue to explore options
    to include such programs in other future competitions, including, but
    not limited to, the Behavioral Health Workforce Education and Training
    program, and the Geriatric Academic Career Awards. HRSA currently
    anticipates posting the Notice of Funding Opportunity for the Graduate
    Psychology Education program in November 2021.
        Question. The Centers for Medicare & Medicaid Services (CMS) posted
    a final rule for Medicare's radiation oncology alternative payment
    model (RO APM) on September 18, 2020. Implementation of the model has
    been delayed by Congress until January 2022.
        Is the Biden Administration reviewing and planning to issue an
    updated RO APM?
        Will HHS commit to working with both Congress and stakeholders to
    improve the RO APM and ensure that a transition to new value-based
    models does not result in reduced patient access to innovative cancer
    treatments?
        Answer. Since 2014, CMS has explored potential ways to test an
    episode-based payment model for radiotherapy (RT) services. In December
    2015, Congress passed the Patient Access and Medicare Protection Act,
    which required the Secretary of Health and Human Services to submit to
    Congress a report on ``the development of an episodic alternative
    payment model'' for RT services. The report was published in 2017 and
    identified three key reasons why RT is ready for payment and service
    delivery reform: the lack of site neutrality for payments; incentives
    that encourage volume of services over the value of services; and
    coding and payment challenges.
        The Radiation Oncology (RO) Model, implemented through the CMS
    Innovation Center, aims to improve the quality of care for cancer
    patients receiving RT and move toward a simplified and predictable
    payment system. The RO Model tests whether prospective, site neutral,
    modality agnostic, episode-based payments to physician group practices,
    hospital outpatient departments, and freestanding radiation therapy
    centers for RT episodes of care reduces Medicare expenditures while
    preserving or enhancing the quality of care for Medicare beneficiaries.
    I am happy to work with Congress and other stakeholders to address any
    concerns about this model.
        The Consolidated Appropriations Act, 2021 enacted on December 27,
    2020 included a provision that prohibits implementation of the
    Radiation Oncology Model prior to January 1, 2022, effectively delaying
    the start date by at least 6 months. CMS intends to address the delay
    and make other modifications to the RO Model through notice and comment
    rulemaking.
        Question. Analysis of CDC data and other reports indicate a
    reduction in routinely recommended vaccination of children and youth
    last year resulting from the disruption to routine healthcare caused by
    the COVID-19 pandemic. Lack of proper vaccinations could provide an
    additional challenge to the return to in-person learning in the fall.
        How is HHS working with the Department of Education to support the
    vaccination of children and youth needed for school enrollment for in-
    person learning?
        Answer. CDC issued a Call to Action in April 2021 encouraging
    healthcare providers to identify and follow up with families whose
    children have missed doses, and to schedule appointments for those
    children. CDC encouraged schools and state and local government
    agencies to use the state's immunization information system's reminder-
    recall capacity to notify families whose children have fallen behind on
    routine vaccines and encourage compliance with vaccination
    requirements. In June 2021, CDC issued an MMWR article describing the
    decrease in routine childhood and adolescent immunizations in 10 U.S.
    jurisdictions during March-September 2020 as compared with the same
    period in 2018 and in 2019.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        Question. Secretary Becerra, the budget proposes $767 billion for
    Medicare. One of the greatest drivers of outlays by the Medicare
    program is the cost of chronic conditions, including tobacco-related
    costs. By some estimates, 10 percent of Medicare spending is
    attributable to smoking and the health harms it causes. So it would
    seem that the Department would want to be doing everything it can to
    prevent tobacco use, especially among youth. As you know, youth e-
    cigarette use has skyrocketed over the past decade. Four million kids
    are now vaping--one in every five high school students.
        And for years, the Federal Government failed to regulate these
    addictive, kid-friendly products. Nine months ago, e-cigarette
    companies were required to submit applications to the FDA in order to
    stay on the market. This is a momentous time for the FDA, as it will
    evaluate whether these e-cigarettes are ``appropriate for the
    protection of public health.'' That is a high bar. But the FDA's
    priority should be protecting our youth and preventing a lifetime of
    addiction. I am deeply concerned that the FDA will let a product such
    as JUUL--which has partnered with Marlboro-maker Altria and had a
    years-long documented campaign of hooking our kids on nicotine--to
    remain on the market. In particular, I am worried that FDA will allow
    flavored products--which we know are meant to target kids--to
    proliferate.
        Can you commit to me that HHS and FDA will not authorize any vaping
    products that will lead to more youth use, including flavored products?
        Answer. FDA has a very important responsibility to review new
    tobacco products before they can be legally marketed. FDA determines if
    a new tobacco product may be legally marketed by assessing whether the
    marketing of the product meets the applicable standard Congress set in
    the law to protect the public health.
        As required by statute, a key consideration in our review of
    premarket tobacco product applications submitted for products like e-
    cigarettes is to determine whether permitting the marketing of the
    product would be ``appropriate for the protection of the public
    health,'' taking into account the risks and benefits to the population
    as a whole. This determination includes consideration of how the
    products may impact youth use of tobacco products and the potential for
    the products to completely move adult smokers away from use of
    combustible cigarettes. Importantly, we know that flavored tobacco
    products are very appealing to young people. Therefore, assessing the
    impact of potential or actual youth use is a critical factor in our
    determination as to whether the statutory standard for marketing is
    met.
        Looking forward, FDA continues to work expeditiously to complete
    review of the remaining pending applications. While the Agency cannot
    prejudge applications or categorically deny marketing authorization
    based on certain characteristics, such as flavors, be assured that HHS
    and FDA share your concern about youth initiation and use of tobacco
    products, and we will continue to keep you updated as reviews continue.
        Question. Two decades ago, a CDC study came out that changed the
    way we think about public health. It was called the Adverse Childhood
    Experiences or ``ACEs'' study, and it established the link between
    exposure to trauma--things like witnessing violence or an overdose--and
    our long-term health, education, and economic outlook. We now
    understand how trauma and ACEs harm brain development, and how these
    emotional scars can lead to lower life expectancy, and a higher
    likelihood of suicide or drug use.
        When you look at the public health crisis of gun violence--along
    with the mental health and addiction--it's clear we must focus on the
    root issue of trauma. So Senator Capito and I teamed up in 2018 to pass
    legislation that created an ACEs program at CDC, and I am pleased to
    have secured $10 million over the past 2 years for this work. We also
    passed provisions creating the Interagency Task Force on Trauma-
    Informed Care that brings our Federal agencies around the table to
    promote this understanding of trauma in every Federal grant program,
    increasing the authorization for the National Child Traumatic Stress
    Network, and authorizing a $50 million trauma and mental health
    services grant program for schools, which we have not yet been able to
    fund. This grant program--Section 7134 of the SUPPORT for Families and
    Communities Act--would assist schools in adopting trauma-informed
    practices, training more staff, engaging families, and forging
    partnerships with clinical mental health professionals.
        Now, the 2022 budget proposes a $61 million increase to SAMHSA's
    Project AWARE mental health funding, and a $100 million investment at
    CDC in community-based violence interventions, working with
    neighborhood organizations and hospitals to deliver services. Chicago
    is home to many of these programs--including street outreach efforts,
    trauma programming in schools, and hospital programs that pair victims
    of violence with social workers to address their trauma and reduce the
    current 50 percent re-injury rate.
        Secretary Becerra, can you explain how this new CDC community-
    violence proposal can support programs like those in Chicago, and how
    you envision this constellation of programs working together?
        Secretary Becerra, in addition to, or as part of, the proposed
    increase to Project AWARE, would you also support appropriations for
    this already-authorized Sec. 7132 program to address the breadth of
    trauma needs in schools--setting up comprehensive plans, trainings, and
    partnerships?
        Answer. The Community Violence Initiative (CVI) proposal would help
    CDC address the root causes of community violence and support systemic
    approaches to violence prevention. CDC would prioritize implementing
    evidence-based, community strategies to reduce rates of violence;
    expand our prevention data surveillance, conduct research to address
    critical gaps; and enhance what is known about what works to prevent
    community violence. This approach includes prevention strategies that
    address the structural determinants of health that contribute to
    violence inequities within and across communities, such as those
    currently implemented in Chicago. In addition, Hospital-Community
    Partnerships, such as HEAL, represent an important type of strategy to
    prevent and reduce community violence and could be supported under the
    proposed Community Violence Initiative.
        A comprehensive approach is critically important to achieving and
    sustaining long-term reductions in community violence. A strong and
    growing research base demonstrates that there are multiple prevention
    strategies that are scientifically proven to reduce violence
    victimization and perpetration. Many of these strategies are upstream
    approaches that have yielded community savings that far outweigh
    implementation costs. These upstream approaches, coupled with programs
    like hospital-community partnerships, can create safe, healthier, and
    more resilient communities.
        In addition to funding 25 cities with the highest overall number of
    homicides and the 25 cities with the highest number of homicides per
    capita, the CVI proposal would also fund up to five non-governmental
    organizations that have expertise in partnering with communities most
    impacted by community violence. Doing so will build a network of
    violence prevention efforts, from local health departments to community
    organizations. The CVI proposal will also help modernize data systems
    like the National Violent Death Reporting System (NVDRS) to provide
    more timely data on causes of violence in communities.
        SAMHSA is also committed to effective school based mental health
    services that address the needs of children and families. Project AWARE
    grantees have established mechanisms to provide tiered services in
    school settings. This tiered system has three main components. One pays
    attention to the overall school climate and promotes social and
    emotional learning opportunities and supports for all children. The
    next tier has special programming for children at risk for the
    development of behavioral health conditions. The third and final tier
    is comprehensive services for children and their family with serious
    emotional disturbance (SED). A comprehensive approach to behavioral
    healthcare in schools is critical to build resilience in our children
    and youth include building trauma-informed school systems and providing
    training and community partnerships in trauma-informed care. Building
    in trauma-informed care to AWARE projects and augment that work with
    additional partnerships to address the breadth of need in schools is
    critical to meet the mental health needs of our children and youth.
        Several programs funded by HRSA are focused on measuring and
    addressing the impact of ACEs, as well as providing trauma-informed
    care in schools.
          national coordinating committee on school health and safety
        HRSA in collaboration with CDC leads the National Coordinating
    Committee on School Health and Safety (NCCSHS) to support student well-
    being and ensure school facilities are healthy and safe environments.
    Since its inception in 1996, NCCSHS aims to support communication among
    governmental agencies and national non-governmental organizations in
    order to share resources and disseminate information about school
    health and safety to local and state partners. NCCSHS members are
    working to coordinate communication and encourage uptake at the state/
    local levels of school-based approaches that protect student's mental
    health and well-being through expanding comprehensive, trauma-informed
    mental health services in schools and the Whole School, Whole
    Community, Whole Child model (WSCC). NCCSHS includes 170 members
    including eight Federal agencies and non-governmental organizations
    such as the American Academy of Pediatrics, American Psychological
    Association, and Council of Chief State School Officers.
       collaborative improvement and innovation network for school-based
                                health services
        The Collaborative Improvement and Innovation Network for School-
    Based Health Services (CoIIN-SBHS) provides trauma-informed, behavioral
    health technical assistance to state partners (e.g., Title V Maternal
    and Child Health programs, state Medicaid programs, child mental health
    agencies, education agencies, state-level non-profit organizations),
    school districts, comprehensive school mental health systems and
    school- based health centers. This program is in its fifth of 5 years
    of funding and is administered by the School Based Health Alliance in
    partnership with the National Center for School Mental Health.
         adverse childhood experiences (aces) in primary care settings
                             demonstration project
        The newly awarded Adverse Childhood Experiences (ACEs) in Primary
    Care Settings Demonstration Project will study how best to implement,
    in primary care settings, screening protocols and evidence-based
    interventions for children and adolescents who have experienced ACEs.
    The goal of this program is to yield a model for integrating ACEs
    screening and strength-based, trauma-informed services into primary
    care settings. This three-year demonstration project aims to:
      --Study how primary care settings can best screen and provide care to
            children impacted by ACEs, including strengths, limitations,
            and implementation challenges; and
      --Produce a scalable model that can help pediatric providers
            effectively integrate screening with strength-based, trauma-
            informed care and services in primary care settings.
    National Survey of Children's Health:
        The National Survey of Children's Health (NSCH), funded and
    directed by HRSA's Maternal and Child Health Bureau, is the nation's
    largest annual survey of children's health at the state and national
    levels.
        This parent-reported survey includes questions to assess a range of
    Adverse Childhood Experiences (ACEs) among U.S. children.
        Data from 2019-2020, show that 21.7 percent of U.S. children ages
    0-17 had experienced one ACE in their lifetime, while 18.1 percent had
    experienced two or more ACEs. Data from the 2021 NSCH will be released
    on October 3rd, 2022.
        Question. Secretary Becerra, the United States is world's largest
    importer of personal protective equipment. Three-quarters of N95 masks
    in the U.S. are produced overseas, the majority from China. And from
    2019 to 2020, American imports of PPE from China skyrocketed from $2
    billion to $14 billion. This created shortages and price spikes--
    resulting in those horrific images of our health heroes wearing garbage
    bags to stay safe. 80 percent of nurses reported re-using masks meant
    for single use. When it came to our prized Federal backstop--the
    Strategic National Stockpile--the supply was inadequate. 5 million N95
    masks in the Stockpile were expired. Governors only got a fraction of
    the masks, gowns, and gloves they asked for.
        Senator Cassidy and I have introduced the PPE in America Act to
    boost domestic manufacturing of PPE and medical supplies so we no
    longer have to rely on China and others to keep our health workers
    safe. Our bill would use the purchasing power of the Stockpile as an
    engine to sustain domestic PPE manufacturers. And it would enable a
    replenishable, churning mechanism for the Stockpile to routinely sell
    supplies to other agencies, states, and the commercial market . . . and
    re-stock equipment from domestic producers. This arrangement will
    provide predictability that domestic PPE manufacturers can depend on .
    . . and will improve their coordination with the Stockpile to avoid
    expiration of supplies.
        Secretary Becerra, I'm pleased to see the budget proposes a $200
    million increase for the Stockpile. Do you support policies that boost
    domestic PPE production, mitigate risk for expiration, and provide
    sustainability for manufacturers, including through replenishing
    mechanisms for the SNS?
        Answer. The global pandemic has highlighted the vulnerabilities of
    the global supply chain. It is critical that steps are taken to invest
    in expansion of U.S. domestic manufacturing capacity. To that end, the
    Office of the Assistant Secretary for Preparedness and Response (ASPR)
    is leveraging the authorities delegated to the Secretary under the
    Defense Production Act (DPA) to ensure that private sector partners
    making life-saving products are able to acquire raw materials, retool
    their machinery, scale their production facilities, train their
    workforces, and ultimately deliver their product. Throughout the COVID-
    19 response, ASPR has used the DPA authority to issue 46 priority
    ratings for United States Government (USG) contracts for health
    resources, eight priority ratings for USG contracts for industrial
    expansion, and 3 priority ratings for non-USG contracts to indirectly
    support COVID-19 and/or mitigate the potential stockout of critical
    lifesaving therapies. Going forward, ASPR will continue to build
    capacity and partnerships with private industry toward the shared goal
    of ending the COVID-19 pandemic and preparing for future pandemics.
        ASPR is also working to support efforts in expanding the domestic
    industrial base. These industrial base expansion (IBx) efforts seek to
    reduce supply chain vulnerabilities and generate a domestic ``warm-
    base'' for manufacturing that can be leveraged in a crisis. During the
    COVID-19 pandemic, all contracts--competitive and sole-sourced--awarded
    by the Department of Health and Human Services for N95 respirators were
    for U.S.-produced supplies. A total of approximately 800 million
    domestically produced N95 respirators were procured for the Strategic
    National Stockpile. Contracting actions executed in March 2020 were
    intended to encourage manufacturers to immediately increase production
    of N95 respirators, and these manufacturers with domestic production
    capabilities stepped up to support the nation with quality products at
    the best prices for the USG. Furthermore, with $10 billion received for
    emergency medical supplies enhancement, ASPR has been establishing and
    maintaining domestic capacity for critical supplies.
        Lastly, ASPR's Hospital Preparedness Program (HPP) included two
    requirements in the fiscal year 2019-2023 funding opportunity
    announcement to help address supply chain vulnerabilities. First, HPP
    recipients and their healthcare coalitions must conduct a supply chain
    integrity assessment to evaluate equipment and supplies that will be in
    demand during emergencies and develop mitigation strategies to address
    potential shortfalls. Second, each healthcare coalition must update and
    maintain a regional resource inventory assessment.
        ASPR will continue to assess and monitor domestic manufacturing
    capabilities going forward. As the COVID-19 pandemic continues, we will
    modify and refine efforts, as needed, to ensure they do not interfere
    with the private sector but support efforts to maintain and build a
    robust domestic capability.
        Question. One of the major lessons learned from the pandemic was
    the need to bolster our healthcare workforce. But this is not a new
    problem. Even before COVID-19, our nation faced a shortfall of 120,000
    doctors and a quarter-million nurses, with many rural and urban areas
    facing recruitment challenges. Across Illinois, 5 million people live
    in shortage areas for mental health providers, 3 million with too few
    primary care doctors. The problem starts with medical education in
    America. We take promising students, put them through years of rigorous
    education and training, and license them on one condition: student loan
    debt that can average more than $200,000. The burden of paying off
    these loans steers our brightest minds into higher- paying specialties
    and more affluent communities. This is especially true for healthcare
    providers of color. You may be aware there are fewer Black men entering
    medical school today than there were in the 1970s. Black and Latinx
    Americans make up 31 percent of the nation's population, yet just 6
    percent of doctors. We know that this discrepancy leads to worse care
    and outcomes for patients of color.
        Thankfully, the National Health Service Corps helps to address
    these gaps by providing scholarship or loan repayment for healthcare
    workers who commit to serve in urban and rural areas with shortages.
    President Biden's American Rescue Plan included a provision I authored
    with Senator Rubio to provide $1 billion in loan repayment and new
    scholarship awards to the National Health Service and Nurse Corps. It
    will help surge tens of thousands of new clinicians into under-served
    areas, representing the largest single-year appropriation to our
    healthcare pipeline in history. We know that scholarship-based awards
    can make a particularly meaningful difference when it comes to
    emphasizing recruitment from under-represented populations.
        The pandemic has also magnified acute workforce shortages in
    communities facing natural disasters or other public health
    emergencies. The GAO has recently reported on how the National Disaster
    Medical Service--which activates health personnel from private
    practices for deployment intermittent Federal employees--does not have
    the planning in place to ensure a workforce capable of responding to
    nationwide or multiple concurrent health events, and that its workforce
    is only a fraction of its target level. I have introduced legislation
    with Senator Rubio (S.54, the Strengthening America's Health Care
    Readiness Act), to test a pilot program that provides supplemental loan
    repayment for NHSC alumni who continue to practice in a shortage area,
    and current NHSC clinicians, who concurrently serve in the NDMS and are
    available for rapid, short-term deployment for health emergencies.
    Under this pilot program, HRSA and ASPR would have the authorities and
    directive to coordinate to ensure adherence to their core missions and
    the appropriate application of NHSC contract requirements and covered
    benefits/protections of NDMS employment. I have also introduced
    legislation with Senator Blackburn (S.924, Rural America Health Corps
    Act), to increase recruitment and retention of NHSC clinicians in rural
    areas, given the fact that only 5 percent of incoming medical students
    hail from rural areas and one-third of placements are in rural
    communities. This legislation would test a pilot program to explore
    whether an elongated service commitment and increased loan repayment
    award--5 years and $200,000--could enhance recruitment and retention in
    rural America.
        Secretary Becerra, your budget proposes a $47 million increase to
    the National Health Service Corps. Do you support using appropriations
    for certain pilot program approaches that test and evaluate new
    strategies to address specific nuances and acute gaps in our country's
    health workforce needs, including in health preparedness, health
    disparities, and in rural America?
        Answer. HRSA will implement the programs that Congress enacts. The
    aim of National Health Service Corps (NHSC) is to address the primary
    care needs of underserved populations and to provide them with access
    to quality healthcare. The $47 million request for the NHSC will be
    dedicated to bolstering the health workforce in rural and underserved
    communities where there is an existing shortage of primary care
    providers. Similar, in part, to the goals of the Rural America Health
    Corps Act, the proposed funding will expand access to primary care
    services to vulnerable populations, specifically those areas facing
    barriers to obtaining evidence-based substance use disorder (SUD)
    treatment services. The NHSC Rural Community Loan Repayment Program
    (LRP), SUD Workforce LRP, and the traditional NHSC LRP will serve as
    the mechanisms for distributing this requested funding, as these
    programs have proven their effectiveness in mobilizing and retaining
    providers in the areas where they are needed most. A total of 28,405
    clinicians in the NHSC and Nurse Corps completed their service between
    2012 and 2019; of these, 80 percent continue to serve in Health
    Professional Shortage Areas (HPSAs) after their service obligation is
    completed. One out of three of those NHSC alumni work in rural
    communities. Over the same timeframe, 78 percent of the NHSC
    participants who completed their service obligation at a site in a
    rural area continue to work in a rural area, with over 50 percent
    continuing to work in a HPSA in the same county where they completed
    their NHSC service.
        The Hospital Preparedness Program (HPP) supports efforts to
    strengthen healthcare sector readiness to provide coordinated, life-
    saving care in the face of emergencies and disasters. The HPP portfolio
    supports a comprehensive, national network for healthcare preparedness
    and response. The programs and activities within the HPP portfolio are
    coordinated to address the many, complex facets of the nation's
    healthcare system, creating mechanisms and infrastructure to improve
    coordination between localities, states, and regions, as well as
    developing new capabilities (e.g., telemedicine, specialty healthcare,
    etc.) specific to key challenges within the modern threat landscape
    (e.g., highly pathogenic disease; biological/chemical incidents, etc.).
        As the primary source of Federal funding for healthcare system
    preparedness and response, HPP promotes a consistent national focus to
    improve patient outcomes during emergencies and to enable rapid
    healthcare service resilience and recovery. Since 2002, investments
    administered through HPP have improved individual healthcare entities'
    preparedness and have built a system for coordinated healthcare system
    readiness and response through healthcare coalitions (HCCs) and other
    partnerships, such as the Regional Disaster Health Response System
    (RDHRS) demonstration project. With respect to infrastructure needs,
    recipients of funding are expected to consider how to provide and plan
    for uninterrupted care when faced with damaged or disabled healthcare
    infrastructure during an emergency response; however, the HPP
    cooperative agreement does not allow for construction or major
    renovation costs.
        HPP provides cooperative agreement funding to states to support
    healthcare system preparedness efforts. Specific to Colorado, if
    appropriated at the requested level in fiscal year 2022, it is
    estimated that Colorado will receive $3,584,461 via the HPP cooperative
    agreement. Colorado will delegate this funding within the state to
    support such efforts, including enhancing rural capabilities.
      --Additional ASPR Programs and Tools Concerning Colorado and Rural
            Health:
        --The Denver Health and Hospital Authority was also recently
                awarded the Partnership for Disaster Health Response System
                Cooperative Agreement to establish the Region 8 Mountain
                Plains RDHRS demonstration site. To address gaps in
                regional healthcare delivery during disasters, ASPR
                developed the RDHRS: a tiered system that builds upon and
                unifies existing healthcare and ASPR assets within states
                and across regions that supports a more coherent,
                comprehensive, and capable healthcare disaster response
                system able to respond to health security threats. The
                RDHRS helps improve disaster readiness capabilities and
                capacity, increase medical surge capacity, and extend
                provision specialty care--including trauma, burn and
                infectious disease, among others--during large-scale
                disasters or public health emergencies.
        --Additionally, the Rural Health Care Surge Readiness Portal was
                established in 2020 to provide the most up-to-date and
                critical resources for rural healthcare systems preparing
                for and responding to a COVID-19 surge. The resources span
                a wide range of healthcare settings (including EMS,
                inpatient and hospital care, ambulatory care, and long-term
                care) and cover a broad array of topics ranging from
                behavioral health to healthcare operations to telehealth.
                This portal was developed by the COVID-19 Healthcare
                Resilience Working Group, a partnership with the U.S.
                Department of Health & Human Services, the U.S. Department
                of Homeland Security, and other Federal agencies, to
                provide support and guidance for healthcare delivery and
                workforce capacity and protection.
                                     ______

                    Questions Submitted by Senator Jack Reed
        Question. My colleague on the LHHS Subcommittee, Sen. Capito, and I
    authored the Childhood Cancer Survivorship, Treatment, Access, and
    Research (STAR) Act--the most comprehensive childhood cancer bill in
    history--which was signed into law on June 5, 2018 (Public Law No: 115-
    180). Every year since becoming law, Congress has provided full funding
    ($30 million) to support the programs created by the STAR Act. However,
    two provisions remain to be implemented: Title 2, Section 201(a), which
    requires the Secretary of Health and Human Services to make awards to
    establish pilot programs to develop, study, or evaluate model systems
    for monitoring and caring for childhood cancer survivors throughout
    their lifespan, including evaluation of models for transition to adult
    care and care coordination; and Title 2, Section 201(b), which requires
    the Secretary to conduct a review of HHS activities related to
    workforce development for healthcare providers who treat pediatric
    cancer patients and survivors and to report the findings within 2 years
    of the enactment of the STAR Act.
        Could you provide a status update on the implementation of these
    two key provisions of the STAR Act?
        Answer. Senator Reed, first, thank your sponsorship of the
    Childhood, Cancer Survivorship, Treatment, and Research Act (STAR Act).
    The STAR Act enhances the research on the late effects of childhood
    cancers and is a critical step toward improving the quality of life for
    survivors of childhood cancer. The Agency for Healthcare Research and
    Quality (AHRQ) has partnered with the National Cancer Institute (NCI)
    to commission three evidence reports as part of the Department's
    response to the two provisions of the Act that you reference: Section
    201(a) and 201(b).
      --Disparities and Barriers to Pediatric Cancer Survivorship Care
            (https://effectivehealthcare.ahrq.gov/products/pediatric-
            cancer-survivorship/research). The report was posted on the
            AHRQ for public comment in October 2020, with simultaneous peer
            review and the final report was published March 1, 2021.
        --Findings from the report were presented on April 20, 2021 on a
                free NCI- sponsored webinar. The recording can be found at
                https://cancercontrol.cancer.gov/ocs/events/disparities-
                and-barriers.
        --A manuscript titled ``Interventions to address disparities and
                barriers to pediatric cancer survivorship care: a scoping
                review'' derived from the report was published in the
                Journal of Cancer Survivorship on June 16, 2021.
        --Findings from the technical brief were presented at University of
                Cincinnati Hematology-Oncology Grand Rounds (5/28/2021); MD
                Anderson Cancer Survivorship Grand Rounds (6/18/2021);
                Cancer Support Community Seminar (7/27/2021); and the
                University of Kentucky Markey Cancer Center Affiliate
                Network's 15th Annual Cancer Care Conference (9/30/2021).
        The NCI used the findings of the report to provide administrative
    supplements for the ``NCI P30 Cancer Center Support Grants'' to support
    research to understand and address organizational factors that
    contribute to disparities in outcomes among childhood cancer survivors.
    Additionally, this report has already begun to inform the broader
    cancer survivorship research community and survivorship care providers
    based on dissemination of the review findings.
      --Models of Care That Include Primary Care for Adult Survivors of
            Childhood Cancer (https://effectivehealthcare.ahrq.gov/
            products/pediatric-adolescent-cancer-survivorship/protocol).
            This report was posted on the AHRQ website for four weeks of
            public comment in June 2021, with simultaneous peer review. The
            report is now being finalized. The final report is expected to
            be shared with NCI and publicly posted by the end of 2021.
        AHRQ and NCI expect to widely disseminate this report to the
            research community and the general public once it can be
            publicly posted to raise awareness of the role that primary
            care providers can play in the care of adult survivors of
            childhood cancer. The NCI also plans to use the findings of
            this report to evaluate its current grant portfolio, to
            identify and assess potential gaps and opportunities for
            additional research on this topic.
        Transitions of Care from Pediatric to Adult Services for Children
            with Special Healthcare Needs (https://
            effectivehealthcare.ahrq.gov/products/transitions-care-
            pediatric-adult/protocol). The draft report was posted on
            AHRQ's website in September 2021 for four weeks of public
            comment and simultaneously underwent peer review. A final
            report will be shared with NCI and posted publicly in 2022.
        Similar to the Models of Care report, AHRQ and NCI expect to widely
            disseminate this report to the research community and the
            general public once it can be publicly posted to raise
            awareness of challenges in transitioning care from pediatric to
            adult services for children with special healthcare needs. This
            report is expected to serve as a resource for those with
            interests related to a number of serious healthcare diseases
            and conditions including cancer. The NCI also plans to use the
            findings of this report to evaluate its current grant
            portfolio, to identify and assess potential gaps and
            opportunities for additional research on this topic.
                                     ______

                 Questions Submitted by Senator Jeanne Shaheen
        Question. While I am pleased that we've made so much progress on
    vaccinations and getting through this pandemic, I continue to hear from
    hospitals and nursing homes in New Hampshire that are running on tight
    budgets after significant financial losses due to the pandemic. In
    particular, many of these hospitals and nursing homes are located in
    southern New Hampshire counties that were left behind in previous
    rounds of the Provider Relief Fund. These providers did not qualify for
    previous rural-focused rounds of the grants, despite treating
    significant portions of patients from surrounding counties that are
    rural. To help address that, we worked to give HHS more flexibility to
    make these types of hospitals and nursing homes eligible for the $8.5
    billion in Provider Relief Fund grants from the American Rescue Plan
    Act of 2021.
        Do you have an update that you can share on the plans that HHS has
    for the remaining Provider Relief Fund grants that have not yet been
    awarded?
        Answer. HHS is committed to distributing the remaining provider
    relief payments as quickly, transparently, and equitably as possible
    while utilizing effective safeguards to protect taxpayer dollars. HHS
    is planning for future Provider Relief Fund (PRF) allocations,
    including the $8.5 billion from American Rescue Plan Act and Phase 4 of
    the General Distribution.
        HHS is actively considering feedback from stakeholders, as well as
    operational lessons learned from prior PRF payments, as part of the
    planning process. The feedback from Members of Congress and other
    stakeholders informs HHS' ability to administer the PRF in a manner
    that bolsters the healthcare system and helps providers experiencing
    COVID-related financial hardships during this crisis. HHS will publish
    additional information on future distributions on the Health Resources
    and Services Administration's PRF webpage, at www.hrsa.gov/provider-
    relief, as soon as it becomes available.
        Question. I am pleased that the President has announced his
    intention to resettle 62,500 refugees in the second half of this fiscal
    year. However, the enormous cuts to refugee resettlement over the past
    4 years under the previous Administration have severely decimated the
    U.S. Refugee Admissions Program's capacity to provide local support for
    newly arrived refugees. Local resettlement agencies face substantial
    challenges as they work to restore their staffing and the services they
    provide, and they need timely support in order to hire and train the
    new staff necessary to meet the needs of increased numbers of newly-
    arrived refuges.
        What specific measures are you taking to help resettlement agencies
    bolster capacity and prepare for the increased rate of refugee arrivals
    in the second half of this fiscal year?
        Answer. The President's fiscal year 2022 budget request includes an
    increase of $515 million over the fiscal year 2021 enacted level for
    Refugee and Entrant Assistance programs to accommodate the expected
    increase in arrivals through the end of this calendar year and beyond.
    This request would support a total of up to approximately 214,000
    arrivals in fiscal year 2022, including up to 125,000 refugees as well
    as other entrants, such as asylees, Cuban and Haitian entrants, and
    Special Immigrant Visa holders.
        This includes more than doubling the Refugee Support Services
    program, from $207 million in fiscal year 2021 to $450 million in the
    fiscal year 2022 Budget. This is one of the major sources of funding
    for resettlement agencies to bolster their capacity.
        In addition to the potential budgetary support, ORR has taken
    several programmatic steps to ensure that the resettlement network is
    prepared for an increase in refugee and other ORR-eligible arrivals.
    ORR conducted listening sessions in the spring of 2021 to better
    understand current state and local capacity to resettle refugees, plans
    to increase resettlement capacity, and barriers to such growth. ORR and
    the Department of State/PRM conducted a joint training for State
    Refugee Coordinators to ensure understanding of their role in local
    capacity planning.
        ORR and PRM are exploring options to strengthen policy and practice
    for the required community consultations, as well as private
    sponsorship. ORR staff are conducting coordinated outreach with other
    Federal agencies to ensure access to mainstream benefits and services.
    We are also planning for enhancements to existing services such as
    mental health, employer engagement, youth and family literacy,
    Preferred Communities and Matching Grant in anticipation of increased
    arrivals.
        Question. Does ORR anticipate being able to provide forward funding
    to refugee resettlement agencies, so they have the advance funding
    necessary to build capacity in anticipation of the increased rate of
    refugee arrivals?
        Answer. ORR continues to provide support and guidance to its
    partners and anticipates being able to provide sufficient forward
    funding through the President's fiscal year 2022 budget request.
                                     ______

                  Questions Submitted by Senator Brian Schatz
        Question. In the hearing, you agreed that Congress should move
    forward with legislation to expand telehealth coverage in Medicare and
    committed that you would work with Congress to provide the necessary
    data and technical assistance to enact telehealth legislation this
    year. You also stated that you need ``greater accountability'' and
    ``better authority.''
        What authority to ensure accountability and put safeguards into
    place for telehealth services does HHS need that it does not already
    have?
        What measures to ensure accountability does HHS plan to put into
    place when Congress expands coverage of telehealth services?
        What has the HHS Office of Inspector General determined about
    concerns related to fraud, waste, and abuse associated with expanded
    utilization of telehealth during the COVID-19 pandemic?
        Last July, ASPE released early data on Medicare beneficiary use of
    telehealth. Is HHS planning to release additional data on the use of
    telehealth in Medicare during the pandemic?
        What is the expected timeframe on the study that CMS has
    commissioned on the telehealth flexibilities during the COVID-19
    pandemic?
        What Center for Medicare and Medicaid Innovation (CMMI) models
    include telehealth waivers, and what are those waivers for? For each
    waiver, please specify how many model participants have elected the
    waiver and how many beneficiaries have used telehealth services under
    the waiver.
        In which CMMI models have waivers enabled healthcare professionals
    other than physicians and practitioners to furnish telehealth services,
    and how many participants have used those waivers?
        A 2018 OIG report recommended that CMS offer education and training
    sessions to practitioners on Medicare telehealth requirements. How has
    CMS addressed this recommendation?
        Answer. Telehealth is an important tool to improve health equity
    and improve access to healthcare. Healthcare should be accessible, no
    matter where you live. HHS continues to examine the telehealth
    flexibilities developed for the current public health emergency and
    determine how we can build on this work to improve health equity and
    improve access to healthcare. An HHS study released by ASPE has shown
    that massive increases in the use of telehealth helped maintain some
    healthcare access for Medicare beneficiaries during the pandemic. CMS
    also released a data snapshot showing increases in Medicare
    telemedicine utilization during the pandemic. Lessons learned from CMS
    Innovation Center models also provide valuable insight into how
    providers furnish high-value care and innovate in care delivery,
    including the use of telehealth. In addition to looking at which
    flexibilities HHS can and should continue administratively, I look
    forward to working with Congress to address changes that may need to be
    done through legislation.
        HHS is also dedicated to making sure providers are aware of the
    telehealth options available to them as they treat their patients. CMS
    routinely educates practitioners through various channels, including
    the Medicare Learning Network, weekly electronic newsletters, and
    quarterly compliance newsletters. CMS will continue to use channels
    such as these to educate and provide training sessions for
    practitioners on Medicare telehealth requirements and related
    resources.
        ASPE/HHS is currently preparing a follow-up issue brief on Medicare
    FFS beneficiary use of telehealth compared with in-person visit trends
    in 2020 which will examine telehealth use by beneficiary
    characteristics including race/ethnicity, urban/rural geography, state,
    visit type (primary care, specialist, mental health. The brief will
    also examine various telehealth modalities, including audio-only
    visits, telecommunications in addition to two-way interactive video-
    based telehealth visits and whether the beneficiary was located at home
    or in a health-care setting for the telehealth visit. This issue brief
    is anticipated to be published later this fall.
        OIG is conducting significant oversight work (8 ongoing audits and
    studies) assessing telehealth services during the public health
    emergency. Once complete, these reviews will provide objective,
    independent findings and recommendations to policymakers and other
    stakeholders regarding the effect that the public health emergency
    flexibilities had on telehealth. This work will help HHS ensure the
    potential benefits of telehealth are realized for patients, providers,
    and HHS programs without being compromised my fraud, abuse, or misuse.
    OIG anticipates the first telehealth work products to be published this
    fall.
        Question. The Bipartisan Budget Act of 2018 authorized Medicare
    Advantage plans to offer additional telehealth benefits in their annual
    bid amount beyond eligible telehealth services under Medicare fee-for-
    service.
        What percentage of plans have offered additional telehealth
    benefits?
        What type of additional telehealth benefits have been offered
    (i.e., types of services, types of healthcare professionals, etc.)?
        Has HHS determined if there are any concerns related to fraud,
    waste, and abuse associated with additional telehealth benefits in
    Medicare Advantage plans?
        Answer. Beginning in plan year 2020, Medicare Advantage plans have
    been permitted, but not required, to offer additional telehealth
    benefits as part of the basic benefit package beyond what is allowable
    under the original Medicare telehealth benefit. These benefits can be
    available in a variety of places, and people with Medicare Advantage
    plans can use them at home instead of going to a healthcare facility.
    For plan year 2021, over 94 percent of Medicare Advantage plans offered
    additional telehealth benefits reaching 20.7 million beneficiaries.
        Medicare Advantage plans have the flexibility to determine which
    services are clinically appropriate to furnish through additional
    telehealth benefits on an annual basis, consistent with the limits in
    statute and regulations. For example, a Medicare Advantage plan may
    offer a dermatology exam using store-and-forward technology.
        All Medicare Advantage plans are required to have an effective
    program to prevent, detect, and correct Medicare Advantage
    noncompliance and fraud, waste, and abuse. HHS is committed to
    oversight of plan compliance with this requirement while ensuring
    access to care for Medicare Advantage enrollees through additional
    telehealth benefits.
        Question. In January, HHS said that the COVID-19 public health
    emergency declaration would likely be in place for all of 2021.
        As we are now halfway through 2021, does HHS have an updated
    expectation for how long the public health emergency will last?
        What are the factors you are considering for when the public health
    emergency could be declared over (i.e., vaccination rates, daily cases,
    etc.)?
        Answer. The Secretary of Health and Human Services may, under
    section 319 of the Public Health Service (PHS) Act, determine that: (a)
    a disease or disorder presents a public health emergency (PHE); or (b)
    that a public health emergency, including significant outbreaks of
    infectious disease or bioterrorist attacks, otherwise exists. If and
    when declared, a PHE lasts until the Secretary declares that the
    emergency no longer exists or for 90 days, whichever comes first, but
    it may be extended for additional 90-day periods as needed and as
    determined by the Secretary.
        HHS will continue to evaluate the infection rate of COVID-19 and
    will modify the PHE, as needed, when cases decrease and the authorities
    under a PHE are no longer needed to support response operations.
        Question. In the hearing, you agreed that it would be helpful for
    Federal response agencies, such as CDC, FDA, and NIH to be able to
    respond proactively to public health emergencies before they get out of
    control.
        Would automatic funding to the Public Health Emergency Fund upon
    the declaration of certain public health emergencies--including
    infectious disease outbreaks--modeled after FEMA's Disaster Relief
    Fund, be helpful to ensure a quick and effective response to public
    health emergencies?
        Answer. A key lesson learned during the ongoing COVID-19 pandemic
    is that having available funding in the Public Health Emergency Fund
    would ensure that HHS can immediately respond while working in
    partnership with Congress on broader supplemental needs. For example,
    during the initial days of the COVID-19 pandemic, the Biomedical
    Advanced Research and Development Authority (BARDA) shifted program
    funds and redirected contracts from some of its investments in emerging
    infectious diseases (Zika and Ebola contracts) and leveraged pandemic
    influenza preparedness contracts to support vaccine and therapeutic
    development efforts. The funds were used to start a few critical
    programs early on; however, there were insufficient funds available to
    start the multi-pronged approach that led to success in both the
    vaccine and therapeutic development efforts. Using funds planned for
    other programs impacted the long-term investments that were in place
    for other identified threats, and there is no guarantee in a future
    public health emergency, that it would be possible to similarly shift
    program funds.
        If funded, the Public Health Emergency Fund would ensure that HHS
    could take immediate action to respond to a public health emergency
    before Congress enacts supplemental funding legislation. Immediate
    action can reduce the overall societal and economic impact of the
    public health emergency, reduce the lead time for development of
    supporting resources (e.g., medical countermeasure development if
    needed), and ultimately result in less overall expenditures if
    potential threats are quickly contained.
        Question. The pandemic has illustrated that Native communities
    often do not have access to the same resources that other communities
    do. For example, IHS-funded Tribal epidemiology centers are public
    health authorities, but do not have access to CDC public health
    authority data. And HHS agencies do not often work with states and
    other public health authorities to improve data collection to allow for
    disaggregation of American Indian/Alaska Native/Native Hawaiian
    information.
        How will you ensure that Native health systems, especially Native
    public health systems, have parity access to HHS resources going
    forward?
        What steps is HHS taking to include Native Hawaiians, who are too
    often overlooked and left out, in HHS programs and initiatives?
        Answer. Regarding your question about Native health systems, the
    HRSA funding opportunities for which tribes and tribal organizations
    were eligible to compete, as well as awards to tribes and tribal
    organizations have expanded.
        HRSA's Office of Intergovernmental and External Affairs leads the
    agency's Tribal Affairs, participates in HHS Tribal Consultations, and
    collaborates with IHS and other Federal and community stakeholders to
    address tribal issues. In response to tribal requests, the HRSA Tribal
    Advisory Council is being established to provide advice on how HRSA
    programs can better address tribal needs. HRSA IEA regional offices
    regularly communicate with tribal leaders to respond to issues and
    ensure they are aware of HRSA funding opportunities, program updates,
    and technical assistance.
        In fiscal year 2020, tribes and tribal organizations were awarded
    more than $16 million from Rural Tribal COVID-19 Response Program. The
    awards were distributed to 57 recipients across 22 states.
        Additionally, in fiscal year 2020, the Health Center Program
    awarded grant funding as further described below for Tribal/Urban
    Indian health center organizations.
      --Awarded nearly $88 million in annual operational grant funding to
            35 health center organizations operating over 250 service
            delivery sites serving Native communities across the U.S.
      --Awarded over $2.3 million to Tribal/Urban Indian health centers to
            support infrastructure needs related to disaster response and
            recovery efforts.
      --Awarded $31 million in Health Center Program supplemental funding
            to Tribal/Urban Indian health centers to support efforts to
            address the impact of the COVID-19 pandemic.
        Below are fiscal year 2021 Health Center Program actions related to
    health centers that are tribes or tribal organizations providing health
    services within Native American communities:
      --Continued annual health center operating grants, totaling
            approximately $88 million for 35 health center organizations.
      --Awarded $60 million to 35 Tribal/Urban Indian health centers, as
            part of the American Rescue Plan Act awards. Health centers use
            the funds to support and expand COVID-19 vaccination, testing,
            and treatment for vulnerable populations; deliver needed
            preventive and primary healthcare services to those at higher
            risk for COVID-19; and expand health centers' operational
            capacity during the pandemic and beyond, including modifying
            and improving physical infrastructure and adding mobile units.
            This investment will help increase access to vaccinations among
            hard- hit populations, and increase confidence in the vaccine
            by empowering local, trusted health professionals in their
            efforts to expand vaccinations.
      --In fiscal year 2021, HRSA and the Centers for Disease Control and
            Prevention launched the Health Center COVID-19 Vaccine Program
            to allocate COVID-19 vaccines to HRSA-supported health centers
            directly. The program ensures our nation's underserved
            communities and those disproportionately affected by COVID-19
            are equitably vaccinated against COVID-19. HRSA invited all
            HRSA funded health centers to participate in the program,
            including the 35 Tribal/Urban Indian health centers. Eight
            tribal organizations have set up accounts to participate in the
            Health Center COVID-19 Vaccine Program. Six of the eight tribal
            organizations have placed at least one order through the
            program.
      --In late September 2021, HRSA expects to announce approximately $1
            billion in awards supporting health center construction,
            expansion, alteration, renovation, and other capital
            improvements to modify, enhance, and expand healthcare
            infrastructure.
        HRSA projects that 32 grants totaling approximately $18 million
    will be awarded to Tribal/Urban Indian health centers through this
    funding opportunity.
                      native hawaiian health care systems
        In fiscal year 2021, HRSA provided $20.5 million in grants and
    scholarship awards to Native Hawaiian Health Care Systems to improve
    the provision of comprehensive disease prevention, health promotion,
    and primary care services to Native Hawaiians.
        Additionally, in fiscal year 2021, HRSA provided $20 million under
    the American Rescue Plan Act to Native Hawaiian Health Care Systems to
    aid their response to COVID-19. The awards provided six Native Hawaiian
    Health Care Improvement Act (NHHCIA) recipients resources to strengthen
    vaccination efforts, respond to and mitigate the spread of COVID-19,
    and enhance healthcare services and infrastructure in their
    communities.
             technical assistance--health centers located in hawaii
        HRSA continues to make technical assistance available for Hawaii
    health centers to identify and address the primary healthcare needs of
    their target communities and populations, and to aid in identifying
    Federal programs to support those efforts. HRSA IEA Region 9 Office can
    assist Hawaii stakeholders with technical assistance and other HRSA
    resources.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. Secretary Becerra, as you may be aware, Federal data
    shows that more than 1.5 million students experienced homelessness in
    the 2017-2018 school year, and in my home state of West Virginia, we
    had well over 10,000 students identified as homeless during the 2019-
    2020 school year alone. Unfortunately, identification and reporting
    challenges have existed for years, and when you couple those existing
    challenges with the COVID-19 pandemic- we can only expect these numbers
    will be far greater than pre-pandemic levels. The Administration of
    Children and Families (ACF) is tasked with promoting the economic and
    social well-being of families and children, including those
    experiencing homelessness. That is why, in the height of the pandemic,
    I worked alongside Senator Murkowski and others to introduce the
    Emergency Family Stabilization Act; that would have created a dedicated
    funding stream through ACF to assist children, youth, and families
    experiencing homelessness during the COVID-19 pandemic. While I was
    able to work with my colleagues to secure dedicated funding through the
    Department of Education for identifying and assisting children and
    youth experiencing homelessness, it is not a permanent solution and
    does not incorporate the all the needed resources to address the issue.
        In recognizing the pandemic has greatly increased the need for
    better access to services for children, youth, and families
    experiencing homelessness; how does the President's budget further
    improve resources for those charged with identifying and connecting our
    children and youth experiencing homelessness with the services provided
    by ACF?
        Answer. The Administration for Children and Families receives
    funding, through the Runaway and Homeless Youth Act (RHYA), to provide
    services and resources to youth experiencing homelessness. Through the
    Family and Youth Services Bureau (FYSB), ACF funds a National
    Communications System (NCS), which is a national, toll-free, runaway
    and homeless youth crisis hotline to assist runaway and homeless youth,
    and those at risk of running away, in communicating with their families
    and with service providers. The NCS includes telephone, Internet,
    mobile applications, and any technology-driven services used for
    runaway and homeless youth or youth who are at risk of running away.
    The NCS provides crisis intervention, referral services, information,
    and prevention resources to youth at risk of separation from their
    families, runaway and homeless youth, their families, legal guardians,
    and service providers.
        The RHYA also authorizes the Runaway and Homeless Youth Training &
    Technical Assistance Center (RHYTTAC) to provide training and technical
    assistance to RHY program-funded grantees and allied professionals.
    RHYTTAC assists these organizations in developing effective approaches
    for serving runaway and homeless youth, accessing new resources to
    enhance their ability to serve these youth, and establishing linkages
    with other programs with similar interests and concerns. RHYTTAC also
    helps to ensure that grantees have effective interventions in place to
    build skills and capacities that contribute to the healthy, positive,
    and productive functioning of children and their successful transition
    from youth into adulthood.
        The President's fiscal year 2022 Budget proposed to fund RHY
    programs at a level of $144,987,000, which would be an increase of
    $8.2M from the fiscal year 2021 appropriation level. With the proposed
    increase, ACF/FYSB will seek to increase the number of RHY grantees and
    continue to support training and technical assistance. ACF commits to
    working with other Federal youth-serving agencies to increase awareness
    of resources available through RHY Programs, and to further develop
    coordinated efforts to support prevention, outreach, engagement, and
    timely referral to ACF services as well as services available from
    other Federal agencies. Additionally, Head Start and Child Care
    Development Fund (CCDF) Block Grants also serve families with young
    children experiencing homelessness.
        Question. During the COVID-19 pandemic, rural health providers have
    been hit hard. Last year alone, West Virginia had three hospitals
    close, putting patients at risk of accessing care. In response Congress
    passed $8.5 billion in the American Rescue Plan aimed at supporting
    rural health providers. Since this was signed into law, HHS has made no
    announcements on the plan to distribute this funding, yet rural health
    providers remain at risk.
        When will this funding begin to be allocated to our rural
    communities?
        Answer. HHS is working to finalize the $8.5 billion in American
    Rescue Plan Act of 2021 funding for rural Medicare and Medicaid
    providers and suppliers. HHS is considering operational lessons learned
    from prior Provider Relief Fund (PRF) payments, as well as feedback
    from Members of Congress and other stakeholders.
        Question. During the previous Administration, determining the
    status of the Provider Relief Fund was nearly impossible to do. Will
    you commit to ensuring transparency when distributing this $8.5 billion
    for rural providers?
        Answer. HHS is committed to an equitable, transparent, and
    responsive approach when distributing future provider relief payments.
    HHS has listened to stakeholder input and feedback and is committed to
    ensuring equity in future PRF distributions, better support to
    providers applying for funds, and transparency in communication to
    providers. Furthermore, the Administration is committed to building a
    strong working relationship with Congress going forward and plans to
    provide periodic updates on the distribution of $8.5 billion for rural
    providers.
        Question. The COVID-19 pandemic had significant impacts on rural
    communities in West Virginia, who were already at a disadvantage when
    it comes to accessing healthcare services. We have seen exponential
    growth in telehealth adoption across Americans of all ages, locations,
    and conditions to help address these disparities. Telehealth is a
    lifeline to countless patients and their doctors in my state of West
    Virginia. Telehealth among Medicare beneficiaries has been made
    possible by temporary flexibilities in place for the duration of the
    public health emergency. You have previously committed to work to
    expand certain telehealth policies after the end of the public health
    emergency. And we have learned and seen in practice that telehealth has
    saved lives throughout this pandemic.
        Secretary Becerra, how do we ensure that there is equitable access
    to telehealth services, particularly for individuals who lack a
    connection to broadband and rely on audio-only methods to communicate
    with their doctors?
        Answer. Telehealth is an important tool to improve health equity
    and improve access to healthcare. Healthcare should be accessible, no
    matter where you live. HHS continues to examine the telehealth
    flexibilities developed for the current public health emergency and
    determine how we can build on this work to improve health equity and
    improve access to healthcare.
        There are a number of efforts underway to help underserved
    communities and individuals, particularly rural and tribal communities,
    utilize telehealth services through access to broadband Internet
    connections. HRSA's Office for the Advancement of Telehealth serves as
    HHS's focal point on telehealth, which includes the management of the
    Telehealth.HHS.gov website and improving collaboration across HHS and
    Federal agencies. For example, HRSA's Office for the Advancement of
    Telehealth leads a Rural Telehealth Initiative, established through a
    memorandum of understanding with HHS, the Federal Communications
    Commission, and the
        U.S. Department of Agriculture, to increase access to affordable
    broadband services, which is the foundation for improving access to
    telehealth services. HRSA's Office for the Advancement of Telehealth
    also supports grants such as a Telehealth Broadband Pilot Program to
    measure access to high speed Internet in rural and underserved
    communities as well as programs to support the provision of direct
    telehealth services, telementoring, research, licensure portability,
    and technical assistance to providers and patients through the
    Telehealth Resource Center Programs.
        Question. What steps is the Department of Health and Human Services
    taking to ensure that Americans who have come to rely on telehealth
    services don't lose access when the public health emergency ends?
        Answer. Telehealth services are an important tool to improve health
    equity and access to healthcare. Throughout the pandemic, telehealth
    services have filled an urgent need to maintain access to care while
    social distancing was necessary. For example, federally Qualified
    Health Centers and Rural Health Clinics were able to be paid by
    Medicare as distant site telehealth service providers, which had not
    been permitted outside of the COVID-19 public health emergency. After
    the pandemic, HHS will continue to support telehealth services. HHS is
    currently reviewing the telehealth flexibilities developed for the
    current public health emergency to determine which can and should
    continue after the public health emergency has ended. HHS plans to
    continue to support telehealth after the pandemic through resources
    like the Telehealth.HHS.gov website and the Telehealth Resource Centers
    so patients and providers have access to telehealth technical
    assistance.
        Question. The 340B program is essential for providing access to
    safe and affordable medications for low-income West Virginians.
    Recently HHS determined that six pharmaceutical companies have violated
    the program, by restricting access to contract pharmacies. The
    undermining of the 340B program by pharmaceutical companies and
    pharmacy benefit managers has taken its toll on West Virginia's
    hospitals, community health centers and their contract pharmacy
    partners.
        What are the next steps HHS will be doing to ensure the integrity
    of the 340B program?
        Answer. On May 17, 2021, HRSA sent letters to six pharmaceutical
    manufacturers stating that HRSA has determined that their policies
    placing restrictions on 340B Program pricing to covered entities that
    dispense medications through pharmacies under contract have resulted in
    overcharges and are in direct violation of the 340B statute. In
    addition, the letters explain that the 340B Program Ceiling Price and
    Civil Monetary Penalties final rule (CMP final rule) states that any
    manufacturer participating in the 340B Program that knowingly and
    intentionally charges a covered entity more than the ceiling price for
    a covered outpatient drug may be subject to a Civil Monetary Penalty
    (CMP) not to exceed $5,000 for each instance of overcharging. Any
    assessed CMPs would be in addition to repayment for each instance of
    overcharging.
        In its letters, HRSA informed the pharmaceutical manufacturers that
    continued failure to provide the 340B price to covered entities
    utilizing contract pharmacies, and the resultant charges to covered
    entities of more than the 340B ceiling price, may result in CMPs as
    described in the CMP final rule. While there is ongoing litigation on
    these matters, HRSA is actively reviewing each manufacturer's response
    to its May 17, 2021, letter to determine whether subsequent action,
    such as referral to the HHS Office of the Inspector General for the
    imposition of CMPs is warranted.
                                     ______

                    Questions Submitted by Senator Roy Blunt
                               covid-19 boosters
        Question. Mr. Secretary, at our last two hearings--one with the CDC
    Director and one with the NIH Director--the issue of whether we need
    vaccine boosters was raised. Even from our own officials, there seems
    to be a divide as to whether they'll be necessary. In early May, BARDA
    notified the Subcommittee that they intend to purchase 400 million
    vaccine doses for boosters for $7.9 billion. Does that notification
    mean that you believe boosters are necessary? Even though neither the
    Directors of CDC or NIH have officially said the same? My concern is
    that it could be very dangerous if vaccine companies, rather than
    public health experts, are stetting the public's expectations around
    COVD-19 boosters.
        Answer. Throughout the COVID-19 pandemic, BARDA has worked to
    develop and ensure that once authorized and/or approved by the FDA
    medical countermeasures (including vaccines) would be available to the
    American public immediately or with minimal delay. This has meant,
    contracting with companies to purchase millions of doses of vaccines
    prior to FDA authorization based on the lead time for vaccine
    manufacturing to ensure doses are available. Further, many
    manufacturers require orders to be placed several months ahead of the
    expected delivery date. Placing the order after a need is identified
    would result in a lapse/gap in production and ultimate delivery.
        Supporting the early manufacturing of countermeasures ensures that
    once the FDA issues an EUA, vaccine doses are immediately available. It
    has also meant that, if a vaccine we invested in failed, the USG would
    have realized the financial risk associated with the aggressive
    development strategy underlying Operation Warp Speed which is now
    called the Countermeasures Acceleration Group or CAG. BARDA is taking
    the same approach to purchasing additional vaccine doses to be
    available immediately if/when the FDA authorizes/approves boosters.
                   covid-19 vaccines donated internationally
        Question. Secretary Becerra, on June 3, 2021, the Administration
    announced it would donate 80 million vaccines to the international
    community by the end of June. Did the Department of Health and Human
    Services fund the vaccines that are being donated?
        Specifically, which vaccines are being donated? Please provide
    estimates based on vaccine producer and number of doses.
        Answer. All vaccine doses the Department of Health and Human
    Services has purchased to date were ordered for domestic use. However,
    international donations have been made available from amounts that have
    been in excess of demand once vaccines were available for use.
                              barda misused funds
        Question. In January, the Office of Special Counsel investigated
    the misuse of funds appropriated to BARDA. The Special Counsel found
    that at least since fiscal year 2010, the Office of Assistant Secretary
    for Preparedness and Response misused funds appropriated for BARDA and
    failed to accurately report this mismanagement to Congress. In fact,
    the practice of using BARDA funding by ASPR for non-BARDA purposes was
    so common that it was referred to in the agency as the ``Bank of
    BARDA.'' Mr. Secretary, has the Department determined whether these
    actions violated the Anti-deficiency Act and what steps has HHS taken
    to address this issue?
        Answer. HHS/ASPR is committed to ensuring taxpayers dollars are
    used in the most judicious manner and in accordance with statutory
    obligations. In response to the HHS Inspector General's report, HHS's
    Office of Finance is undertaking an internal review of the HHS
    Assistant
        Secretary for Preparedness and Response (ASPR)'s use of advanced
    research and development funding from the Public Health and Social
    Services Emergency Fund for fiscal years 2015 through 2019 to identify
    any potential Anti-deficiency Act violations. HHS also hired an outside
    accounting firm which is auditing ASPR's use of these funds. Both
    reviews are estimated to be completed in 2021.
                                   disease x
        Question. The COVID-19 pandemic has highlighted the need for the
    Federal government to respond rapidly to the next fast-moving, novel
    infectious disease. The fiscal year 2021 LHHS bill included language
    that encouraged the Department of Health and Human Services to work
    with the Department of Defense to implement a program focused on
    developing flexible vaccines and antiviral treatments to address
    emerging and previously unidentified infectious disease threats,
    referred to as Disease X. Mr. Secretary, what progress has the
    Department made in implementing such a program and how is the
    Department planning to develop countermeasures for previously
    unidentified viral threats?
        Answer. While no specific Disease X program has been established,
    BARDA does have processes and capabilities to prepare to respond to
    various disease threats. While BARDA has a mandate to develop medical
    countermeasures against emerging infectious disease threats, these
    efforts cross over and could support a robust and effective response to
    any rapidly emerging infectious disease event, subsequent to funding
    availability. One example is BARDA's support of platform technologies
    to develop vaccines and therapeutics for Ebola Zaire virus (Merck,
    Janssen, Regeneron) and Zika (Moderna). When COVID-19 outbreaks began,
    BARDA was able to pivot these efforts to develop medical
    countermeasures to aid the response to the emerging threat.
                             unaccompanied children
        Question. Mr. Secretary, while your Department has no role in
    setting border policy or enforcing border security, HHS is responsible,
    by law, for the safety and well-being of the unaccompanied children
    referred to its care. And this fiscal year, HHS is on track to have the
    highest number of referrals of unaccompanied children on record, with
    almost 69,000 referrals already. Instead of working to open multiple
    Influx facilities that provide an equivalent standard of care for
    children as the shelters in the permanent network, HHS created a new
    concept of Emergency Intake Sites that do not have the same
    accountability requirements as Influx facilities and provide children
    with only a minimal level of care. Why, months after this crisis began,
    have you not opened additional Influx facilities or transitioned some
    of these Emergency Intake Sites into Influx facilities?
        Answer. ORR's preference is to place unaccompanied children into
    state-licensed care provider facilities, including transitional foster
    homes while their sponsorship suitability determinations or immigration
    cases are adjudicated (in cases when a child has no viable sponsor).
    ORR has prioritized increasing its network of state licensed beds by:
    (1) safely bringing back online beds that were impacted by COVID-19
    restrictions, (2) partnering with current providers to provide
    additional bed capacity through recipient-initiated supplements, and
    (3) engaging non-governmental organizations and governmental
    jurisdictions to identify ways to expand bed capacity. However, during
    a time of sustained high referrals, ORR activates and operates Influx
    Care Facilities and Emergency Intakes Facilities (EIS) to meet its
    statutory obligations to care for unaccompanied children (UC)
    transferred from the Department of Homeland Security (DHS) and ensure
    that children are not waiting in CBP custody for longer than 72 hours.
    Since March 2021, ORR has activated a total of 14 EISs, and to date,
    ORR operates only one ICF and three EIS. At a minimum, these EISs
    provide lifesaving services, consistent with best practices in
    humanitarian and disaster response efforts. In addition, ORR has been
    working diligently to ramp up services including wrap-around services,
    where possible, to ensure the safety and well-being of the children in
    ORR care and custody.
        Question. When do you expect to ensure that every unaccompanied
    child in the care of HHS receives the required standard of care?
        Answer. ORR recognizes that children who enter ORR care may have
    experienced significant trauma not only in their home countries but
    also during their journey to the United States, and ensures that ORR's
    continuum of care remains rooted in trauma-informed care, and
    prioritizes the best interest of each child across its network of care
    provider facilities, including Carrizo ICF and the EISs.
        Question. HHS has transferred or reprogramed almost $3 billion to
    cover the costs of the influx of unaccompanied children crossing at the
    southern border. Do you expect that the transferred amount will cover
    the costs of the UC program for the remainder of the fiscal year?
        Answer. Yes. HHS anticipates that the allocated amount will cover
    the costs of the UC program through the end of the fiscal year.
        Question. Do you anticipate that your request of $3.3 billion for
    the program in fiscal year 2022 accurately reflects the amount needed
    for the next fiscal year?
        Answer. HHS strongly supports the President's budget request.
    However, given the ever- evolving situation at the southern border, it
    can be challenging to predict medium-to-long term funding needs with
    any degree of certainty. HHS continues to gather data and employ
    rigorous evaluation methods to inform its budgetary requests and
    decisionmaking, and will continue to update the Office of Management
    and Budget (OMB) and both the House and Senate Appropriations
    Committees on the dynamic situation at the southern border and the
    resultant resource requirements. HHS remains committed to working with
    Congress to ensure all relevant funding needs are communicated in a
    timely manner.
        Question. What are the key assumptions behind both of those cost
    estimates?
        Answer. To arrive at its cost estimates, ORR considers a variety of
    factors such as external political events, natural disasters, and other
    issues that may impact the number of referrals from DHS.
        Additionally, cost estimates for fiscal year 2022 includes
    expanding the scope of post-release services and the number of children
    who receive them, as well as other critical programmatic reforms such
    as improving case management and implementing policies and procedures
    intended to reduce the time it takes to unify children with their
    sponsors.
                             organ transplantation
        Question. Mr. Secretary, I was pleased to see the Administration
    move forward with finalizing the Centers for Medicare and Medicaid
    Services' (CMS) rule to improve oversight and accountability of organ
    procurement organizations (OPOs) (CMS-3380-F2).
        Related, a government contractor, the United Network for Organ
    Sharing (UNOS), has great influence over the protocols and processes
    for organ procurement and allocation. UNOS has held the government
    contract to run the Organ Procurement and Transplantation Network
    (OPTN) for roughly 35 years and appears to operate with little to no
    oversight by HHS. Over the course of the last few years, UNOS policies
    have had the effect of redistributing donated organs from the Midwest
    and South to more urban and coastal areas. In addition to the CMS OPO
    accountability rule, what more can the Department do to bring
    accountability and oversight to the organ procurement process and to
    hold the OPTN contractor accountable to actually improve the organ
    transplantation system in the U.S.?
        Answer. HRSA provides oversight of the OPTN and the OPTN
    contractor. HRSA exercises its oversight according to statutory
    requirements, regulatory requirements, and through the OPTN contract.
    The OPTN Board of Directors develops organ allocation policies with the
    advice of the OPTN membership and other interested parties The OPTN
    contractor neither develops nor approves OPTN policies. HRSA staff are
    ex-officio members of OPTN committees and the OPTN Board of Directors
    and attend all OPTN business meetings.
        HRSA currently works closely with CMS on CMS' regulation of organ
    procurement and transplantation services. Additionally, HRSA and CMS
    collaborated to establish a new Affinity Group on Organ Procurement and
    Transplantation to improve oversight by the two agencies.
        Question. The fiscal year 2021 Appropriations Joint Explanatory
    Statement encouraged CMS to consider removing the disincentive for
    Medicare Certified Transplant Centers to transfer patients suffering
    from complete loss of brain function to organ recovery centers operated
    by organ procurement organizations. What is the status of this work at
    CMS?
        Answer. CMS published a final rule \1\ on December 2, 2020 that
    updates the OPO Conditions for Coverage to change the way OPOs are held
    accountable for their performance. The final rule improves the current
    measures by using objective and reliable data, incentivizes OPOs to
    ensure all viable organs are transplanted, and holds OPOs to greater
    oversight while driving higher OPO performance. Under new outcome
    measures introduced in this final rule, except for pancreas procured
    for research (which is required by law to be counted), an OPO will not
    receive credit for procuring an organ if the organ is not transplanted,
    creating greater incentive for OPOs to place all organs for transplant
    that they procure. Following review, the final rule went into effect
    March 30, 2021 (except for amendment 3).\2\
    ---------------------------------------------------------------------------
        \1\ https://www.Federalregister.gov/documents/2020/12/02/2020-
    26329/medicare-and-medicaid-programs-organ-procurement-organizations-
    conditions-for-coverage-revisions-to.
        \2\ The January 20, 2021 memorandum from the Assistant to the
    President and Chief of Staff, entitled ``Regulatory Freeze Pending
    Review,'' instructed Federal agencies to delay the effective date of
    rules published in the Federal Register, but which have not yet taken
    effect, for a period of 60 days. The effective date of the final rule,
    except for amendment number 3, which would have been February 1, 2021,
    became March 30, 2021. CMS also included a 30-day public comment period
    on the rule to allow interested parties to provide comments about
    issues of fact, law and policy raised by the rule. The 60-day delay in
    effective date was necessary to give Department officials the
    opportunity for further review of the issues of fact, law, and policy
    raised by this rule.
    ---------------------------------------------------------------------------
                                 mental health
        Question. The pandemic has exacerbated the children's mental health
    crisis across the country and we are seeing alarming increases in
    children presenting in emergency rooms in severe crisis. Could you
    comment on how your budget addresses this crisis and ensures that
    children can get access to mental and behavioral health services
    earlier, closer to home, and in their communities?
        What are your thoughts on further efforts we should consider to
    direct funding to address this crisis, such as Children's Hospital
    Graduate Medical Education which helps train frontline professionals
    focused on treating children's mental and behavioral health?
        Answer. HHS is committed to improving access to mental and
    behavioral healthcare services for children and families. The fiscal
    year 2022 President's Budget requests includes an additional $756
    million for SAMHSA to increase access to children's behavioral health
    services, which includes $473 million for mental health, $281 million
    for substance use treatment, and $2 million for substance use
    prevention related services and activities.
        Within HRSA, the Budget provides $10 million for pediatric mental
    healthcare access to increase access to behavioral health. This
    investment promotes behavioral health integration in pediatric primary
    care by supporting the development of new, or the improvement of
    existing, statewide or regional pediatric mental healthcare telehealth
    access programs.
        The Children's Hospitals Graduate Medical Education (CHGME) Program
    is a formula based payment program that helps eligible hospitals
    maintain Graduate Medical Education (GME) programs to support graduate
    training for physicians to provide quality care to children. As such,
    the program supports the training of pediatric psychiatrists and other
    pediatric physician behavioral subspecialists. In Academic Year 2019-
    2020, 199 Child and Adolescent Psychiatry fellows received training
    through the CHGME Program. In addition, CHGME-funded hospitals served
    as sponsoring institutions for 42 residency programs and 252 fellowship
    programs, and also served as major participating rotation sites for 628
    additional residency and fellowship programs. The CHGME Program also
    supported the training of 5,433 Pediatric residents that included
    General Pediatrics residents, as well as residents from seven types of
    combined pediatrics programs (e.g., Internal Medicine/Pediatrics). In
    total, 3,055 Pediatric Medical Subspecialists, including 199 Child and
    Adolescent Psychiatry fellows, received training.
                                 hyde amendment
        Question. Mr. Secretary, for more than forty years, Democrat and
    Republican-led Administrations, as well as Democrat and Republican-led
    Congresses have supported the principle that taxpayer dollars should
    not fund elective abortions. As members of Congress, President Biden,
    Vice President Harris, and you, Mr. Secretary, all voted in favor of
    funding bills year after year that included this prohibition. It
    remains unclear why this radical change in public policy is suddenly an
    imperative for the Biden Administration to fund elective abortions with
    taxpayer dollars. Further, your request does not detail the cost this
    change will have on the U.Ss taxpayer. Can you please provide an
    estimate of how many abortions would receive Federal funding, and what
    amount of Federal expenditures would be incurred to pay for abortions,
    relative to current law for this fiscal year and the next ten?
        Answer. The Hyde Amendment disproportionately impacts the growing
    number of low- income, women of color who are enrolled in Medicaid, and
    is a barrier to expanding access to healthcare. That is why the
    President's first budget calls for Congress to remove the restriction
    from government spending bills.
        The Department of Health & Human Services implements the laws that
    Congress passes. Implementation of any changes in coverage related to
    the President's Budget would depend on the final language Congress
    passes. After passage of any legislation, agency staff and counsel
    review the language to determine the agency's authority and options for
    implementation action, such as initiating notice and comment rulemaking
    or issuing guidance documents.
        Question. HHS issued a proposed rule in April that would allow
    Title X grantees to promote abortion as a form of family planning. The
    preamble of the proposed rule cites ``that Planned Parenthood conducted
    a major fundraising campaign with the 2019 Title X regulatory changes
    as its key motivating message. If funds are more efficiently gathered
    and distributed via a program such as Title X than through such private
    campaigns, the efficiency would represent a cost savings attributable
    to the proposed rule.'' It is widely known that Planned Parenthood
    walked away from the Title X program in 2019, so I am troubled by the
    fact that HHS' proposal implies that Planned Parenthood is somehow
    entitled to taxpayer funding. This notion and the rush to finalize the
    proposed rule also raises questions about your agency's ability to be
    impartial in awarding of future Title X grants. How is this proposed
    rule not a kickback to Planned Parenthood?
        Answer. On January 28, 2021, President Biden issued a ``Memorandum
    on Protecting Women's Health at Home and Abroad'' directing the
    Department to review the 2019 Title X Final Rule and ``consider, as
    soon as practicable, whether to suspend, revise, or rescind, or publish
    for notice and comment proposed rules suspending, revising, or
    rescinding, those regulations, consistent with applicable law,
    including the Administrative Procedure Act.'' The memorandum stated
    that undue restrictions on the use of Federal funds have made it harder
    for women to access medical information.
        After conducting an extensive review and consideration of the 2019
    Title X Final Rule (84 Fed. Reg. 7714) pursuant to the Presidential
    memorandum, the Department published a Notice of Proposed Rulemaking
    (NPRM) entitled ``Ensuring access to equitable, affordable, client-
    centered, quality family planning services'' in the Federal Register
    that was open for public comment from April 15, 2021 to May 17, 2021.
        As outlined by the Title X statute and reinforced in its
    regulations, ``None of the funds appropriated under this title shall be
    used in programs where abortion is a method of family planning.''
    Consistent with the program's statute and regulations, any public or
    private nonprofit organizations, including faith-based organizations,
    state, county, local, and tribal governments, school districts, and
    public and state higher education institutions are eligible to apply
    for Title X grant funds. Title X's regulations, in the NPRM, also
    clearly define the criteria the Department uses to decide which family
    planning services projects to fund and in what amount.
              psychological clinical science accreditation system
        Question. The fiscal year 2021 Appropriations Joint Explanatory
    Statement encouraged HHS to ``review the accreditation and eligibility
    requirements for the Public Health Service Corps and behavioral health
    workforce programs to allow access to the best qualified applicants,
    including those who graduate from Psychological Clinical Science
    Accreditation System (PCSAS) programs.'' Currently, there are more than
    40 PCSAS University accredited doctoral programs in psychological
    clinical science, including Washington University in St. Louis, but the
    Department's guidance and regulations were adopted prior to the
    establishment of PCSAS and do not permit the graduates of PCSAS
    programs to be eligible to compete for these funding opportunities.
    What is the status of this review and updates at the Department and
    within the Health Resources and Services Administration, as it relates
    to the behavioral health workforce programs?
        If this process has not yet started, please provide an explanation,
    an estimated start date, and any additional information that may be
    necessary to proceed.
        Answer. HRSA is currently exploring options to include PCSAS
    doctoral programs as eligible entities in the upcoming fiscal year 2022
    Graduate Psychology Education competition. HRSA will continue to
    explore options to include such programs in other future competitions,
    including, but not limited to, the Behavioral Health Workforce
    Education and Training program, and the Geriatric Academic Career
    Awards. HRSA currently anticipates posting the Notice of Funding
    Opportunity for the Graduate Psychology Education program in November
    2021.
                           provider relief fund (prf)
        Question. Mr. Secretary, Congress provided $178 billion over the
    course of the last year for the Provider Relief Fund, and the American
    Rescue Plan included an additional $8.5 billion for rural providers.
    How is HHS planning to distribute the approximately $50 billion
    remaining, and when can we expect to see the distribution?
        Answer. HHS is committed to distributing the remaining provider
    relief payments as quickly, transparently, and equitably as possible
    while utilizing effective safeguards to protect taxpayer dollars.
        HHS is planning for future Provider Relief Fund (PRF) allocations,
    including the $8.5 billion from American Rescue Plan Act and Phase 4 of
    the General Distribution.
        HHS is actively considering feedback from stakeholders, as well as
    operational lessons learned from prior PRF payments, as part of the
    planning process. The feedback from Members of Congress and other
    stakeholders informs HHS' ability to administer the PRF in a manner
    that bolsters the healthcare system and helps providers experiencing
    COVID-related financial hardships during this crisis. HHS will publish
    additional information on future distributions on the Health Resources
    and Services Administration's PRF webpage, at www.hrsa.gov/provider-
    relief, as soon as it becomes available.
        Question. How are you planning to account for the ongoing needs of
    rural hospitals and rural healthcare providers in the distribution of
    the $8.5 billion?
        Answer. HHS is working to finalize the $8.5 billion in American
    Rescue Plan Act of 2021 funding for rural Medicare and Medicaid
    providers and suppliers. HHS will publish additional information on
    future distributions on the Health Resources and Services
    Administration's PRF webpage, at www.hrsa.gov/provider-relief, as soon
    as it becomes available.
                                    opioids
        Question. There is no question that the pandemic has been
    challenging for many people and the data shows an unprecedented rise in
    opioid overdose deaths in 2020. What can you say about the latest
    trends in opioid overdoses and what we need to do to build on the
    investments of the last 6 years to combat the opioid epidemic?
        Answer. The overdose crisis has certainly worsened in the face of
    the COVID-19 public health emergency. Estimates from the CDC find that
    more than 90,000 drug overdose deaths have occurred in the 12 months
    ending in September 2020. That represents a year-over-year increase of
    close to 29 percent. For the last few years, this increase in lives
    lost is principally driven by synthetic opioids like fentanyl, but
    increasingly, we are seeing stimulants, including methamphetamine and
    cocaine also involved. HHS is investing $11.2 billion in programs
    responding to the overdose crisis, an increase of $3.9 billion over
    fiscal year 2021 Enacted, with the goal of ending the crisis of opioids
    and other substance use by increasing funding for States and Tribes for
    medication-assisted treatment, and by expanding the behavioral health
    provider workforce. Of the $11.2 billion, $6.6 billion is from SAMHSA's
    prevention and treatment activities that address the substance use and
    opioid crisis, an increase of $2.6 billion over Fiscal year 2021
    enacted. HHS is committed to investments in the Substance Abuse
    Prevention and Treatment Block grant to expand implementation of
    evidence-based prevention, treatment and recovery support services for
    individuals, families, and communities across the nation. The budget
    includes a new 10 percent set-aside to direct funds to states for
    recovery support services, which can be provided prior to, during,
    after, and in lieu of treatment. This funding will allow SAMHSA to
    serve 2.1 million people in fiscal year 2022 and to significant
    strengthen the Nation's recovery support services infrastructure. The
    fiscal year 2022 President's Budget also makes significant investments
    in First Responder Training programs to train first responders to
    respond to and prevent opioid overdose deaths, as well as expanding
    treatment for SUD for pregnant and post-partum women.
        HHS is committed to continued support for efforts to increase
    access to SUD and broader behavioral healthcare services through the
    Rural Communities Opioid Response Program (RCORP). The budget includes
    a total of $165 million to support prevention, treatment, and recovery
    services for opioids and other SUDs in the highest-risk rural
    communities. Through RCORP, more than 23,000 individuals received
    medication-assisted treatment; and the number of DATA-waivered
    providers serving rural communities was increased. In fiscal year 2019
    and 2020, the National Health Service Corps Rural Community Loan
    Repayment Program (NHSC RC LRP) also served to further increase access
    to behavioral healthcare workforce services in rural communities with
    651 providers working in rural communities, and 118 of those working
    specifically at RCORP service sites.
        Other considerations to address the overdose epidemic include:
        Treatment Capacity: The SAMHSA-HRSA Workforce projections report
    indicates a shortage of over 10,000 full time equivalents for child
    psychiatrists and master's level mental and SUD counselors by the year
    2025. The report also highlights the need for peer specialists in a
    wide variety of integrated and specialty care settings. Peers, as
    members of integrated healthcare teams, support all team members in
    working at the top of their scope of practice, improving efficiency and
    maximizing skill utilization.
        Decreasing Barriers: Research reveals geographic and
    sociodemographic barriers to receiving treatment.\3\ Indeed, many
    treatment facilities are found in urban and suburban areas, and there
    is disparity in access to buprenorphine providers and Opioid Treatment
    Programs (OTPs).\4\ Recent policy changes, such as The Practice
    Guidelines for the Administration of Buprenorphine for Treating Opioid
    Use Disorder, remove perceived barriers to obtaining a DATA-2000 Waiver
    and expand access to this treatment.. New flexibilities enable more
    OTPs to establish mobile medication units (e.g., vans), which can
    improve geographic access and expand the provision of opioid use
    disorder treatment to disparate populations. Grants such as the State
    Opioid Response (SOR), Medicated Assisted Treatment for Prescription
    Drug and Opioid Addiction (MAT-PDOA), Targeted Capacity Expansion-
    Special Projects (TCE-SP), and Screening, Brief Intervention and
    Referral to Treatment (SBIRT) will be used to address this need. The
    fiscal year 2022 President's Budget Request proposes increases for each
    of these programs.
    ---------------------------------------------------------------------------
        \3\ Sharma RN, Casas RN, Crawford NM, Mills LN. Geographic
    distribution of California mental health professionals in relation to
    sociodemographic characteristics. Cultur Divers Ethnic Minor Psychol.
    2017 Oct;23(4):595-600.
        \4\ Goedel WC, Shapiro A, Cerda M, Tsai JW, Hadland SE, Marshall
    BDL. Association of Racial/Ethnic Segregation With Treatment Capacity
    for Opioid Use Disorder in Counties in the United States. JAMA Netw
    Open. 2020;3(4):e203711. Published 2020 Apr 1. doi:10.1001/
    jamanetworkopen.2020.3711.
    ---------------------------------------------------------------------------
        Wrap Around Services Addressing Social Determinants of Health:
    These services not only improve the treatment experience, but also
    provide support to clients during their recovery. For example, research
    demonstrates that women's SUD treatment outcomes are improved when
    women-specific needs are addressed through wraparound services, such as
    the provision of childcare, employment assistance, or mental health
    counseling.\5\ Additionally, the receipt of basic needs, child care,
    educational, family, and medical services is associated with
    improvements in several outcomes.\6\ These services represent an
    important opportunity to support clients and to ameliorate many of
    those social determinants of health that precipitate substance misuse.
    That is why the fiscal year 2022 President's Budget Request proposes
    increase for programs such as the Pregnant & Postpartum Women,
    Treatment, Recovery, and Workforce Support, Adult and Family Treatment
    Drug Courts.
    ---------------------------------------------------------------------------
        \5\ Oser C, Knudsen H, Staton-Tindall M, Leukefeld C. The adoption
    of wraparound services among substance abuse treatment organizations
    serving criminal offenders: The role of a women-specific program. Drug
    Alcohol Depend. 2009;103 Suppl 1(Suppl 1):S82-S90. doi:10.1016/
    j.drugalcdep.2008.12.008.
        \6\ Pringle, J, et al. The Role of Wrap Around Services in
    Retention and Outcome in Substance Abuse Treatment: Findings From the
    Wrap Around Services Impact Study. Addict Disord Their Treatment
    2002;1:109--118.
    ---------------------------------------------------------------------------
        Telehealth: The recent pandemic has demonstrated the utility of
    telehealth in reaching disparate populations. Telehealth is a mode of
    service delivery that has been used in clinical settings for over 60
    years and empirically studied in the mental health space for over 20
    years.\7\ Telehealth is not an intervention itself, but rather a mode
    of delivering services. This mode of service delivery increases access
    to screening, assessment, treatment, recovery supports, crisis support,
    and medication management \8\ across diverse behavioral health and
    primary care settings. Practitioners can offer telehealth through
    synchronous and asynchronous methods. The increase requested under
    SAMHSA's SOR grants can be used to address this need.
    ---------------------------------------------------------------------------
        \7\ Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P.
    M. (2016). The empirical evidence for telemedicine interventions in
    mental disorders. Telemedicine and e-Health, 22(2), 87-113.
        \8\ Substance Abuse and Mental Health Services Administration.
    (2015). Using technology-based therapeutic tools in behavioral health
    services. Treatment Improvement Protocol (TIP) Series 60.
    ---------------------------------------------------------------------------
        Evidence Based Practice: There is a need for combining leadership
    development with organizational strategies to support a climate
    conducive to evidence based practice implementation.\9\ This represents
    an opportunity to promulgate the evidence and best practices through
    SAMHSA publications, reports, and announcements. Beyond this, SAMHSA
    will work with grantees to consider implementation science strategies
    that support program sustainability and fidelity to the evidence base.
    The Evidence-Based Practice Center and Technical Assistance Grants will
    be used to address this need. Additionally, the Prevention Technology
    Transfer Center Network and the Addiction Technology Transfer Network
    will continue to help states develop capacity through training,
    consultation, and technical assistance and SAMHSA's new Peer Recovery
    Center of Excellence, authorized under Section 7152 of the SUPPORT Act
    for Patients and Communities, will continue to provide training and
    technical assistance to support integration of peer support workers
    into non-traditional settings, build and strengthen recovery community
    organizations, a key component of recovery support services
    infrastructure. It will also enhance the professionalization of peers
    through workforce development, providing evidence-based and practice-
    based toolkits and resources to diverse stakeholders.
    ---------------------------------------------------------------------------
        \9\ Aarons GA, Ehrhart MG, Moullin JC, Torres EM, Green AE. Testing
    the leadership and organizational change for implementation (LOCI)
    intervention in substance abuse treatment: a cluster randomized trial
    study protocol. Implement Sci. 2017 Mar 3;12(1):29.
    ---------------------------------------------------------------------------
        Harm Reduction Activities: The promotion and distribution of
    naloxone and fentanyl test strips, similar to the existing syringe
    services programs, represents an opportunity to not only promote life-
    saving interventions, but to also provide education on drug potency and
    mortality.\10\ This might be achieved in partnership with public safety
    agencies, providers, community organizations and the public.
    Additionally, syringe services programs reduce transmission of HIV and
    viral hepatitis within the community. A comprehensive and coordinated
    approach must incorporate innovative and established prevention and
    response strategies, including those focused on polysubstance use.
    Among the programs that can support these efforts are the Treatment
    Systems for Homeless and Minority AIDS program, both of which request
    an increase in funding.
    ---------------------------------------------------------------------------
        \10\ Han JK, Hill LG, Koenig ME, Das N. Naloxone Counseling for
    Harm Reduction and Patient Engagement. Fam Med. 2017 Oct;49(9):730-733.
    ---------------------------------------------------------------------------
        Education: Medical school graduates play a pivotal role in
    educating their patients and colleagues; screening, diagnosing, and
    treating patients; and modeling positive attitudes to reduce the stigma
    attached to SUDs. Research demonstrates that SUD educational
    interventions, using various approaches and durations, produce a
    positive impact on medical students' knowledge, skills, and
    attitudes.\11\ Studies also reveal that simply increasing exposure to
    patients with addiction does not provide the formative knowledge
    required to identify, treat or even prevent SUDs without the presence
    of a concurrent, comprehensive didactic curriculum.\12\ Even as the
    overdose crisis deepens, there remains wide heterogeneity in SUD
    curricula across medical schools.\13\ This adversely impacts patient
    care--a lack of preparedness has been identified as a barrier in the
    provision of buprenorphine to patients with opioid use disorder by
    early career family physicians.\14\ Moreover, a lack of appropriate
    education has also been shown to foster negative attitudes towards the
    treatment of SUD with buprenorphine.\15\ Such negative attitudes
    adversely impact patient-physician dialogues and contribute to the
    under treatment of SUDs by primary care and specialty providers.\16\
    Comprehensive and uniform medical school teaching on SUDs, addiction,
    and treatment modalities has the potential to overcome these deficits
    and to positively impact all graduates and their patients. It also
    represents an important area of engagement with academic institutions.
    The Provider's Clinical Support System--Universities (PCSS-
    Universities) grant will be used to address this need and would be
    further supported by the increase proposed in the fiscal year 2022
    President's Budget Request.
    ---------------------------------------------------------------------------
        \11\ Muzyk A, Smothers ZPW, Akrobetu D, Ruiz Veve J, MacEachern M,
    Tetrault JM, Gruppen L. Substance Use Disorder Education in Medical
    Schools: A Scoping Review. Acad Med. 2019 Nov;94(11):1825-1834. doi:
    10.1097/ACM.0000000000002883. PMID: 31663960.
        \12\ Tetrault, J. Improving Health Professions Education to Treat
    Addiction: The Time Has Come. The Josiah Macy Jr Foundation, News and
    Commentary. May 2018.
        \13\ Blanco, C., Wiley, T.R.A., Lloyd, J.J. et al. America's opioid
    crisis: the need for an integrated public health approach. Transl
    Psychiatry 10, 167 (2020). https://doi.org/10.1038/s41398-020-0847-1.
        \14\ DeFlavio JR, Rolin SA, Nordstrom BR, Kazal LA Jr. Analysis of
    barriers to adoption of buprenorphine maintenance therapy by family
    physicians. Rural Remote Health. 2015;15:3019.
        \15\ Tong ST, Hochheimer CJ, Peterson LE, Krist AH. Buprenorphine
    Provision by Early Career Family Physicians. Ann Fam Med.
    2018;16(5):443-446. doi:10.1370/afm.2261
        \16\ Kennedy-Hendricks A, Busch SH, McGinty EE, et al. Primary care
    physicians' perspectives on the prescription opioid epidemic. Drug
    Alcohol Depend. 2016;165:61-70.
    ---------------------------------------------------------------------------
        Reducing Stigma: Stigma can reduce willingness of policymakers to
    allocate resources, reduce willingness of providers in non-specialty
    settings to screen for and address substance misuse , and may limit
    willingness of individuals with SUDs to seek treatment.\17\ Negative
    attitudes toward patients with substance use disorder are common among
    health professionals, who generally lack adequate education, training
    and support structures to effectively serve patients with SUD. Health
    professionals' negative attitudes reduced patients' feelings of
    empowerment and diminished treatment outcomes. These attitudes resulted
    in less provider engagement, a more task-oriented approach to care
    delivery, and diminished empathy.\18\ All of these factors may help
    explain why so few individuals with SUDs receive treatment. Public
    education that reduces stigma and provides information about treatment
    is needed. This represents an opportunity to engage across multiple
    disciplines and modalities. Among others, PCSS-U and SOR grants seek to
    overcome stigma. The fiscal year 2022 President's Budget requested
    increases for both programs.
    ---------------------------------------------------------------------------
        \17\ Yang LH, Wong LY, Grivel MM, Hasin DS. Stigma and substance
    use disorders: an international phenomenon. Curr Opin Psychiatry.
    2017;30(5):378-388.
        \18\ van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL.
    Stigma among health professionals towards patients with substance use
    disorders and its consequences for healthcare delivery: Systematic
    review. Drug and Alcohol Dependence. 2013;131(1):23-35.
    ---------------------------------------------------------------------------
        Partnering With Public Safety Officials And Community
    Organizations: Working with law enforcement, community groups,
    patients, and treatment teams to address the growing overdose epidemic
    has the potential to channel new ideas, data sources, and efforts
    towards reducing mortality and use of illicit substances. Such
    engagement promotes cross collaboration and encourages the creation of
    innovative and community focused interventions, such as pre- and post-
    arrest deflection to treatment. Increases proposed to SAMHSA grants
    such as the First Responder Training/Rural Emergency Medical Services
    can help address this need.
        Question. This Subcommittee has worked in a bipartisan fashion to
    provide $4 billion in fiscal year 2021 to address the opioid epidemic,
    including $1.5 billion for State Opioid Response grants. This is a
    flexible grant provided directly to states to use funds as they see
    fit. Unfortunately, we continue to hear that states are not spending
    those funds in a timely manner. Does HHS know why this is the case?
        Answer. The State Opioid Response (SOR) grants give states
    flexibility in providing a range of prevention, treatment, and recovery
    support services for opioid and stimulant use disorders. The grants
    also support infrastructure development to enhance/expand systems of
    care. One of the most common reasons grantees attribute spending
    challenges to is state procurement processes. Procurement challenges
    include state legislative timelines that do not align with Federal
    appropriation cycles; reluctance from contract bidders because of the
    short duration of the grant (i.e., 2 years); and delays that result
    from contract negotiations. Grantees have also cited challenges related
    workforce shortages. Additionally, the COVID-19 pandemic has also
    impacted states' ability to spend funds.
        Question. How does this trend align with the 50 percent budget
    increase for SOR?
        Answer. The fiscal year 2022 President's Budget increased the State
    Opioid Response grant program to allow grantees to enhance and expand
    evidence-based opioid and stimulant use disorder prevention, treatment
    and recovery support activities currently underway. Additionally,
    grantees will have the ability to increase their focus and efforts on
    continued areas of need such as workforce development, harm reduction
    and public education and training. This will also increase access to
    opioid and stimulant use disorder treatment services in states,
    territories, and tribes. Within this total, SAMHSA will direct $75
    million to the Tribal Opioid Response grant program to specifically
    address the opioid substance use needs in tribal communities. This
    critical investment will drive funding to States and Tribes to increase
    community-level response to the opioid crisis, expand access to
    evidence-based treatment and recovery services, and provide targeted
    investment to crisis services and recovery support services. HHS is
    committed to working to ensure that the SOR program supports states in
    addressing and investing in evidence-based treatment and recovery
    services for the ongoing opioid and substance use epidemic. SAMHSA is
    committed to providing technical assistance to ensure states understand
    how they can utilize these funds, as well as oversight to ensure funds
    are spent appropriately in a timely manner.
        Question. What can be done to increase the spending rates by
    states?
        Answer. Currently, SAMHSA monitors grantees' program implementation
    activities and provides feedback to states when benchmarks are not
    being met. SAMHSA also has a wealth of general and targeted technical
    assistance resources that SOR grantees may access. For example, the
    Addiction Technology Transfer Center (ATTC) Network is a
    multidisciplinary resource for professionals in the addiction treatment
    and recovery services field. The ATTC Network's mission and vision are
    to: accelerate the adoption and implementation of evidence-based and
    promising addiction treatment and recovery-oriented practices and
    services; heighten the awareness, knowledge, and skills of the
    workforce that addresses the needs of people with substance use or
    other behavioral health disorders; and foster regional and national
    alliances among culturally diverse practitioners, researchers, policy
    makers, funders, and the recovery community. SAMHSA also funds the
    Opioid Response Network (ORN) which was designed to provide training
    and other resources in efforts to address the opioid crisis. The ORN
    has local consultants in all 50 states and nine territories to respond
    to local needs by providing free educational resources and training to
    states, communities and individuals in the prevention, treatment and
    recovery of opioid use disorders and stimulant use. SAMHSA has also
    extended flexibilities to grantees considering the COVID-19 pandemic
    including granting no-cost extensions to give grantees up to an
    additional 12 months to use any unexpended funds from the official
    grant period.
        Question. To respond to the changing nature of the opioid epidemic,
    the fiscal year 2020 LHHS bill expanded the State Opioid Response grant
    authority to allow states to use funds on stimulants, like cocaine and
    methamphetamine. Mr. Secretary, how is the rising use of stimulants
    impacting the ability for state and local communities to provide
    effective treatment for opioid use disorders?
        Answer. The Department has no evidence to suggest that the rise in
    use of stimulants is impacting states' ability to provide effective
    treatment for opioid use disorders.
        It is important to consider stimulant misuse in the context of
    polysubstance misuse--increasingly, substances are not used in
    isolation. Individuals with polysubstance misuse involving alcohol,
    marijuana, opioids, and/or stimulants receive care in a variety of
    settings, and often require withdrawal management, psychological and
    FDA-approved pharmacological treatment, and monitoring as part of their
    care plan.
        SAMHSA recently created an Evidence-Based Practice Guide to address
    polysubstance misuse. Through a literature review and consensus from
    technical experts, SAMHSA identified three effective practices used to
    treat polysubstance misuse in adults. These are (1) FDA-approved
    pharmacotherapy with counseling; (2) Contingency management (CM) with
    FDA-approved pharmacotherapy and counseling, and (3) Twelve-step
    facilitation (TSF) therapy with FDA-approved pharmacotherapy. These
    treatments should be delivered in a patient-centered and integrated
    manner in order to achieve the best outcomes. Many facilities offer
    such treatments, and they demonstrate a high level of success.
        There currently are no Food and Drug Administration-approved
    medications specific for stimulant use disorders, making it important
    that behavioral health and healthcare service providers understand and
    offer (or offer referrals for) CM or other psychosocial treatments.
    Despite an increase in research into psychosocial treatments for people
    with stimulant use disorders, currently the only treatment with
    significant evidence of effectiveness is CM. Other psychosocial
    treatments that have some support (especially if used in combination
    with CM) are cognitive--behavioral therapy/relapse prevention,
    community reinforcement, and motivational interviewing. These
    interventions demonstrate efficacy in treating stimulant use disorder
    across age ranges. SAMHSA's State Opioid Response grants allow the use
    of Federal funds to provide CM. In treating stimulant use disorder,
    clinicians also are recommended to promote harm reduction (especially
    because of the high level of contamination of the drug supply with
    fentanyl and analogs) through educating about needle exchange programs,
    offering naloxone, and encouraging the use of fentanyl test strips, as
    these strategies can help save lives.
                           ``ending hiv'' initiative
        Question. I was pleased to see the fiscal year 2022 budget increase
    of $267 million for the Ending the HIV Epidemic initiative, started by
    this Subcommittee in fiscal year 2020. The Trump Administration,
    however, was notably more aggressive in their funding requests to
    address the HIV epidemic, requesting $716 million in the second year of
    the initiative. After the challenging year of the pandemic, where do we
    stand as a nation in combatting new HIV infections?
        Answer. Although it is too early to assess quantitatively the full
    impact of COVID-19 on HIV research, based on listening sessions
    conducted by the NIH OAR across the United States, the COVID-19
    pandemic has placed a tremendous strain on sustaining research in
    general. Basic and translational research unrelated to COVID-19 in
    academic settings was suspended for months, severely delaying progress
    for trainees and principal investigators. Healthcare workers and
    clinical researchers were diverted to the care of COVID-19 patients,
    while clinical research resources had to be redirected to COVID-19.\19\
    Recruitment and staffing for HIV and other clinical trials was halted
    due to distancing, travel restrictions and ``lockdown'' measures.
    Broadly, public health measures required to control the spread of
    severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have led
    to societal restrictions that have negatively impacted the economy and
    limited access to routine non-emergency healthcare. Specifically, the
    COVID-19 pandemic has had a negative effect on HIV testing, linkage to
    care, and access to treatment and HIV research laboratories and
    investigation sites.
    ---------------------------------------------------------------------------
        \19\ nature.com/articles/s41581-020-00336-9.
    ---------------------------------------------------------------------------
        Preliminary reports suggest that COVID-19 is likely to affect key
    HIV study outcomes. For example, adverse events may be caused by SARS-
    CoV-2 infection or by deferral of care for other health issues due to
    fear of contracting SARS-CoV-2 infection. Research study participants
    likely changed their lifestyles to minimize contact with others, which
    may affect research outcomes. SARS-CoV-2 infection could worsen HIV
    comorbidities, such as glycemic control in persons with diabetes, blood
    pressure control in those with hypertension, or accelerate progression
    of chronic kidney disease.\20\
    ---------------------------------------------------------------------------
        \20\ academic.oup.com/jid/advance-article/doi/10.1093/infdis/
    jiab114/6167835.
    ---------------------------------------------------------------------------
        The impact of COVID-19 on HIV research has been bidirectional.
    Contributions by the HIV researchers and community to COVID-related
    efforts are significant: from the successful mRNA vaccine platform, to
    clinical trials networks for testing candidate vaccines, to rapid
    testing and molecular epidemiology for tracking--the HIV research
    footprint is widely recognized in the response to COVID-19. In
    addition, there have been some positive aspects related to the COVID-19
    response, such as the accelerated innovations that have advanced the
    way we conduct clinical research overall. These include new approaches
    to conduct remote visits by telehealth, use home-based testing or
    monitoring technologies. The NIH OAR HIV and COVID-19 Taskforce is
    meeting to discuss further impacts of the COVID-19 pandemic on HIV
    research progress and investigator retention within the NIH extramural
    community.
        Question. What factors were considered for the fiscal year 2022
    funding request? Please provide an updated cost estimate of resources
    needed over the next 5-years, by fiscal year and Operating Division for
    the Ending the HIV Epidemic initiative.
        Answer. The Centers for Disease Control and Prevention (CDC)
    developed a methodology to estimate the number of people who need to be
    tested, diagnosed, and provided HIV medical care and treatment or PrEP.
    The CDC's methodology then informed the initial EHE budget for HRSA,
    which was developed to meet the EHE goal of enrolling newly diagnosed
    and people with HIV no longer in care into EHE-funded medical,
    treatment, and support services.
        CDC provided data to HRSA on the number of diagnosed people with
    HIV in each Eligible Metropolitan Area, Transitional Grant Area, or
    State (not just the county of interest). HRSA then used CDC estimates
    for the percent of people with HIV who are undiagnosed in each state to
    calculate estimated undiagnosed. Using this data, overall cost
    estimates were then developed using the average RWHAP costs per person
    served.
        The HRSA cost estimates for the EHE initiative are outlined in the
    table below. The Health Center fiscal year 2022 budget request for the
    EHE Initiative was developed in the context of increasing participation
    in the Phase I targeted areas. The estimated number of clients served
    (reflected below) through the EHE were adjusted from the initial
    estimates for the EHE initiative to align with appropriated funds.
        Projections for fiscal year 2023 and beyond are under development.

                              [Dollars in millions]
    ------------------------------------------------------------------------
                                                        Fiscal Year
                                             -------------------------------
                                               2021 Enacted     2022 Budget
    ------------------------------------------------------------------------
    Health Centers..........................         $102.25         $152.25
    HAB EHE.................................         $105.00         $190.00
                                             -------------------------------
        Total...............................         $207.25         $342.25
                                             -------------------------------
    Estimated Clients:
    Budget Health Centers (PrEP)............         285,000         425,000
    HAB EHE.................................          27,000          50,000
    ------------------------------------------------------------------------

        Question. The jurisdictions involved in the Ending the HIV Epidemic
    program have invested significant resources. Do you anticipate any
    changes to the geographic distribution of the funding?
        How does the initiative account for new HIV outbreaks, such as
    what's happening in West Virginia, which wasn't one of the seven
    targeted states?
        Answer. No, HRSA does not anticipate any changes to the geographic
    distribution of funding in fiscal year 2022.
        HRSA health centers continue to make HIV prevention technical
    assistance and training available nationwide, including those centers
    with increasing HIV prevalence in their communities. In total for
    fiscal year 2020, health centers across the U.S. reported providing
    approximately 2.5 million HIV tests and PrEP related services to
    389,000 health center patients.
        HRSA also responds to HIV outbreaks through the RWHAP's established
    care, treatment and support systems in partnership with the CDC. Since
    2015, HRSA's RWHAP has worked closely with CDC to address HIV outbreaks
    that have resulted from injection drug use, such as what is happening
    in West Virginia. This collaboration has been crucial in helping states
    and local communities identify those at risk for HIV due to injection
    drug use, getting at-risk individuals tested for HIV and hepatitis C,
    and getting people linked to and engaged in services for HIV and
    hepatitis care or for pre-exposure prophylaxis, substance use disorder
    treatment and other needed services.
                    supplemental and reconciliation funding
        Question. In response to the COVID-19 pandemic, states have
    received billions of dollars in aid, with the intent of giving them
    maximum flexibility to respond to their unique needs and challenges. It
    is my understanding there is a sizable portion of unobligated funds
    remaining from the bipartisan emergency supplemental bills. And now
    there is even more funding provided for similar activities as part of
    the partisan reconciliation bill. While it is important to know how
    fast HHS is getting this funding into the hands of the frontline
    responders on the state level, it is just as important to know if the
    states are actually spending the money. What are the spend rates that
    HHS is seeing at the state level?
        Answer. HHS has awarded over $146 billion to states across six
    supplemental appropriations. In many cases, funds were directed to
    states by Congress in the COVID supplemental appropriations. As of
    early November, award recipients have drawn down $29.5 billion, or
    twenty percent, of the total funding awarded. When examining the first
    four supplementals, state recipients have drawn down at least 50
    percent or significantly higher percentages for resources appropriated
    at the earliest stages of the pandemic. Evaluating how the funds are
    being used cannot be achieved by examining draw down data alone since
    it is not a good indicator of how much jurisdictions have spent. States
    and jurisdictions are able to bill again their awards through the end
    of the established period of performance for that specific award.
    Funding recipients will typically draw down funds as expenses are
    incurred or after activities are executed and invoices are reconciled
    to confirm reimbursement totals. Drawdowns may occur monthly,
    quarterly, or at another frequency depending on the awardee. As a
    result there can be a significant time lag in the draw down data since
    actual state and jurisdiction expenditures are usually greater than the
    amount reflected in our draw down data. HHS grants policies and
    regulations require monitoring and award recipient reporting and HHS
    agencies closely monitor award recipient performance, activities, and
    progress through regular engagement.
        Question. What accountability do the states have to tell the
    Department how they used the funds?
        Answer. With respect to Centers for Disease Control and Prevention
    (CDC) grant awards, HHS awarding agencies adhere to HHS Grant Policies
    and Regulations, which detail required monitoring and reporting for
    award recipients. These may differ in frequency by type of award or
    program.
        CDC for example continuously and closely monitors recipient/
    jurisdiction performance, activities, and progress through regular
    engagement. Monitoring activities include routine and ongoing
    communication between CDC and recipients, site visits, and recipient
    reporting (including work plans, performance, and financial reporting).
    Monitoring includes tracking recipient progress in achieving the
    desired outcomes, ensuring the adequacy of recipient systems that
    underlie and generate data reports, and creating an environment that
    fosters integrity in program performance and results.
        Monitoring may also include the following activities deemed
    necessary to monitor an award.
      --Ensuring that work plans are feasible based on the budget and
            consistent with the intent of the award.
      --Ensuring that recipients are performing at a sufficient level to
            achieve outcomes within stated timeframes.
      --Working with recipients on adjusting the work plan based on
            achievement of outcomes, evaluation results and changing
            budgets.
      --Monitoring performance measures (both programmatic and financial)
            to assure satisfactory performance levels.
        CDC complies with HHS requirements to implement internal tracking
    methods for issued Federal awards. Award recipients report expenditures
    into HHS' Payment Management System (PMS) quarterly and submit a Final
    Financial Report 90 days after the end of the budget period. All awards
    have assigned budget activity codes that are used to track and monitor
    funding
        Question. Given the unprecedented amount of funding going out from
    HHS as a result of the partisan reconciliation bill, can you explain
    HHS' decisionmaking process and planning mechanisms for deploying such
    large sums of money in such a short period of time?
        How does HHS plan for states and the public health infrastructure
    to sustain these advancements when the funding runs out?
        Answer. The American Recuse Plan provided over $160 billion for
    activities across HHS agencies. The legislation identified specific
    purposes for the resources appropriated to HHS agencies and many were
    intended to support states public health. In many cases, HHS was able
    to leverage existing program mechanisms to efficiently and quickly
    execute funding. For example, the American Rescue Plan appropriated
    substantial resources for existing block grants within ACF for child
    care development, and for mental health and to prevent substance abuse
    within SAMHSA. HHS was able to leverage existing program mechanisms to
    rapidly award funds when they were needed most by the population served
    by these critical programs. These large infusions of funds are
    supporting state implemented programs to meet both demands and other
    challenges presented during the COVID pandemic. Looking forward, HHS
    will work within the Administration to identify future investments in
    public health programs through the annual budget process taking into
    consideration experiences from the COVID response.
        Question. The Administration has placed an emphasis on addressing
    health equity, especially as it relates to the pandemic response
    efforts. What trends are you seeing in rural communities right now with
    regard to the pandemic?
        How does the HHS' health equity work account for the needs of rural
    communities?
        Answer. COVID had a disproportionate impact in rural areas given
    limited clinical infrastructure (for example, fewer number of beds,
    workforce staffing issues already a challenge pre-pandemic, challenges
    accessing PPE). Rural communities suffered with high case rates and
    high mortality rates, often worse than in urban areas.
        HHS has been intentional about targeting COVID relief to rural
    communities (and those populations with at higher risk within rural)--
    for example HRSA provided funding to grantees in the Mississippi Delta
    Region to promote the vaccine, supported regional trainings for
    community health workers in that region as well as the region along the
    U.S.--Mexico border, programs that have been proven effective in
    populations of racial and ethnic minorities that often face even higher
    health disparities than the broader rural populations.
        Programs this year targeted Rural Health Clinics and small rural
    hospitals to support testing and mitigation activities for these key
    providers of the rural health safety net. Additionally, funding to
    support vaccine distribution and confidence was distributed to Rural
    Health Clinics--getting funding to trusted community providers.
        We are enhancing our focus on the need to look at rural health
    issues through the lens of health equity; expanding the use of our
    research centers to gather more data to inform future work in this
    area; and providing targeted outreach to key underserved communities
    and populations to help them leverage our funding.
        Question. Throughout the pandemic, and to date, we have heard
    concerns about the impact to the NIH research community. For example,
    scientists who had to close their labs and cull their animals lost
    valuable research data and post-doctoral candidates couldn't finish
    their research in time to get jobs in September. What is the strategy
    for using fiscal year 2021 or fiscal year 2022 dollars for COVID-19
    related expenses and how much of non-emergency supplemental funding has
    been used by agencies to address these concerns?
        Answer. As noted in the question, research on many NIH grants was
    impacted by the pandemic, causing delays in research activities and
    outcomes. NIH is considering various strategies to address these
    coronavirus disease 2019 (COVID-19) related expenses to support our
    recipients, such as:
      --Providing extensions, both funded and un-funded, for recipients of
            NIH Fellowship (F) and NIH Career Development (K) awards who
            have been impacted by COVID-19 \21\
    ---------------------------------------------------------------------------
        \21\ grants.nih.gov/grants/guide/notice-files/NOT-OD-21-052.html.
    ---------------------------------------------------------------------------
      --Supporting administrative supplements, competitive revisions, and
            extensions to existing grants
      --Allowing extensions to one's early-stage investigator status due to
            effects related to pandemic shutdowns \22\
    ---------------------------------------------------------------------------
        \22\ nexus.od.nih.gov/all/2020/04/09/can-esi-status-be-extended-
    due-to-disruptions-from-covid-19/.
    ---------------------------------------------------------------------------
      --Temporary extensions of eligibility for select NIH programs,
            including the NIH K99/R00 Pathway to Independence Award \23\
    ---------------------------------------------------------------------------
        \23\ NOT-OD-21-158 and NOT-OD-21-106, and those listed on
    grants.nih.gov/policy/natural-disasters/corona-virus.htm under
    Temporary Extension of Eligibility.
    ---------------------------------------------------------------------------
      --Flexibilities for NIH-funded clinical trials and human subjects for
            the duration of the declared public health emergency \24\
    ---------------------------------------------------------------------------
        \24\ NOT-OD-20-087 and grants.nih.gov/sites/default/files/
    Considerations-New-Ongoing-Human-Subjects-Research-During-the- COVID-
    19-Public-Health-Emergency.docx.
    ---------------------------------------------------------------------------
      --Flexibilities for assured institutions for activities of
            institutional animal care and use committees \25\
    ---------------------------------------------------------------------------
        \25\ 25 NOT-OD-20-088.
    ---------------------------------------------------------------------------
        The budgetary impact of these flexibilities and additional funding
    on new grants funded is not yet fully known. NIH will continue to
    analyze the data on the impact of COVID-19 on the biomedical research
    community, and its potential impact on our budget and grant activities.
        NIH received the authority in Section 152 of the Continuing
    Resolution signed into law in September 2020 to extend multi-year
    funded grants awarded in fiscal year 2015, specifically for those
    active when the COVID-19 public health emergency was declared.\26\ The
    project period end dates for those limited number of awards were
    extended through August 31, 2021. NIH is also requesting a similar
    extended disbursement authority for certain amounts available for
    obligation through fiscal year 2016 that were obligated for multi-year
    research grants, such that those amounts would continue to be available
    through fiscal year 2022.
    ---------------------------------------------------------------------------
        \26\ 26 Section 152. (a) Funds made available in Public Law 113--
    235 to the accounts of the National Institutes of Health that were
    available for obligation through fiscal year 2015 and were obligated
    for multi-year research grants shall be available through fiscal year
    2021 for the liquidation of valid obligations incurred in fiscal year
    2015 if the Director of the National Institutes of Health determines
    the project suffered an interruption of activities attributable to
    SARS--CoV--2. (b)(1) This section shall become effective immediately
    upon enactment of this Act.
    ---------------------------------------------------------------------------
                                   influenza
        Question. Influenza occurs seasonally each year, and has on
    occasion caused devastating pandemics in the past. Reports are already
    speculating that the next flu season may be bad after a year of hardly
    any flu cases. The budget requests an increase of $25 million for CDC
    Influenza Planning and Response and an increase of $48 million for
    ASPR's Pandemic Flu program. Are these resources sufficient to meet the
    needs outlined in the U.S. National Influenza Vaccine Modernization
    Strategy, which projected far greater needs over 10 years?
        How will the budget request advance the National Strategy?
        Answer. The budget request aligns with and supports the pandemic
    influenza strategy. The key investments you note are also critical down
    payments to incorporate what we are learning in the ongoing COVID-19
    response. Specifically, the budget provides $335 million, an increase
    of $48 million above fiscal year 2021 enacted, for pandemic influenza
    preparedness activities carried out by ASPR and the Office of Global
    Affairs (OGA). ASPR will continue to support priorities in the 2019
    Executive Order, ``Modernizing Influenza Vaccines in the United States
    to Promote National Security and Public Health,'' and apply lessons
    learned from the COVID-19 response to improve pandemic influenza
    response capabilities. Through established public-private partnerships,
    ASPR will advance non-egg-based vaccine platforms, including more
    flexible manufacturing technologies (e.g., cell-based and recombinant
    technologies) that can produce influenza vaccine more quickly in the
    event of a pandemic. The budget also supports the development of
    alternative devices for vaccine administration to allow for rapid,
    large-scale vaccinations. The COVID-19 pandemic response has
    demonstrated the importance of therapeutics that can prevent
    progression to severe disease and treat severely ill individuals.
        ASPR will continue to support the advanced development of new
    influenza therapeutics and diagnostic platforms to allow for earlier
    detection and, subsequently, faster treatment of influenza infections.
    OGA will continue to enhance international influenza preparedness by
    providing strategic coordination and technical expertise on health
    policy development and diplomacy to global partners, including nearly
    200 Ministries of Health.
        In addition, CDC provides technical expertise, resources, and
    leadership to support diagnosis, prevention, and control of influenza
    domestically and to address the threat posed by seasonal and pandemic
    influenza. The fiscal year 2022 Centers for Disease Control and
    Prevention budget request invests an additional $25 million to continue
    supporting implementation of the influenza planning and response
    activities outlined in the 2020-2030 National Influenza Vaccination
    Modernization Strategy. These activities include expanding vaccine
    effectiveness monitoring and evaluation, enhancing virus
    characterization, and expanding vaccine virus development for use by
    industry, increasing genomic testing of influenza viruses, and
    increasing influenza vaccine use.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
        Question. On August 2, 2019, the Centers for Medicare and Medicaid
    Services (CMS) finalized the Inpatient Prospective Payment System
    (IPPS) payment rule, which updated Medicare payment policies for
    hospitals in states with a low Area Wage Index (AWI). CMS's AWI
    calculation has plagued states like Alabama since its inception. Prior
    to the IPPS rule being finalized in August 2019, Alabama had the lowest
    AWI floor and ceiling of any state in the country, around .66 and .8
    respectively. The IPPS rule made formula changes to Medicare's AWI for
    fiscal years 2020--2024, which have benefitted several states to this
    point, including Alabama, by boosting annual hospital revenue for
    Alabama hospitals collectively by $35--$40 million annually, which
    saved many rural hospitals from closing their doors prior to the COVID-
    19 pandemic.
        This is an important issue to all residents of Alabama. The ability
    to deliver healthcare in small towns maintains their ability to recruit
    businesses to the area. What are your thoughts on the AWI changes that
    were made in the fiscal year 2020 IPPS final rule?
        Answer. The Inpatient Prospective Payment System (IPPS) pays
    hospitals for services provided to Medicare beneficiaries using a
    national base payment rate, adjusted for a number of factors that
    affect hospitals' costs, including the cost of hospital labor in the
    hospital's geographic area. This adjustment, or Area Wage Index, is
    updated by CMS annually.
        In the fiscal year 2020 IPPS Final Rule,\27\ to help mitigate wage
    index disparities between high wage and low hospitals, CMS adopted a
    policy to increase the wage index values for certain hospitals with low
    wage index values (the low wage index hospital policy). This policy was
    adopted in a budget neutral manner through an adjustment applied to the
    standardized amounts for all hospitals. CMS also indicated that this
    policy would be effective for at least 4 years, beginning in fiscal
    year 2020, in order to allow employee compensation increases
    implemented by these hospitals sufficient time to be reflected in the
    wage index calculation. For fiscal year 2022, CMS is continuing the low
    wage index hospital policy.
    ---------------------------------------------------------------------------
        \27\ Final Rule (CMS-1716-F) and Correction Notice (CMS-1716-CN2)
    available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
    Payment/AcuteInpatientPPS/fiscalyear2020-
    IPPS-Final-Rule-Home-Page-Items/fiscalyear2020-IPPS-Final-Rule-
    Regulations.
    ---------------------------------------------------------------------------
        Question. I understand that the pending fiscal year 2022 IPPS rule
    includes some significant policy changes regarding organ
    transplantation, which could yield a significant negative impact to
    transplant centers. Constituents have told me that the rule was written
    without input from stakeholders in the transplant community, without
    adequate analysis of the impact to patients' access to transplantation,
    and without consideration of budgetary impact, if any, on state
    Medicaid/CHIP programs. I am concerned about unintended consequences if
    this rule were to go into effect, including to access to care,
    especially for the children.
        Will you ensure that my concerns will be addressed before this rule
    is finalized? Will you also engage with all stakeholders on the issues
    I've raised?
        Answer. The Medicare Program supports organ transplantation by
    providing an equitable means of payment for the variety of organ
    acquisition services. I can assure you that CMS will take all comments
    and concerns into consideration before issuing a final decision on the
    proposed Medicare usable organ counting policy.
        Question. The overall budget requests $10.7 billion to fight the
    opioid epidemic. Previous Administrations have spent billions of
    dollars on all aspects of the epidemic including prevention, research,
    education, and treatment and there are still severe issues.
        Please provide details as to how the Department plans to spend this
    money and how it will have a different impact than the money spent
    before.
        Answer. The budget takes action to address the epidemic of opioids
    and other substance use, investing $11.2 billion, including $10.7
    billion in discretionary funding, across HHS, $3.9 billion more than in
    fiscal year 2021. The impact of this epidemic is felt in our
    communities, and the budget will direct funding to states and Tribes to
    increase community-level response. The budget will also increase access
    to medications for opioid use disorder and expand the behavioral health
    provider workforce, particularly in underserved areas. HHS will
    continue to build on the investments the American Rescue Plan provided
    to the Substance Abuse Prevention and Treatment Block Grant, Community
    Mental Health Services Block Grant, and Certified Community Behavioral
    Health Centers. This crisis is evolving--overdose deaths involving
    substances other than opioids are also increasing. HHS will ensure our
    work is responsive to the needs of communities across the country.
        Specifically, the $3.9 billion increase in funding includes:
      --FDA: +$38 million above fiscal year 2021, for a total of $113
            million, to develop opioid overdose reversal treatments and
            treatments for opioid use disorder and continue to support
            opioid research efforts.
      --HRSA: +$190 million above fiscal year 2021, for a total of $1.1
            billion to increase behavioral health workforce grant programs
            and expand response to the opioid crisis in rural communities.
      --IHS: +$27 million above fiscal year 2021, for a total of $42
            million to expand activities that increase access to culturally
            appropriate opioid use interventions, including medication-
            assisted treatment, for American Indians and Alaska Natives
            ($15 million) and improve prevention and treatment of Hepatitis
            C and HIV in tribal communities ($27 million). The prevalence
            of Hepatitis C and HIV in Indian Country is closely linked to
            rates of injection drug use.
      --CDC: +$244 million above fiscal year 2021, for a total of $733
            million to address infectious diseases associated with
            injection drug use and expand opioid overdose prevention
            programs to communities heavily impacted by the overdose
            crisis. The additional resources will support collection and
            reporting of real-time, robust mortality data and investments
            in prevention for people put at highest risk as well as for
            testing, diagnosis, linkage to care, and treatment for
            infectious diseases related to injection drug use.
      --NIH: +$627 million above fiscal year 2021, for a total of $2.2
            billion to increase opioid, stimulant, and substance use
            research. Within this total, $811 million supports the Helping
            to End Addiction Long-term (HEAL) Initiative, NIH's aggressive,
            trans-agency effort to provide scientific solutions to the
            opioid crisis. Over $1.4 billion supports ongoing research in
            this critical area.
      --SAMHSA: +$2.7 billion above fiscal year 2021, for a total of $6.8
            billion to increase funding for SAMHSA block grants and grant
            programs directing funding to local public health response to
            the substance use and opioid crisis, including Certified
            Community Behavioral Health Clinics. This increase also will
            expand access to treatment for pregnant and post-partum women,
            access to medication-assisted treatment, access to recovery
            support services, and access to drug treatment activities.
      --AHRQ: +$7 million above fiscal year 2021, for a total of $10
            million for new research grants to increase equity in substance
            use disorder (SUD) treatment access and outcomes, accelerate
            the implementation of effective evidence-based care in primary
            and ambulatory care, and develop whole person models of care
            that address the social factors that shape SUD treatment
            adherence and long-term recovery.
      --CMS: +$12.9 million above fiscal year 2021, for a total of $16.3
            million, to increase opioid activities, including funding
            certain SUPPORT Act provisions. The funding requested will be
            used for data and information technology needs, provider
            education, monitoring and auditing, performance measurement,
            and claims analysis. CMS will continue to provide technical
            assistance to states on behavioral health, developing an
            updated opioid and SUD Action Plan, working with the Office of
            National Drug Control Policy on the National Drug Control
            Strategy, and collaborate with other HHS operating divisions on
            opioid and SUD actions, behavioral health, and pain
            initiatives.
      --ACF: +$40 million above fiscal year 2021, for a total of $140
            million to increase state child abuse prevention grant funding
            focusing on developing infant safe care plans and expansion of
            kinship navigator and regional partnership grants which assist
            families at risk due to substance use of a family member.
      --ACL: +$1 million above fiscal year 2021, for a total of $3 million
            to increase grants for adult protective services and opioid-
            related activities to maximize the impact on direct services to
            the most affected clients.
        The fiscal year 2022 President's Budget provides $713 million for
    CDC's opioid overdose prevention and surveillance activities, which is
    an increase of $239 million from fiscal year 2021. With the support of
    Congress and increases in appropriations in previous years, CDC has
    scaled its overdose surveillance and prevention program from 5 states
    in 2014 to 47 states, 16 localities, and two territories today.
        With the fiscal year 2022 increased funding request, CDC would
    continue improving the timeliness and comprehensiveness of drug
    overdose data and scaling overdose prevention strategies, evaluation,
    and applied research. Because successful response strategies must be
    tailored to local communities, CDC would also use the increased funding
    to scale local investments so more local communities can quickly
    identify changes in local drug supply and prevent overdoses. The
    increased funding would also support states and communities that
    require additional resources to respond to an increase in overdoses due
    to the COVID-19 pandemic.
        Question. After significant investment over the past several years,
    state Prescription Drug Monitoring Programs (PDMPs) are still not real-
    time, not interoperable, and are not incorporated into a provider's
    workflow, yet the technology exists to fix all these issues. How does
    your budget support improvements to PDMPs and will any funds
    specifically support upgrading these systems to address the concerns
    I've outlined?
        Answer. CDC's goal is to maximize interconnectivity of all
    resources within this space. CDC's Overdose Data to Action (OD2A)
    program expanded previous Prescription Drug Monitoring Program (PDMP)
    investments and has worked to make PDMPs easier to use and more
    accessible to both clinicians and under-resourced communities. Under
    OD2A, required activities related to PDMPs include:
      --Universal use among providers within a state
      --Inclusion of more timely or real-time data contained within a PDMP
      --Actively managing the PDMP in part by sending proactive or
            unsolicited reports to providers to inform prescribing
      --Ensuring that PDMPs are easy to use and access by providers
      --Propose activities to enhance and maximize the use of PDMPs, such
            as moving towards real-time data collection
        In addition to the base OD2A funding provided to recipients to
    implement required PDMP activities, states were provided with the
    option to apply for additional funds to make PDMP data more actionable
    both within and across state borders. Activities under this
    supplemental funding include integrating state PDMPs with other health
    systems data and integrating the PDMP across state lines/interstate
    operability.
        With Federal funding and substantial technical assistance provided
    by CDC, the Bureau of Justice Administration (BJA), the Centers for
    Medicaid & Medicare Services (CMS),SAMHSA, and the Office of the
    National Coordinator for Health Information Technology (ONC), states
    have made significant strides in reporting data faster and achieving
    interstate and intrastate PDMP operability, most commonly via the
    RxCheck hub or PMP Interconnect. As of May 2021, there are 46
    jurisdictions that are live on the RxCheck hub and actively able to
    share data across state lines. PMP Interconnect, from the National
    Association of Boards of Pharmacy, currently includes 51 participating
    jurisdictions. In addition to those jurisdictions sharing data across
    states, 45 states and territories are also engaged in intrastate
    integration with electronic health records (EHRs), Health Information
    Exchanges (HIEs), and Pharmacy Dispensing Systems. CDC collaborated
    with other Federal partners to support PDMP/EHR integration in states
    through several different projects, including OD2A. CDC also
    collaborated with Office of the National Coordinator for Health
    Information Technology to select three states (Kentucky, Utah, and
    Illinois) as pilots to demonstrate how to integrate PDMP data with EHR
    information through the RxCheck Hub.
        Currently, only the Oklahoma PDMP has real-time data reporting.
    However, 49 state, district, and territory PDMPs have daily or next day
    reporting. CDC and BJA funds continue to help states report data
    faster. For example, Maine is moving towards real-time PDMP reporting
    by using CDC funds to support reporting dispensed controlled substances
    no later than the next business day. With fiscal year 2022 funds, CDC's
    OD2A program will continue supporting states to improve PDMPs and
    maximize interconnectivity. CDC will also support states to increase
    data sharing within states, particularly increasing PDMP data within
    EHRs and HIEs.
        Question. What are your thoughts on continuing the CMS issued
    flexibilities around telehealth once the Public Health Emergency has
    ended?
        Answer. Telehealth is an important tool to improve health equity
    and improve access to healthcare. Healthcare should be accessible, no
    matter where you live. HHS continues to examine the telehealth
    flexibilities developed for the current public health emergency and
    determine how we can build on this work to improve health equity and
    improve access to healthcare. In addition to looking at which
    flexibilities HHS can and should continue administratively, I look
    forward to working with Congress to address changes that may need to be
    done through legislation.
                                     ______

                   Questions Submitted by Senator Jerry Moran
        Question. Before turning to the fiscal year 2022 budget request, I
    would like to discuss the remaining money in the Provider Relief Fund.
    According to May data from the Health Resources and Services Agency,
    there is around $24 billion left in the PRF plus the additional $8.5
    billion allocated to rural healthcare providers in the American Rescue
    Plan. While HHS has rolled out programs using some of the remaining PRF
    funding, I want to ensure the PRF is still serving its original purpose
    of protecting healthcare facilities.
        Are you considering allocating any of the remaining PRF funds to
    assist rural hospitals who may still be struggling in the aftermath of
    the pandemic?
        Answer. HHS is committed to distributing the remaining provider
    relief payments as quickly, transparently, and equitably as possible
    while utilizing effective safeguards to protect taxpayer dollars. HHS
    is planning for future Provider Relief Fund (PRF) allocations,
    including the $8.5 billion from American Rescue Plan Act and Phase 4 of
    the General Distribution.
        HHS is actively considering feedback from stakeholders, as well as
    operational lessons learned from prior PRF payments, as part of the
    planning process. The feedback from Members of Congress and other
    stakeholders informs HHS' ability to administer the PRF in a manner
    that bolsters the healthcare system and helps providers experiencing
    COVID-related financial hardships during this crisis. HHS will publish
    additional information on future distributions on the Health Resources
    and Services Administration's PRF webpage, at www.hrsa.gov/provider-
    relief, as soon as it becomes available.
        Question. The CARES Act established the PRF to prevent hospitals
    from closing during the most severe pandemic mitigation measures and
    rural hospitals in particular needed this financial assistance. While
    the PRF was largely successful, hospitals that opened in late 2019 did
    not receive enough relief and are now strapped for cash. Rock Regional
    in Derby, Kansas, which opened just months before the pandemic in 2019,
    is one such hospital that deserves more PRF funding under the
    guidelines of the Consolidated Appropriations Act of 2021.
        Would you consider reopening Phase 3 PRF applications to accept
    updated documentation consistent with guidelines of the Consolidated
    Appropriations Act?
        Answer. In processing PRF applications, HHS has sought to make
    payments as quickly and equitably as possible while taking appropriate
    precautions to safeguard taxpayer dollars. HHS recognizes that
    providers may have questions regarding the accuracy of their PRF
    payments. HHS will provide any updates on Phase 3 payments on the
    Health Resources and Services Administration's PRF webpage, at
    www.hrsa.gov/providerrelief, as soon as they becomes available.
        Question. Given the purpose of the PRF, if hospitals are still
    struggling, that ought to lead to consideration of a Tranche 4
    targeting such healthcare facilities, especially those that opened in
    2019.
        Is this something you will consider as you look at allocating the
    remaining PRF funding?
        Answer. As HHS plans for future Provider Relief Fund (PRF)
    allocations, including the $8.5 billion from American Rescue Plan Act
    and Phase 4 of the General Distribution, we are cognizant that
    hospitals that began operating in 2019 and 2020 are facing unique
    financial burdens related to the pandemic. Under the previous PRF
    distribution payment methodology, HHS paid new providers based on the
    average lost revenues and increased expenses for their provider type to
    avoid disadvantaging these entities.
        As we move forward, HHS is actively considering feedback from
    stakeholders, as well as operational lessons learned from prior PRF
    payments, as part of the planning process for future funding. The
    feedback from Members of Congress and other stakeholders informs HHS'
    ability to administer the PRF in a manner that bolsters the healthcare
    system and helps providers experiencing COVID-related financial
    hardships during this crisis.
        HHS will publish additional information on future distributions on
    the Health Resources and Services Administration's PRF webpage, at
    www.hrsa.gov/provider-relief, as soon as it is available.
        Question. I have been concerned with the challenges that the senior
    living community has faced throughout the duration of the pandemic.
    Long-term care and assisted living facilities were tasked with caring
    for the population most vulnerable to COVID-19. In caring for the over
    two million seniors across the country, these facilities faced
    increasing costs in protecting residents and their staff. As you have
    heard me mention before, these senior living facilities have not been
    receiving enough support from HHS and are in need of assistance.
        Can you confirm that senior and assisted living facilities will
    actually see meaningful financial support from the remaining Provider
    Relief Fund money in a timely manner?
        Answer. As of June 4, 2021, over 10 percent of the total PRF
    payments made and kept by providers were directed to nursing homes,
    assisted living facilities, and skilled nursing facilities, including
    more than $9 billion in PRF Targeted Distribution payments and over $3
    billion in PRF General Distribution payments to provider organizations
    with at least one nursing home, skilled nursing facility, assisted
    living facility, or long term care facility.
        HHS appreciates the care being given to seniors across the nation
    and recognizes that some assisted living facilities are still
    experiencing financial burdens related to the pandemic. HHS is
    committed to distributing the remaining provider relief payments as
    quickly and equitably as possible while utilizing effective safeguards
    to protect taxpayer dollars. At present, HHS is planning a Phase 4 of
    the General Distribution. Congress also appropriated an additional $8.5
    billion, which has not yet been obligated, in the American Rescue Plan
    Act for Medicare and Medicaid providers and suppliers in rural areas or
    who serve rural patients.
        HHS is actively considering feedback from stakeholders, as well as
    operational lessons learned from prior PRF payments, as part of the
    planning process. The feedback from Members of Congress and other
    stakeholders informs HHS' ability to administer the PRF in a manner
    that bolsters the healthcare system and helps providers experiencing
    COVID-related financial hardships during this crisis. HHS will publish
    additional information on future distributions on the Health Resources
    and Services Administration's PRF webpage, at www.hrsa.gov/provider-
    relief, as soon as it becomes available.
        Question. I would like to ask about your approach to Community
    Health Centers. Health Centers in Kansas have been among the leaders in
    responding to the COVID-19 pandemic. Since the beginning of the year,
    Kansas Health Centers have tested nearly 20,000 patients and
    administered vaccines for over 48,000 patients. The fiscal year 2022
    budget request mentions the Administration looks forward to working
    with Congress to advance the President's goal of doubling the Federal
    investment in community health centers. However, the budget also
    included a $45 million cut to the overall program due to budget
    sequestration.
        Could you please discuss HHS' support for greater health center
    funding and how you intend to work with Congress to double Federal
    investments in community health centers?
        Answer. HRSA supports the President's goal to double the Federal
    investment in community health centers and looks forward to working
    with Congress to expand the Health Center Program to: (1) increase
    access to primary medical care services in the high need communities;
    (2) ensure that health center patients receive a full range of
    comprehensive primary healthcare services; (3) improve health outcomes
    and reduce health disparities through new, evidence-based and
    innovative approaches to care; and (4) invest in local healthcare
    infrastructure and expand employment opportunities in medically
    underserved communities.
        Question. As I'm sure you're aware, the Children's Hospital
    Graduate Medical Education (CHGME) program supports the specialized
    training that occurs in many children's hospitals. For example,
    Children's Mercy in Kansas City trains the majority of pediatricians
    that serve the state of Kansas, instructing nearly 230 pediatric
    residents and fellows annually. The fiscal year 2022 budget request
    included $350 million for CHGME, marking the first time since fiscal
    year 2021 the budget request included a separate request for CHGME.
        Could you expand on HHS' goals for the separate funding request and
    fiscal year 2022 increase for the CHGME?
        Answer. The budget requests $350 million for CHGME to provide
    continued support for the pediatric workforce. The funding amount of
    $350 million aligns with the fiscal year 2021 enacted funding level and
    is expected to support approximately 7,700 resident full-time
    equivalents (FTEs). CHGME payments are for direct and indirect medical
    expenses for medical residency training programs. The funding will also
    support contracts to meet legislative requirements such as the FTE
    reconciliation which ensures correct reporting and that residents are
    not funded by other Federal programs to prevent duplicate payments.
                                     ______

                  Questions Submitted by Senator John Kennedy
        Question. A recent report indicated that HHS has approximately $24
    billion in unspent CARES funding. Many healthcare providers are still
    working their way through the financial effects of the COVID-19
    pandemic, and this funding is crucial.
        Can you indicate if healthcare providers, including air ambulances,
    can expect to see this funding made available, or will you be returning
    unspent CARES funding so that we can reduce the overall financial
    impact of spending related to the pandemic response?
        Answer. HHS is committed to distributing the remaining provider
    relief payments as quickly, transparently, and equitably as possible
    while utilizing effective safeguards to protect taxpayer dollars. HHS
    is planning for future Provider Relief Fund (PRF) allocations.
        HHS is actively considering feedback from stakeholders, as well as
    operational lessons learned from prior PRF payments, as part of the
    planning process. The feedback from Members of Congress and other
    stakeholders informs HHS' ability to administer the PRF in a manner
    that bolsters the healthcare system and helps providers experiencing
    COVID-related financial hardships during this crisis. HHS will publish
    additional information on future distributions on the Health Resources
    and Services Administration's PRF webpage, at www.hrsa.gov/provider-
    relief, as soon as it becomes available.
        Question. If HHS is going to retain unspent CARES Act funds, can it
    be used to waive recoupment of Medicare Advanced Payments?
        Answer. HHS is committed to distributing the remaining provider
    relief payments as quickly, transparently, and equitably as possible
    while utilizing effective safeguards to protect taxpayer dollars. HHS
    is planning for future Provider Relief Fund (PRF) allocations.
        As we move forward, HHS is actively considering feedback from
    stakeholders, as well as operational lessons learned from prior PRF
    payments, as part of the planning process for future funding. The
    feedback from Members of Congress and other stakeholders informs HHS'
    ability to administer the PRF in a manner that bolsters the healthcare
    system and helps providers experiencing COVID-related financial
    hardships during this crisis.
        HHS will publish additional information on future distributions on
    the Health Resources and Services Administration's PRF webpage, at
    www.hrsa.gov/provider-relief, as soon as it is available.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. Secretary Becerra, new data has just been released by
    NORC at the University of Chicago finding that nearly two-thirds of
    assisted living facilities reported no deaths from COVID-19 in 2020.
    Despite this positive data, some have expressed concerns assisted
    living providers caring for nearly 2 million elderly individuals have
    received less than 1 percent of all provider relief funding to date. It
    is my understanding that assisted living providers expended a great
    deal of capital in order to ensure COVID-19 safety in their facilities,
    as well as to compete for staffing in a tight nursing labor market. I
    have been informed that assisted living caregivers will suffer $30
    billion in losses through June 2021 due to these efforts and that over
    half of assisted living facilities nation-wide are operating at a loss
    currently.
        How can HHS help support these assisted living providers, through
    the PRF and otherwise?
        Answer. As of June 4, 2021, over 10 percent of the total PRF
    payments made and kept by providers were directed to nursing homes,
    assisted living facilities, and skilled nursing facilities, including
    more than $9 billion in PRF Targeted Distribution payments and over $3
    billion in PRF General Distribution payments to provider organizations
    with at least one nursing home, skilled nursing facility, assisted
    living facility, or long term care facility.
        HHS appreciates the care being given to seniors across the nation
    and recognizes that some assisted living facilities are still
    experiencing financial burdens related to the pandemic. HHS is
    committed to distributing the remaining provider relief payments as
    quickly and equitably as possible while utilizing effective safeguards
    to protect taxpayer dollars.
        HHS is actively considering feedback from stakeholders, as well as
    operational lessons learned from prior PRF payments, as part of the
    planning process. The feedback from Members of Congress and other
    stakeholders informs HHS' ability to administer the PRF in a manner
    that bolsters the healthcare system and helps providers experiencing
    COVID-related financial hardships during this crisis. HHS will publish
    additional information on future distributions on the Health Resources
    and Services Administration's PRF webpage, at www.hrsa.gov/provider-
    relief, as soon as it becomes available.
        Question. Your budget calls for the elimination of the Hyde
    Amendment to allow taxpayer funding of abortion through Medicaid,
    Medicare, and other programs under Labor/HHS appropriations.
        Why is this Administration insistent on reversing four decades of
    bipartisan precedent and ignoring the will of most Americans who object
    to their tax dollars funding the destruction of human life?
        Answer. The Hyde Amendment disproportionately impacts the growing
    number of low-income, women of color who are enrolled in Medicaid, and
    is a barrier to expanding access to healthcare. That is why the
    President's first budget calls for Congress to remove the restriction
    from government spending bills.
        The Department of Health & Human Services implements the laws that
    Congress passes. Implementation of any changes in coverage related to
    the President's Budget would depend on the final language Congress
    passes. After passage of any legislation, agency staff and counsel
    review the language to determine the agency's authority and options for
    implementation action, such as initiating notice and comment rulemaking
    or issuing guidance documents.
        Question. Your budget proposes a 19 percent increase in funding for
    the Title X family planning program by $53.521 million to $340 million
    from $286.479 million. I am concerned that Title X will be a slush fund
    for Planned Parenthood and the abortion industry.
        Can you ensure that these new funds will not be used to bolster
    abortion giant Planned Parenthood and its cohorts?
        Answer. The Title X program does not provide abortion services.
    Section 1008 of the Public Health Service Act specifically states that
    ``None of the funds appropriated under this title shall be used in
    programs where abortion is a method of family planning.'' Consistent
    with the program's statute and regulations, any public or private
    nonprofit organizations, including faith-based organizations, state,
    county, local, and tribal governments, school districts, and public and
    state higher education institutions are eligible to apply for Title X
    grant funds. Title X's regulations, in the NPRM, also clearly define
    the criteria the Department uses to decide which family planning
    services projects to fund and in what amount.
        Question. As you know, the previous administration disallowed $200
    million in Medicaid funds from California because it was literally
    forcing nuns to buy abortion insurance in violation of conscience
    protection laws.
        Will you commit to not reversing the findings made by career
    professionals supporting the disallowance and not otherwise restoring
    the money to California?
        Answer. In my ethics agreement signed on January 17, 2021, and the
    subsequent authorization issued on March 31, 2021, I have agreed not to
    participate in any litigation involving the State of California that
    was pending during my tenure as Attorney General. I understand that
    there has been no litigation on this matter, however, as Attorney
    General I did issue a public statement on the matter. After consulting
    with the HHS Acting Designated Agency Ethics Official, I have
    determined that it is prudent for me to recuse myself from this
    Medicaid financing matter to avoid even an appearance of impropriety. I
    trust that the very talented employees of the Department who, at the
    working level, handle the vast amounts of work, including specific
    enforcement and program financing matters, will resolve this matter in
    a manner that is consistent with the Department's obligations and in
    the best interest of the American people. If leadership input is
    required, the Chief of Staff will either handle the case without any
    input from me or will refer the case to the appropriate person for
    decision.
        Question. Your budget asks for a $9 million increase for the Office
    for Civil Rights (OCR), yet OCR inherited over $60 million in
    enforcement settlement funds that you are free to use right now to
    support the bulk of OCR operations.
        Do you think it is appropriate for you to ask Congress for more
    taxpayer money for an Office that is sitting on such a huge sum of
    money?
        Answer. The Health Insurance Portability and Accountability Act of
    1996 ( HIPAA) law requires the Office for Civil Rights (OCR) to spend
    any money that it collects in HIPAA settlements on HIPAA enforcement
    only. This means that these funds are limited in their use as directed
    by Congress.
        The proposed increase in OCR's budget would support civil rights
    authorities and operations, specifically working on improving overall
    enforcement stemming from OCR's authority over healthcare.
        Question. Will you commit to preserving the Conscience and
    Religious Freedom Division as a Division within OCR?
        Answer. HHS will continue to protect the religious, civil, and
    constitutional rights of all Americans. This means that we will
    continue to enforce conscience and religious freedom protections,
    including receiving complaints, investigating cases, and making
    findings consistent with the law.
        Question. A few weeks ago you announced that HHS will interpret
    prohibitions on sex discrimination in healthcare to include ``sexual
    orientation and gender identity.''
        As I read your announcement, male or female are no longer to be
    understood as being based on biology. What does it mean to be a man or
    a woman going forward under these laws?
        Under your announcement, do doctors, who receive HHS funding, have
    a right to decline to perform procedures that violate their religious
    beliefs or conscience?
        Do you favor HHS funds being available for sex-reassignment
    surgeries in minors? If so, please explain your justification under
    current Federal law.
        Do you favor HHS funds being available for puberty blockers and
    cross-sex hormones for young children? If so, please explain your
    justification under current Federal law.
        Answer. HHS will continue to protect the religious, civil,
    constitutional rights of all Americans.
        Question. As of this week over 60 percent of Americans have
    received at least one dose of the COVID-19 vaccine. This extraordinary
    milestone was made possible by the unprecedented speed of developing a
    vaccine less than 1 year after the start of the COVID-19 pandemic.
    However, when the next pandemic hits, the U.S. will need to move even
    faster. With the frequency of epidemics and pandemics increasing, the
    next fast-moving, novel infectious disease pandemic could occur within
    the next 10 years. In addition to naturally occurring threats, rapid
    advances in biotechnology increase the chance that novel pathogens
    could be created with the potential to start major outbreaks. Given the
    uncertainty about how the next pandemic will arise, we must harness
    innovative technologies, outside the box thinking, and game changing
    science to develop countermeasures that are pathogen-agnostic. In the
    fiscal year 2021 House and Senate Committee Reports we included
    language that encouraged the Department to work with the Department of
    Defense to implement a dedicated medical countermeasures program
    focused on developing flexible vaccines and antiviral treatments to
    address emerging and previously unidentified infectious disease
    threats, referred to as Disease X.
        Mr. Secretary, what progress has the Department made in
    implementing such a program?
        How is the Department planning to develop countermeasures for
    previously unidentified viral threats?
        Answer. The U.S. Department of Health and Human Services recognizes
    the importance of developing flexible, broadly applicable technologies
    for the development of medical countermeasures, especially vaccines, to
    be able to respond quickly to emerging infectious diseases. The
    development of highly adaptable vaccine platforms and structural
    biology tools enabling the design of novel and improved immunogens have
    helped usher in a new era of vaccinology. In addition, the development
    of broadly acting antivirals and other therapeutics will be critical as
    we prepare to respond to a future Disease X.
        The National Institute of Allergy and Infectious Diseases (NIAID)
    at the National Institutes of Health (NIH) supports and conducts
    research to both identify previously unidentified viral threats and to
    develop medical countermeasures that can be used to respond to them. On
    August 27, 2020, NIAID established the Centers for Research in Emerging
    Infectious Diseases (CREID), a multidisciplinary global network that
    seeks to identify how and where viruses and other pathogens emerge from
    wildlife and spillover to cause disease in people. The CREID network,
    along with other U.S. Government funded global surveillance efforts,
    will enable early warnings of emerging diseases wherever they occur,
    facilitate a coordinated outbreak response to an emerging virus, and
    may be a crucial tool in early identification of a future Disease X
    with pandemic potential. This program will build upon prior U.S.
    Government efforts in global disease surveillance and complement
    important ongoing activities supported by Federal partners.
        NIAID supports basic, translational, and clinical research to
    develop novel medical countermeasures, including novel vaccine
    platforms, adjuvants, and directly acting oral antivirals. These
    medical countermeasures are often developed for broad pathogen families
    and can be quickly modified for efficacy against related emerging
    pathogens with pandemic potential. NIAID also makes available to the
    broader research community a suite of preclinical services that can
    help lower the risk to developers and help to advance novel
    diagnostics, therapeutics, and vaccines. In addition, NIAID has
    leveraged and strengthened global and domestic clinical research
    networks to facilitate preparedness for rapid launch of clinical trials
    in outbreak situations. These long-standing NIAID investments were
    crucial to the response to the emergence of severe acute respiratory
    syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19.
    For example, the NIAID Vaccine Research Center played a key role in
    both the development of novel vaccine platforms and the design of the
    stabilized prefusion spike protein immunogen used in all three of the
    COVID-19 vaccines currently authorized under an Emergency Use
    Authorization from the FDA. The development--in record time--of these
    highly efficacious vaccines with the potential for saving millions of
    lives was only possible through an extraordinary multidisciplinary
    effort leveraging decades of basic, preclinical, and clinical science.
        NIH- and NIAID-supported advances in medical countermeasure
    research and development, as well as other efforts across HHS to
    prepare for novel disease threats, were vital to the Federal response
    to COVID-19. Throughout the COVID-19 pandemic, NIH has supported HHS'
    efforts to leverage highly productive public-private partnerships with
    industry, academia, and the public-sector; utilize longstanding
    relationships with community partners to facilitate the biomedical
    research response; and engage existing domestic and international
    research infrastructure to respond to COVID-19. The whole-of-government
    approach that began under Operation Warp Speed and has continued under
    the current HHS and Department of Defense Countermeasure Acceleration
    Group partnership has efficiently supported the development of safe and
    effective COVID-19 medical countermeasures. This effort led to the
    rapid identification and clinical testing of candidate therapeutics for
    the treatment of COVID-19, as well as multiple COVID-19 vaccine
    candidates that progressed in record time from concept to FDA emergency
    use authorization. Lessons learned from the Federal response to COVID-
    19 will be used to inform future pandemic preparedness efforts at NIH
    and across HHS.
        In addition to developing platforms that allow for the accelerated
    development of vaccines for emerging pathogens, there is a need to move
    beyond chasing the different viral strains or variants as they emerge.
    NIAID is leading efforts to develop ``universal'' influenza vaccines to
    protect against multiple strains of seasonal and pandemic influenza
    viruses that may emerge. NIAID also is conducting early-stage research
    on the development of pan-coronavirus vaccines designed to provide
    broadly protective immunity against multiple coronaviruses, especially
    SARS-CoV-2 and others with pandemic potential. New viral threats will
    continue to emerge, and the development of universal influenza vaccines
    and pan-coronavirus vaccines will help us be better prepared for future
    infectious disease threats.
        Gaining a deeper understanding of the interplay between pathogens
    and the human immune system also could expedite the development of
    medical countermeasures against emerging pathogens. NIAID supports a
    number of research initiatives to define human immune mechanisms that
    provide protective anti-viral immunity or contribute to disease
    pathogenesis. For example, the NIAID Vaccine Research Center is
    establishing the Pandemic Response Repository through Microbial/Immune
    Surveillance and Epidemiology (PREMISE) program. This program will use
    data from T and B cell immune surveillance to inform diagnostic,
    prophylactic, and therapeutic countermeasures and accelerate the global
    response to pandemic threats. NIAID anticipates the research conducted
    by PREMISE, and other similar NIAID initiatives, will advance our
    knowledge of the immune response to vaccination and infection and help
    inform the response to future pandemic threats.
        The COVID-19 pandemic is an important reminder of the value of
    sustained and robust support for the U.S. biomedical research
    enterprise, which continues to accelerate the development of medical
    countermeasures to protect against emerging and re-emerging infectious
    diseases. NIH remains committed to working with our partners across the
    Federal Government to continue advancing the research that will help us
    respond to future pandemic threats from Disease X. NIAID will continue
    to support the development of flexible vaccine platforms, novel
    adjuvants, and antiviral treatments to address emerging and previously
    unidentified infectious disease threats. NIAID also anticipates
    launching new initiatives focused on preparing for future pandemic
    threats from Disease X. These initiatives will continue to build on
    long-standing NIAID efforts in this area, as well as lessons learned
    from the research response to COVID-19.
        Question. As you know from your previous role as a Member of the
    Ways and Means Committee, chronic kidney disease (CKD) is unique to
    Medicare in that individuals with irreversible kidney failure are
    eligible for Medicare regardless of age or other disability. Over its
    nearly 50-year existence, this unique coverage has saved tens of
    thousands of lives, including 750,000 Americans who currently are on
    dialysis or who have a functioning kidney transplant. Individuals with
    chronic kidney disease cost Medicare $130 billion in fee-for-service
    spending per year, almost $50 million of which is for patients with
    irreversible kidney failure. Kidney failure patients represent 1
    percent of Medicare beneficiaries but 7 percent of FFS expenditures.
    Improving detection and care of early stage CKD can help reduce health
    expenditures and improve patients' lives, yet an estimated 90 percent
    of our nation's 37 million adults with CKD are unaware they have it.
        How will you prioritize changes at your Department to expand the
    focus on awareness, early detection, and early treatment to help
    prolong kidney function and help ensure the solvency of Medicare?
        Nearly 20 years ago, the CDC created the Chronic Kidney Disease
    Initiative to increase awareness of the disease and expand public
    health surveillance activities. Unfortunately, funding has been mostly
    stagnant throughout its history, and it currently receives only $2.6
    million, despite the tremendous cost of CKD to society, Medicare, and
    Medicaid. The previous Administration created the Advancing American
    Kidney Health Initiative, which was very favorably received by the
    kidney community. One of the most important goals of AAKH, correlating
    to the CDC kidney initiative, was to increase awareness and early
    detection of kidney disease via a national kidney disease awareness
    public health initiative.
        Please comment on efforts to expand the Chronic Kidney Disease
    Initiative to meet this awareness and early detection need.
        COVID-19 has disproportionately affected kidney patients, who have
    experienced some of the highest rates of hospitalization and mortality
    from the pandemic. Additionally, COVID-19 is linked to acute kidney
    injury (AKI) and to kidney disease in recovering COVID-19 patients who
    have no prior history of kidney disease. A March 2021 study from Yale
    University indicates that AKI occurred in up to 57 percent of COVID-19
    hospitalizations and 78 percent of intensive care unit admissions. In
    addition, reports from early in the pandemic indicate that barely a
    third of patients who developed AKI had not yet recovered baseline
    kidney function at a median of 21 days after leaving the hospital.
    (https://www.ajmc.com/view/study-illustrates-kidney-impact-after-covid-
    19-resolves)
        Without intervention, these patients could develop chronic kidney
    disease. What steps will HHS take to ensure COVID-19 patients have
    access to the kidney services and care they need going forward?
        Answer. Many beneficiaries with end-stage renal disease (ESRD)
    suffer from poor health outcomes and face increased risk of
    complications with underlying diseases. For example, people with ESRD
    who get coronavirus disease 2019 (COVID-19) have higher rates of
    hospitalization. Last year, CMS established the End-Stage Renal Disease
    (ESRD) Treatment Choices (ETC) Model, a mandatory Medicare payment
    model tested under the authority of section 1115A of the Social
    Security Act. The ETC Model tests the use of payment adjustments to
    encourage greater utilization of home dialysis and kidney transplants,
    in order to preserve or enhance the quality of care furnished to
    Medicare beneficiaries while reducing Medicare expenditures. This
    payment model is expected to encourage participating healthcare
    providers to invest in and build their home dialysis programs, allowing
    patients to receive care in the comfort and safety of their home. Home
    dialysis gives patients the freedom to choose the therapy that works
    best with their lifestyles, without being tied to the dialysis
    facility's schedule. The ETC Model also includes financial incentives
    for participating ESRD facilities and clinicians to encourage
    transplantation based on their transplant rate, calculated as the sum
    of the transplant waitlist rate and the living donor transplant rate.
        Increasing access to affordable coverage will increase access to
    care, including preventive services and treatments that prolong kidney
    function. The President's fiscal year 2022 Budget includes numerous
    provisions that would work together to give Americans additional,
    lower-cost coverage options. One provision would give people age 60 and
    older the option to enroll in the Medicare program with the same
    premiums and benefits as current beneficiaries, but with financing
    separate from the Medicare Trust Fund. In States that have not expanded
    Medicaid, the President has proposed extending coverage to millions of
    people by providing premium-free, Medicaid-like coverage through a
    Federal public option.
        Question. Sec Becerra, as you know, influenza occurs seasonally
    each year and throughout history has caused devastating pandemics--
    including the 1918 pandemic that killed an estimated 675,000 Americans.
    While this year's flu season was extremely mild, next year's could be
    much worse. The U.S. National Influenza Vaccine Modernization Strategy
    was released 1 year ago, with an ambitious vision of a domestic
    influenza vaccine enterprise that is highly responsive, flexible,
    scalable, and more effective at reducing the impact of seasonal and
    pandemic influenza viruses. The HHS Budget included a $25 million
    increase within CDC's Influenza Division and a $48 million increase for
    ASPR Pan Flu.
        Are these resources sufficient? The previous administration
    estimated $1billion over 10 years would be needed to sufficiently
    resource the Strategy.
        Answer. ASPR/BARDA has a long and successful history of focused
    efforts to invest in increasing influenza vaccine production capacity
    in preparation for a pandemic influenza response. While these efforts
    benefit seasonal influenza (e.g., cell-based vaccine, recombinant
    protein vaccine), they are not specific for seasonal influenza. In
    2020, ASPR/BARDA also worked with industry to develop respiratory panel
    diagnostics that test for influenza and SARS-CoV-2 infection
    simultaneously. ASPR/BARDA looks forward to continuing these efforts as
    part of the National Influenza Vaccine Modernization Strategy and
    working with our colleagues at NIAID supporting early development of a
    universal influenza vaccine.
        Question. Sec Becerra, the Administration has requested $30 billion
    over 4 years in mandatory funding to protect Americans from the next
    pandemic. According to the latest budget request, $24 billion of that
    would be allocated to HHS for medical countermeasures manufacturing and
    other initiatives.
        Please elaborate on the need for this $30 billion investment.
        Answer. The President's request for $30 billion over 4 years would
    help protect Americans from future pandemics through major new
    investments in medical countermeasures manufacturing; research and
    development; and related biopreparedness and biosecurity. This includes
    investments to shore up our nation's strategic national stockpile;
    accelerate the timeline to research, develop and field tests and
    therapeutics for emerging and future outbreaks; accelerate response
    time by developing prototype vaccines through Phase I and II trials,
    test technologies for the rapid scaling of vaccine production, and
    ensure sufficient production capacity in an emergency; enhance U.S.
    infrastructure for biopreparedness and investments in biosafety and
    biosecurity; train personnel for epidemic and pandemic response; and
    onshore active pharmaceutical ingredients. COVID-19 has claimed
    hundreds of thousands of American lives and cost trillions of dollars,
    demonstrating the devastating and increasing risk of pandemics and
    other biological threats. The American Rescue Plan serves as an initial
    investment of $10 billion. With this new major investment in preventing
    future pandemics, the United States will build on the momentum from the
    American Rescue Plan, bolster scientific leadership, create jobs,
    markedly decrease the time from discovering a new threat to putting
    shots in arms, and prevent or mitigate future biological catastrophes.
        Question. Will any of these funds be targeted at influenza, which
    has the potential for a pandemic even more devastating than Covid-19?
        Answer. HHS will follow the requirements spelled out in statute and
    follow the latest science in directing resources toward current and
    future pandemics.
        Question. Please also provide greater clarity into how those funds
    would be allocated within HHS.
        Answer. HHS is thankful for the resources provided by Congress to
    address the COVID-19 pandemic. We will follow the statutory
    requirements for use of funds appropriated to HHS and take a broad
    approach to addressing COVID-19 by continuing to support research on
    prevention, therapeutics, and vaccines; supporting workforce expansion
    to ensure equitable distribution of vaccines and therapeutics;
    investing in testing and screening to allow our schools and businesses
    to remain open; addressing our supply chain and manufacturing
    challenges; as well as addressing the mental health of those affected
    by COVID-19 whether they lost a family member or friend, suffered
    COVID-19, or lost the ability to fully participate in significant life
    events over the past 18 months or more. We will invest in the science
    and follow the science during this unprecedented time and do our best
    to address the challenges it has brought to our public health
    infrastructure.
        Question. One of the silver linings of this pandemic has been the
    wide-spread adoption of technology to bring people together, whether it
    be families scattered across the nation or patients and their
    providers. We have seen exponential growth in telehealth adoption
    across Americans of all ages, locations, and conditions. Telehealth
    among Medicare beneficiaries has been made possible by temporary
    flexibilities in place for the duration of the public health emergency.
        These include allowing Medicare beneficiaries to have telehealth
    visits from their home, regardless of where they live across the
    country. This has also allowed new types of providers, such as physical
    therapists and speech pathologists to practice via telehealth.
        Sec. Becerra, do you agree that access to telehealth has been
    critical to protecting patients and providers during the nation's
    response to COVID-19? b.Sec. Becerra, do you agree that providers and
    beneficiaries have seen immense value from expanded access to
    telehealth over the past year? Do you agree that Americans have been
    overwhelming satisfied with care received virtually during the
    pandemic?
        Sec. Becerra, can you tell us where telehealth ranks in terms of
    your priorities? d.Sec. Becerra, how can Congress ensure that Medicare
    beneficiaries do not lose access to telehealth after the public health
    emergency expires?
        Will you commit to working with Congress to ensure that the
    millions of Medicare beneficiaries enrolled in fee-for-service Medicare
    do not face a telehealth service coverage cliff when the public health
    emergency expires?
        Sec. Becerra, as Congress considers permanent telehealth reform, we
    will need your support, including an evidence-based assessment of how
    many of the telehealth flexibilities extended in response to the
    pandemic impacted both the Medicare program and beneficiaries. With
    that said, do you believe that there are some telehealth regulatory
    restrictions that Congress and HHS can work together to address in the
    near term that do not require additional data?
        About 46 million Americans, nearly 15 percent of the U.S.
    population live in rural areas. Those living in rural areas are more
    likely to die prematurely and face higher risks for chronic conditions
    like heart disease and diabetes. Americans living in rural communities
    face 17 percent higher prevalence of diabetes than those living in
    urban areas and may have to wait months before needing to travel great
    distances to see an endocrinologist to help manage their condition.
    This scenario is not uncommon and instead is the reality of rural
    Americans that routinely encounter not just a lack of specialty care,
    but in my cases, primary care. Digital health tools, including
    telehealth and remote monitoring, have the potential to relieve some of
    the key healthcare challenges facing rural America.
        Sec. Becerra, can you speak to the promise and value of telehealth
    and digital health more broadly to rural communities?
        Answer. Telehealth is an important tool to improve health equity
    and improve access to healthcare. Healthcare should be accessible, no
    matter where you live. HHS continues to examine the telehealth
    flexibilities developed for the current public health emergency and
    determine how we can build on this work to improve health equity and
    improve access to healthcare. In addition to looking at which
    flexibilities HHS can and should continue administratively, I look
    forward to working with Congress to address changes that may need to be
    done through legislation.
        Throughout the pandemic, telehealth services have filled an urgent
    need to maintain access to care while social distancing was necessary.
    For example, federally Qualified Health Centers and Rural Health
    Clinics were able to be paid by Medicare as distant site telehealth
    service providers, which had not been permitted outside of the COVID-19
    public health emergency. After the pandemic, HHS will continue to
    support telehealth services. HHS is currently reviewing the telehealth
    flexibilities developed for the current public health emergency to
    determine which can and should continue after the public health
    emergency has ended. HHS plans to continue to support telehealth after
    the pandemic through resources like the Telehealth.HHS.gov website and
    the Telehealth Resource Centers so patients and providers have access
    to telehealth technical assistance.
        Question. More than 147 million Americans are living with chronic
    conditions. It's estimated that 180 million Americans are living with
    mental health challenges. According to a 2017 RAND Corporation Study,
    90 percent of the US healthcare spend is on chronic conditions, this
    includes $327 billion on diabetes and $131 billion for the treatment of
    hypertension. These are staggering figures. I believe that technology
    has the potential to empower patients, improve access and allow those
    Americans already living with these chronic conditions a chance at a
    happier, healthier life. Unfortunately, Medicare has been slow to adopt
    innovative digital health tools, some of which has been limited by
    outdated statutory limitations.
        Beyond telehealth, can you speak to the Administration's efforts to
    enable Medicare beneficiaries to leverage digital health tools for the
    prevention and treatment of disease?
        Are their limitations in your ability to expand access to these
    valuable resources for those that want to use them within Medicare?
        What do you see CMMI's role to be in facilitating the demonstration
    and evaluation of virtual care solutions and digital health tools?
        Could you discuss how remote patient monitoring is used today in
    Medicare and Medicaid today, in addition to telehealth, to help in the
    care of those living with chronic conditions like diabetes,
    hypertension, asthma or kidney disease?
        Remote patient or physiologic monitoring (RPM) has shown great
    value in facilitating the management of both acute and chronic
    conditions. Using connected devices, individuals can, in real time,
    have data shared back with their care team to allow for intervention
    and ultimately prevention of more severe health outcomes. While HHS has
    begun to allow for the reimbursement of RPM, use of the codes in
    Medicare fee-for-service remains rather low.
        Do you see value in enabling adoption of additional virtual care
    technologies, such as remote monitoring, for Medicare beneficiaries?
        From a health equity perspective, what more can be done to make
    resources like remote monitoring tools available to all Americans,
    especially those living with chronic conditions?
        RPM solutions, which for someone with diabetes, may be leveraged
    for years, warrants a recurring monthly 20 percent copay. Is there
    value in revisiting copay structures for remote monitoring and chronic
    care management services?
        Answer. Innovation is important to advancing goals in healthcare,
    including by learning how to better leverage digital health tools for
    the prevention and treatment of disease. Individuals with chronic
    disease benefit from access to comprehensive and coordinated care to
    manage and treat their chronic conditions and prevent the need for more
    costly care. Ensuring access to remote patient monitoring services,
    including through evaluating the adequacy of payments, will be
    important to beneficiaries who may benefit from these and other virtual
    services that allow their physicians to help manage and treat their
    health conditions outside of regular office visits. The CMS Innovation
    Center is integral to the Administration's efforts to promote high-
    value care and encourage healthcare provider innovation, including
    virtual and digital health innovation. I look forward to hearing from
    Congress on ideas to change coinsurance for Medicare covered services.
                                     ______

                   Questions Submitted by Senator Marco Rubio
        Question. I am incredibly concerned about the Biden
    Administration's decision to upend decades of bipartisan agreement by
    failing to include the Hyde Amendment in the proposed budget.
        Does the Administration support taxpayer-funded abortion?
        When Congress likely rejects this radical proposal and includes the
    Hyde Amendment in future spending bills--will the Administration follow
    the law and ensure that Federal Medicaid dollars are not used to
    finance abortions?
        Answer. The Hyde Amendment disproportionately impacts the growing
    number of low- income, women of color who are enrolled in Medicaid, and
    is a barrier to expanding access to healthcare. That is why the
    President's first budget calls for Congress to remove the restriction
    from government spending bills.
        The Department of Health & Human Services implements the laws that
    Congress passes.
        Question. Of additional concern, the NIH announced that it will end
    its Ethics Advisory Board for reviewing external research applications
    for Federal funding involving the use of human fetal tissue.
        Why has the NIH moved to end the Ethics Advisory Board?
        What plan does the NIH have in place to provide adequate oversight
    and ensure Federal laws are followed?
        Answer. NIH's mission is to seek fundamental knowledge about the
    nature and behavior of living systems and apply that knowledge to
    enhance health, lengthen life, and reduce illness and disability. Under
    its broad research mission, and as authorized by the Public Health
    Service Act, NIH conducts and funds biomedical research involving the
    study, analysis, or use of human fetal tissue for a range of diseases
    and conditions. NIH also funds research to develop, demonstrate, and
    validate experimental models that are alternatives to the use of human
    fetal tissue.
        Given the current administration taking a different position on the
    merit of this research, the U.S. Department of Health and Human
    Services decided to rescind the 2019 decision that all research
    applications for NIH grants and contracts proposing the use of human
    fetal tissue from elective abortions will be reviewed by an Ethics
    Advisory Board. So on April 16, 2021, NIH published an Update on
    Changes to NIH Requirements Regarding Proposed Human Fetal Tissue
    Research (NOT-OD-21-111),\28\ stating that HHS was reversing its 2019
    decision that all research applications for NIH grants and contracts
    proposing the use of human fetal tissue from elective abortions will be
    reviewed by an Ethics Advisory Board. Accordingly, HHS/NIH will not
    convene another NIH Human Fetal Tissue Research Ethics Advisory Board.
    Please note that all other requirements described in NOT-OD-19-128 \29\
    and updated in NOT-OD-19-137 \30\ for extramural research remain
    unchanged. Furthermore, NIH reminded the scientific research community
    of expectations to obtain informed consent from the donor for any NIH-
    funded research using human fetal tissue, and of continued obligations
    to conduct such research only in accord with any applicable Federal,
    state, or local laws and regulations, including prohibitions on the
    payment of valuable consideration for such tissue.\31\ The same
    requirements apply to the NIH intramural research program.
    ---------------------------------------------------------------------------
        \28\ grants.nih.gov/grants/guide/notice-files/NOT-OD-21-111.html.
        \29\ grants.nih.gov/grants/guide/notice-files/NOT-OD-19-128.html.
        \30\ grants.nih.gov/grants/guide/notice-files/NOT-OD-19-137.html.
        \31\ grants.nih.gov/grants/guide/notice-files/not-od-16-033.html.
    ---------------------------------------------------------------------------
        All NIH-supported organizations certify that they will comply with
    the NIH Grants Policy Statement,\32\ which summarizes NIH policies
    regarding the use of human fetal tissue in research and incorporates
    Federal statutory requirements for research with human fetal tissue
    (sections 498A and 498B of the PHS Act, 42 U.S.C. 298g-1 and 298g-2).
    ---------------------------------------------------------------------------
        \32\ grants.nih.gov/grants/policy/nihgps/HTML5/introduction.htm.
    ---------------------------------------------------------------------------
        Question. With much of the country finally moving to pre-pandemic
    operations, and as Americans are taking flights, riding trains, and
    generally living their lives, all without a Federal vaccine
    requirement, there is one industry that the CDC continues to treat
    differently.
        The White House Press Secretary has stated: ``The government is not
            now, nor will we be supporting a system that requires Americans
            to carry a credential. There will be no Federal vaccinations
            database and no Federal mandate requiring everyone to obtain a
            single vaccination credential . . . Our interest is very simple
            from the Federal Government, which is American's privacy and
            rights should be protected so that these systems are not used
            against people unfairly,''
        Mr. Secretary, if this were true, then the CDC would not be
    restricting cruise activities, and would not be putting unfair guidance
    in place that essentially requires that a minimum number of cruise
    passengers be vaccinated.
        If the Biden Administration wants to protect the rights of
    Americans and ensure that policies do not discriminate against certain
    Americans, then why does the Biden Administration support vaccine
    requirements for cruises that discriminate against families with young
    children?
        Answer. The Conditional Sail Order (CSO) is a phased approach for
    the resumption of passenger operations on cruise ships in the U.S. The
    timing of these phases depends on cruise ship operators' demonstrated
    ability to mitigate COVID-19 risk on board their ships with crew.
    Phases can also be adjusted based on lessons learned from the previous
    phases.
        Under the CSO, cruise ships are not mandated to require cruise
    passengers to be vaccinated. CDC recommended that cruise operators
    incorporate COVID-19 vaccination strategies to maximally protect
    passengers and crew in the maritime environment, seaports, and land-
    based communities to further reduce spread of SARS-CoV-2.
        CDC is committed to ensuring that cruise ship passenger operations
    are conducted in a way that protects crew members, passengers, and port
    personnel, particularly with emerging COVID-19 variants of concern.
        Question. When does the Biden Administration plan to end
    discriminatory policies that make it more difficult for families with
    children to go on vacation?
        Answer. CDC currently recommends people delay travel until they are
    fully vaccinated. Fully vaccinated travelers are less likely to get and
    spread COVID-19 and can now travel at low risk to themselves within the
    United States. If people are traveling with children who cannot get
    vaccinated at this time, CDC recommends choosing safer travel options.
        Question. I assume the vaccine mandate is based on science? If so,
    can you elaborate on that science?
        Answer. Under the CSO, cruise ships are not mandated to require
    cruise passengers to be vaccinated. CDC recommended that cruise
    operators incorporate COVID-19 vaccination strategies to maximally
    protect passengers and crew in the maritime environment, seaports, and
    land-based communities to further reduce spread of SARS-CoV-2. COVID-19
    vaccinations significantly reduce the risk of severe illness,
    hospitalization, and death.
        Question. Does this science also apply to airlines, busses, or
    trains?
        Why or why not?
        Answer. Yes, CDC's science applies in all travel settings. CDC's
    current domestic and international travel recommendations suggest
    people delay travel until they are fully vaccinated. Fully vaccinated
    travelers are less likely to get and spread COVID-19 and can travel at
    lower risk to themselves.
                                     ______

                  Questions Submitted by Senator Patrick Leahy
        Question. The COVID-19 pandemic has disproportionately impacted
    rural hospitals and healthcare providers that were already operating on
    shrinking margins. The Department has proposed an increase of $71
    million for Rural Health programs to ensure access to high-quality care
    that caters to the unique needs of rural communities. This funding is
    vital to ensure that our rural providers remain viable.
        The COVID-19 pandemic has also exposed serious inequities in
    healthcare for BIPOC and underserved populations. Rural communities
    have been no exception to this issue. How can any funding proposed for
    rural health programs help improve outcomes for BIPOC patients in rural
    areas?
        Answer. This is an important issue; one fifth of rural Americans
    are from a racial or ethnic minority group. The Federal Office of Rural
    Health Policy has added language in Notices of Funding Opportunity.
    Applicants for rural health grants will be expected to address issues
    of equity by targeting underserved communities and populations to
    ensure program dollars can reach the people most in need to improve
    their health outcomes.
        While rural Americans face a range of disparities in terms of
    mortality, life expectancy and chronic disease burden, those gaps are
    even more pronounced for members of racial and ethnic groups who live
    in rural communities, and ensuring the data analysis disaggregates race
    and ethnicity, when possible, helps monitor progress toward eliminating
    disparities. We will continue to do all we can to make sure rural
    communities with populations adversely affected by persistent poverty
    or inequality are leveraging our grant programs.

                              SUBCOMMITTEE RECESS

        Senator Murray. This committee will next meet in Dirksen
    138 Wednesday, June 16 at 10 a.m. for a hearing on the Biden
    administration's budget request for the Department of
    Education. The hearing is adjourned.
        [Whereupon, at 11:48 a.m., Wednesday, June 9, the
    subcommittee was recessed, to reconvene at 10 a.m., Wednesday,
    June 16.]

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

                                  ----------

                            WEDNESDAY, JUNE 16, 2021

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Durbin, Reed, Shaheen, Manchin,
    Blunt, Moran, Hyde-Smith, and Braun.

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    STATEMENT OF HON. MIGUEL CARDONA, SECRETARY

                   OPENING STATEMENT OF SENATOR PATTY MURRAY

        Senator Murray. Good morning. The Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education and
    Related Agencies will please come to order.
        Today we are having a hearing on the Biden administration's
    fiscal year 2022 budget request for the Department of
    Education. Senator Blunt and I will each have an opening
    statement. And then I will introduce our witness, Secretary
    Cardona. After his testimony, Senators will each have 5 minutes
    for a round of questions. And while we are unable to have the
    hearing fully open yet to the public or media for in-person
    attendance, live video is available on our committee website.
    And if you are in need of accommodations, including closed
    captioning, you can reach out to the committee or the office of
    congressional accessibility services.
        Secretary Cardona, after years of proposed budget cuts and
    school privatization from your predecessor, this budget would
    increase education funding by 40 percent to $103 billion, and
    it is a much-needed breath of fresh air. It proposes bold
    investments to help our schools and students as they respond to
    and recover from this pandemic, and addresses long-standing
    inequities in education, which COVID-19 has made even more
    damaging.

                       LOST LEARNING TIME AND DISPARITIES

        One of the biggest issues facing our Nation is getting our
    students back on track and addressing the lost learning time
    that they have experienced. We know students of color, students
    with disabilities, students in rural and Tribal communities,
    and students from families with low incomes have borne the
    brunt of this pandemic.
        One study, for example, found the pandemic set students of
    color back 3 to 5 months from where they would be in a typical
    year, and set white students back 1 to 3 months. We need to
    make sure every student, no matter who they are, or where they
    live, or how much money they or their family make, can receive
    the supports they need to thrive despite this pandemic.
        So I am glad this budget takes the task of reckoning with
    these inequities seriously, with investments across a range of
    programs to help ensure all students can get a quality public
    education. It invests $20 billion in a new initiative intended
    to reduce disparities in public, elementary, and secondary
    education in our country, and proposes to use this funding to
    help public schools address a variety of issues, including
    inequities in State and local education funding, expanding high
    quality preschool programs, and improving outcomes for all of
    our students.

                  INDIVIDUALS WITH DISABILITIES EDUCATION ACT

        Of course, improving outcomes for students means we must
    also do more to support students with disabilities. This budget
    takes an historic step on that front by proposing a $3 billion
    increase for the Individuals with Disabilities Education Act.
    Over the years, Congress has fallen short of its promise to use
    40 percent of the funding to support the education of students
    with disabilities through IDEA (Individuals with Disabilities
    Education Act).
        Currently only 13 percent is provided and struggling States
    and districts have been left to fill in the gaps. President
    Biden's proposal will help us better keep this promise and help
    schools across the country, address the shortage of teachers
    for students with disabilities, and provide early intervention
    services so students can get the support they need to succeed
    as soon as possible.
        And when it comes to supporting students' academic, social,
    emotional, and mental health needs, this budget proposes a $413
    million increase for full-service community schools, an
    increase of $120 million for English Language Acquisition
    Grants, and a new $1 billion initiative to ensure students have
    access to school counselors, nurses, and mental health
    professionals.
        This is especially critical, given the mental health
    challenges students, educators, and school staff have faced
    during the pandemic. These challenges will persist well into
    the next school year. We need to make investments to support
    student and staff wellbeing, and we need to bring in more
    counselors, nurses, and psychologists. In Washington State we
    only have one school psychologist for every 1,000 students.
    This budget will help us tackle inequities in higher education
    as well, and significantly expand support for students pursuing
    a postsecondary education, including by increasing the maximum
    Pell Grant by almost a third.

                                HIGHER EDUCATION

        This is so important. Federal support like Pell Grants
    allowed my six brothers, and sisters, and I, to all go to
    college. But Pell has gone from covering 75 percent of the
    average cost of a 4-year degree at its peak to less than 30
    percent today. We have to strengthen and expand Pell. And this
    budget is a clear step in the right direction. Ultimately, we
    need to do even more to double the maximum Pell award over the
    next 6 years, protect Pell from being cut by budget shortfalls,
    and expand Pell Grants to more students.
        Today, I join colleagues in the House and Senate to
    introduce legislation to accomplish all of that. And I hope to
    work with you, Secretary Cardona, and my colleagues here in
    Congress to get this done. And increased Pell Grants are just
    one of several investments, this budget proposes to make higher
    education more accessible and affordable for all students,
    provides funding to help implement the Bipartisan FAFSA (Free
    Application for Federal Student Aid) Simplification Bill I
    worked to pass last December.
        This will make it easier for all students to apply for
    financial aid, including Pell Grants, expand the number of
    students eligible for support, and increase financial aid to
    students with low incomes. It increases funding for TRIO
    programs, which help first-generation college students,
    students with disabilities, and students from families with low
    incomes to get to and go through college successfully.
        It nearly doubles funding for quality campus-based
    childcare to support student and parents under the CCAMPIS
    (Child Care Access Means Parents in School) Program. And it
    provides increased funding for historically under-resourced
    colleges and universities, including $345 million, which is a
    44 percent increase, in funding for minority serving
    institutions, like Historically Black Colleges, and
    Universities, and other institutions predominantly serving low-
    income students, like community colleges. And finally, this
    budget increases funding for the Department's Office for Civil
    Rights.

                                    TITLE IX

        Between this budget and the public hearings, the Department
    started last week on the previous administration's inadequate
    Title IX Rule, it is clear we have a President who is focused
    on protecting students, no matter their race, ethnicity,
    religion, sex, including sexual orientation, and gender
    identity, or disability.
        I will be watching your work in this space closely, and
    encourage the Department to continue its efforts, to hear,
    acknowledge and address the stories and concerns of survivors
    of sexual assault.

                   EDUCATION FOR HOMELESS CHILDREN AND YOUTHS

        I will say, one area where I would like to see an increased
    investment, is funding to support education for children and
    youth who are experiencing homelessness. But overall, this
    budget is night-and-day different from the previous
    administration. I always say a budget is a reflection of your
    values. And this budget shows President Biden understands the
    money we spend on schools, students, and public education is an
    investment in our future. What our Nation accomplishes in the
    years ahead will be determined by the opportunities and support
    we are able to give children across the country, now.
        I look forward to working with the administration and with
    my colleagues on this committee to make the investments in
    education we need to make so we have a brighter future for our
    families.
        With that, I will turn it over to Senator Blunt for his
    remarks.

                         STATEMENT OF SENATOR ROY BLUNT

        Senator Blunt. Well, thank you, Senator Murray. And welcome
    to the hearing, Secretary Cardona. I know this is your first
    time to appear before this committee, and I am sure by the end
    of the hearing, you will be looking forward to next year when
    you get to come back, and the other discussions we will have
    between now and then. I am just glad we had a chance to talk,
    not only during the confirmation process, but again yesterday,
    and look for more opportunities to do that.
        Certainly, the last year has been one of the most
    challenging years for students, for parents, for school
    administrators, for teachers, for everybody in the education
    field, including cafeteria workers, and bus drivers who, in a
    virtual setting, wound up without a job while everybody else's
    jobs became maybe even longer in a day to get ready for the new
    challenges of virtual education, where that occurred, and to
    try to get back to school, as quickly as they could.
        You know, you and I are both first-generation college
    graduates, and we have both been classroom teachers, and so I
    think because of that, hopefully, we have an understanding of
    just how important education is, and what a difference, just a
    slight change it points along the way of your trajectory of
    where you think your life can take you, can make for the people
    we taught, just like we both saw happen with us.
        We also understand the critical role education plays in our
    society. Our ability to compete around the world, the values
    that we transmit from one generation to another, all very
    important. I am a proud supporter of many of the programs we
    are going to be talking about today, career and technical
    education, state grants, IDEA, Title I, the TRIO Programs,
    school-based mental health, that you and I talked about
    yesterday.
        Now I am concerned about the spending level. I just heard
    the Chair mentioned the importance of this huge increase of
    about 41 percent in spending. I think that increase on top of
    the $280 billion in COVID-19 supplemental funding for
    education, last year, is a lot of input into the system in a
    very short period of time. In fact, last year's spending was
    about four times as much as the Department normally receives in
    annual appropriations each year. This year the request is
    $102.8 billion, which is almost $30 billion, or 41 percent
    greater than last year's spending.
        It is a lot of money to try to put into the system all at
    once. I look forward to hearing your plans and, hopefully, some
    of your concerns about how that much new funding going into the
    system would go in, in the best possible way. As a former
    university president, I am particularly concerned about the
    proposal to make community college tuition free for all
    students. As, you know, my view is if you want to make a
    college education really expensive, make it free, but we will
    talk about that.
        We will talk about what we are doing now to make it
    possible for people to go to college and what you are proposing
    in terms of making those first 2 years free at community
    colleges. I would point out that in the average community
    college in America, if you qualify for the full Pell Grant, you
    have more money in that grant than books, fees, and tuition. I
    think the average Pell Grant recipient was $3,946, the average
    tuition and fees at community colleges was $3,700. I think
    there may be other ways to make it possible for more people to
    go to community college, and all other schools without cost.
    But we are going to talk about that today, and as we move
    forward with this budget.
        Many States across the country already have programs that
    make up the difference, and at a community college in Missouri
    the A+ scholarship pays the community college tuition for
    eligible students for up to 2 years. I do think those colleges
    play an incredibly important role in the country. Both as an
    access point for education, but also as a way to get people
    ready for jobs that are available, or could be available, in a
    specific community.
        I am concerned that free community college for everybody
    unfairly subsidizes higher-income students. And if it is
    community college only, it creates an incentive for students to
    attend schools that may not be the best fit for them. Through
    the Pell Grant limited taxpayer dollars have targeted students
    in the most need. It maintains the ability of students to Pell
    Grant, and most of our other programs, to pick institutions
    that best meet their individual needs.
        Since this committee worked to reinstate year-round Pell
    Grants, with Senator Murray and I working hard to lead on that
    effort, students have the flexibility to accelerate their post-
    secondary studies and complete their programs more quickly.
        I am pleased to see that the budget does not include
    widespread loan forgiveness. However, the Department has not
    outlined a plan at the same time for borrowers to get back into
    the repayment process. Federal student loan borrowers have gone
    for over a year without being required to make a payment on
    their loans. And I think it is important that the Department
    begins communicating to those borrowers early and often to
    ensure that all borrowers understand their responsibilities,
    and their repayment options when a payment or a loan comes due
    October 1 of this year. I don't see any discussion about that
    in the comments you are making today, and something I would
    like to see more thought given to.
        I am also concerned that the Department has not announced
    how long the student loan servicing will be handled moving
    forward, once the legacy servicing contracts end later this
    year. We have spent a lot of time in this committee looking at
    past proposals on changing that system. As you and I discussed
    yesterday, I look forward to hearing your thoughts as to how
    that system moved forward.
        We both support increased educational opportunities in
    every State, such as Title I and IDEA. It is my goal to find
    ways we can work together. This budget proposes a 10 percent
    increase, or $120 million in discretionary funding for career
    and technical education, teamed with $1 billion in mandatory
    funding for a New Career Pathways Program. I do think it is
    critically important we provide students with meaningful
    information about the jobs that are out there with the work-
    based learning opportunities and exposure to different career
    paths early in high school.
        We have been talking about that for some time. There is a
    lost decade for so many people from the time they graduate
    until the time they really settle in, to the career that
    provides the most promise and the most satisfaction for them.
        So I look forward to working together on this. I know we
    are going to have a number of questions and concerns about this
    budget, but it is a critically important part of how people
    move forward in our country, giving them those opportunities
    and the information they need. And I look forward to working
    with you to find the appropriate balance between fiscal
    responsibility and meaningful investment that supports access
    to quality education for all students.
        Thank you, Chair.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Good morning. Thank you, Chair Murray. And thank you, Secretary
    Cardona, for appearing before the Subcommittee today to discuss the
    Department of Education's FY2022 budget request.
        This has been a long and challenging year for all Americans, but it
    has been particularly difficult for students, parents, teachers, school
    administrators, and all those in the education field. You and I are
    both first generation college graduates and classroom teachers, we know
    how much education can change the trajectory of a person's life,
    because we saw it in our own lives and in the lives of the people we
    taught. We also understand the critical role education plays in our
    society and its impact on our nation's ability to compete in a global
    economy.
        Because of that, I am proud to support key programs that the
    Department of Education administers such as career and technical
    education state grants, IDEA, and Title I, Part A. However, I am
    concerned with the unprecedented level of spending proposed in this
    budget request, particularly at a time when Congress has already
    provided almost $280 billion in COVID-19 supplemental funding for
    education in the last year. For reference, that is about four times as
    much as the Department receives in annual appropriations each year.
        The FY2022 budget request for the Department of Education is $102.8
    billion, which is $29.8 billion, or 41 percent, more than FY2021.
    Future generations can't afford this budget. It also invests the
    majority of new funding in new programs--and the budget provides few
    details on how these programs will work and who will benefit.
        As a former university president, I am particularly concerned about
    the proposal to make community college tuition ``free'' for all
    students. As the saying goes, if you think college is expensive now,
    wait until you see what it costs when it's free.
        First, for most low-income students who receive a Pell Grant,
    community college tuition is already free. Last school year, the
    average Pell Grant recipient at a community college received $3,946,
    while the average tuition and fees at these schools were only $3,700.
        Second, many states across the country already have programs to
    make up the difference between a student's Pell Grant and the cost of
    community college if there is one. In Missouri, the A+ Scholarship pays
    the community college tuition for an eligible student for up to two
    years.
        Finally, while community colleges play a crucial role in our
    diverse higher education system in America, they may not be the best
    choice for every student.
        Rather than subsidizing higher income students and incentivizing
    students to attend schools that may not be the best fit for them, we
    should instead focus our investments in programs that make a student's
    choice in college affordable. And the best way to do so is through the
    Pell Grant program and other programs like the GI bill, work study and
    SEOG.
        Through the Pell Grant program, limited taxpayer dollars are
    targeted toward students most in need. It maintains the ability of
    students to pick the institutions that best meets their individual
    needs. And since this Subcommittee reinstated year-round Pell Grants in
    FY2017, students have the flexibility to accelerate their postsecondary
    studies and complete their programs more quickly. This Subcommittee has
    boosted the maximum Pell Grant award for the past four years, and I
    hope we can do so again this year.
        While I am pleased to see that the budget request does not include
    widespread loan forgiveness, I am concerned that the Administration has
    not outlined a plan to transition borrowers back into repayment when
    the student loan pause ends this fall. Federal student loan borrowers
    have gone over a year without making a payment on their loans.
        It is absolutely imperative that the Department begins
    communicating with borrowers early and often to ensure that all
    borrowers understand their responsibilities and their repayment options
    when a payment or loan come due on October 1, 2021.
        As borrowers begin to repay their loans after such a long pause,
    student loan servicing will be more important than ever. However, I am
    concerned that the Department has not announced how student loan
    servicing will be handled moving forward once legacy servicing
    contracts end later this year and early next year. This Subcommittee
    has worked closely with the Department over the past several years as
    it continues to reform and modernize the Federal student loan servicing
    system, and I hope that will continue.
        Mr. Secretary, while there are issues on which we disagree, we have
    many shared priorities that are reflected in the budget request. I know
    we both share a strong desire to fund programs that are proven and
    benefit all students, and I know we both support increased educational
    opportunities in every state, such as Title I and IDEA. It is my goal
    for us to work together on many of these and other important issues.
        In particular, the budget proposes a 10 percent increase, or $128
    million, in discretionary funding for career and technical education,
    teamed with $1 billion in mandatory funding for a new career pathways
    program. While this Subcommittee will only consider the discretionary
    request, I am interested in your ideas for how this and other efforts
    could improve educational opportunities for students beginning in high
    school, or earlier, to pursue the full-range of post-secondary college
    and career opportunities.
        Providing students meaningful work-based learning opportunities and
    exposure to different career paths early in high school, or even middle
    school, can help them identify interests that lead to well-paying jobs
    and careers. Too often individuals only find opportunities through
    apprenticeships or high-quality credential programs later in life, in
    their late twenties or thirties.
        I call this the Lost Decade and have provided the Department $10
    million each of the past two years to work toward addressing these
    issues. I think giving more students access to these opportunities
    earlier on is an area of interest for us both, and I hope it is
    something we can work on together.
        Mr. Secretary, I look forward to working with you this year to find
    the appropriate balance between fiscal responsibility and meaningful
    investments that support access to quality education for all students.
        Thank you again for being here today.

        Senator Murray. Thank you, Senator Blunt.
        Our witness is today, is Miguel Cardona, Secretary of the
    Department of Education. Secretary Cardona, thank you for
    joining us today. And I am so glad you could be here. I look
    forward to your testimony, and you may begin now.

                    SUMMARY STATEMENT OF HON. MIGUEL CARDONA

        Secretary Cardona. Thank you. Good morning, Chairwoman
    Murray, Ranking Member Blunt, and distinguished members of the
    subcommittee.
        I recently attended an International Thespian Induction
    ceremony at a high school where students were being inducted
    for their commitment to theater after this long year. My
    daughter was one of those students. I can tell you, it was the
    first time we came together as a school community in over a
    year. So the room was filled with a lot of emotion.

              FULFILLING OUR ROLES TO IMPROVE THE EDUCATION SYSTEM

        One thing caught my eye, there was a banner hanging that
    had a quote from the renowned poet, Alexander Pope, and the
    banner read, ``Act well your part, there all the honour lies.''
    In other words, do your part, and that is where you will find
    the honor.
        I come to you today representing the Department of
    Education, as we boldly do our part to serve the students
    across the country. That is our responsibility and our
    privilege. And that is where our collective honor lies.
        To that end, I am proud to testify today about President
    Biden's fiscal year 2022 budget request for the Department of
    Education, because it makes good on the President's campaign
    commitment to invest in education. It also begins to address
    the significant inequities that students, primarily students of
    color, confront every day in schools, in pursuit of higher
    education, and career technical education. I want to thank
    members of the subcommittee and your staff who have helped
    ensure the passage of the American Rescue Plan, bringing vital
    resources to our schools and colleges across the country. The
    American Rescue Plan funds will ensure that school buildings
    reopen for full-time in-person instruction safely and quickly.

                           EDUCATION AS AN EQUALIZER

        I come to you today with a great sense of urgency about the
    work we have to do. Generations of inequity have left far too
    many students without equitable access to high-quality,
    inclusive learning opportunities, including in our rural
    communities. Education can be the great equalizer like it was
    for me and for many of you, but we have to prioritize,
    replicate, and invest in what works for all students. Not just
    some.
        We must do more to level the playing field, including
    providing a strong foundation from birth, improving diversity
    among the teacher workforce, creating learning pathways that
    work for all students. To that end, the budget proposal calls
    on Congress to invest nearly $103 billion in the Department of
    Education's programs, a 41 percent increase over the fiscal
    year 2021 appropriation to support students' success.

                         OVERVIEW OF THE BUDGET REQUEST

        The fiscal year 2022 request also makes a meaningful down
    payment toward the Biden-Harris administration's goal of
    reversing inequities. That is what is at stake here, reversing
    inequities. The centerpiece is a proposal for a new $20 billion
    Title I equity grants program that would address inequities and
    disparities between under-resourced schools and their wealthier
    counterparts.
        It would support competitive compensation for teachers and
    Title I schools, expand access to pre-kindergarten, and
    increase preparation for, access to, and success in rigorous
    coursework. Our requests would put the Nation on a path to
    double the number of school counselors, nurses, and mental
    health professionals in our schools, and significantly expand
    support for community schools to help increase the availability
    of wraparound service services to students and families in
    underserved schools and communities.
        The pandemic reinforced the need for this. We also think it
    is past time for the Federal Government to make good on its
    commitment to students with disabilities, and their families,
    and the request makes a significant move toward full funding of
    IDEA, proposing a 20 percent increase for IDEA State grants of
    $2.6 billion.
        Turning to higher education, an area that needs immediate
    attention. Our budget proposal begins the Biden-Harris
    administration's critical work to increase access and
    affordability for students. The budget proposal coupled with
    increased proposals--proposed in the American Families Plan
    would be the largest increase to Pell Grant ever, helping
    millions of students and families pursue their goals.
    Importantly, our proposal would ensure that Dreamers may also
    receive Pell Grants if they meet current eligibility
    requirements.
        The fiscal year 2022 request paints a bold picture for the
    future of our institutional and student support programs. The
    budget increases institutional capacity and student supports at
    minority-serving institutions, with additional funding for
    HBCUs (Historically Black Colleges and Universities), Hispanic-
    Serving Institutions, Asian-American, and Native-American
    Pacific Islander-serving Institutions, and Tribally Controlled
    Colleges and Universities, as well as our beloved TRIO and GEAR
    UP programs to help ensure underserved students succeed and
    graduate from college.
        Finally, we would prioritize efforts to enforce civil
    rights laws related to education through a 10 percent increase
    for the Office for Civil Rights, to protect students and
    advance equity and educational opportunity, and delivery in
    preschool through college. This is a fundamental right we are
    committed to for all students.
        Working together with stakeholders, including students and
    educators, we can and will heal, learn, and grow together,
    during this challenging time. I am committed to working
    collaboratively with each of you to strengthen our schools, and
    campuses, and to help improve opportunities, pathways, and
    outcomes for students across the country, including students in
    our rural communities.
        Thank you. And I look forward to answering any questions
    you may have.
        [The statement follows:]
                   Prepared Statement of Hon. Miguel Cardona
        Good morning Chairwoman Murray and Ranking Member Blunt.
        I am pleased to join you today, and I am proud to testify on behalf
    of President Biden's fiscal year 2022 Budget Request for the Department
    of Education. The full fiscal year 2022 Budget Request, which was
    released a little over two weeks ago, makes good on President
        Biden's campaign commitment to reverse years of underinvestment in
    Federal education programs and would begin to address the significant
    inequities that millions of students--primarily students of color--and
    teachers confront every day in underserved schools across America.
    These inequities in opportunity and access continue to be experienced
    by students pursuing higher education and career and technical
    education credentials as well.
                            american rescue plan act
        Before I begin, I want to thank the Members of the Subcommittee--
    and your staff--who helped carry the American Rescue Plan Act to the
    finish line. I can tell you from immediate experience that the ARP
    funds will make all the difference in ensuring that schools re-open for
    full-time, in-person instruction as safely and soon as possible. In
    addition, ARP funds will enable schools to address the mental health,
    social, and emotional needs of students that the pandemic has laid
    bare, and to fully recover from the massive impact of lost
    instructional time on student achievement during the pandemic.
        The plans to reopen are bold--and will require coordination among
    key stakeholders at the Federal, State, and local levels. But they
    match the urgency the challenges before us demand. It's important to
    remember that once we fully reopen schools, we still have work to do.
    Our job will not be done. Generations of inequity have left far too
    many students without equitable access to high-quality, inclusive
    learning opportunities. Education can be the great equalizer--it was
    for me--if we prioritize, replicate, and invest in what works for all
    students, not just some.
        We must do more to level the playing field, including providing a
    strong foundation from birth, improving diversity among the teacher
    workforce, and creating learning pathways that work for all students.
    To that end, the fiscal year 2022 budget proposal for the Department of
    Education provides strong investments in key areas to ensure students
    of all ages have what they need to succeed.
                     department of education funding levels
        The President's fiscal year 2022 request calls for a significant
    and long-overdue increase in Federal support for education from birth
    through college and career. The proposed discretionary request of $103
    billion for Department of Education programs, an increase of almost $30
    billion over the fiscal year 2021 enacted level, would be complemented
    by additional mandatory investments under the American Jobs Plan and
    the American Families Plan. We understand that some have raised
    questions about the unprecedented increase in Federal education funding
    proposed by President Biden, particularly coming on top of emergency
    appropriations over the past year to address the impact of the COVID-19
    pandemic on our schools. However, it's important to recognize that
    these bold proposals follow a decade of virtually no funding growth in
    real terms for Department programs, a significant under-investment in
    light of the rising needs of students and families.
        The $73.5 billion that Congress appropriated for the Department for
    the current fiscal year, fiscal year 2021, is about 8 percent more than
    the fiscal year 2011 total of $68.3 billion. Title I funding did a
    little better, up 10 percent, or 1 percent a year, over the same period
    of time. The total Federal investment in elementary and secondary
    education grew at the same rate--just 1 percent annually over the past
    10 years--not even keeping up with inflation.
            funding inequities in state and local education systems
        This underinvestment in K-12 education matters because of the
    dramatic and longstanding inequities in State and local education
    funding systems, which despite more than half a century of litigation
    and reform, too often continue to provide significantly less funding
    for high-poverty districts and schools, which are more likely to serve
    students of color, resulting in a disproportionate impact on these
    students. Reversing these funding inequities, as well as immediately
    addressing the negative impact of those inequities in service of
    students, are critical goals of the Biden-Harris Administration's
    racial equity agenda, and the President's fiscal year 2022 request for
    the Department of Education would make a meaningful down payment toward
    these goals. Addressing these inequities are critical to our nation's
    future. Our country and our economy will be stronger when every child
    is prepared to succeed in tomorrow's economy, regardless of race, zip
    code, their family's income, or disability.
           investment in title i grants to local educational agencies
        The centerpiece of that request is $20 billion for a new Title I
    Equity Grants program--part of the President's commitment to
    dramatically increase funding for Title I schools--that would help
    address long-standing funding disparities between under-resourced
    school districts and their wealthier counterparts; ensure teachers in
    Title I schools are paid competitively; support expanded access to
    preschool; and increase preparation for, access to, and success in the
    rigorous coursework needed to prepare for postsecondary education and
    high-paying, in-demand careers. This proposal will further the goals of
    Title I as outlined by President Johnson in partnership with Congress
    back in 1965 as part of the War on Poverty, to help ensure that all
    students--especially students from low-income backgrounds and students
    of color in underserved communities--receive the high-quality education
    they need to thrive and achieve their dreams.
          investment in improving students' physical and mental health
        Long before the COVID-19 pandemic there was increasing evidence
    that the conditions of poverty--especially concentrated poverty--take a
    tragic toll on the physical and mental health of students. This
    warrants significant investments in mitigating the impact of this toll
    in order to improve student outcomes. Congress recognized this problem,
    in part, through the creation and rapid increase in funding for the
    Title IV-A Student Support and Academic Enrichment program. Our request
    would build on these efforts through a $1 billion investment for a new
    School-Based Health Professionals program to support the mental health
    needs of our students by increasing the number of counselors, nurses,
    and mental health professionals in our schools, and building the
    pipeline for these critical staff, with an emphasis on underserved
    schools.
                            community-based programs
        In addition, the President's request would help increase the
    availability of a broad range of wrap-around services to students and
    families in underserved schools and communities through a significant
    expansion of the Full-Service Community Schools program, from $30
    million in fiscal year 2021 to $443 million in fiscal year 2022. This
    program recognizes the role of schools as the centers of our
    communities and neighborhoods, and funds efforts to identify and
    integrate the wide range of community-based resources needed to support
    students and their families, expand learning opportunities for students
    and parents alike, support collaborative leadership and practices, and
    promote the family and community engagement that can help ensure
    student success. The request would support implementation of the
    community schools model at roughly 800 additional schools serving up to
    2.4 million students, family members, and community members.
        Our request also would help strengthen communities by fostering
    diverse schools through renewed efforts to improve school racial and
    socioeconomic diversity. We would provide $100 million for a new
    Fostering Diverse Schools program that would help communities develop
    and implement strategies that will build more racially and
    socioeconomically diverse schools. Research suggests that diverse
    learning environments benefit all students and can improve student
    achievement, serve as engines of social and economic mobility, and
    promote school improvement. Our proposal also would build evidence
    around effective practices for addressing the growing concern that our
    Nation's schools are becoming less diverse and more segregated each
    year.
                         support for special education
        We also think it is past time for the Federal Government to make
    good on its commitment to students with disabilities and their
    families, as expressed in the Individuals with Disabilities Education
    Act. The President's request makes a significant move toward full
    funding of the IDEA with a $2.6 billion, or 20 percent, increase for
    IDEA Part B Grants to States above the regular fiscal year 2021
    appropriation, for a total of $15.5 billion. Notably, this increase
    would raise the Federal share of the excess cost of serving students
    with disabilities for the first time in 8 years-demonstrating that IDEA
    has been yet another casualty of the Federal underinvestment in
    education over the past 10 years.
        In addition, we would increase funding for the IDEA Part C Grants
    for the Infants and Families program by more than 50 percent, or $250
    million above the regular fiscal year 2021 appropriation level, for a
    total of $732 million to expand access to early intervention services
    for infants and toddlers with disabilities. We would pair this
    increased funding with reforms to strengthen the Part C program,
    particularly for children who have been historically underrepresented
    in the program, including children of color.
        The President's Request would also boost the Preschool Grants
    program by $105 million over the 2021 appropriation, to aid in the
    provision of special education and related services for children with
    disabilities aged 3 through 5.
                          teacher training and support
        The Title I Equity Grants proposal is just one demonstration of
    President Biden's strong commitment to teachers. Other key investments,
    split between discretionary and mandatory American Families Plan
    funding, include $412 million ($132 million in discretionary funding
    and an additional $280 in mandatory authority for fiscal year 2022) for
    Teacher Quality Partnerships to address teaching shortages, improve
    training and supports for teachers, and boost teacher diversity,
    particularly through investment in teacher residencies and Grow Your
    Own programs; $340 million ($250 million in discretionary funding and
    an additional $90 million in mandatory authority for fiscal year 2022)
    for Special Education Personnel Preparation to ensure that there are
    adequate numbers of personnel with the skills and knowledge necessary
    to help children with disabilities succeed educationally; and $60
    million ($20 million in discretionary funding and an additional $40 in
    mandatory authority for fiscal year 2022) to fund for the first time
    the Hawkins Centers of Excellence program designed to increase the
    quality and number of new teachers of color. In addition, the American
    Families Plan would make a one-time mandatory investment of $1.6
    billion to support additional certifications at no cost for more than
    100,000 educators in high-demand areas like special education,
    bilingual education, career and technical education, and science,
    technology, engineering, and mathematics. We are also requesting,
    through the American Families Plan, $200 million in mandatory authority
    for a new Expanding Opportunities for Teacher Leadership and
    Development program to support opportunities for experienced and
    effective teachers to lead and have a greater impact on their school
    community while remaining in the classroom (and be compensated for
    additional responsibilities) through such activities as high-quality
    teacher mentorship programs and job-embedded coaching. Lastly, the
    American Families Plan would double TEACH Grants from $4,000 to $8,000
    for future teachers while earning their degrees.
                           improving career pathways
        The President's Request also recognizes that a skilled workforce is
    critical for both strong communities and a strong economy by proposing
    to make targeted investments that would help build the capacity of our
    workforce development system. These investments include an increase of
    $108 million in Career and Technical Education National Programs to
    support an innovation grants initiative focused on youth work-based
    learning and industry credential attainment, along with a $25 million
    increase under Adult Education National Leadership Activities to expand
    college bridge programs for low-skilled adults without a high school
    degree. In addition, the American Jobs Plan would provide $1 billion in
    mandatory funding in fiscal year 2022 ($10 billion total over 10 years)
    to expand career pathways for underserved middle and high school
    students that include partnerships with employers, community colleges
    and other partners and allow students to earn credentials or college
    credit while still in high school; and also would invest $100 million
    annually over the next 10 years to help connect job-seeking adults to
    employment opportunities by focusing on foundational skills and
    embedded career services.
                      postsecondary education investments
        Turning to higher education, our budget proposal would make
    postsecondary education more affordable for students from low-income
    households through a $400 increase to the maximum Pell Grant. In
    combination with the $1,475 increase to the maximum Pell Grant proposed
    in the American Families Plan, the increase in 2022 would be the
    largest increase to the Pell Grant ever. This historic increase is just
    a first step in a more comprehensive proposal to double the grant.
    Importantly, our proposal also would ensure that postsecondary students
    who are DACA recipients may receive Pell Grants and other federal aid
    if they meet current eligibility requirements.
        Through the American Families Plan, our budget proposal would
    provide two years of free community college to first-time students and
    those wishing to reskill. It would also make college more affordable
    for low- and middle-income students at four-year Historically Black
    Colleges and Universities (HBCUs), Tribal Colleges and Universities
    (TCUs), and Minority Serving Institutions (MSIs) such as Hispanic-
    Serving Institutions (HSIs) and Asian American and Native American
    Pacific Islander-Serving Institutions (AANAPISIs).
        The fiscal year 2022 request also would increase institutional
    capacity and student supports at HBCUs, TCUs, and MSIs, and other
    under-resourced institutions, such as community colleges. The
    discretionary request includes more than $600 million in additional
    funding for institutional supports programs and programs like TRIO and
    GEAR UP, to help ensure underserved students succeed in and graduate
    from college. The American Families Plan also provides historic
    mandatory investments over ten years in college access and success,
    including $46 billion for HBCUs, TCUs, and MSIs, and $62 billion for a
    new Completion Grants program that would make formula grants to States
    to support the use of evidence-based strategies to strengthen
    completion and retention rates at institutions that serve students from
    our most disadvantaged communities like community colleges.
                             school infrastructure
        Too many students attend schools and child care centers that are
    run-down, unsafe, and pose health risks. These conditions are dangerous
    for our kids and exist disproportionately in schools with a high
    percentage of low-income students and students of color. We can't close
    the opportunity gap if low-income kids go to schools in buildings that
    undermine health and safety, while wealthier students get access to
    safe buildings with labs and technology that prepare them for the jobs
    of the future. Accordingly, the American Jobs Plan would provide $10
    billion in mandatory funding in 2022, and $50 billion over five years,
    for grants to upgrade existing school facilities and build new public
    elementary and secondary schools. Outside of the Department of
    Education, funding would leverage an additional $50 billion in
    investments in school infrastructure through bonds. The American Jobs
    Plan would also provide $2.4 billion in mandatory funding in 2022, and
    $12 billion over five years, for grants to invest in community college
    facilities and technology in order to help protect the health and
    safety of students and faculty, address education deserts (particularly
    for rural communities), grow local economies, improve energy efficiency
    and resilience, and narrow funding inequities.
                           student aid administration
        In addition to making college more affordable, our budget proposal
    will improve the services we provide students and families to help them
    pay for college. We are requesting $2.1 billion to administer the
    Federal student aid programs in fiscal year 2022, an increase of $200
    million over the fiscal year 2021 appropriation. The requested funds
    are necessary to implement the FAFSA(r) Simplification Act and FUTURE
    Act, which together will greatly ease the process of applying for
    student aid and accessing affordable, income-driven repayment options;
    provide high-quality loan servicing to more than 40 million student
    loan borrowers; and protect the personally identifiable information of
    around 75 million students and parents.
                        enforcement of civil rights laws
        Finally, we would prioritize efforts to enforce the Nation's civil
    rights laws, as they relate to education, through a 10 percent increase
    for the Office for Civil Rights to protect students, providing a total
    of $144 million to advance equity in educational opportunity and
    delivery at Pre-K through 12 schools and at institutions of higher
    education.
                                closing remarks
        Thank you again for this opportunity to share more about the
    President's plan to invest in students of all ages and the institutions
    that serve them. I look forward to hearing your reactions to this
    historic budget request, and to learning more about your individual
    interests and priorities related to Department of Education programs
    and activities. I am committed to working collaboratively with each of
    you, to the greatest extent possible, to help improve educational
    opportunities and outcomes for all students.
        Thank you, and I will do my best to respond to any questions you
    may have.

                              RESOURCE ALLOCATION

        Senator Murray. Thank you so much, Mr. Secretary. We will
    now begin around a 5-minute questions of our witness, and I ask
    our colleagues to, please, keep track of your clock. Stay
    within those 5 minutes.
        Mr. Secretary, the President's budget calls for major
    investments in our Nation's public schools, acknowledging the
    significant resource disparities between schools serving more
    students from families with low incomes and their wealthier
    peers. These resource discrepancies contribute to the
    achievement gap between students of color who represent more
    than half of our students served in Title I schools and white
    students. One of the key provisions we included in the
    Reauthorization of the Elementary and Secondary Education Act,
    is a requirement to review the resource inequities in schools
    which have been identified for support and improvement.
        And we also included a requirement for per pupil
    expenditure reporting for all States and school districts in
    the Nation, a requirement that still has not been fully
    implemented years after we passed the law. I believe that
    combination of additional Federal education investments,
    accurate and timely reporting, and thoughtful review of how all
    education funds are being allocated and used in schools needing
    additional support would improve the quality of education
    services for all of our students and families.
        I know the pandemic has likely impacted the implementation
    of these resource allocation reviews, but can you share your
    plans for supporting and monitoring State and local agencies
    conducting these reviews, as well as your plans for ensuring
    States and school districts do comply with the SEA's (State
    Educational Agencies) fiscal equity reporting requirements?
        Secretary Cardona. Thank you, Senator Murray. And you start
    with an issue that is critically important that we must address
    together. The opportunity gaps and achievement disparities and
    outcomes are significant, so much so that I have been an
    educator for over 20 years, it has almost become normalized.
    And we have an opportunity here to address it, with the budget
    proposal, and the American Families Plan, there is a
    transformational opportunity for our country, to not only
    recover from the pandemic, but to be better than we ever were
    before in education.
        And I look forward to ensuring that every penny that is
    allocated is used to support our students in a way that is
    equitable. You know, we talk a lot about education being the
    great equalizer, well, this budget proposes strategies to get
    there. And it is important for me to make sure that while the
    resources are there, we have equal amounts of accountability to
    make sure that the funds are being used for what they were
    intended.
        So, absolutely, to me, the work that we do at the agency to
    ensure that the funds are being used for what they were
    intended for is critically as important as providing resources.
    We can't get to equalizing the playing field if the resources
    are not being used where they are supposed to.
        So I, and the team at the Department of Education, will be
    very vigilant, especially with this new American Rescue Plan,
    and the funding that has been provided over the last year. We
    are going to be vigilant to make sure that the funds are being
    used for what they are intended to be used for. And I will add
    that as we rolled out the American Rescue Plan, we required
    States to provide transparent reports on how they were going to
    use the money, and engage stakeholders, so they are a part of
    the process early and ensure that equity is at the heart of the
    plan.
        I envision this being something that is going to help lift
    our students. And I look forward to working with you and others
    to make sure it happens.

                    INVESTMENTS TO SUPPORT HIGHER EDUCATION

        Senator Murray. Okay. Thank you. And on higher Ed, the
    pandemic really exacerbated, as we know, the financial
    challenges a lot of our students face pursuing a post-secondary
    education. Congress, as you know, responded by providing
    significant relief to students and borrowers, including
    flexible funding to address students' basic needs during this
    pandemic. But as our country begins to recover from this
    pandemic, many of the financial strains that are facing
    students who are low-income, students of color, student
    parents, and first-generation students are really out there for
    them.
        This is not just the cost of tuition and fees I am talking
    about, but housing, food, childcare, unexpected bills that can
    quickly derail a student's plans. And as we turn this corner on
    COVID, we should redouble our efforts to help all students
    pursuing a post-secondary education. And this budget I think is
    a positive step in that direction. But can you speak for a
    moment about the increases for Pell Grants, and childcare, for
    students, parents, TRIO, why those investments are so critical
    right now?
        Secretary Cardona. Thank you, Senator. We recognize now
    that if we don't act with urgency, we are going to lose many of
    our students who are thinking about higher education as an
    opportunity to continue their growth. The increase in Pell
    Grants, which is significant under the American Families Plan,
    $1,400, and $400 increase here in this budget show the
    commitment that the President has toward ensuring equitable
    access to higher education for our students.
        And we recognize that that, with other supports, are going
    to allow for our students to continue to engage in college,
    free community college for students, talk about giving an
    opportunity to students who might not even think of higher
    education, because it is too far off, or the fear of being in
    debt for the rest of their lives. With that said, the pause on
    loan repayment has provided--saved over $5 billion a month for
    over 41 million borrowers. So we know how critically important
    that is. It has covered 1.1 million borrowers in the process,
    but programs like the Pell increase provide access to college
    for many more students. And we were confident with support of
    programs like that, and programs like TRIO, more and more
    students will look at higher education as an option for
    themselves.
        Senator Murray. Okay. Thank you very much.
        Senator Blunt.
        Senator Blunt. Thank you, Chairman.

                             FREE COMMUNITY COLLEGE

        Secretary, let's talk a little about the first 2 years of
    college education being free, or at least if you choose to go
    to a community college. I am much more inclined to be receptive
    to your arguments about increasing the Pell Grant, increasing
    even the level of maybe whether you qualify for that maximum
    Pell sooner. What are you thinking about in terms of 2 years of
    free community college education?
        I am a big supporter of the community college system, every
    community college in my State, I believe, understands that, but
    I don't quite understand, one, why we want to make community
    college free for everybody regardless of need. And then my
    second question is going to be: Why just community colleges?
    But how do you expect this plan to work? And would all students
    who choose the community college have no cost of going to that
    college?
        Secretary Cardona. Thank you, Senator. I recognize that
    there are many States that are doing amazing work providing
    access to higher education institutions. I was in Michigan
    recently, and I saw amazing efforts there to make college
    affordable and accessible to students in Michigan. But this
    plan would allow 5.5 million students to have access to higher
    education who might not have had it previously.
        And we know that not only is it a benefit for these
    students, but it is a benefit for their families, their
    community, and there is an economic benefit. Graduates of 2-
    year colleges, on average, earn 21 percent more than students
    with a high school diploma. We know that the skills that are
    needed in the workforce today are skills that would require
    some level of training.
        So with good coordination, our free community colleges
    connecting with our high schools, connecting with the workforce
    and 4-year colleges, which stand to gain because there is going
    to be a wider net of students seeking higher education. We do
    feel that this is a step forward for the country.
        Senator Blunt. Good. I don't disagree with any of those
    thoughts, except your point that there would be, I think you
    said 5 million students that would not have access to community
    college, otherwise. What about all the students that could go
    to community college, otherwise, that we are--are we now paying
    that tuition as well?
        Secretary Cardona. Many of those students are benefiting
    from supports now. What we are doing is leveling.
        Senator Blunt. No, no. That is not what I am asking. What I
    am asking is if any student at any income level wants to go to
    community college, can they go for free under this program?
        Secretary Cardona. Yes, it would be accessible to all who
    want to study in a community college.

         EXPANDING FREE COLLEGE PROPOSAL TO ALL ACCREDITED INSTITUTIONS

        Senator Blunt. So why would--so let's go to a second
    question. Why would you focus that first 2 years on a community
    college when students might want--that even qualify for, for
    instance, the Pell Grant now, they can take that Pell Grant
    money and go to any college, any accredited institution, public
    or private, they want to, and many of those institutions now
    with fully qualified Pell students, figure out how there is no
    other costs beyond Pell. Why would you not allow them to
    continue to have that same ability to go free to those schools
    as well, if they are students in real economic need?
        Secretary Cardona. Under this proposal, students will still
    have the choice to attend the college that they would like,
    benefiting from Pell Group programs if they are eligible. So it
    does not limit options. If anything it provides more options,
    and provides more opportunity for students who might not have
    considered higher education an option for them due to the
    costs.
        Senator Blunt. What about, generally, to continue this
    discussion, we should have free first 2 years of college, or
    free college for everybody, but that almost always talks about
    a college in a public school setting, as opposed to an
    accredited school setting. I think one of the real strengths of
    the American higher education system since World War II has
    been virtually all of our programs, whether they were the GI
    benefit, or Pell Grants, or any other Federal Government
    program, you had the ability to use that at any accredited,
    post-secondary institution.
        What is your view on that? As we continue to discuss how
    access to various levels of grants and fundings public--versus
    both public and private competing with each other after high
    school?
        Secretary Cardona. Thank you, Senator. You know, I look
    forward to continuing conversations with you and others to find
    the right pathway. What we want to do is provide access to
    higher education for students across the country; we know that
    access to higher education affords students the opportunities
    to better options in life, higher earning potential. And that
    is good, not only for the student, but for the community and
    the economy, as I said earlier. So I am a big proponent of
    providing options for students who want to pursue different
    careers, or different educational institution based on their
    choice. And I would be in support of exploring options to make
    sure that that is accessible under this plan.
        Senator Blunt. Well, the current system, as you know,
    creates lots of options to accredited institutions. I hope that
    continues to be the case, and certainly something you and I
    will continue to talk about. Thank you, Secretary.
        Secretary Cardona. Thank you.
        Senator Blunt. Thank you, Chair.
        Senator Murray. Senator Shaheen.
        Senator Shaheen. Thank you, Madam Chairwoman.

                    ACCESS TO AND USE OF COVID RELIEF FUNDS

        Mr. Secretary, we are delighted to have you here today. I
    want to start with a challenge that we are having in New
    Hampshire. As you know, Congress has provided nearly $200
    billion for emergency relief for elementary and secondary
    schools as a result of the COVID pandemic. This funding was
    intended to assist schools during this emergency, and Congress
    was very clear when we passed that legislation, that the intent
    of these funds is to be--allow them to be at the school's
    discretion to meet a wide variety of local needs, including for
    construction projects, such as HVAC (Heating, Ventilation, and
    Air Conditioning) repairs and improvements.
        I am very concerned about the delays that many New
    Hampshire schools have experienced when trying to access this
    relief funding. And I have been troubled by the Department's
    delay in issuing clear implementation guidance that regards
    regulatory requirements on States and school districts. Now I
    appreciate the guidance that was just provided to--by the
    Department to New Hampshire yesterday.
        I hope it resolves some of this uncertainty, but there are
    still questions that schools have, and in order for them to
    benefit from this money, we have a limited time for
    construction during the summer, and so it would be really
    important to have the Department be very clear on the use of
    these funds. So can you talk a little bit about how the
    Department is working to allow expeditious access to the funds
    that have been approved and appropriated by Congress?
        Secretary Cardona. Thank you, Senator. You are absolutely
    right. The importance of being expedient in the use of funds to
    get them into the schools, to provide the resources that are
    needed, to get the students what they need to be in the
    classroom quickly and as safely as possible. And with the
    distribution of funds, we recognize that different parts of the
    country have different needs. I was in Philadelphia recently,
    and I learned how the ventilation issues in those schools
    prevented students from coming in at the same rate as
    communities that had schools that were a bit newer and had
    better ventilation. So in that particular area, the issue was
    ventilation.
        So what we want to do is balance flexibility around how the
    funds are used with ensuring that the funds are being used to
    safely reopen schools, and address inequities that were
    exacerbated during the pandemic. And by the strategies that we
    are taking is becoming accessible, and making sure we are
    working with States on their individual needs, and their
    individual challenges. We worked closely with various States,
    meeting with them and having conversations with not only their
    educators, but their elected officials, to ensure that
    maintenance of effort is being kept, and that the funds are
    being moved quickly to help the schools, and getting out to the
    LEAs (Local Education Agency) as soon as possible, and we will
    continue to do that.
        Senator Shaheen. Well, I appreciate that, but that hasn't
    happened as expeditiously in New Hampshire, as the school
    districts really need it to happen. The ventilation systems,
    the HVAC systems are clearly an issue in many of our schools,
    and again, when Congress passed these funds, we tried to make
    it very clear that we wanted them to be as flexible as possible
    for use by the schools. So as you point out, the more the
    Department can be accommodating, and working with States on
    their needs as quickly as possible, the better.
        Secretary Cardona. Thank you, Senator.
        Senator Shaheen. So do I have your commitment that the
    Department will continue to work with the State of New
    Hampshire?
        Secretary Cardona. We will be on the phone with New
    Hampshire today, Senator.

                             STUDENT LOAN REPAYMENT

        Senator Shaheen. Thank you. All right. I am going to hold
    you to that. You and Senator Murray talked a little bit about
    the student loan program, and the effort to help address the
    challenge that many students are facing. This moratorium is
    scheduled to end September 30. I just wonder if the Department
    considers the final date of the moratorium, are you looking at
    a further extension? One of the challenges we have heard from
    people is needing certainty, as they are thinking about going
    back to school, and both loan agencies and students themselves.
        Secretary Cardona. Yes. You know, we are aiming to provide
    as much of an on-ramp for these borrowers as possible. And the
    date in September payments are--we are starting in October is
    something that we have, but we are continuing conversations
    about if that is the best time. No announcements today, but we
    continue to have those conversations. We recognize that for
    many families the recovery of this pandemic will come around
    the same time. Students are going to be returning to schools,
    mortgages have to start getting paid, and loans have to start
    getting paid. So we want to make sure we are sensitive to the
    needs of the borrowers and aware of the other challenges that
    they have.
        We are going to continue to do as much as we can with our
    authorities. Just today we are announcing $500 million in new
    discharges for, over 18,000 borrowers who attended ITT
    technical college just to make--technical institutes, excuse
    me, just to make sure that every authority that we have
    currently, we are taking advantage of it to support our
    borrowers who are in need. And we do want to provide timely
    information, as Senator Blunt also mentioned, and make sure we
    have as long an on ramp for these borrowers to start repayment.
        Senator Shaheen. Well, thank you. I appreciate that. And I
    know that it is a huge concern for borrowers, but the sooner
    decisions can be made, I think the better people can plan.
        Secretary Cardona. Thank you.
        Senator Shaheen. So thank you. Thank you, Madam Chair.
        Senator Murray. Thank you.
        Senator Moran.
        Senator Moran. Thank you, Chairwoman.

                       INDIVIDUALS WITH DISABILITIES ACT

        Mr. Secretary, thank you for your presence today. Let me
    just highlight a couple of things that I am pleased with, and
    that would be IDEA. The increased funding support for that is
    valuable, commitments were made a long time ago, and those
    commitments have not been kept for a long time. And a
    significant component of our success in education will be our
    ability to educate those who need the IDEA aspect of our public
    education system.

                                   IMPACT AID

        And I look forward to working with you to see that we
    continue to provide additional support for those students. I
    also want to highlight the importance of Impact Aid; Kansas
    with Fort Riley and Fort Leavenworth, they are hugely important
    to assist our school districts that have a large presence of
    public lands. And I look forward to working with you to see we
    support Impact Aid and its ability to level the playing field
    in the finance of education in my State.

                                      TRIO

        Let me ask a question about TRIO. The Biden Administration
    proposed investing $62 billion in new college retention and
    completion services. This, to me, seems unnecessary spending on
    a duplicative program when we have TRIO programs. And I noticed
    in your comments you bragged about the significance and value
    of TRIO, but what is the circumstance that suggests that this
    is not duplicative or that the resources that you are putting
    into new programs could not be utilized in the TRIO programs to
    achieve the same outcome?
        Secretary Cardona. Thank you, Senator. And I do agree that
    the investment in special education is so needed. I have spoken
    to families of children with disabilities, in particular,
    families with children with autism, who have said, ``you know,
    the laptop alone is not going to cut it.'' So I am hopeful that
    our students with disabilities are going to get the support
    that they need, and that we are on a path to fully funding it.
        With regard to the TRIO programs, you know, one thing we
    have heard is, students who are in our community colleges or in
    our 4-year colleges, due to the pandemic have had to leave. And
    there is a lot of concern whether or not they are going to be
    able to come back. And we also know that this translates into
    high school students who were maybe once thinking about going
    to college, not having that opportunity, or having to work now
    to supplement the income of the home, and have other factors
    that are pulling them in a different direction.
        So the $200 million increase in the TRIO programs, to me,
    addresses what we know to be the case. What we are hearing from
    educators, what we are hearing from families, what we are
    hearing from students is that going to college for some
    students who might have been considering it, it seems a little
    bit further removed. And we want to make sure we are addressing
    that, so that we do continue to have students in colleges
    across the country.
        Senator Moran. Well, my concern is not that you are
    increasing the TRIO program by $200 million; it is if TRIO is a
    valuable program, which I believe it is, why would we create
    new programs with new funding, the $62 billion, without further
    utilizing the TRIO programs that already exist? We have a habit
    I think in Congress, and I can't imagine that is--an
    administration that is immune. We in politics and public policy
    have a habit, when we try to highlight the value or the
    importance we place on something, we create a new program.
        And my suggestion is, my request is an understanding of why
    current programs, such as TRIO, would not be the vehicle by
    which you deliver new assistance. There are lots of schools in
    Kansas and across the country that would love to have a TRIO
    program, would love to expand the number of TRIO programs they
    have. Those are restrained in many instances because of lack of
    funding, and yet we are putting significant new dollars into a
    new program, which I would suggest has a pretty similar
    objective as TRIO.
        Secretary Cardona. Thank you, Senator. Well, we want to
    make sure we have opportunities for all students. And I agree
    with you, the TRIO program is successful when it is able to get
    students into college. And I hear your question. You are
    saying, why are we duplicating services if TRIO does similar? I
    look forward to working with you to discuss this further. And
    we would be happy to have conversations about where you feel we
    should be looking at things, and combining them instead of
    setting a new programs.
        Senator Moran. I look forward to working with you. And I
    was particularly interested in your response to Senator Blunt's
    question, which I--the answer at least to me, was incomplete.
    And I would be welcoming to see why, that the ideas that
    Senator Blunt suggested are ones that don't, in your view, have
    merit. Thank you.
        Secretary Cardona. Thank you.
        Senator Murray. Senator Durbin.
        Senator Durbin. Thanks Madam Chairman.
        Mr. Secretary, thanks for being here.
        Secretary Cardona. Glad to be here.

                              FOR-PROFIT COLLEGES

        Senator Durbin. This is not a trick question, but do you
    have any idea what percent of post-secondary students in
    America enroll in for-profit colleges and universities?
        Secretary Cardona. Off the top of my head, sir, I don't,
    but I can get you that information.
        Senator Durbin. I will tell you what it is. I will give you
    the answer, and it is not to trick you. It is 8, 8 percent
    post-secondary students in America enroll in for-profit
    colleges and universities.
        Next question, what percent of student loan defaults in
    America are accounted for by for-profit college students?
        Secretary Cardona. I have a feeling you are going to share
    that answer with me, sir. So, I will, turn it back to you.
        Senator Durbin. As I said, I am not trying to trick you,
    30.
        Secretary Cardona. Thirty.
        Senator Durbin. Eight percent of the students, 30 percent
    of the student loan defaults. What does it tell us? It tells us
    they are enrolling students who cannot finish, won't finish. It
    tells us also they are charging money that students cannot
    repay even if they are employed, 8 percent, 30 percent. As
    often as I meet you here each year, I am going to ask you the
    same question, because the numbers don't change.
        But here is what is interesting, in the COVID-19 situation,
    colleges and universities across America are generally
    struggling for enrollment, except for the for-profit schools.
    They have seen a 3 percent increase in students. How can that
    be? Are they that good? They market and advertise constantly.
    You don't have to turn on television, or look into the news
    except to see the latest ad for them. Now, the reason I raise
    that is because I think that raises a serious policy question
    about a branch of higher education that is failing so many
    students and yet receives such a handsome Federal subsidy.
        Now you have many roles, a Secretary of Education,
    educator, principal, president of the university, all these
    things, all of the above, and you certainly have the background
    for it, but there is one aspect of your responsibility then I
    want to delve into that is not often brought up. You are the
    Nation's--one of the Nation's biggest bill collectors. You are
    a credit agency, you are a banker. And I want to tell you the
    record that was written by your predecessor in this field is
    not one that I think we want to see continue. For example, if I
    might. Public service loan forgiveness. Are you familiar with
    it?
        Secretary Cardona. Sure.

                                 STUDENT LOANS

        Senator Durbin. Do you know what the DeVos administration
    did with public service loan forgiveness? I will tell you. 99
    percent of those who applied were denied, that is just
    outrageous. And then Congress tried to extend the program with
    a new version. That was ignored as well. So Secretary DeVos was
    channeling Henry Potter and not George Bailey many, many times.
    When it came to borrower defense of 108,000 students who
    applied, and said that they were the victims of fraud by for-
    profit colleges and universities, the DeVos Education
    Department, as they were leaving town, denied 80,000 of them
    after waiting month after month, and year after year. The lives
    of these borrowers have been compromised.
        Now, I don't know how familiar you are with ECMC
    (Educational Credit Management Corporation). Has your staff
    given you a briefing on your collection agency?
        Secretary Cardona. Yes. I have heard it.
        Senator Durbin. They have?
        Secretary Cardona. Yes.
        Senator Durbin. Well, I will tell you, the last point I
    want to make before I turn it over for your response is this.
    They are outrageous. The policies that they use to collect on
    student loans, I don't think any of us want to try to defend in
    public. If someone goes into bankruptcy court and tries with
    the one narrow exception to the bankruptcy code for student
    loans, undue hardship, they don't have a chance. ECMC is going
    to beat them back, whether or not you are dealing with
    veterans, who are so disabled that they can't pay back their
    loans, people subsisting on Social Security Disability, people
    with terminal illness, they are all beaten back and denied by
    your collection agency. So, open question: What would you like
    to do about it?
        Secretary Cardona. Thank you, Senator Durbin, for bringing
    out the facts, on something, that I will be very frank with you
    is the top priority at the agency. We have done a disservice
    and it is time to act. It is time to have our students at the
    center of the conversations there. It is a high priority for me
    to make sure that we correct that, it is unacceptable to have a
    98-99 percent refusal with public service loan forgiveness.
        I had a conversation with students who had to go through
    that process and were given the run around. I was frustrated
    after that call. They had to hold on and go through different
    hoops to try to get an answer. And then the answers were not
    accurate, and they had to go somewhere else. So, there is a lot
    of work that has to be done.
        I recently hired Richard Cordray. He was recently appointed
    by the President. And we need to have a consumer protection
    mentality, we need to put the students at the center of the
    conversation, and we need to make sure that what we are doing
    at the agency, is a model for what we expect. And we have to
    put our loan providers on notice that we are going to put the
    students first.
        We have not been sitting around waiting either though, we
    have provided a $1.5 billion in relief through borrower
    defense, by delivering a billion in full relief to 72,000
    borrowers, and approving 500 million in discharges, as I
    mentioned with ITT. So, we are taking every opportunity now to
    change the culture there. And the message is very clear to
    Richard. Fix this. Fix this, and move quickly, and be
    transparent, and change the culture that people perceive.
        As you pointed out, we have a culture to change and we have
    better--we have to implement strategies better. Our students
    cannot wait, and we are contributing to the problem, you will
    see a turnaround in that. That is a priority for me.
        Senator Durbin. Thank you. Channel George Bailey. Thank you
    very much.
        Senator Murray. Thank you.
        I will turn to myself, and then Senator Blunt for a second
    round. I would just notify all committee--members and staff to
    please tell your members to be here, because if there is no one
    else to present at after that time we will wrap up this
    hearing. I know Mr. Secretary, you are sad to hear that.
        Secretary Cardona. I know.

                        RATIONALE FOR ADDITIONAL FUNDING

        Senator Murray. Mr. Secretary, the President's budget calls
    for major new investments in our Nation's public, elementary,
    and secondary schools, totaling $66 billion. That is an
    increase of $25 billion more than last year's, LHHS (Labor,
    Health and Human Services) bill, now Republican and Democrats
    were able to work together on COVID relief in our regular
    appropriations bills last year. The $125 billion in K-12
    education investments included in the American Rescue Plan Act
    passed earlier this year did not have bipartisan support. And
    some of our Republican colleagues expressed concern that those
    funds would not be spent quickly or were unnecessary.
        Tell us why you think the additional K-12 investments
    proposed in the President's budget are needed on top of the
    significant COVID supplemental appropriations that are already
    enacted into law?
        Secretary Cardona. The technical support that the
    allocations provide are critical, and I will get into that, but
    let me first talk about how important it is that the President
    signal a transformational change in how we view education as
    the foundation of our country's growth.
        As the First Lady said, any country that out-educates us
    outperforms us. So, this administration understands the
    important investment in education. And I don't have to remind
    you, because you mentioned it in your opening comments, years
    of underinvestment in education. I have seen that. I was a
    principal when we were asked to do more with less. I had class
    sizes that were very high, with teachers who were doing their
    very best to meet the needs of students, and those needs kept
    increasing, but the funds kept decreasing.
        There is a realization here, that if we don't get this
    right, so much else is going to suffer. So, when we talk about
    what this investment can turn into, it can turn into smaller
    class sizes. It can turn into better teacher preparation.
    Students are coming back from a trauma-filled year. I spoke to
    a student at Harvey Milk School 2 days ago, in New York, who
    told me his grandmother and his significant other died in the
    last year.
        This student is going back to school. If we are not
    investing in additional trauma support, training to make sure
    everyone, including our school bus drivers, our cafeteria aides
    who have been heroes this past year, have the support and
    training to help meet the needs of these students when they
    come in, then we don't stand a chance. If we are not providing
    funds to give students access to digital devices and broadband
    so that they can have access to learning wherever they are,
    then we lost an opportunity.
        The pandemic exacerbated the need. You mentioned it in your
    opening comments, the impact that it is having on our poor
    communities, in our rural communities students didn't have
    access to broadband during the entire pandemic. We cannot
    continue under-investing in education and think that we are
    going to continue to produce students that are going to lead
    the world. We have an opportunity here, an obligation, a
    privilege to make sure we are funding our schools, and giving
    our educators the tools that they need to be successful. More
    importantly, giving our students the tools that they need to be
    successful.
        Imagine our country, when students don't have to worry
    about not having a teacher in front of their classroom, enough
    materials, or access to technology so that they could get
    access to basic deliverables in education. That is where we are
    going. And this bill does that. The American Family Plan boldly
    communicates that. And I am excited about supporting it moving
    forward.

           SIMPLIFICATION OF FREE APPLICATION FOR FEDERAL STUDENT AID

        Senator Murray. Thank you. I really appreciate that
    response. Mr. Secretary, too many students miss out on college
    financial aid that they are eligible for, like Pell Grants, in
    part because the application process has been so cumbersome.
    Last December we were able to finally reach a bipartisan
    agreement to significantly simplify the Federal Student Aid
    Application process with the passage of FAFSA Simplification
    Act, and that law, by the way, also expands eligibility for
    Federal financial aid.
        The administration's budget request does include a
    significant increase in funding to implement those and other
    related changes. But unfortunately, the Department announced
    last week, as you know, that some of those changes cannot be
    implemented quite as fast as all of us had really hoped. This
    is not a criticism of the Department. Everyone wants the law
    implemented as quickly as possible, but tell us what the
    Department is doing to implement FAFSA as quickly as possible,
    including moving forward with key benefits for students on
    time?
        Secretary Cardona. Thank you. And I recognize it is not a
    criticism, but, but we need to get moving on this. And I thank
    you, and Senator Blunt, and others who have really pushed this,
    and understand the importance of that simplification process. I
    have talked to students who said, you know what, that is too
    much. Or families, I can't do that. And they have missed out on
    opportunity.
        So, the simplification process is critically important, but
    the reality is we walked into a system that doesn't have the
    capacity. As I mentioned in the previous statement, you know,
    under-investment leads to results. Well, we have a 45-year-old
    computer system that can't handle the changes that are needed,
    and that you voted for.
        So, we need to move quickly, swiftly, to make sure we are
    prioritizing that, that is critically important, the FAFSA
    simplification. We are on it. We are going to prioritize that,
    again, another area that Richard is really prioritizing. And we
    are going to keep you updated. You deserve to be updated on
    what progress we are making, what challenges we have, that is a
    priority for the agency, and for me as Secretary.
        Senator Murray. Thank you very much.
        Senator Blunt.

                     TRANSPARENCY OF COVID RELIEF SPENDING

        Senator Blunt. Thank you. Thank you, Chair. On the topic of
    new money to schools, Congress provided in the American Rescue
    Plan and the COVID supplementals, a total of $190 billion to K
    through 12 education. Data provided to us by the Department as
    of June 4, less than $9 billion of that has actually been spent
    by schools. What can we do to ensure that that money gets
    spent, and there is more transparency about how and where it is
    being spent?
        Secretary Cardona. Thank you for that question. And it
    gives me an opportunity to share that as the commissioner of
    education, during the beginning of the pandemic and throughout
    most of the pandemic, we also had to develop systems that did
    not exist before, to distribute money in this unprecedented
    time, to make sure that LEAs had the support they needed. And
    as the Senator mentioned earlier, in some places that process
    is slower than we would like.
        So we are in communication with our districts, our State
    LEAs, and we recognize, however, and I can tell you from
    experience that, you know, a good portion, sometimes 80 percent
    of budget is human resources, right? So that money is drawn
    down as the contract, or the year goes by. And we recognize
    also that this is a 3- to 4-year process where the funds are
    going to be used to provide services for multiple years. Also,
    contracts that are signed off on are not paid for until the
    services are provided. And in many cases that extends years.
        So, we recognize the need. I think the transparency, what
    you brought up is critically important. We asked that any
    planning that is being done for funds with the American Rescue
    Plan have transparency that are posted on websites and that
    engage stakeholders, so that folks know how the money is being
    used. We have a responsibility to ensure every dollar of
    taxpayer money is being used to support what it was intended to
    use.
        Senator Blunt. Right. Now I certainly agree with that. And
    I think we actually assumed that more of that money would be
    spent on technical support and things that wouldn't have been
    part of the normal education system that districts had in
    place, as opposed to long-term contracts with individuals, and
    things that probably were in their normal and regular budget.

                             IN-PERSON INSTRUCTION

        I hope we are looking carefully to see that that money is
    spent, to be more ready for virtual education when we need it,
    and different kinds of communication when we need it.
    Obviously, as Senator Murray has pointed out, and others have,
    the loss of learning in many cases to people who couldn't go to
    school, either they didn't engage in a virtual class, or that
    wasn't the right way for them to learn. Where do you think we
    are going to be in the fall in terms of in-person learning?
    What percentage of American public school students do you think
    we will be back in school in the fall in person?
        Secretary Cardona. Some of the expenditures that take time,
    as you mentioned, are critical, virtual learning access,
    broadband access, and that does take some time. With that said,
    I do expect 100 percent of the students across the country to
    have access to in-person learning. April data shows that 96
    percent of the K-8 students had an opportunity to learn in
    person. But I would argue that hybrid isn't a great option.
        In many cases families can't do the hybrid option because
    parents have to work. It is all or nothing. I am pushing really
    hard to make sure that we are addressing, and we are working
    with States, and local LEAs to address whatever factors might
    be preventing them from offering full in-person learning, full-
    time for all students in the fall.
        That is my expectation. And we are having conversations
    regularly with different State leaders, and local education
    leaders to make sure that that is--the message is clear, and
    that the expectation is there. The funds are there. We have to
    make it happen for our students, Senator.

                             STUDENT LOAN SERVICING

        Senator Blunt. Let's talk about loan servicing for just a
    minute. Certainly, as you pointed out, and I was pleased to be
    in involved in trying to simplify those loan forms. Senator
    Murray and Senator Alexander and the Authorizing Committee,
    last year, did a great job of leading there. Now there has been
    a discussion with the Title IV additional servicers, how we
    connect better with students--with individuals who have student
    loans.
        This committee was not supportive of the last plan for the
    next generation of student loans. We are about to run out of
    the current framework of contracts. I think the current not-
    for-profit servicers contracts, and between December of this
    year and March of next year, there appears to be no plan to
    replace the current system. What I am asking is: Will you use
    the authority you have in the fiscal year 2021 labor bill to
    extend these legacy of servicing contracts while you work on a
    long-term servicing solution? Or do you expect to have a long-
    term service solution in place by December of this year?
        Secretary Cardona. We are working aggressively to make sure
    we have a system that has very high standards for loan
    servicers. We have to put the students at the center, while I
    don't have an announcement to make today, I will tell you that
    we plan on having an update, and we will update you within the
    next month or so to share what the plans are with that.
        Senator Blunt. Well, I will tell you. I have been very
    involved in this discussion. I would like to be updated, and
    would hope to be updated before you absolutely have a plan you
    are ready to announce. And then if, for whatever reason, that
    plan can't be put in place by the time these servicing and
    agreements run out I hope you are thinking about the authority
    that we gave you to extend those agreements if that was the
    best thing to do.
        Thank you, Chair.
        Secretary Cardona. Thank you, Senator. We will be in touch.
        Senator Murray. Thank you.
        Senator Braun.
        Senator Braun. Thank you, Madam Chair. I remember in our
    first or second conversations along the way, we have had a--
    kind of a spirited discussion on resources that we put beyond
    education, in general. And in my opinion education, along with
    one's healthcare, we ought to be doing that as well as
    possible, not only through public, but through the private
    arena as well.

                RETURN ON INVESTMENT IN POST-SECONDARY EDUCATION

        And post-secondary education now has the dubious
    distinction of being the place where costs are going up more
    per year than any other significant sector of our economy. Just
    eclipsed a few years ago, the rate of increase in healthcare,
    which is a place I have, since I have been here wanted to
    reform and try to fix, because I think it is a broken system
    there in terms of what we do through the private sector, and
    through government, because we have got the entity itself, the
    system that doesn't deliver, it has cost us in healthcare twice
    as much as what it does in other countries.
        So, I think it is silly to pour more resources in anything
    that is not delivering outcomes that look like they are at
    least headed in the right direction. So do you think when it
    comes to the results, and let us look at post-secondary
    education, I will come back to secondary in a moment. Do you
    think we have been getting a good bang for our buck?
        Secretary Cardona. There is always room for improvement,
    Senator. And I can assure you that the team that we are
    assembling recognizes the importance, and the moment that we
    have to make sure we are improving access and affordability.
    Again, I mentioned earlier, the American Families Plan provides
    opportunities for students to access community colleges for
    free. We know how important that is to give them an opportunity
    to join the workforce with skills that they need to be
    successful. And that the earning potential of graduates of
    community colleges can be up to 21 percent higher.
        We have work to do and we are going to be aggressive to
    make sure that students are getting a good return on investment
    in post-secondary education. And we are addressing the issues
    that exist, where students are being taken advantage of, or
    sold a bill of goods and never delivered on. We are on that.
    And that is a priority for me.
        Senator Braun. So my observation before I got here is that
    you generally don't pour resources into something until you
    look at what you have got, that you are trying to rebuild, re-
    energize, or make better. And 41 percent increase over fiscal
    2021 levels is embedded in this budget proposal. And my
    observation, from being on a school Board for 10 years, to
    wrestling with education at the State level as a State
    legislator, it is not about spending more money, it is really
    more about finding how we change the system.
        To me it is analogous to healthcare. And as long as we are
    here, since we live with no constraints, now added in the two-
    and-a-half years I have been here, nearly $10 trillion in
    national debt. The need to be a little more entrepreneurial, a
    little more concerned about changing the paradigm. And here I
    see most of this just pouring more resources into something
    that doesn't need to tell us any more clearly, that it is not
    delivering the goods.

                 SECONDARY EDUCATION ALIGNMENT WITH JOB MARKET

        Before I run out of time, let me pivot back to, the same
    point would be made in secondary education, before you get to
    college. College is runaway with costs that even parents are
    really scratching their heads. Is it worth it to send my kid
    into a system that 50 percent of the kids that go there don't
    pursue it, and many get a misguided degree, and employers don't
    have a market for?
        Why don't we try to get it better at the secondary level
    and match training and skills with the high-demand, high-wage
    jobs that all of us have out there? My State of Indiana,
    checked with my kids, I think we have got 70 to 80 job openings
    in our own company, out of a total employment of 1200. We don't
    need any more 4-year degrees, because the jobs that we have in
    a State like Indiana, where we ship out twice as many 4-year
    degrees as we use in the State, we need better skills that are
    being delivered out of high school.
        I look at a place like Garrett High School, west of Fort
    Wayne that catches kids and, obviously, parents, when they are
    fifth graders, before they go to middle school. That is
    something that would cost no more money, but would change the
    dynamic of where we need to change our emphasis in how we do
    things. And until education does that, until healthcare does
    that, I really think we are just going to be borrowing more
    money and putting it down a dubious hole. I won't refer to the
    word that comes to mind. So, a quick comment on that.
        Secretary Cardona. Thank you. I agree with you. If we do
    what we have done, we are going to get what we have gotten. So,
    you know, the plans discussed CTE (Career and Technical
    Education) changes. We really, if you recall, my hearing, one
    of my goals as Secretary of Education is to make sure we evolve
    our secondary schools to meet the demands of the workforce, and
    the careers that are available today, as you mentioned, in your
    own community.
        So, this is something that I am eager to work with. Not
    only in the budget do we see that in there. And it is not just
    resources, it is the change in mindset. We are going to get
    there. And I look forward to working with you on that. I know
    the Jobs Plan has funds for that, the Families Plan. I know the
    President gets it, it is in the budget, and we are going to
    make it happen. And I look forward to working with you on that.
        Senator Braun. Thank you. And I would invite you to take a
    road trip to Indiana and visit some of the places that are
    setting the trend on what we, as employers, need which is a
    better elementary and especially secondary education, before
    you start pushing kids into a broken system after that. Thank
    you.
        Secretary Cardona. Look forward to working with you on
    that.
        Senator Murray. Senator Reed.
        Senator Reed. Thank you very much, madam Chairwoman.

                             SCHOOL INFRASTRUCTURE

        Welcome, Mr. Secretary. Your experience as a State
    Commissioner of Education is, I think, invaluable because you
    have seen these issues up close and personal, as they used to
    say on television. And one of the issues I hope is not
    debatable is the poor status of school infrastructure, and this
    is not just an urban issue, it is a national issue.
        I have been working very hard to get resources in for
    infrastructure repairs in schools, and also in the context of
    infrastructure repairs, you can do a lot of things like, change
    the heating system to be more efficient. We discovered in the
    pandemic, in Providence they had to teach all winter with the
    windows open, because the HVAC system, and you probably had the
    same situation in Connecticut, the HVAC system would not
    support a safe instruction, and was probably built in 1930, et
    cetera.
        I am pushing very hard to get $100 billion in the Jobs Plan
    for the schools. And I hope you can assist me in doing that,
    with the President and with my colleagues.
        Secretary Cardona. Thank you, Senator. Part of the ``Help
    Is Here Tour'' we visited about nine or ten different States,
    and visited about ten different schools. And as I mentioned in
    an earlier response, the needs in different communities, post-
    pandemic, were different. And one really stood out to me. I was
    in Philadelphia, and I visited schools that were over 120 years
    old. You know, where the windows are shut with paint.
        Senator Reed. Lead paint?
        Secretary Cardona. Yes. The students, they need better. And
    it really just brought to the surface what educators have known
    for years; that facilities do matter, but what is the first
    thing that goes in local budgets when there is not enough
    funds, the facilities' maintenance. I remember as commissioner
    of education, talking to district leaders who said, our system
    hasn't been touched in years, the maintenance of the system
    hasn't been touched in years, the filters haven't been changed
    out.
        I learned more about MERV 13, MERV 15, more than I ever
    thought I needed to know. But the point is there has been
    negligence on facilities for years. And what we are finding is,
    in order to get students back into school safely and ensure a
    safe learning environment where the community could feel
    confidence in their schools. When we talk about reopening
    schools, we have to take that into account. So, I agree with
    you. Part of the Jobs Plan has the upgrade and building new
    public schools where it is needed, the $50 billion over 5
    years.
        But the community colleges also need the support, and the
    $12 billion over 5 years there, is a commitment to making sure
    that our facilities are safe places for our learners, for our
    educators. So that kids go to school, they attend regularly,
    and they have a learning environment where they can grow. So, I
    agree with you there, wholeheartedly, Senator.
        Senator Reed. Well, thank you. And I must confess part of
    my passion is the fact that my father was a school custodian.
    And so he would get to--in fact supervisor custodian--so he
    would get those calls in the middle of a winter night to go fix
    the boiler that was installed in 1927 or something like that.
        Secretary Cardona. Exactly.

                                    LITERACY

        Senator Reed. A further question. I had an interesting
    discussion with adult education providers, and they reported
    that 95 percent of the students that they are serving, come to
    them with virtually no literacy skills. They can't read, they
    might graduate from high school, or at least going the length
    of time they have to, but they can't read. And if they can't
    read, it is very difficult to train someone for a job,
    particularly in the sophisticated, post-industrial economy.
        Secretary Cardona. Right.
        Senator Reed. One issue I think is if making sure we know
    what at least the rates are. And I have just wondered, do you
    have national, local, and States' reliable statistics about
    literacy?
        Secretary Cardona. We do, we have data that we are tracking
    in terms of where the States are. But we have to do more. We
    have to do more to make them transparent, and to ensure that
    the funds that are being used through the American Rescue Plan
    are aimed at addressing those literacy gaps. I will tell you;
    we know in education that if a student is not reading by 3rd
    grade, you are going to be intervening for the rest of that
    student's school career.
        And in the process, probably disengaging that student in
    ways where they can't take the courses that they want to
    select, or think about college as early as they need to, to
    make sure they have the same opportunities as other students.
    But that is where I also believe, sir, that the American Family
    Plan and the commitment on early childhood education.
        Three- four-year-old programs, I saw as a principal, when
    5-year-olds walked into the kindergarten classroom on day one,
    we knew which students had access to high quality programs. We
    could tell which students didn't, and we knew, day one,
    kindergarten, which students were going to need intervention
    and support. So you pay now or pay later, we really need to
    focus on early childhood education, and literacy skills early,
    science-based, research-based practices, to make sure that we
    are allowing our students to have the best opportunity in life
    by reading by 3rd grade.
        Senator Reed. I agree, but we also have to pay attention to
    adults who will miss these prospective reforms but still have
    low literacy skills.
        Secretary Cardona. Right.
        Senator Reed. Thank you. My time has expired.
        Secretary Cardona. Thank you. Thank you, sir.
        Senator Murray. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Madam Chairman. And thank
    you, Mr. Secretary, for being here. I absolutely loved the
    background that you have, and it is very obvious that you
    really get it.
        Secretary Cardona. Thank you.
        Senator Hyde-Smith. And I appreciate that, because I can
    tell by your passion that you know exactly what these students
    are going through. So that I truly want you to know how much I
    appreciate that.
        Secretary Cardona. Thank you.

                      FLEXIBILITY IN USE OF COVID FUNDING

        Senator Hyde-Smith. As we know from COVID, so many kids got
    just really far behind in so many areas, and great concern, not
    just in Mississippi, but everywhere. But Mississippi has
    recently received significant American Rescue Plan funding to
    help reopen our schools. The reality is that most Mississippi
    schools have been open for in-person learning for nearly 10
    months, as many Mississippi schools resumed classroom
    instructions last August. We really got back in quick with good
    results, and made some good decisions there that our leaders
    made. But the school year for most Mississippi schools ended in
    early May, and students are already out for their summer break.
        In your submitted testimony you stated that the plans to
    reopen are bold, and will require coordination among key
    stakeholders at the Federal, State, and local levels. However,
    this statement, and several others from the Department, seem to
    ignore the fact that many other States, like Mississippi, have
    been opened since fall of 2020. So, we have this money, but we
    have already been open, but how much flexibility are schools
    being given to use the American Rescue Plan funding? Because
    that is the calls that I get, and that is the questions that I
    get, from my schools and my educators.
        Secretary Cardona. Yes. Thank you, for first of all, for
    your comments, and for the thoughts that you are bringing up on
    behalf of the constituents you serve. And like you, my own
    children have attended since August, and I have been fortunate
    that some of the students in Mississippi that were able to
    attend in person, early, safely. That is critical.
        So, we know, as I mentioned in a previous response that the
    impact of COVID effected some regions differently than other
    regions. And we have to be aware of that and provide the
    flexibilities where needed. We recognize that in some places,
    while students have been in school, it might have been in a
    hybrid model, or some students have had access more than other
    students, due to, whether it is confidence, or trauma with the
    pandemic, some students will still need support even if they
    are going into school, maybe half-time, or full-time even.
        We also know that summer learning will help bridge those
    gaps of learning that we experienced through the disruption of
    COVID-19. So, flexibility is important. And what we are trying
    to do is balance flexibility while making sure that the impacts
    of COVID-19 are being addressed with the American Rescue Plan,
    as was the expectation from Congress.
        So, we are working closely with States to communicate
    flexibilities, and we are available, if there are questions in
    Mississippi, to discuss how their plans are being rolled out,
    and questions that they might have around flexibilities, or
    adherences to specific requirements that might have come out of
    the agency.
        Senator Hyde-Smith. So, all we have to do is really contact
    your Department and for these individual questions, because I
    know they have some really good ideas, but we want to make sure
    we are following the guidelines the way that we are supposed to
    be doing that.
        Secretary Cardona. Sure. Senator, you know, we do encourage
    innovation also. So, we look forward to hearing it. As matter
    of fact, we will reach out, just to make sure that we are
    partnering with Mississippi to make sure that their questions
    are answered, and that we can promote as much flexibility to
    meet the needs of the students as needed.

                                CHARTER SCHOOLS

        Senator Hyde-Smith. Thank you. And I have a little time
    left. We have seven charter schools operating in Mississippi
    and, you know, charter schools have given parents the
    flexibility to decide which schools best fits their child's
    needs, individually, and not the government. In some instances,
    charter schools also have the freedom to adapt their classrooms
    as they see fit. And over the years, charter schools have seen
    increases in academic gains. We have had a lot of success
    there, which allow children more opportunities as they continue
    in their academic career.
        And with your commitment to ensuring all students have
    access to a quality education, how will you support school
    choice in order to expand access to higher quality charter
    schools?
        Secretary Cardona. I am a big proponent of high-quality
    schools for all students across the country. And I recognize
    that students have options and, public charter schools are
    options for students. And I feel that all schools should be
    held to similar standards of accountability. And I think that
    is where I stand with that. I have seen examples of schools
    that needed a lot of intervention, but I have also seen
    examples of schools that really met the needs of the student
    and the families in a charter school.
        Senator Hyde-Smith. Because we really had some good luck.
    We had a Senator Michael Watson, State Senator at the time,
    really worked on this a long time. He is Secretary of State
    right now. But it really proved that we made a lot of ground
    there that were good decisions and beneficial. So, you will
    continue to support funding for the charter school program? Is
    that what you are saying?
        Secretary Cardona. Yes. The President made it very clear.
    You know, we don't--we are not going to be promoting a private
    charter school growth, but we are endorsing the programs that
    exist now where students are taking advantage of public charter
    schools.
        Senator Hyde-Smith. Great. Thank you very much.
        Thank you, Madam Chairwoman.
        Senator Murray. Thank you. My understanding is Senator
    Manchin is going to walk in the door behind me at any moment.
    He will be our last questioner.

                         STATE PLANS FOR ESSER FUNDING

        While we are waiting for him. Mr. Secretary, I just wanted
    to thank you and your staff for all the hard work implementing
    the American Rescue Plan Act and other COVID-19 Relief
    Legislation, and the fiscal year 2021 Appropriations Bill. I
    know you got a lot on your plate. And I know the processes--the
    Department is really in the process of reviewing the State
    plans that are being submitted for each State's final one-third
    share of ESSER (Elementary and Secondary School Emergency
    Relief Fund) allocations under the American Rescue Plan.
        But one of my priorities really is, is that the
    legislation--in the legislation is the required State and
    school district set asides for evidence-based interventions
    that address the academic, and social, and emotional needs of
    students of color, students experiencing homelessness,
    underserved students.
        Secretary Cardona. Yes, right.
        Senator Murray. And I really appreciate the Department's
    template for State plans that include descriptions of state
    strategies, for carrying out these required activities, and
    strategies for States to support these district plans. Can you
    just assure us that the Department will only approve high-
    quality plans that effectively address the requirements of the
    law?
        Secretary Cardona. Yes. As I said at the beginning, that is
    where the honor lies, making sure that we are serving our
    students. And on behalf of the 50 million students, when we
    review those plans, we want to ensure that we are building back
    better, and that the plans are addressing the inequities that
    were exacerbated by the pandemic, that the plans engage our
    stakeholders in different ways, because that is critically
    important. Many folks who were already struggling in school
    prior to the pandemic are now further away. So, we need to
    engage them to make sure that the schools that we are reopening
    are welcoming places that are able to meet their needs as well.
        Senator Murray. Well, thank you. I really appreciate that
    commitment. And I just ask that you keep my staff updated on
    the review of those plans. As you know, high quality plans are
    only successful if they are effectively implemented. And I know
    your Department has hosted webinars, and established a
    clearinghouse, and taken some other actions, which I really
    appreciate.
        And while we are waiting for Senator Manchin, share some
    thoughts on how the Department will support and monitor those
    plans.
        Secretary Cardona. Senator, I appreciate you mentioning the
    actions that we have taken. We have--take your time. This is
    something I want to talk about. So, we do have a best practices
    clearinghouse, innovation doesn't come from Washington, D.C.,
    alone. In fact, across the country, we have over 1,100
    submissions of innovative practices to reopen schools, and
    engage those students that were hardest to engage during the
    pandemic.
        So, we are lifting our best practices from across the
    country. And, you know, I always say, we are going to heal
    together, we are going to learn together, we are going to grow
    together. And the tools that we have are at the disposal of the
    districts now are tools that were developed with them, not for
    them, with them. And I have to say that, you know, we are
    continuing that conversation. We are having an equity summit
    next week, where we are inviting everyone to come take a look
    at what it means to rethink addressing inequities, and be bold.
    Our students deserve it. Looking forward to that.
        Senator Murray. Thank you. Thank you.
        Senator Manchin.
        Secretary Cardona. Senator.
        Senator Manchin. Did I interrupt you?
        Secretary Cardona. No. Not at all.

                               HOMELESS EDUCATION

        Senator Manchin. Thank you so much. Let me, a few things.
    And I appreciate so much, Secretary, on the difficult job you
    have. And I want to go through a few things because a lot of it
    either makes sense or doesn't make sense. But the main thing
    is, I have really a problem with homelessness with children.
    And I noticed that the budget hadn't been increased for that.
    But I know that we put, myself and Murkowski, and all of our
    colleagues on both sides of the aisle supported $800 million
    going into that. But if the base doesn't move because, if it
    hasn't moved, it has been flat.
        Secretary Cardona. Right, right.
        Senator Manchin. It is growing. I hope you would show
    attention to that. I know we were able to meet it this year,
    but we won't be able to meet a year after that.
        Secretary Cardona. Right.
        Senator Manchin. Okay? So, if you can.
        Secretary Cardona. Sure. And I appreciate that. I recall
    experiences with students in the district where I worked
    before, who were experiencing homelessness. And I was always
    amazed at how they were able to engage in learning, and be a
    part of extracurriculars with housing instability, not knowing
    where they were going to go.
        And that reduces the bandwidth for learning when you are
    thinking about where am I going to sleep tonight? So, the
    money, the $800 million for homeless education through ARP
    (American Rescue Plan) is critically important. But I also want
    to share that the focus on community schools--the focus on
    community schools, and the vast proposal in the American
    Families Plan, is also intended to address some of these issues
    that lead to homelessness, right?
        Senator Manchin. And I think homelessness, and I was just
    asking, we need to describe it make sure we are all on the same
    page.
        Secretary Cardona. Right.
        Senator Manchin. McKinney-Vento describes homelessness one
    way, and the Department describes it another way. So, they
    might show in West Virginia we don't have that many. We know we
    have because we are basically talking to the schools. We know
    kids have been disrupted, things like that.
        Secretary Cardona. Right.
        Senator Manchin. We need to get that definition on the same
    wavelength. And let me go through a few more.
        Secretary Cardona. Sure.
        Senator Manchin. So, on that one there, and the second
    tranche of money is going to supposed to come out for them, the
    McKinney-Vento. These are very, very important. The other thing
    I wanted to talk about is community college. Okay. First of
    all, I will talk about pre-K 3 and 4, which I agree one million
    percent.
        Secretary Cardona. Yes.
        Senator Manchin. We have been doing it when it wasn't even
    popular.
        Secretary Cardona. Right.
        Senator Manchin. Let me tell you why we did it. Just on
    nutrition, just giving kids some stability in life. And we had
    a challenge in Appalachia. So, we had to. And I did it when I
    was governor, we have done it, and it has worked out great. So,
    I am glad the whole Nation, because you cannot get ahead of the
    curve if you don't start at 3 and 4 years of age.
        Secretary Cardona. Right.

                         FREE COMMUNITY COLLEGE PROGRAM

        Senator Manchin. God bless you on that. Where I disagree a
    little bit on community and technical colleges, and I disagree
    on free.
        Secretary Cardona. Mm-hmm.
        Senator Manchin. And I said, let me earn it. I have told
    people this and, you know, someone said free college. I said, I
    have a child, who is up 30-40 years of age. If they had had
    free college, they would still be in college. They never left,
    they loved it so much. That is just a little tidbit on that.
        But on community, here is the thing. Community technical
    colleges usually trained to skills, skill sets. It is not the
    same as a 4-year baccalaureate, or it gives them a segue,
    because their grades might not have been good enough. Okay. I
    understand all that. But most of it is skill sets.
        If we could determine the skill sets we need in different
    categories, in different parts of our country. So, if our
    community colleges are training for one thing in West Virginia,
    you are training for another thing in California, another thing
    in different parts of the country. If those skill sets are met
    by someone who is going, and we have a Stafford loan that we
    basically guarantee federally, you take the loan out. You, you
    accomplish that within a 2-year period of a community college,
    and you have that associate degree, then it should be forgiven.
        Let them earn it. Don't give it on the front end, earn it
    on the back end. You be surprised how much more they respect
    and appreciate something they have earned, than something you
    have given them. That is the only thing I have said about that,
    because I can tell you, as a parent, it works and works very
    well. And it is very efficient. You know, that would be like
    the same as a kid getting it: Where is my allowance, dad? And
    he is 35 years old. Do you understand where I am coming from?
        Secretary Cardona. Yes. Thank you, Senator. And I look
    forward to hearing more, and working with you, too. We need to
    make sure that all students have access.
        Senator Manchin. Right.
        Secretary Cardona. We need to make sure that all students
    have either access to the skilled development that you
    mentioned. And you are absolutely right, the workforce needs--
    --
        Senator Manchin. And for a time, either way.
        Secretary Cardona. But also, it might be an opportunity for
    students who don't think that they have the potential to go to
    college, to get access to a 2-year college and then continue on
    to a 4-year school.
        Senator Manchin. No problem.
        Secretary Cardona. So, we are widening the net, and we know
    the earning potential is greater when you graduate college. And
    I can tell you, 21 percent for community college graduates, I
    believe this is good for the economy in the long term. It is
    really creating a workforce with higher earning potential,
    better discretionary income, and I do think it is----

                               FINANCIAL LITERACY

        Senator Manchin. What is the dropout rate? You ever look at
    the dropout rate? Do you know why student loans are so high?
    Because we cannot even demand that they have financial
    literacy. They come in, we cannot even have a registrar say,
    no, you are not getting that much, Miguel, you don't, you only
    need $4,000. I know you qualify because your family is for
    $11,004, but $4,000 is going to be fine. They cannot say that.
    So, end up stacking up debt, 2 years they flunk out or they
    quit because they haven't had to pay any payments out. And all
    of a sudden it comes tumbling down.
        Secretary Cardona. Yes.
        Senator Manchin. We do a horrible job of managing student
    debt, but we are talking about, eliminated before you have
    people responsible for it.
        Secretary Cardona. We are going to be aggressive on the
    student debt, and making sure that we are communicating, that
    we are advocating for students, working with students, putting
    the students at the center. I am eager to get going on that and
    get started.
        Senator Manchin. I cannot wait to work--I cannot wait to
    work with you.
        Secretary Cardona. Same here.
        Senator Manchin. There are so many good things--and I would
    love to----
        Secretary Cardona. Same here. Thank you, Senator.
        Senator Murray. Thank you.
        Senator Manchin. Thank you.
        Senator Murray. That will end our hearing today. I want to
    thank all of our fellow committee members for their
    participation. Secretary Cardona, thank you for your very
    thoughtful answers today, and to talk about the President's
    budget. I do look forward to continuing to work with you, to
    support students and families in our country.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any senators who wish to ask additional questions,
    questions for the record will be due Friday, June 25, at 5 p.m.
    The hearing record will also remain open until then for any
    member who wishes to submit additional materials for the
    record.
        Secretary Cardona. Thank you.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted to Hon. Miguel Cardona
                  Questions Submitted by Senator Patty Murray
        Question. I'd like to follow-up on our discussion during the
    hearing about implementation of fiscal equity requirements under
    current law. These requirements include resource allocation reviews by
    states, school districts and schools identified for support and
    improvement. Earlier this year, the Government Accountability Office
    (GAO) reported most states (43 of 51) indicated helping districts
    identify resource inequities as somewhat or very challenging based on
    survey results prior to the pandemic.
        Please share the Department's plans in fiscal year 2021 and fiscal
    year 2022 for supporting, enhancing and monitoring resource allocation
    reviews by state and local education agencies and schools?
        Answer. Section 1111(d)(3)(A)(ii) of the Elementary and Secondary
    Education Act of 1965 (ESEA) requires a State educational agency (SEA)
    to periodically review resource allocation to support school
    improvement in each local educational agency (LEA) in the State serving
    a significant number of schools identified for support and improvement.
    This requirement is part of the Department's monitoring protocol for
    Title I, Part A (available at: https://oese.ed.gov/files/2020/08/SEA-
    Protocol-Title-I.docx, under ``Support for LEA and School
    Improvement''). Specifically, the protocol asks each SEA to describe
    how it periodically reviews resource allocation to support school
    improvement in each LEA serving a significant number or percentage of
    schools identified for comprehensive or targeted support and
    improvement.
        In addition, the Department has been providing on-going technical
    assistance to States regarding this requirement. For example, the State
    Support Network, created by the Department in 2016 to provide technical
    assistance to support the transition to the Every Student Succeeds Act
    (ESSA), hosted a community of practice (CoP) with 13 States in 2019
    that focused on planning for school resource allocation reviews. Please
    find more information and several resources here: https://oese.ed.gov/
    resources/oese-technical-assistance-centers/state-support-network/
    resources/resource-allocation-reviews-community-practice-summary/. The
    State Support Network also created a number of tools to assist with
    school improvement planning, including Tools for School Improvement
    Planning, a CoP for ``Implementing Needs Assessments'' and other
    resources for developing needs assessments. It also published several
    blogs about using school financial data in decisionmaking, including
    ``Going Beyond Finances in Resource Allocation Decisions''.
        Further, the Department's Comprehensive Centers have provided
    individualized technical assistance to several States on this topic. In
    the past 2 years (since the 2019 competition established new TA
    providers), the Comprehensive Centers have been supporting States in
    their implementation of ESEA requirements. Two centers specifically
    have provided assistance to States on resource allocation reviews. The
    Region 15 Comprehensive Center is supporting Utah in the State's work.
    WestEd and the Region 15 Comprehensive Center have worked on an equity
    driven resource allocation framework during another State collaborative
    session. The Region 13 Comprehensive Center has worked with the
    Oklahoma State Department of Education to design a Resource Allocation
    Review toolkit. The Region 2 Comprehensive Center is supporting efforts
    in Connecticut and Rhode Island to develop a process to conduct
    resource allocation reviews.
        The fiscal year 2022 request would build on these efforts to
    strengthen fisal equity through the Title I Equity Grants proposal,
    which would require each State to collect and make publicly available
    detailed data on the allocation of State and local education funding to
    school districts and schools. The proposal also would require the use
    of a consistent definition of per-pupil expenditures to support
    identification and mitigation of disparities in funding for high-
    poverty districts and schools, along with goals, interim targets, and
    timelines for closing identified gaps.
        In addition, our proposal would encourage States to undertake a
    comprehensive review of their school finance systems through a $50
    million reservation for voluntary State School Funding Equity
    Commissions that would (1) identify funding and educational opportunity
    gaps based on measures of equity and adequacy; (2) through extensive
    community engagement, develop detailed action plans for addressing
    existing gaps that include goals, interim targets, and timelines for
    closing identified gaps; and (3) report on progress toward these goals
    and targets.
        Question. The Every Student Succeeds Act (ESSA) established a
    policy requiring the reporting of actual personnel and nonpersonnel
    expenditures, disaggregated by Federal, state and local source of funds
    for each school and school district in each State. Transparently
    providing this information would allow a range of uses from parents
    seeing easily how their school's spending compares to other schools in
    the district to other stakeholders using the information to participate
    in equity conversations on differences within and between states.
        What is the Department's plan for ensuring states and school
    districts comply with ESSA's policy requiring the reporting of actual
    personnel and nonpersonnel expenditures, disaggregated by Federal,
    state and local source of funds for each school and school district and
    such information is made available to the public in an accessible and
    understandable manner?
        Answer. The Department will ensure that SEAs and LEAS meet the
    report card requirements in ESEA section 1111(h), including the
    requirement to report per-pupil expenditure data. As you are aware, to
    help facilitate compliance with these requirements, the Department
    released non-regulatory guidance on State and local report cards in
    September 2019 (available at: https://oese.ed.gov/files/2020/03/report-
    card-guidance-final.pdf). This document includes detailed guidance for
    SEAs and LEAs regarding how to calculate per-pupil expenditures. The
    guidance encourages SEAs to establish uniform statewide procedures for
    calculating per-pupil expenditures so that that data are uniform,
    understandable, and comparable across each LEA and school in a State.
        To help ensure SEAs and LEAs comply with applicable requirements,
    including reporting per-pupil expenditures, a complete review of State
    and local report cards is included in the Department's Title I, Part A
    monitoring protocols, which are found at: https://oese.ed.gov/offices/
    office-of-formula-grants/school-support-and-accountability/performance-
    review/). An important aspect of our consolidated monitoring is a
    thorough review, for each State monitored in a particular year, of the
    State's report card to ensure that it includes all required elements.
    In addition, each January, the Department reviews each State website to
    determine if States and districts were in compliance with certain
    report card requirements, including reporting per-pupil expenditure
    data. The Department shares the results of its review with each State.
        Over the past few years, the Department has initiated several
    technical assistance activities through the State Support Network, a
    four-year technical assistance contract begun in 2016 to support States
    and districts as they transitioned to the new ESSA requirements. Some
    of the technical assistance initiatives focused on State and local
    report cards, several of which have had a particular focus on per-pupil
    expenditure data. For example, in 2018 a community of practice
    involving Arkansas, Montana, North Dakota, New Mexico, Nevada, and
    Oklahoma focused on improving financial transparency. Other relevant
    communities of practice have focused on data quality, State and local
    report cards, and resource allocations. Information about these
    communities of practice can be found at: https://oese.ed.gov/resources/
    oese-technical-assistance-centers/state-support-network/resources/. The
    Network also created the ``Financial Transparency and Reporting
    Readiness Assessment Tool.'' This tool can help States and districts
    meet the ESSA reporting requirements by identifying and analyzing
    school level expenditure data. This tool contains two components--a
    self-diagnostic framework and an analysis tool--that are designed to
    help districts and States understand the dynamics of school-level per-
    pupil reporting in their own district financial data. The tool can be
    found at: https://oese.ed.gov/resources/oese-technical-assistance-
    centers/state-support-network/resources/financial-transparency-
    reporting-readiness-assessment-tool/.
        The Department is also funding the National Comprehensive Center's
    work with Georgetown University's Edunomics Lab to improve the quality
    and utility of school-level per-pupil expenditure data that is reported
    on State and local report cards as required under ESSA. Edunomics'
    initial work through this project involved analyzing the utility and
    usefulness of the school-level per-pupil expenditure data reported by
    each State (https://edunomicslab.org/state-data-tracker/). The current
    phase of the National Comprehensive Center's project with Edunomics is
    focused on working with a little under 20 school districts across
    different States to analyze each district's school-level expenditure
    data and build staff capacity to use data to drive decisionmaking for
    school improvement and equitable allocation of resources. After
    piloting tools and communication materials with these school districts,
    Edunomics will create a data visualization tool that all districts will
    be able to access to analyze their school-level per-pupil expenditure
    data and use it for finance decisionmaking.
        Additionally, the Department's National Center for Education
    Statistics (NCES) has been working with over 20 States to improve the
    quality of expenditure data reported through a voluntary data
    collection. Recently, NCES issued a report on highlights of school-
    level finance data that were previously reported (https://nces.ed.gov/
    pubs2021/2021305.pdf).
        The Department looks forward to expanding and building upon these
    efforts.
        Question. I appreciate the Secretary's commitment to properly
    implementing the American Rescue Plan Act of 2021, including required
    state and school district set-asides for evidence-based interventions
    that address the academic, social, and emotional needs of students of
    color, students experiencing homelessness and other underserved student
    groups disproportionately impacted by the pandemic.
        Please describe in detail how the Department will support, monitor
    and enforce requirements of the Elementary and Secondary School
    Emergency Relief Fund (ESSER) related to these set-asides and
    implementation of State and district ESSER plans related to these state
    and district learning loss requirements.
        Answer. We support these requirements through the State plan
    process that the Department established, technical assistance efforts,
    non-regulatory guidance documents, and ongoing communication with
    States through our program officers.
        The ARP ESSER State plan template requires grantees to describe how
    they will use each required set-aside under the ARP Act. We will
    monitor grantees against their approved ARP ESSER State plans as well
    as statutory requirements. As needed, the Department will issue any
    findings and develop corrective action plans to address those findings.
    We are committed to working with grantees to resolve any findings.
        In July, the Department issued a notice inviting comment related to
    data submission requirements for the ESSER (including ESSER I, ESSER
    II, and ARP ESSER) annual performance report (APR). The public is asked
    to comment on data quality and burden-related concerns related to
    collecting data on evidence-based summer learning or summer enrichment
    programs, evidence-based afterschool programs, and extended
    instructional time, among other items. After the data collection
    instrument is finalized and APR data is submitted, the Department will
    review grantee submissions to identify technical assistance needs and
    inform future monitoring of grantees.
        Question. Department regulations state the Secretary may make a
    continuation award for a direct grant for a budget period after the
    first budget period of an approved multi-year project if Congress has
    appropriated sufficient funds for that purpose and the grantee is
    making substantial progress toward meeting the goals of the project,
    among other factors. The regulations further state ``In deciding
    whether a grantee has made substantial progress, the Secretary may
    consider any information relevant to the authorizing statute, a
    criterion, a priority, or a performance measure, or to a financial or
    other requirement that applies to the selection of applications for new
    grants.''
        For fiscal year 2018 and 2019, how many direct grantees did not
    receive a continuation award for any reason? How many of such denials
    were related to the lack of substantial progress on performance? How
    much total funding was associated with such denial of a continuation
    award due to lack of substantial progress on performance?
        Answer. In fiscal years 2018 and 2019, 11 grantees received a
    continuation award of $1, which is equivalent to a denial of a
    continuation award but is the amount required to keep the grant award
    active so grantees can complete work already funded. Of those, 10 were
    at least in part because of issues related to substantial progress. The
    total amount impacted grantees requested in their initial grant
    applications for the budget period not funded is approximately $38
    million. In addition, the Department reduced continuation awards for
    other grantees if appropriate based on lack of substantial progress or
    other considerations. Further, some grantees asked for their
    continuation award to be reduced or for the grants to end early due to
    their concerns about not being able to implement their projects
        Question. What policies or criteria have the Department adopted for
    considering information in making a determination of substantial
    progress? If none, how does the Department consistently evaluate
    substantial progress?
        Answer. The Department follows the procedures for non-competing
    continuation awards as set forth in 34 CFR 75.253 and has internal
    policy about how to determine substantial progress, including what
    should be included in documentation for non-competing continuation
    award documents. The policy includes considerations to support
    decisionmaking, including program- and grantee-specific context,
    monitoring grantee performance, and discussing performance concerns
    with grantees. There are also internal discussions across offices to
    share about office practices and lessons learned, particularly in light
    of the COVID-19 pandemic and how best to consider associated
    disruptions to the project activities in making substantial progress
    determinations.
        Question. Earlier this year, the Department withdrew a notice
    inviting applications for equity assistance centers (EACs) issued by
    the previous administration and extended existing contracts for 1 year.
    Equity Assistance Centers can play an important role in addressing
    racial and other equity concerns and designing and implementing school
    desegregation plans.
        What are the Department's plans for the new notice inviting
    applications?
        Answer. The Department plans to publish a notice inviting
    applications for new awards in the Federal Register in early 2022.
        Question. How does the Department evaluate the resources needed for
    EACs to carry out this important work? Please share any analysis
    completed that supports the sufficiency of the $6.5 million requested
    for EACs to delivery timely and effective services across the entire
    United States.
        Answer. We have not carried out any detailed analysis of EAC
    resource needs, but we do ask the EAC grantees to tell us in their
    annual performance reports the percentage of technical assistance
    requests received from organizations that they accepted during the
    performance period. Annually across 2017 to 2020, the EACs were able to
    accept between 95 percent and 98 percent of the technical assistance
    requests they received from the field.
        Question. As of June 11, more than sixty percent of the CARES
    Elementary and Secondary School Emergency Relief (ESSER) funds ($8
    billion of $13.2 billion) have been recorded as spent and outlaid from
    the Federal Treasury, while $2.1 billion of $54.3 billion provided
    through ESSER in the Coronavirus Response and Relief Supplemental
    Appropriations (CRRSSA) Act, 2021 and $25 million of $81 billion
    obligated from ESSER funds in the American Rescue Plan (ARP) Act of
    2021 have been so reported. The Department also is in the process of
    reviewing state plans for the obligation of the remaining one-third of
    the ARP ESSER funds. However, earlier this year the Government
    Accountability Office reported ``Federal spending data alone provide an
    incomplete picture of states' and school districts' spending'' noting
    ``there is often a significant gap between when a district uses the
    funds and when those funds are reported as spent in state and Federal
    reporting systems''.
        Please describe actions taken and planned by the Department to
    provide a more complete reporting of the use and status of ESSER funds.
        Answer. Section 15011 of the CARES Act specifies the reporting
    requirements for covered programs. Existing reporting requirements,
    established under the Federal Funding Accountability and Transparency
    Act of 2006 (FFATA), Public Law No. 109--282, as amended by the Digital
    Accountability and Transparency Act (DATA Act), Public Law No. 113--
    101, were deemed sufficient to meet many of the reporting requirements
    for ESSER fund program. Specifically, States were required to report to
    the General Services Administration's FFATA Subaward Reporting System
    (FSRS), the amount of ESSER funds granted to school districts. These
    data are required to be reported directly from States and are made
    available to the Department and the public through USAspending.gov.
        To further meet the Section 15011 reporting requirements and
    additional reporting requirements described within the ESSER
    Certification and Agreements, the Department created an annual
    reporting process for ESSER grantees (States). The annual report
    captures the following information (1) award and outlay information
    from the Department to ESSER grantees (States); (2) award and outlay
    information from ESSER grantees to their subgrantees (school districts/
    LEAs); and (3) subgrantee expenditure data. States were required to
    provide these data for district awards/expenditures made March 13,
    2020--September 30, 2020 to the Department in early 2021. States will
    be required to provide additional reports on ESSER funds annually
    thereafter. The current ESSER reporting form is available for review
    through: https://api.covid-relief-data.ed.gov/collection/api/v1/public/
    docs/ESSER_Data_Collection_Final.pdf.
        The Department acknowledges the importance of collecting and
    publicly reporting information on school districts' financial
    commitments (obligations), as well as outlays in order to more
    completely reflect the status of their use of Federal COVID-19 relief
    funds. Earlier this year, the Department proposed modifications to its
    ESSER annual report on State and school district spending data to
    include obligations data in subsequent reporting cycles. The proposed
    modifications, in accordance with the Paperwork Reduction Act, are
    currently available for public comment on the Federal Register:
    (https://www.Federalregister.gov/documents/2021/07/02/2021-14200/
    agency-information-collection-activities-comment-request-education-
    stabilization-fund-elementary-and).
        Question. The Department's fiscal year 2022 Annual Performance Plan
    includes plans to identify opportunities to further build and use
    evidence in both formula and competitive grant programs.
        How many competitive grant programs will include an evidence
    priority in fiscal year 2021?
        Answer. In fiscal year 2021, 19 competitions required the use of
    evidence through a requirement or an absolute priority and 6
    competitions included a competitive priority for evidence, and 18
    encouraged applicants to rely on evidence by including it in selection
    criteria. An additional 2 competitions encouraged the use of evidence,
    such as through an invitational priority. Note that two competitions
    included evidence in more than one way and are thus counted in multiple
    categories. An unduplicated total of 43 competitions, or almost 60
    percent of all competitions in fiscal year 2021, included evidence in
    at least one of these ways.
        Question. How many competitive grant programs does the Department
    plan to include an evidence priority in fiscal year 2022?
        Answer. The Department is discussing how best to use and build
    evidence in fiscal year 2022 competitions in alignment with statutory
    requirements, the body of available evidence, and lessons learned from
    previous competitions.
        Question. Please identify the formula programs in which evidence
    building and use will be promoted and supported and the specific
    strategies to accomplish these goals.
        Answer. The Department is supporting evidence building and use in
    the ESEA formula grant programs under Titles I, II, and IV. Evidence is
    also important within the context of IDEA formula grant programs. The
    Department works with the Comprehensive Centers, the Regional
    Educational Laboratories, and the technical assistance centers funded
    by the Office of Special Education programs to identify and share
    resources related to evidence building and use. To further support the
    identification of evidence-based practices, The Institute of Education
    Sciences' What Works Clearinghouse has recently added a new feature to
    its website--evidence tier ``badges''--making it easier for users to
    know whether a given approach meets regulatory definitions of strong,
    moderate, or promising evidence. The WWC has also produced a series of
    technical assistance materials supporting the use of this feature and
    of the site overall. In addition, the Department is providing resources
    related to the evidence-based strategies required under the Elementary
    and Secondary School Education Relief Fund (ESSER Fund) under the
    American Rescue Plan. Within the context of safely reopening all
    schools, the Department has created the Safer Schools and Campuses Best
    Practices Clearinghouse. The Clearinghouse provides resources for
    practices that can be leading examples of how best to provide support
    to students and educators.
        Question. Please describe efforts the Department has undertaken to
    build the internal capacity of staff in the use and implementation of
    evidence in activities funded through formula and competitive grant
    programs.
        Answer. Measuring Skills. In 2020, ED developed and fielded the
    inaugural Data and Evidence Use Survey to measure staff skills. In Q3,
    the Office of the Chief Data Officer and the National Center for
    Educational Evaluation finalized the survey to respond to requirements
    of the Evidence Act and the Federal Data Strategy. CDOs in other
    agencies, including DHS, Commerce, Labor, and the Air Force have
    requested and received ED's survey to support their efforts. The
    results of the ED Survey are used to target staff training to improve
    data literacy and the capacity to use evidence.
        The Evidence Act requires ED to assess its evaluation activities
    and agency capacity to support the development and use of evaluation.
    Congress explicitly made this requirement an agency-wide focus by
    instructing the Evaluation Officer to coordinate activities with agency
    officials in carrying out the functions of the Evaluation Officer in
    section 313(d) of title 5. Additionally, the Open Government Data Act
    requires the Chief Data Officer to support the Evaluation Officer in
    identifying and using data to carry out their statutory functions
    (Sec. 3520(c)(9)). The Evaluation Officer and the Chief Data Officer
    share common interest and authority in carrying out these functions and
    collaborate to field the annual Data and Evidence Use Survey.
        Enhancing Skills. In 2021 ED launched its new Data Literacy
    Program, an intentional commitment to upskilling and continual
    learning. The program's goal is to develop a data culture at ED which
    enables all staff to speak a shared language around data and evidence.
    An expert-based approach was designed with support from The Data Lodge
    to provide a comprehensive corpus of flexible training to reach 3,500
    staff. A partnership among ED's data office, research office, and human
    resources office resulted in a committee of 5 SES and GS15 leaders
    (including ED's Evaluation Officer) who developed the program
    blueprint. The blueprint mapped out a programmatic approach over 3
    years, engaging ED offices in waves of customized, highly interactive
    sessions. Learning pathways were developed using Skillsoft. ED also
    developed plans for its own developed content and OCDO-led introductory
    workshops. Current training consists of four major components: (1) a
    hallmark initial, interactive 2-hour session ``Exploring Data
    Literacy,'' (2) a one-hour ED-specific session, ``Data Literacy 101''
    (3) four self-paced Learning Pathways of SkillSoft and external courses
    around evidence, decisionmaking, visualization, and analytics and (4)
    Learning Bytes, 15 min interactive topics recorded for easy use.
        As ED staff begin to build data literacy, we continue our efforts
    to ensure that all staff are increasingly well-versed in the role of
    evidence in the work of schools, States, districts, and institutions of
    higher education. This past year, the Institute of Education Sciences
    and the Office of Planning, Evaluation, and Policy Development's Grants
    Policy Office (GPO) began offering ``Evidence 101: Evidence Use at the
    Department of Education'' to all new hires each quarter. As part of
    that training, new staff are introduced to statutory and regulatory
    requirements related to evidence use, the history of evidence use at
    the Department, and Department resources that can support their work.
    IES and GPO have also worked to build a virtual ``community of
    practice'' focused on evidence use based on a monthly newsletter to
    staff and associated website, the Evidence Connection. Approximately
    250 staff across the Department are currently members and receive
    regular updates about resources that can support their efforts to use
    evidence in their own work and support the work of Department grantees.
        Question. What is the Department's plan for continuing to build
    this capacity in the coming year?
        Answer. In 2022, the ED Data Literacy Program will advance general
    staff ability to use, understand, and apply data and evidence to
    support decisionmaking around programs, policy, and operations. In
    2022, the program will mature current engagement, curriculum, and
    resources. First, our engagement will broaden and deepen. Current Data
    Literacy Ambassadors for the first wave of ED offices participating in
    the program will customize and deliver existing program resources for
    relevant and actionable professional development. We will onboard
    additional offices to reach all 3,500 staff. Second, we will expand our
    current curriculum and add new courses, both interactive and virtual,
    asynchronous training. In 2022, we would like to add 4 major ED-
    specific courses featuring ED leaders, data processes, core data
    collections, and projects and tools. Lastly, we plan to augment and
    enhance resources around data language (e.g., Glossary), expertise
    (e.g., Directory) best practices and technology. To address the
    specific capacity-building needs of ED data professionals who support
    the production of evidence for grant programs, ED launched its new Data
    Professionals Community of Practice (DPCoP) in August 2021. In
    alignment with ED Data Strategy Objective 2.3 ``Establish clear career
    paths and training curriculums for data professionals'', the DPCoP will
    be a member-driven collaborative forum open to all ED data
    professionals. It will provide opportunities to share resources, tools,
    and successful practices in ED, inform leadership of data-related
    issues or concerns, and establish workgroups to address specific topics
    and challenges.
        Question. How will the Department measure the growth of this
    capacity and expected improved targeting of resources to activities
    authorized by current law and aligned with evidence of effectiveness?
        Answer. Evidence Use. As noted above, the Department is currently
    fielding the second iteration of its Data and Evidence Use Survey. The
    survey provides repeated cross-sectional estimates of ED staff capacity
    to use evidence in their work in areas including: (1) designing
    performance measures, (2) providing technical assistance on evidence
    definitions and requirements, and (3) monitoring grantees for effective
    evidence use. These data can be used to inform professional development
    opportunities for ED staff and the production of new resources for both
    staff and stakeholder use.
        Resource Targeting. The Department will continue to work with SEAs,
    LEAs, institutions of higher education and other entities to support
    and increase the use of evidence to inform decisionmaking.
        Question. How does the Department support and monitor SEA and LEA
    decisionmaking related to reasonably available determinations for
    evidence use under provisions of ESEA? What are the Department's plan
    to monitor and further support such determinations?
        Answer. To support States, local educational agencies (LEAs), and
    schools in understanding the levels of evidence and interventions that
    meet them, the Department continues to disseminate information and
    provide technical assistance that highlights the evidence levels
    associated with a wide range of interventions, strategies, and
    approaches. Specifically, the Institute of Education Sciences What
    Works Clearinghouse (WWC) provides information on the evidence levels
    of interventions, strategies, and approaches on a wide range of topics
    through both Intervention Reports and Practices Guides, as well as
    individual studies. These user-friendly resources describe the level of
    evidence demonstrated, the characteristics of students, and the setting
    (urban, rural, suburban) of the research studies included. When
    evaluations produced through discretionary grant programs are submitted
    to the WWC for review to determine if they meet the evidence levels as
    defined in the ESSA, they can be highlighted in the WWC for use in
    supporting formula grantees. In addition, the Department's technical
    assistance network also produces resources to support their respective
    target audiences in understanding and using evidence. For example, this
    resource from the Regional Education Laboratory West provides important
    considerations for using evidence-based interventions.
        With respect to monitoring use of evidence consistent with
    statutory and regulatory requirements, the Department includes
    questions regarding State and local compliance with evidence
    requirements as relevant in its monitoring protocols. In addition to
    understanding compliance with these requirements, these monitoring
    protocol questions allow program officers to identify areas for future
    technical assistance to support States, LEAs, and schools in their
    efforts to support student achievement.
        Question. Last year, Congress removed a limitation on Federal
    education funds that prevented the use of such funds for transportation
    costs associated with school integration efforts.
        How will the Department and its technical assistance providers work
    with state educational agencies (SEAs), local educational agencies
    (LEAs) and schools to inform and support them in this use of funds?
        Answer. While Congress has removed certain limitations on the use
    of Federal education funds for transportation costs related to school
    integration plans, section 8526(2) of the Elementary and Secondary
    Education Act of 1965 (ESEA; 20 U.S.C. 7906(2)) prohibits ESEA funds
    from being used for transportation unless otherwise authorized by the
    ESEA. Most ESEA programs, including Title I Grants to LEAs and Title
    IV-A Student Support and Academic Enrichment Grants, do not authorize
    the use of funds to transport students to or from the regular school
    day.
        In addition, section 802 of the Education Amendments of 1972 (20
    U.S.C. 1652), titled ``Prohibition against busing'' includes a
    restriction for the use of funds under ED programs for the
    transportation of students or teachers to carry out a plan of racial
    desegregation of any school system, subject to certain contingencies.
        Question. The previous administration failed to hire sufficient
    staff at the Office for Civil Rights, despite increases in
    appropriations and direction to do so.
        Please describe the impact of each staff member having such a large
    caseload on their ability to thoroughly investigate complaints for
    associated evidence of systemic discrimination, timely process
    complaints, conduct compliance reviews, and monitor corrective actions.
        Answer. A critical component of OCR's mission is the prompt
    investigation and resolution of complaints. A large per-staff caseload
    hinders OCR's ability to discharge this responsibility in a timely
    manner, which is also unacceptable to both complainants and recipients.
    OCR enforcement staff are required to conduct investigations and make
    determinations that are factually accurate and legally sound. Ensuring
    that these standards are met is a process that requires careful
    consideration of evidence provided by complainants and recipients.
    There are no ``short cuts'' to fulfilling OCR's mission. Current
    caseload numbers may impact OCR's ability to pursue proactive
    enforcement activities--compliance reviews and directed
    investigations--as well as effectively address an anticipated increase
    in complaints. In short, large caseloads can slow the delivery of
    justice for complainants and disserve school districts and
    postsecondary institutions that need guidance from the Department to
    ensure that they provide all students with an environment that is free
    from discrimination.
        Question. How would the additional staff requested in the budget be
    utilized to enable OCR to more effectively fulfill its mission?
        Answer. The majority of the additional staff will be utilized to
    resolve complaints and proactive activities (compliance reviews and
    directed investigations). OCR also requested additional legal staff
    that will develop policy guidance and regulatory materials for civil
    rights enforcement. Additional administrative staff will respond to
    Freedom of Information Act (FOIA) requests and help reduce the FOIA
    backlog and support Civil Rights Data Collection. Requested
    administrative staff are also needed to provide oversight of OCR's IT
    security, systems operations, website and records management.
        Question. With respect to the Charter School Grants program, the
    fiscal year 2022 Congressional Justification indicates: ``The
    Department will work to ensure that Charter Schools Grants funds
    support schools that are opened and operated with demonstrated family
    and community support, serve students from diverse racial and
    socioeconomic backgrounds, provide meaningful access to instruction for
    students with disabilities and English learners, maintain diverse
    educator workforces, and are subject to strong accountability,
    transparency, and oversight.'' The document also indicates that 14
    state entity grantees provide or plan to provide technical assistance
    to charter school subgrantees in meeting the needs of students with
    disabilities, while 13 provide or plan to provide technical assistance
    to subgrantees in meeting the needs of English learners.
        Please describe how the Department will accomplish each of the
    objectives outlined above.
        Answer. The Department looks forward to working with you and with
    other stakeholders to address these important priorities.
        Question. What does the Department know about the evidence base
    supporting the state entity technical assistance strategies for
    students with disabilities and English learners? With which tier, if
    any, of the definition in section 8101(21)(A) of the Elementary and
    Secondary Education Act (ESEA) do they align?
        Answer. The program statue does not require applicants to propose
    evidence-based technical assistance strategies, as such, information
    regarding the evidence base for specific state entity (SE) technical
    assistance strategies implemented by SE grantees to support students
    with disabilities and English learners was not examined as part of the
    review referenced in the program's Congressional Justification.
        Question. Please describe how the Department would use national
    activities funds available in fiscal year 2022 or supported by fiscal
    year 2022 appropriations for each of the national activities
    authorities available under the ESEA.
        How would these plans be informed by evidence of effectiveness and
    the needs of those served by each of the authorities?
        Answer. The Department does not yet have detailed plans for
    national activities in fiscal year 2022, since most planning for
    discretionary grant programs, including national activities
    authorities, takes place in the summer and fall prior to the beginning
    of the fiscal year. In addition, such plans depend in part on
    completion of final appropriations action, which includes both final
    funding levels and any applicable Congressional priorities for the use
    of national activities funds. Consideration of the needs of those
    served by our programs, as well as maximizing the use of evidence-based
    practices in meeting those needs, is the starting point for the
    Department's planning process.
        Question. Under the Every Student Succeeds Act, SEAs and LEAs were
    required to develop plans for how they will identify and address the
    disparities of low-income and minority children being
    disproportionately taught by ineffective or inexperienced teachers.
        How does the Department plan to support the timely implementation
    of such plans, including through the use of funds appropriated and
    requested for Title II-A of ESEA and other current law authorities?
        Answer. ESEA section 1111(g)(1)(B) requires each SEA to describe
    how low-income and minority children enrolled in Title I, Part A
    schools are not served at disproportionate rates by ineffective, out-
    of-field, or inexperienced teachers, and the measures the SEA will use
    to evaluate and publicly report the progress of the SEA with respect to
    such description. Consistent with ESEA section 8302, the Department
    determined that this description was required as part of the
    consolidated State plan. Thus, each SEA was required to provide a
    description and how it will publicly report its progress in addressing
    any identified disparities. This provision does not require each SEA to
    submit a plan to the Department regarding how it will address those
    disparities. Information about the ESSA Consolidated State Plan,
    including each State's plan, can be found at: https://oese.ed.gov/
    offices/office-of-formula-grants/school-support-and-accountability/
    essa-consolidated-state-plans/.
        The Department includes a review of this requirement in our
    monitoring protocols for Title I, Part A (available at: https://
    oese.ed.gov/files/2020/08/SEA-Protocol-Title-I.docx). The Department
    requires each SEA monitored to describe how it evaluated its progress
    toward ensuring that low-income and minority children in Title I
    schools are not served at disproportionate rates by ineffective, out-
    of-field, and inexperienced teachers and requests updated educator
    equity data. The Department also requires each SEA to describe how it
    publicly reported its progress toward meeting this requirement and asks
    for documentation of public reporting. Finally, the Department asks
    each SEA to describe how it supports LEAs in meeting this requirement.
    The SEA must describe how it ensures each LEA receiving a Title I, Part
    A subgrant identifies and addresses disparities resulting in low-income
    and minority students having disproportionate access to ineffective,
    out-of-field, and inexperienced teachers and requests that the SEA
    provide the following documentation, if applicable: LEA plan template
    reflecting this requirement; SEA guidance for LEAs related to equitable
    access to educators; and/or SEA monitoring protocol that demonstrates
    the SEA is verifying compliance with this requirement.
        In our review of States over the past several years, the Department
    has issued two monitoring findings related to these requirements. In
    2020, the Department cited Kentucky for two issues: 1) the State
    publicly reported inaccurate educator equity data; and 2) the State did
    not adequately document how it ensures that each LEA receiving a Title
    I subgrant identifies and addresses disparities resulting in low-income
    and minority students having disproportionate access to ineffective,
    out-of-field, and inexperienced teachers. In 2019, the Department
    issued a finding for New Jersey because although the State provides
    LEAs with multiple sources of related data, NJDOE is not currently
    evaluating or publicly reporting its progress in ensuring that low-
    income and minority children in Title I, Part A schools are not served
    at disproportionate rates by ineffective, inexperienced, and out-of-
    field teachers. The Department also issued a recommendation that New
    Jersey incorporate the requirement in ESEA section 1112(b)(2) in the
    State's subrecipient monitoring protocol to ensure that LEAs are
    meeting the statutory requirements to ensure that low-income and
    minority children in Title I, Part A schools are not served at
    disproportionate rates by ineffective, inexperienced, and out-of-field
    teachers. The reports for Kentucky and New Jersey (and all information
    related to the Department's consolidated monitoring, can be found at:
    https://oese.ed.gov/offices/office-of-formula-grants/school-support-
    and-accountability/performance-review/).
        Regarding the use of Title II, Part A funds, the ESEA consolidated
    State plan asks each State to describe how it will use Title II, Part A
    funds to address this requirement, if it chooses to do so. In addition,
    the Department conducts an annual use-of-funds survey that asks SEAs to
    account for how State-level Title II, Part A funds are used. In school
    year (SY) 2019-2020, the most recent year for which survey data are
    available, 20 States indicated that they had spent at least some of
    their State-level Title II, Part A funds on activities to improve
    equitable access to effective teachers. The Department also conducts an
    annual survey on how LEA-level Title II, Part A funds are used; this
    survey is distributed to a nationally- and State-level-representative
    sample of LEAs in the country. In the survey covering expenditures in
    SY 2029-2020, 34 percent of responding LEAs indicated that they had
    spent at least some of their Title II, Part A funds on strategies to
    recruit, hire, and retain effective educators, although it is not clear
    if these expenditures specifically focused on ensuring equitable access
    effective educators in the districts. Additional detail on the results
    of the 2019-2020 surveys on how Title II, Part A funds were used is
    available at https://ies.ed.gov/ncee/pubs/2021011/index.asp.
        The Department looks forward to expanding and building upon these
    efforts.
        Question. Analysis of CDC data and other reports indicate a
    reduction in routinely recommended vaccination of children and youth
    last year resulting from the disruption to routine healthcare caused by
    the COVID-19 pandemic. Lack of proper vaccinations could provide an
    additional challenge to the return to in-person learning in the fall.
        How is the Department working with HHS to support the vaccination
    of children and youth needed for school enrollment for in-person
    learning?
        Answer. The Department is working to support HHS/CDC in the
    dissemination of guidance on vaccination of children and youth in the
    following manner:
      --Collaborated and hosted a number of webinars to share mitigation
            strategies and guidance with the educators, school personnel,
            families, education stakeholders, and public
      --Participated in bi-weekly ED/CDC planning calls to coordinate and
            organize scheduled webinars with HHS/CDC and the Department
      --Posted resource materials on the Department of Education website,
            federally supported National Technical Assistance websites, as
            well the newly launched Safer Schools and Campuses Best
            Practices Clearinghouse (https://
            Bestpracticesclearinghouse.ed.gov)
      --Participated in weekly established ED/CDC K-12 Touchbase calls to
            share information/research/guidance/upcoming agency planned
            activities
      --Released Guidance Handbooks for the education community and
            included information on the topic
        Question. The Department is developing supplemental priorities that
    may be applied to fiscal year 2022 and future grant competitions. The
    fiscal year 2022 Congressional Justification cites building and
    enhancing the instructional skills of a more diverse educator workforce
    as one possible supplemental priority.
        What other supplemental priorities may be applied in fiscal year
    2022 competitions?
        Answer. The Department published a Notice of Proposed Priorities on
    June 30, 2021. There are six draft priorities: (1) Addressing the
    Impact of COVID-19 on Students, Educators, and Faculty; (2) Promoting
    Equity in Student Access to Educational Resources, Opportunities, and
    Welcoming Environments; (3) Supporting a Diverse Educator Workforce and
    Professional Growth to Strengthen Student Learning; (4) Meeting Student
    Social, Emotional, and Academic Needs; (5) Increasing Postsecondary
    Education Access, Affordability, Completion, and Post-Enrollment
    Success; and (6) Strengthening Cross-Agency Coordination and Community
    Engagement to Advance Systemic Change.
        Question. Please identify the programs in which supplemental
    priorities will be applied.
        Answer. The public comment period on the Notice of Proposed
    Priorities closed on July 30. The Department is reviewing the comments
    received and is considering how best to incorporate the Secretary's
    priorities in fiscal year 2022 competitions once the priorities are
    finalized.
        Question. The budget includes $180 million, an increase of $15
    million more than the fiscal year 2021 LHHS bill, for the National
    Assessment of Educational Progress (NAEP). The requested funds would
    maintain the current assessment schedule and provide funding for
    initial research and development investments intended to improve
    assessment quality and reduce future program costs. Over the past year,
    staff of the Department, National Center for Education Sciences and
    National Assessment Governing Board have provided informative updates
    on COVID-19-induced changes to the NAEP schedule and cost increases.
    Please provide:
        A description of the policies and procedures implemented to ensure
    sufficient oversight and monitoring of contracts, including cost
    controls.
        Answer. All Institute of Education Sciences (IES) acquisition
    activities, including NAEP, adhere to the Department's internal control
    strategies, policies, and procedures, with support from the
    Department's Contracts and Acquisition Management (CAM) team and Budget
    Service:
      --Budget Service reviews every planned and on-going contract over
            $100k. The Budget Service team reviews, approves, and allots
            funds in the Department's payment management system before
            funds can be obligated to support payments to vendors (by CAM).
      --CAM ensures that new and current contracts are legal and consistent
            with the Federal Acquisition Regulations (FAR). Contracting
            Officers (who possess warrants to sign off on new acquisitions
            and day-to-day commitments) independently review every invoice
            submitted by vendors before payment to ensure that costs are
            allowable. CAM also partners with IES to validate that FAR
            requirements are maintained across the lifecycle of every
            individual Assessment contract.
        In the Department's most recent A-123 internal control entity level
    review of IES, completed in Fall 2020, IES (including the Assessment
    Division) provided evidence that IES meets and effectively implements
    all 17 GAO Green Book principal areas across all five GAO Internal
    Control component areas. IES recognizes that we need to do more to
    better anticipate the challenges of increased cost and uncertainties
    related to our assessment activities and unforeseeable events such as
    COVID-19.
        IES recently established an Acquisition Program Management Office
    (PMO) that is focused on modernizing IES acquisition practices to
    better align with our business model and improve outcomes for
    customers. IES also recently awarded a small contract to conduct an
    independent validation and review of our current controls and funds
    management practices for the Assessment program. We initiated this
    contract in part due to the rising costs of assessments, reflected in
    the 2019 NAEP Alliance contracts, and in part due to the recent volume
    of unplanned and unforeseen task revisions and cost adjustments within
    the NAEP Alliance contracts resulting directly from COVID-19. We expect
    the results of this quick-turnaround review at some point early in the
    2022 calendar year.
        Question. The amount and descriptions of additional funding needed
    in each of fiscal year 2022, fiscal year 2023 and fiscal year 2024 for
    research and development investments;
        Answer. The requested $15 million increase would support NAEP
    operations to fiscal year 24 and beyond for the current assessment
    schedule and would begin to support necessary R&D investments. However,
    we anticipate that additional investments would be needed in future
    years both to maintain NAEP as the gold standard of large-scale
    assessments and to produce cost savings and efficiencies in program
    administration costs over time (see responses to 1d and e below).
        We also note that while this response is based on the most accurate
    budgetary estimates currently available, there may be adjustments to
    these estimates based on additional modifications to NAEP alliance
    contracts in response to the impact of COVID-19 on NAEP activities.
        Estimated Allocations to Operations and R&D based on increase of
    $15 million per year (as of 8.4.21)

    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                     Total
                             Funding stream                              FY22       FY23       FY24       FY25       FY26       FY27       FY28      approp
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Operational.....................................................       $14M       $10M       $12M       $12M       $12M       $12M       $12M       $84M
    Current R&D\*\..................................................        $1M        $5M        $3M        $3M        $3M        $3M        $3M       $21M
        Total.......................................................       $15M       $15M       $15M       $15M       $15M       $15M       $15M      $105M
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    \*\See response to question 1d below for current R&D activities.

        Question. The amount of additional funding needed in each of fiscal
    year 2022, fiscal year 2023 and fiscal year 2024 for operating costs;
        Answer. Please see the response to 1b. above. Based on the best
    estimates available at this time, the requested $15 million increase
    would support operational funding needs through fiscal year 2024;
    however, as noted above, it may not fully support currently planned R&D
    efforts.
        Question. Studies planned and other actions necessary for
    maintaining the continuity and integrity of NAEP in any changes
    implemented to reduce future program costs;
        Answer. We have a number of actions planned to achieve
    efficiencies, starting in 2022. These include (i) transitioning to
    online assessments, (ii) transitioning from Surface Pro tablets to more
    cost-efficient devices in the short term and to school-owned devices in
    the longer term, (iii) introducing automated scoring, (iv) reducing the
    number of field staff needed to conduct the assessments, and (v)
    implementing design changes, including adaptive testing and two-subject
    design. Each change will be carefully studied in multiple rounds of
    reviews to first explore feasibility and examine effect(s), if any, on
    student performance. If any effect on student performance is detected,
    IES will need to implement a bridge study to account for the effect and
    maintain trends.
        Question. Expected savings and supporting information by fiscal
    year associated with research and development investments for reducing
    future program costs; and
        Answer. We expect to realize savings beginning in fiscal year 2024
    as currently funded R&D efforts in automated scoring and the eNAEP test
    platform take effect. These savings, which are measured against
    estimated costs on the current NAEP platform in the absence of proposed
    R&D-based modernization efforts, will grow through fiscal year 2030
    assuming IES is able to implement fully its planned R&D investments on
    eNAEP, which would enable NAEP to be administered on less costly
    devices, including school equipment (device agnostic), and with reduced
    NAEP field staff. We also note that the capacity to test individual
    students in multiple subjects using such devices should dramatically
    reduce student and school sample sizes, yielding further savings.
    Estimated savings by two-year NAEP cycle are in the table below. Total
    expected savings associated with current (and planned future R&D)
    investments over the period are approximately $98 million. Note that
    these estimated savings assume increased R&D funding in future years.

    ------------------------------------------------------------------------
                                                                    Expected
                            Two-year cycle                          Savings
    ------------------------------------------------------------------------
    FY23--24.....................................................        $4M
    FY25--26.....................................................       $20M
    FY27--28.....................................................       $42M
    FY29--30.....................................................       $32M
        Total....................................................       $98M
    ------------------------------------------------------------------------

        Question. Potential additional reductions to future program costs
    or program enhancements resulting from recommendations made under
    current contract with National Academies of Sciences, Engineering, and
    Medicine.
        Answer. An independent expert panel convened by the National
    Academies of Sciences, Engineering, and Medicine (NASEM) is currently
    underway. This 17-month study focuses on how NAEP might modernize its
    operations and reduce costs through innovations such as those mentioned
    in (d) above. We expect that NASEM's recommendations, once released in
    February 2022, will help further refine current plans for
    modernization. Some of the innovations under consideration by NASEM are
    not expected to result in cost savings (e.g., adaptive testing), but
    could improve measurement quality, especially for students scoring at
    below NAEP Basic level.
        Question. The current NAEP assessment schedule outlines plans to
    conduct the Long-Term Trend (LTT) assessment for 17 year-olds in 2022
    as a result of the delay caused by the COVID-19 pandemic. However, also
    repeating the LTT for 9-year-olds in 2022 would provide nationally
    representative information on the impact of COVID-19 on reading and
    math learning, including for students of color. This kind of
    information would be one type of information and research on learning
    loss intended to be funded by the $100 million provided to the
    Institute of Education Science by the ARP.
        Will the assessment schedule be changed to collect this important
    information?
        Answer. Yes. NCES and NAGB agreed that the NAEP schedule should be
    changed to collect this important information for age 9-year-olds in
    2022, while canceling the LTT for 17-year-olds. NAGB will take an
    official vote on the change to the schedule at the August meeting.
    Additionally, preparation for both LTT age 9 and age 17 would be
    unsustainably expensive given available funding and the expected $8m
    cost for each of these age groups. That is, preparation for paper
    booklets, quality control reviews, printing, and distribution could not
    be done for both cohorts given anticipated budget shortfalls in 2024.
    Accordingly, we put preparations for LTT age 17 on hold in June based
    largely on cost considerations. NCES has also confirmed that it is too
    late to restart preparation work for age 17, even if funds were made
    available.
        Question. If the LTT for nine year olds was not paid for with funds
    available to IES in the ARP, how would such a change impact the NAEP
    2021 operating plan? How would such an additional cost for LTT impact
    the rest of the currently approved assessment schedule? Please provide
    a revised operating plan.
        Answer. The Department considered using ARP funds for LTT but
    decided against doing so because of legal concerns with using ARP funds
    for research. Regarding the impact on the NAEP budget, since the data
    collection costs for the two cohorts are comparable, changing from an
    assessment of 17-year-olds to 9-year-olds would have no real effect on
    anticipated outlays. The anticipated shortfall in 2024 would remain the
    same if the requested $15 million increase in fiscal year 2022 is not
    enacted.
        We note that in 2025 the schedule calls for all three ages, 9, 13,
    and 17 to be collected again as part of a bridge study to transition
    the assessments from paper to digital formats.
        Question. ESEA contains provisions on parent and family engagement
    under ESEA programs and authorizes support for Statewide Family
    Engagement Centers. These ESEA provisions include a 1 percent set-aside
    of LEA Title I-A allocations for effective parent and family engagement
    activities, along with requirements for parent, family and community
    engagement activities using English Language Acquisition funds.
        What are the Department's plans for supporting SEAs and LEAs in
    implementing parent and family engagement requirements under section
    1116 of ESEA, including in identifying and overcoming barriers to
    greater participation by parents who have limited English proficiency
    or are of any racial or ethnic minority background?
        Answer. The Department administers the Statewide Family Engagement
    Centers program which is authorized under Title IV, Part E of the
    Elementary and Secondary Education Act of 1965, as amended. The purpose
    of the SFEC program is to provide financial support to organizations
    that provide technical assistance and training to SEAs and local
    educational agencies LEAs in the implementation and enhancement of
    systemic and effective family engagement policies, programs, and
    activities that lead to improvements in student development and
    academic achievement. For those families from diverse background and
    who have limited English proficiency, there are 12 statewide family
    engagement centers across the country that (1) carry out parent
    education and family engagement in education, programs and (2) provide
    comprehensive training and technical assistance to SEAs, LEAs, schools
    identified by SEAs and LEAs, organizations that support family-school
    partnerships and other such programs.
        In addition, the Department administers the Comprehensive Centers
    program, which is authorized under Title II, Sec. 203, of the
    Educational Technical Assistance Act of 2002. The Comprehensive Centers
    address needs identified by SEAs in meeting ESEA student achievement
    goals, as well as priorities established by states. As part of this
    work, Comprehensive Centers have developed resources on various topics
    (e.g., literacy instruction) to support SEAs, LEAs, and educators.
    Building SEA and LEA capacity to engage parents and families is a key
    element of this support (e.g., Evidence Based Literacy Instruction:
    Families as Partners). Comprehensive Centers have also developed
    resources that specifically focus on establishing and nurturing
    successful school-family relationships. Finally, parent and family
    engagement has played an important role in the Summer Learning and
    Enrichment Collaborative (SLEC). Several SLEC sessions have provided
    SEAs, LEAs, and other participants with support on developing
    partnerships for family engagement in high-needs communities, creating
    authentic partnerships with marginalized families and communities, and
    meeting whole student and family needs through collaborative
    partnerships at school.
        The Department looks forward to expanding and building upon these
    efforts.
        Question. How does the Department monitor and support the
    coordination and integration of parent and family engagement strategies
    under Title I-A with other relevant Federal programs?
        Answer. Under ESEA section 1116, an LEA receiving Title I, Part A
    funds must develop a written parent and family engagement policy in
    collaboration with parents and family members of participating
    students. Among other things, the policy must describe how, to the
    extent feasible, the agency will coordinate and integrate Title I
    parent and family engagement strategies with strategies under other
    relevant Federal, State, and local laws and programs. An LEA's policy
    also must describe how it will annually evaluate of the content and
    effectiveness of the parent and family engagement policy, including
    identifying barriers to participation, with particular attention to
    parents who are economically disadvantaged, disabled, have limited
    English proficiency, have limited literacy, or are of any racial or
    ethnic minority background. The Department monitors ESEA section 1116,
    Parent and Family Engagement, as part of the Title I, Part A monitoring
    protocol (available at: https://oese.ed.gov/files/2020/08/SEA-Protocol-
    Title-I.docx). Within the protocols, the Department specifically asks
    each SEA it monitors to describe how it reviews LEA parent and family
    engagement policies and practices to ensure the LEA meets the
    requirements of section 1116, including those referenced above. In
    addition, the Department asks each SEA to describe how, in its review
    of the LEA's parent and family engagement policies and practices, it
    ensures that the LEA's parent and family engagement policies provides
    opportunities for the participation of all parents and family members
    (including parents and family members who have limited English
    proficiency, parents and family members with disabilities, and parents
    and family members of migratory children) and provides information and
    school reports, in a format and, to the extent practicable, in a
    language that parents understand. The Department asks that each SEA
    submit its process to review LEA policies and procedures for family
    engagement as evidence during the monitoring review.
        Additionally, the Department of Education has an Office of
    Communications and Outreach that has a Family and Community Engagement
    Team. The goal of the Team is to expand efforts to help schools,
    districts, and states better engage families in education. This team
    works to monitor and support the coordination and integration of parent
    and family engagements strategies under Title I, Part A (and other
    Titles) with other relevant Federal programs.
        Question. The fiscal year 2022 Annual Performance Plan identifies a
    goal of improving access to quality educational programs in
    correctional settings.
        Please identify the programs and strategies involved in improving
    access to quality educational programs in correctional settings.
        Answer. The Office of Career, Technical, and Adult Education's
    Integrated Education and Training (IET) in Corrections Project will
    identify, develop, and document IET in corrections models to
    demonstrate how to extend existing secondary-postsecondary pathway
    models to include the corrections system. The project is intended to
    provide strategies that can be disseminated and replicated.
        Second Chance Pell (an Experimental Site Initiative) launched in
    2016 and allowed 67 colleges and universities enroll incarcerated
    students using Pell Grants on an experimental basis. In 2020, the
    program was expanded to allow an additional 67 colleges and
    universities to serve even more students. On July 30, 2021, the
    Department announced a further expansion of Second Chance Pell to gain
    critical insights about how to reinstate Pell Grant eligibility within
    correctional facilities, consistent with the implementation of the
    provisions of the Consolidated Appropriations Act of 2021 that will
    expand Pell Grant eligibility for all eligible incarcerated students on
    July 1, 2023. The Department has announced plans to publish regulations
    on the program prior to its implementation and held public hearings in
    June of 2021 to that end.
        The Department has already taken steps to implement changes to the
    Free Application for Federal Student Aid (FAFSA), which incarcerated
    students and education institutions alike have reported as a major
    stumbling block in implementing college-in-prison programming. For
    example, for the 2021-2022 award year FAFSA, the Department has removed
    the impact of responses to questions about Selective Service
    registration and requirements around drug convictions. These questions
    will be removed entirely from future FAFSAs.
        Question. How will the Department work with relevant Federal
    agencies on this goal?
        Answer. The Department currently staffs interagency working groups
    including the Federal Advisory Committee on Juvenile Justice, the Legal
    Aid Interagency Roundtable, and the Interagency Working Group for Youth
    Programs. The Department liaises on a regular basis with other Federal
    agencies including the Departments of Justice, Labor, Health and Human
    Services, and the Consumer Financial Protection Bureau to update these
    agencies on Departmental initiatives, such as Pell reinstatement, that
    are focused on quality educational program in correctional settings.
    The Department also works collaboratively with these agencies as they
    implement programming for incarcerated.
        Question. CRDC data from the 2017-18 school year survey show that
    Black students represented 15 percent of student enrollment but 38
    percent of students who received one or more out-of-school suspensions.
    Such discipline contributes to lost instructional time and negative
    life outcomes.
        Please describe planned activities for how the Department will
    support a reduction in racial disparities in school discipline.
        Answer. The Department is aware of these and other disparities in
    the administration of school discipline nationwide--and the adverse
    impacts that these disparities have on students--and is actively
    planning to address these issues. The Department anticipates issuing
    new guidance following its 2018 rescission of the Dear Colleague letter
    on Nondiscriminatory Administration of School Discipline and related
    materials, which provided guidance to schools on how to identify,
    avoid, and remedy discrimination based on race, color, or national
    origin in the design and administration of school discipline and create
    a positive school climate. As part of that process, on May 11, 2021,
    the Department's Office for Civil Rights (OCR) and the Civil Rights
    Division of the U.S. Department of Justice organized a virtual
    convening session, Brown 67 Years Later: Examining Disparities in
    School Discipline and the Pursuit of Safe and Inclusive Schools, where
    students, educators, school administrators, civil rights lawyers, and
    researchers considered the impact of exclusionary school discipline
    policies and practices on our nation's students, particularly students
    of color, students with disabilities, and LGBTQ+ students. As a follow
    up to the convening, on June 8, 2021, OCR published a Request for
    Information (RFI), seeking public comments on what guidance schools and
    school districts need to ensure all students attend welcoming,
    supportive, and safe schools. As stated in the RFI, OCR recognizes that
    students may experience multiple forms of discrimination at once and
    encourages commenters to identify and address individual and
    intersectional discrimination as appropriate. OCR expects that the
    public comments in response to the RFI will inform future decisions
    about what policy guidance, technical assistance, or other resources
    would assist schools that serve students in pre-K through grade 12 with
    designing and administering school discipline in a nondiscriminatory
    manner and improving school climate and safety. The comment period for
    the RFI closed on July 23, 2021, and OCR is in the process of reviewing
    the comments received.
        Question. The fiscal year 2022 President's budget proposes to
    continue authority for performance partnership pilot and proposes a
    priority for such pilots to include communities disproportionately
    impacted by COVID-19.
        What are the Department's plans for inviting new applications for
    performance partnership pilots?
        How will these pilots be informed by the national evaluation
    released earlier this year, including the recommendations for more
    planning time, additional guidance and technical assistance, and
    support of systems change through developing and implementing related
    metrics?
        Answer. The Department, as part of the ongoing Administration
    transition, is continuing to evaluate the lessons learned from previous
    Performance Partnership Pilots for Disconnected Youth (P3), including
    recommendations from the national evaluation, and how best to position
    the program for maximum impact in the context of State and local needs
    arising from the COVID-19 pandemic (including any flexibilities that
    could facilitate more effective use of ARP funds), as well as other
    Administration priorities.
        Question. The ``Foundations for Evidence-Based Policymaking Act of
    2018'' includes key provisions related to developing a multi-year
    learning agenda, evaluation plan, improving coordination of data
    government at the Department, and improving accessibility of education
    data.
        What is the Department's timeline for release of its multi-year
    learning agenda? Please describe stakeholder consultations that have
    occurred or will occur during its development.
        Answer. Per OMB guidance, the Department will publish its multi-
    year Learning Agenda for fiscal year 22-26 in February 2022, concurrent
    with the release of the President's fiscal year 2023 Budget.
    Consultation with stakeholders will include a broad Request for
    Information published in the Federal Register, along with targeted
    outreach to specific communities based on their role (e.g., chief state
    school officers) or area of emphasis (e.g., researchers focused on, or
    advocacy organizations related to, Federal student aid).
        Question. When will the Department release its evaluation plan?
        Answer. Per OMB guidance, the Department will publish its fiscal
    year 2023 Annual Evaluation Plan in February 2022, concurrent with the
    release of the Presidents' fiscal year 2023 Budget. The Department's
    fiscal year 22 Annual Evaluation Plan, which was delayed so that
    elements of the document could be better aligned to the Secretary's
    priorities and the Department's strategic planning efforts, will be
    posted in August 2021 to https://ed.gov/data.
        Question. What is the Department's timeline for implementing other
    provisions of the Act?
        Answer. ED's implementation of the Evidence Act is informed by the
    recommendations of the Commission on Evidence-Based Policymaking, the
    Federal Data Strategy's Principles and Practices, and the Office of
    Management and Budget's Phase 1 guidance on Evidence Act implementation
    (M-19-23). Our implementation also is informed by discovery and
    assessment activities in our own agency that led to a coherent ED Data
    Strategy that now serves as ED's roadmap to data maturity.
        The ED Data Strategy--the first of its kind for the U.S. Department
    of Education--was released in December of 2020. The four ED Data
    Strategy goals are highly interdependent with cross-cutting objectives
    requiring a highly collaborative effort across ED's offices.
      --The strategy calls for strengthening data governance to administer
            the data it uses for operations, answer important questions,
            and meet legal requirements. To that end, we are developing a
            holistic agency-wide framework with established data governance
            structures, functions, roles, policies, and procedures and
            developing a comprehensive data quality framework for the
            agency.
      --To accelerate evidence-building and enhance operational
            performance, it requires that ED make data more interoperable
            and accessible for tasks ranging from routine reporting to
            advanced analytics. To inform decisionmaking processes, we are
            working to connect fragmented data from disparate sources, so
            we can answer critical questions, and strengthen grant
            programs' performance and accountability measures.
      --The high volume and evolving nature of ED's data tasks necessitates
            a focus on developing a workforce with skills commensurate with
            a modern data culture in a digital age. We are developing an ED
            data workforce plan to support long-term planning for our data-
            related human capital needs; we are also building the capacity
            of our data workforce while we increase data literacy among all
            staff.
      --At the same time, safely and securely providing access for
            researchers and policymakers helps foster innovation and
            evidence-based decisionmaking at the Federal, state, and local
            levels. Aligned with these efforts, we are developing an Open
            Data Plan, while awaiting OMB guidance on final requirements
            for that plan; we are also building toward a comprehensive data
            inventory to catalog data assets for both external open data
            and internal sources and will incrementally expand the number
            of Department data assets listed in the Federal Data Catalog.
        Achieving the four ED Data Strategy goals requires a concerted
    effort to address short-term challenges and thoughtfully set a course
    for long-term data maturity. Each Goal includes a set of objectives--
    designed to be completed in the next 12 to 18 months--that form an
    action plan for tackling short-term challenges to continue building the
    foundation of a data-driven culture. Future objectives under the four
    goals will iteratively represent the next set of implementation
    challenges to raise ED offices and the agency as a whole to an even
    higher level of data maturity.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        Question. The Department notified me and other Members of Congress
    on February 13, that Secretary DeVos had decided not to extend the
    closed school discharge look-back period for students who attended
    schools owned by Education Corporation of America (ECA). As the
    Department has previously stated, ``during the months of March, April,
    and May 2018, ACICS placed many locations of ECA on either campus-level
    show-cause or campus-level compliance warning due to student
    achievement rates'' and on ``May 8, 2018, ACICS placed ECA on show-
    cause due to adverse action by another agency.''
        Actions toward the removal of accreditation are a clear example of
    exceptional circumstances as provided under 34 CFR Sec. 685.214. Will
    you reconsider this decision?
        Answer. Question answered elsewhere in this document.
        Question. In that same February notification, the Department noted
    that Secretary DeVos had not yet made a decision on the request from me
    and other Members of Congress made on December 21, 2018, to extend the
    look back period for Vatterott students--which also met the exceptional
    circumstances bar in the law.
        Will you look into this matter and render a decision?
        Answer. The Department is cognizant of the significant harm to
    students that occurs when a college suddenly closes. We are reviewing a
    number of school closures to determine whether an extension of the
    look-back window is appropriate, and hope to be able to share more on
    the results of that review soon.
        Question. On June 23, 2021, the Department provided a response to a
    letter I sent on October 29, 2020, with several colleagues to then-
    Secretary DeVos. Secretary DeVos failed to respond. Your Department's
    response mentioned the announced rulemaking in several of the areas
    mentioned in the letter--including closed school discharge.
        While I'm pleased the Department is taking up many of these issues
    in rulemaking, when can we expect a decision from you to the specific
    requests in the letter--related to extending closed school look-back
    dates?
        Answer. We are reviewing a number of school closures to determine
    whether an extension of the look-back window is appropriate, and hope
    to be able to share more on the results of that review soon.
        Question. Since June 2018, the Department has released borrower
    defense data on a quarterly basis:
        Please provide a breakdown of ``total denied'' borrower defense
    claims to date by institution.
        Answer. Beginning in December 2019, the term ``total denied'' was
    no longer used in the quarterly borrower defense reports. The term
    ``total ineligible'' is used to refer to applications in which the
    borrower has been notified that their claim does not meet the
    requirements for a borrower defense to repayment discharge.
        Question. Please provide a breakdown of ``total ineligible''
    borrower defense claims to date by institution.
        Answer. An Excel file providing the requested data as of June 30,
    2021, is enclosed.

        Question. Please provide a breakdown of ``total closed'' borrower
    defense claims to date by institution.
        Answer. An Excel file providing the requested data as of June 30,
    2021, is enclosed.

        Question. How many schools are being investigated for misconduct
    due to borrower defense claims filed by their students?
        Answer. The Department does not comment on deliberative,
    preliminary, or ongoing investigative work, including disclosing a
    number or list of institutions that may be subject to such work until
    the outcomes of any investigations have been issued to the institutions
    or entities. Nevertheless, the Department notes that it has opened
    numerous investigations in 2021 and will be holding schools accountable
    where appropriate. For schools with findings of misrepresentation or
    misconduct, the Department will use evidence in connection with our
    borrower defense fact-finding process.
        Question. Please provide a list of for-profit colleges for which
    the Department is aware of pending state or Federal investigations or
    lawsuits--and the corresponding state or Federal entities.
        Answer. The Department does not maintain a formal list of for-
    profit colleges with pending state or Federal investigations or
    lawsuits. However, the Department collaborates closely with law
    enforcement partners where appropriate and requests evidence and input
    when their investigations of for-profit colleges result in evidence
    that the Department may consider in connection with its efforts to hold
    schools accountable.
        Question. For how many borrowers whose borrower defense
    applications have been approved has the Department or its agents made
    corrected reports to credit reporting agencies? What percentage?
        Answer. FSA requires our vendors to remove the credit tradeline for
    any loans that are approved for 100 percent borrower defense relief.
        Question. How many and which institutions is the Department
    currently investigating for purposes of making findings related to
    borrower defense?
        Answer. The Department does not comment on deliberative,
    preliminary, or ongoing investigative work, including disclosing a
    number or list of institutions that may be subject to such work until
    the outcomes of any investigations have been issued to the institutions
    or entities. To the extent that a Department investigation results in
    obtaining evidence that may be relevant to borrower defense claims, the
    evidence will be given to FSA's Borrower Defense Group for use in its
    fact-finding process. Additionally, the Department is in the process of
    increasing staffing within FSA's Investigations Group to advance these
    efforts.
        Question. Since the 2014 collapse and 2015 bankruptcy of Corinthian
    Colleges, Inc., many for-profit colleges have followed suit--closing
    their doors as part of a planned teach-out or shuttering precipitously.
    In these cases, students are eligible for Federal closed school
    discharges. Many are also eligible for Federal student loan discharges
    through the Higher Education Act's borrower defense provision as a
    result of their institution's fraud and misconduct. We cannot let
    students be left holding the bag. At the same time, the Department's
    enforcement failures, failures to hold accreditors accountable,
    attempts to roll back the Gainful Employment and Borrower Defense
    rules--including provisions allowing students to hold institutions
    directly accountable in court for misconduct--mean that taxpayers are
    ultimately on the hook.
        Please provide the cumulative cost of approved closed school and
    borrower defense discharges (including automatic closed school
    discharges under the 2016 Borrower Defense rule) associated with for-
    profit colleges since 2014.
        Answer. As of June 30, 2021, the cumulative effectuated closed
    school and borrower defense discharges amount is approximately $2.2
    billion. This includes almost $1.1 billion in borrower defense
    discharges and more than $1.1 billion in closed school discharges,
    including automatic closed school discharges. The Department is
    continuing to process the discharges of the roughly 91,800 borrower
    defense approvals that have been announced in press releases in recent
    months.
        Question. Please provide the cumulative amount that the Department
    has recouped from institutions for closed school discharge costs
    associated with for-profit colleges since 2014.
        Answer. The Department's recoupment of loan discharge liabilities
    is a trailing process which follows the Department's quantification of
    actual discharged loan amounts and assertion of liabilities. In
    general, when an institution closes, it is required to submit a
    ``Close-Out Audit'' report to the Department. When FSA resolves a
    close-out audit, it quantifies closed school loan discharges and
    asserts liabilities in the final audit determination for the close-out
    audit report. FSA may also pursue additional recovery of liabilities
    arising after the close-out audit is resolved. In all cases, the
    Department must provide institutions with appeal rights to challenge
    asserted liabilities and the Department does not pursue collections
    while an appeal is pending. In addition, the circumstances of some
    school closures may require the Department to pursue recoveries through
    protracted bankruptcy proceedings. To that end, the Department has
    recouped more than $10.4 million from institutions for closed school
    discharge costs associated with for-profit colleges since 2014.
        Question. Please provide the cumulative amount that the Department
    has recouped from institutions for borrower defense discharge costs
    associated with for-profit colleges since 2014.
        Answer. The Department has not recouped any costs associated with
    borrower defense discharges from institutions. All approved claims to
    date relate to closed schools.
        Question. According to the April 2021 borrower defense report, the
    Department currently has nearly 108,000 pending borrower defense
    claims. Please provide:
        The average length of time the 108,000 claims have been pending;
        Answer. The average length of time that all applications have been
    pending as of June 30, 2021, is 748 days. This is not specific to the
    108,000 claims referenced, but rather the total number of pending
    applications, which includes those in the Awaiting Adjudication and
    Pending Notification categories, as of June 30, 2021.
        Question. The percentage of pending claims related to for-profit
    institutions (including institutions that have been for-profit
    institutions within the past 10 years), public institutions, and
    private not-for-profit institutions respectively;
        Answer. As of June 30, 2021, 88 percent of total pending
    applications were related to for-profit institutions; 4 percent were
    related to public institutions; and 8 percent were related to private
    not-for-profit institutions. A small number of applications (less than
    1 percent) include those without a school assigned and those involving
    foreign institutions.
        Question. A breakdown of the 108,000 pending claims by institution;
    and
        Answer. An Excel file providing the requested data as of June 30,
    2021, is enclosed. Please note that institutions may appear on the list
    several times because the data was pulled based on the institutions' 8-
    digit OPEID.

        Question. A list of all group discharge applications the Department
    has received from State attorneys general including the date submitted,
    by whom, the school/programs, and the number of covered borrowers and
    the status of each application.
        Answer. Information regarding the group discharge requests from
    attorneys general is provided in the enclosed file.

        Question. How many of the applications referenced in (d) are
    pending? How many have been granted? How many have been denied? Please
    provide a list of each.
        Answer. All of the AG submissions referenced in (d) are currently
    under review.
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, and
    2021 how many borrowers covered by a group discharge application are in
    default on their Federal student loans?
        Answer. At this time, the Department cannot narrow its reporting to
    individual applications submitted by attorneys general. Most of the
    attorney general submissions did not specifically identify the
    borrowers covered by their group requests, and the Department is
    currently working to identify the borrowers at issue.
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, and
    2021 how many loans of the borrowers covered by a group discharge
    application have been certified by the Department of Education for
    Treasury offset?
        Answer. Please see answer to question 10(f), above.
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, and
    2021 how many borrowers covered by a group discharge application have
    been subject to an administrative wage garnishment order put in place
    by the Department?
        Answer. Please see answer to question 10(f), above.
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, and
    2021 what are the total dollar amounts of Federal student loans
    (interest and principal) covered by each group discharge application
    from a State attorney general?
        Answer. Please see answer to question 10(f), above.
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, 2021
    what are the total dollar amounts collected through the Treasury Offset
    Program on defaulted student loans covered by each group discharge
    application from a State attorney general?
        Answer. Please see answer to question 10(f), above.
        Question. In January 2017, State attorneys general--led by
    Illinois--provided the Department with program-level enrollment data
    for borrowers in their states that were covered by the Department's
    Corinthian job placement misrepresentation findings. How many of these
    borrowers have still not received relief despite being eligible?
        Answer. Due to data limitations, FSA is unable to respond to this
    question at this time. While the Illinois Attorney General did provide
    a borrower list in December 2016, the list did not contain the unique
    identifiers (Social Security Number and/or date of birth) necessary to
    confidently match to borrowers in FSA's systems. The Department is now
    working to identify any borrowers submitted by the Illinois Attorney
    General and any other attorneys general who may be covered by the job
    placement rate findings, as that work was not done previously.
        Question. 34 CFR 685.300 governs Program Participation Agreements--
    the contracts between schools and the Department of Education. CFR
    685.300(e) prohibited schools from making or enforcing class action
    bans and mandatory pre-dispute arbitration agreements.
        Answer. As a preliminary observation, the Program Participation
    Agreement (PPA) is primarily governed by 34 C.F.R. Sec. 668.14. 34
    C.F.R. Sec. 685.300 provides additional participation requirements when
    a school participates in the Direct Loan program. The provisions of 34
    C.F.R. Sec. 685.300 are inapplicable if an institution elects not to
    participate in the Direct Loan program. The provisions were removed
    effective July 1, 2020. Therefore, the response to question a. extends
    only to June 30, 2020.
        Question. In how many schools' Program Participation Agreements did
    the Department include this prohibition?
        Answer. From July 21, 2019 and through June 30, 2020, the
    Department created and executed Program Participation Agreements (PPAs)
    that have included specific language referencing class action bans and
    pre-dispute arbitration agreements for 1,155 schools. As of July 29,
    2021, 1,070 of these schools were approved to participate in the Direct
    Loan program, and 85 schools were not approved to participate in the
    Direct Loan program. PPAs created before July 21, 2019, contained
    overarching language indicating that schools were required to comply
    with all Title IV, Higher Education Act and Direct Loan program
    participation requirements, which would extend to the restrictions
    relating to class action suits and pre-dispute arbitration agreements.
        Question. In how many instances did the Department seek to enforce
    this prohibition? What actions did it take?
        Answer. The Department does not comment on deliberative,
    preliminary, or ongoing investigative work, including the enforcement
    of the Title IV regulations. Generally speaking, through our program
    review authority, we will monitor compliance with the requirements that
    schools end enforcement of any existing mandatory pre-dispute
    arbitration clauses and class action restrictions in enrollment
    agreements.
        Question. Are you aware of any class actions that schools
    participating in Title IV forced into arbitration while the prohibition
    was in effect?
        Answer. The Department is aware of two competing cases that relate
    to the prior regulation, which is no longer in effect. The regulation
    itself was subject to multiple implementation delays and litigation. In
    Kourembanas v. InterCoast Colleges, a class action in the District of
    Maine, 17-cv-00331, the court granted a motion to compel arbitration.
    And in Young v. Grand Canyon University, the appellate court reversed
    the Northern District of Georgia's initial decision to compel
    arbitration in Carr et al. v. Grand Canyon University, 19-cv-01707.
        Question. Please provide a list of all institutions for which the
    Department currently holds a letter of credit or other surety and the
    amount of such letter of credit or other surety.
        Answer. Enclosed is an Excel file containing data on the Letters of
    Credit (LOC) and other surety that the Department held as of July 14,
    2021. As of July 14, 2021, the Department held 403 LOCs and other
    surety from institutions, totaling more than $607.3 million in
    financial protection. The first tab of the Excel file contains
    institutional and other data regarding the LOCs held by the Department
    as of July 14, 2021. The second tab provides the field definitions and
    descriptions of the reasons why a LOC was requested from a listed
    institution. Please note that this report differs from reports posted
    to FSA's Data Center identifying LOCs requested by the Department
    during an Award Year period. It is a ``snapshot'' of LOCs held by the
    Department as of July 14, 2021 and it provides the most recent
    information recorded in FSA's data sources regarding these LOCs. The
    report does not provide historical context for the LOCs held as of July
    14, 2021 in cases where FSA may have required an institution to renew
    or amend a previously provided LOC. In a limited number of cases, the
    report also identifies and includes funds held on deposit by the
    Department in lieu of a LOC.

        Question. Regarding institutional compliance with the incentive
    compensation rules to date, please provide:
        The number of program reviews, investigations, audits, or other
    reviews that have examined institutional compliance with the
    requirements of incentive compensation;
        Answer. The Department has issued determinations for 60 program
    reviews that were initiated during fiscal years 2017--20 and fiscal
    year 2021 through June 30, 2021 that examined institutional compliance
    with incentive compensation requirements.
        The Department received and finalized its review and audit
    resolution process for more than 15,900 compliance audit reports whose
    audit period included any portion of fiscal years 2017, 2018, 2019,
    2020, or 2021 through July 28, 2021. The compliance audit reports were
    prepared either in accordance with the OIG's Guide for Audits of
    Proprietary Institutions and For Compliance Attestation Engagements of
    Third Party Servicers Administering Title IV Programs, or in accordance
    with the OMB Compliance Supplements (2 CFR Part 200, Appendix XI--
    Compliance Supplement) for audits reports prepared under the Single
    Audit Act. The scope of these audits included audit objectives for an
    independent auditor to determine whether the auditees did or did not
    comply with the incentive compensation prohibitions.
        Additionally, the Department conducted close to 300 ``New School
    Visits'' during fiscal years 2017--20 and fiscal year 2021 through July
    28, 2021 that reviewed incentive compensation requirements. A New
    School Visit is a process focused on the start-up issues and needs of
    schools that are new Title IV participants or that might not have
    recent Title IV experience. A New School Visit is not a program review,
    but rather a tool used to identify and eliminate any weaknesses that,
    if left unaddressed, could result in improper use of Federal funds and
    possible liabilities for the school. A standard component of a New
    School Visit includes a discussion of incentive compensation
    requirements, which may lead to the identification of a compliance
    deficiency.
        Question. how many program reviews, investigations, audits, or
    other reviews found;
        Answer. The Department has identified 10 instances of incentive
    compensation noncompliance in the population of finalized program
    reviews, investigations, and other reviews conducted in fiscal years
    2017--20 and fiscal year 2021 through July 28, 2020, and finalized
    compliance audit resolutions whose audit period included any part of
    fiscal years 2017-20 and fiscal year 2021 through July 28, 2021.
        Question. Noncompliance with the requirements of incentive
    compensation; and the actions the Department has taken to ensure that
    institutions correct deficiencies in compliance with the requirements
    of incentive compensation
        Answer. The Department has issued fine actions totaling $3,411,002
    for four institutions in fiscal years 2017--20 and fiscal year 2021
    through July 28, 2021.
        Question. In recent years, several for-profit colleges have
    attempted to convert to not-for-profit status in an effort to avoid the
    stigma associated with the predatory for-profit college industry and to
    avoid regulations meant to protect students and taxpayers. Dream Center
    Education Holdings, which collapsed leaving thousands of students
    stranded and whose conversion received preliminary Department approval,
    is just one example. Please provide a list of all for-profit
    conversions in the last 10 years including those pending (with current
    status), previously approved, and denied or withdrawn.
        Answer. An Excel file providing the requested information is
    enclosed. Within the last 10 years, the Department has received 78
    applications for a for-profit to nonprofit conversion. Of those 78
    applications, the Department has made final decisions on 40 conversion
    requests as of August 1, 2021. Of those 40 decisions, 37 were
    approved.\*\ The Department denied Argosy University's request for
    nonprofit recognition. The Department also denied Grand Canyon
    University's and the American Academy of Art College's requests for
    nonprofit recognition when it approved their respective Change in
    Ownership applications. Additionally, 18 applications, including pre-
    acquisition review applications, were closed due to a voluntary
    withdrawal or school closure. There are 19 outstanding conversion
    requests, and one pending pre-acquisition application where the Change
    in Ownership date is imminent.
    ---------------------------------------------------------------------------
        \*\ In August 2016, the four main locations operated by the Center
    for Excellence in Higher Education (CEHE) were originally denied their
    conversion request. Following the receipt of additional information and
    an updated valuation in October 2018, the Department determined that it
    would be appropriate to grant those institutions conditional approval
    to convert to nonprofit institutions and issued Provisional Program
    Participation Agreements in December 2018. The Department's December
    2018 determination of CEHE's nonprofit status--based on the new
    information CEHE provided--also provided a basis to dismiss a
    longstanding lawsuit filed against the Department, because that was the
    relief sought in the lawsuit. Just recently, under pressure from
    further reviews of its conduct by FSA, CEHE made the decision to close
    its remaining campuses effective Aug. 1, 2021. Additionally, one
    approved Change in Ownership transaction involving Kaplan University
    and Purdue University resulted in Kaplan University's conversion to
    public institution status (rather than to nonprofit institution
    status).

        Question. Please provide, disaggregated for Corinthian Colleges,
    Inc., ITT Educational Services, Inc., Charlotte School of Law,
    Education Corporation of America, Vatterott Colleges, and Dream Center
    Education Holdings, respectively:
        The number of borrowers and the total loan amount of such borrowers
    for whom the Department estimates are eligible for the applicable
    closed school discharge window (either 120 days or as extended due to
    ``exceptional circumstances'');
        The number of borrowers and the total loan amount of borrowers who
    applied for a non-automatic, traditional closed school discharge;
        The number of borrowers and the total loan amount that has been
    discharged through non-automatic, traditional closed school discharge;
        The number of borrowers and the total loan amount that has been
    discharged through automatic closed school discharge; and
        The number of borrowers and the total loan amount of such borrowers
    in some form of debt collection (Treasury offset, wage garnishment,
    assigned to PCAs).
        Answer. Please find an Excel file with the requested data enclosed.

        Question. Your predecessor allowed borrower defense claims to
    balloon at the Department without processing any claim for more than a
    year. At one time, the backlog had grown to several hundred thousand
    claims. As pressure mounted to clear the backlog--of her own creation--
    Secretary DeVos issued blanket and cursory denials of tens of thousands
    of claims. Many of these are potentially meritorious claims that were
    simply cast aside by the previous administration that always looked at
    borrower defense as more of a problem to ignore than a mechanism for
    justice and fairness. What steps will you take to review the DeVos
    Department's borrower defense denials?
        Answer. The Department agrees that all borrowers who have filed
    borrower defense to repayment applications deserve a thorough and fair
    review that is done as expediently as possible. While the Department
    continues to approve new categories of borrower defense claims, I have
    asked Federal Student Aid to conduct extensive outreach to state
    attorneys general, other government agencies, and any other parties
    that might be in possession of evidence showing institutional
    misconduct. I have also asked FSA to reopen any borrower defense
    denials when new evidence, or any other evidence in FSA's possession,
    indicates misconduct or other concerns that were not considered during
    the initial adjudication. In addition, FSA is conducting a review of
    our policies related to borrower defense and will reopen any denied
    claims based upon any of those policy changes.
        The Department is working diligently to process borrower defense
    claims in a timely manner. We are aware of the significant number of
    borrowers with a denied claim and are reviewing potential options for
    these borrowers.
        Question. You recently announced an ambitious higher education
    regulatory agenda which will include topics like gainful employment,
    for-profit conversions, borrower defense, financial responsibility,
    administrative capability. While I'm pleased the Department is
    undertaking this process, it is lengthy and the Department's rules
    subject to litigation. As it goes through the negotiated rulemaking
    process, how will the Department--under your leadership--use its
    extensive existing authorities to engage in aggressive oversight and
    enforcement activities related to predatory for-profit colleges?
        Answer. The Department of Education is working to ensure stronger
    oversight of predatory institutions through multiple venues. I expect
    that the rulemaking process will help the Department to design far
    stronger protections against predatory practices by institutions.
    Additionally, the Office of Federal Student Aid is working to ensure
    careful oversight of institutions, investigating reports of problematic
    practices and increasing monitoring of institutions that receive
    Federal aid under Title IV of the Higher Education Act. The new Chief
    Operating Officer of FSA, Richard Cordray, is committed to ensuring
    consumer protection is embedded in how FSA serves students and
    borrowers.
        Question. During the Obama Administration, then-Secretary Arne
    Duncan created a Federal interagency taskforce to coordinate oversight
    and enforcement efforts related to for-profit colleges. The task force
    was based on a bill that the late Rep. Elijah Cummings and I wrote
    called the Proprietary Education Oversight Coordination Improvement
    Act. The task force was successful in coordinating Federal action in
    response to misconduct by several for-profit colleges--including a $100
    million DeVry settlement with the Federal Trade Commission. Would you
    be open to recreating this task force that was disbanded by Secretary
    DeVos?
        Answer. The Department is deeply interested in strengthening
    oversight of misconduct across higher education. The interagency task-
    force created by the Obama Administration provided a critical
    opportunity for collaboration to identify potential illegal practices
    and misrepresentations. The Department is already working to
    reestablish those relationships with other Federal agencies through
    MOUs and data-sharing agreements, as well as opening the lines of
    communication with state Attorneys General, to improve accountability
    in higher education.
        Question. As part of the American Rescue Plan (Public Law 117-2),
    Congress closed the 90/10 loophole which incentivized for-profit
    colleges to prey on student veterans and servicemembers. I understand
    that the bill prohibited the Department from promulgating regulations
    to implement the statutory change before October 2021. In the meantime,
    will the Department release Federal 90/10 data which counts accurately
    as Federal revenue all revenue received by for-profit colleges from
    Federal taxpayer-funded educational assistance programs? This would
    include Department of Veterans Affairs GI Bill and Department of
    Defense Tuition Assistance funding. While this data could not be used
    for enforcement purposes yet, it would be very helpful to the public's
    understanding of the problem. In fact, the Department released this
    data, upon my request, in December 2016. On December 10, 2018, Chairman
    Takano, Senator Carper, Representative Cohen, Ranking Member Murray,
    Chairwoman DeLauro, Ranking Member Reed, Chairman Adam Smith, Senator
    Blumenthal, Representative Susan Davis, and I wrote to then-Secretary
    DeVos asking her to continue this data release. She refused during her
    tenure.
        Answer. As referenced in your question, section 2013 the American
    Rescue Plan Act modifies section 487(a)(24) of the Higher Education Act
    of 1965 (HEA) to require a proprietary institution to derive not less
    than 10 percent of such institution's revenues from sources other than
    ``Federal funds that are disbursed or delivered to or on behalf of a
    student to be used to attend such institution.'' The Department
    unfortunately does not have an updated report covering Federal 90/10
    data that counts accurately as Federal revenue all revenue received by
    for-profit colleges from Federal taxpayer-funded educational assistance
    programs report to release to you. Additionally, the Department does
    not maintain the requisite VA, DoD, and other Federal education
    benefits program funding data to prepare an updated 90/10 impact
    analysis.
        The Department wishes to clarify that although it released a 90/10
    data report in 2016 covering VA and DoD funds, the Department did not
    prepare that report. The Department's 2016 press release indicates DoD
    and VA prepared that 90/10 estimate. The Department's December 21,
    2016, transmittal letter identifies significant data limitations and
    includes a cautionary note against using the data to draw inferences
    about individual institutions or trends. The Department's subsequent
    March 28, 2019, response to your December 2018 letter reiterated these
    themes.
        Due to the complexity and individualized nature of the 90/10
    evaluation including, but not limited to, a requirement for an
    institution to use the cash basis of accounting under section
    487(d)(1)(A) of the HEA, an institution's 90/10 compliance is disclosed
    in an institution's audited financial statement notes. To perform an
    accurate analysis of the impact of the statutory change, an evaluation
    must be conducted at the individual student account receivable level
    for every recipient of any type of Federal taxpayer-funded educational
    assistance program who attended every proprietary school. This type of
    analysis is necessary in view of the requirements. The Department has
    no confidence that any other analytical approach would yield the
    accurate assessment requested.
        The Department appreciates your longstanding concern with
    institutions receiving Federal education benefits from multiple funding
    sources. However, the knowing release of a report that uses
    questionable data and depends on unsound assumptions could have harmful
    effects in advance of the upcoming rulemaking, including possibly
    misinforming and misleading members of the public who may seek to
    forecast the anticipated impact of new rules, which may undermine
    public trust. The Department is also concerned that the release of an
    inaccurate report would violate the Government Accountability Office's
    (GAO's) Standards for Internal Control in the Federal Government (GAO-
    14-704G), especially Principle 13, ``Use Quality Data.''
        Question. Over the last four fiscal years, this Subcommittee--with
    the support of Chairman Blunt and Ranking Member Murray--has provided
    $24 million to an Open Textbooks Pilot to expand the use of open
    textbooks on college campuses to achieve savings for students. While
    this program may be small, it has energized students and faculty across
    the country who see open textbooks--free, high-quality alternatives to
    costly traditional textbooks--as key to reducing student debt and
    improving learning outcomes. Many students don't purchase required
    course materials because they are too costly. It puts them at an
    academic disadvantage and hits low-income, first-generation, and
    students of color hardest. So, on a bipartisan basis, Congress created
    this program. In early June, the Department made nine new awards with
    its fiscal year 2021 appropriation--funding down the slate of fiscal
    year 2020 applications. I am pleased that the Department took
    Congressional directive and made a great number of awards. In order to
    do so though, the Department only funded 1 year of the applicants'
    projects. It was my understanding that if the Department took that
    step, it would fully fund those nine projects pending the appropriation
    of additional funds in fiscal year 2022.
        Please confirm that remains the Department's intention.
        How is that intention being relayed, with the appropriate caveats,
    to the 9 grantees?
        Answer. The Department worked extensively with Congress to identify
    and implement a funding strategy that would maximize the number of new
    awards in fiscal year 2021 that could be awarded with the $7 million in
    available funding, ultimately making nine new awards from the fiscal
    year 2020 slate. This strategy required a shift from the previous
    strategy of frontloading OTP grantees, an approach that fully paid all
    multi-year project costs with a single year's appropriation, but which
    consequently required making a much smaller number of awards. The
    larger number of awards enabled by the shift to incremental funding
    allowed roughly twice as many highly rated applicants to launch their
    projects in fiscal year 2021 as would have been possible with
    frontloading. The Department used approximately $5.9 million to pay
    first-year costs and approximately $1.1 million to partially pay down
    the second-year costs for the 2021 OTP cohort. We plan to use an
    estimated $8.3 million in fiscal year 2022 funds to pay remaining
    second- and third-year costs for this cohort, as shown in the fiscal
    year 2022 Congressional budget justification for this program.
        While the project period for these grantees does not begin until
    September 1, 2021, program staff have held post-award calls with the
    nine grantees to explain the impact of the change in funding strategies
    for the 2021 OTP cohort.
        Question. When you came before us, I asked you about the high
    percentage of denials under the Public Service Loan Forgiveness (PSLF)
    program. You voiced your support for PSLF and your determination that
    borrowers receive the forgiveness that they expected and to which they
    are entitled. PSLF reform is part of the higher education regulatory
    agenda that you have announced. What steps will you take
    administratively, outside of formal rulemaking, to help fix the
    problems with PSLF?
        Answer. As we continue investigating the challenges of PSLF, the
    Department is committed to undertaking a serious review of the PSLF
    program and to making improvements that will result in better access to
    relief for eligible borrowers. In addition to including PSLF on the
    regulatory agenda, we recently issued a Request for Information (RFI),
    inviting feedback on borrower experiences and possible policy solutions
    with the PSLF program, to identify broader areas for improvement. The
    Department has already begun to make improvements, including by
    launching and updating the PSLF Help Tool, by allowing lump sum and
    prepayments to count as qualifying payments, and by creating a single
    application for PSLF, Temporary Expanded PSLF (TEPSLF), and Employment
    Certification Forms (ECFs). We look forward to making additional
    administrative and operational improvements that help eligible
    borrowers access the benefits they have earned.
        Further, on October 6, 2021, the Department of Education announced
    an overhaul of the PSLF Program that it will implement over the next
    year to make the program live up to its promise. This policy will
    result in 22,000 borrowers who have consolidated loans--including
    previously ineligible loans--being immediately eligible for $1.74
    billion in forgiveness without the need for further action on their
    part. Another 27,000 borrowers could potentially qualify for an
    additional $2.82 billion in forgiveness if they certify additional
    periods of employment. All told, the Department estimates that over
    550,000 borrowers who have previously consolidated will see an increase
    in qualifying payments with the average borrower receiving another 2
    years of progress toward forgiveness. Many more will also see progress
    as borrowers consolidate into the Direct Loan program and apply for
    PSLF, and as the Department rolls out other changes in the weeks and
    months ahead.
        The first major change will result in a limited PSLF waiver that
    allows all payments by student borrowers to count toward PSLF,
    regardless of loan program or payment plan. This waiver will allow
    student borrowers to count all payments made on loans from the Federal
    Family Education Loan (FFEL) Program or Perkins Loan Program. It will
    also waive restrictions on the type of repayment plan and the
    requirement that payments be made in the full amount and on-time for
    all borrowers.
        Given this new policy, borrowers who currently have FFEL, Perkins,
    or other non-Direct Loans, will receive the benefit of this limited
    waiver if they apply to consolidate into the Direct Loan program and
    submit a PSLF form by October 31, 2022. The waiver applies to loans
    taken out by students.
        Also, these changes will allow active duty service members to count
    deferments and forbearances toward PSLF. This solves a problem for
    service members who have paused payments while on active duty but were
    not getting credit toward PSLF.
        The Department is automatically providing credit toward PSLF for
    military service members and Federal employees using Federal data
    matches. The Department will implement data matches next year to give
    these borrowers credit toward PSLF without an application.
        Finally, the Department is reviewing denied PSLF applications for
    errors and giving borrowers the ability to have their PSLF
    determinations reconsidered. These actions will help identify and
    address servicing errors or other issues that have prevented borrowers
    from getting the PSLF credit they deserve.
        Question. Students' Federal financial aid for higher education is
    dependent on their expected family contribution. For many students from
    low-income families, their expected family contribution qualifies them
    for Federal assistance in the form of a Pell Grant. To confirm accurate
    family contributions, some financial aid applications are flagged for
    additional verification. Past data from the Department shows that over
    half of Pell-eligible applicants were selected for verification in
    2015-2016. It is estimated that more than 1 in 5 low-income students
    selected for verification never complete the process, thus never end up
    receiving Federal financial aid. Students who receive Pell grants have
    much higher college retention rates than their peers who are Pell
    eligible but do not receive the aid. This data implies it is possible
    that the verification process is disproportionately harming the
    educational success of low-income students, which is the opposite
    intention of the Pell Grant program. The 2017/2018 Award Year ushered
    in a new verification model. The Quality Assurance Program ended, which
    had given institutions of higher education discretion on application
    verification, leaving the Department to select which students needed to
    be verified. The risk-model developed by the Department to identify
    which FASFA applications needed verification led to a drastically
    higher percentage of applications flagged. In fact, some schools
    reported that nearly 50 percent of Pell eligible students were selected
    for verification multiple times over their course of study even though
    their financial information hadn't changed.
        Please provide the metrics by which the Department selects which
    applications are to be verified.
        Answer. Prior to 2018, FSA relied solely on a Classification and
    Regression Tree (CART) model to choose FAFSA filers for financial
    verification. The CART model used combinations of Targeted Selection
    Criteria (TSC) to choose FAFSA filers for verification. In September
    2017, FSA funded the creation of an advanced Python-coded machine
    learning model (MLM) to improve FSA's verification selection model by
    better identifying applicants for whom an error on the FAFSA was more
    likely to impact their Expected Family Contribution and, ultimately,
    their Federal aid award. FSA has used this model since October 1, 2018.
    The MLM updates the criteria used for selection of FAFSA filers for
    verification to a gradient boosting classification and regression
    model. The metrics the model employs to choose FAFSA filers for
    verification include data from the FAFSA, as well as demographic data,
    in several complex algorithms. In certain cases, TSC are used to
    supplement MLM selection, and a small percentage of applicants are
    randomly selected to provide necessary data for model building and
    evaluation. As part of this single, overall selection process, a
    separate TSC model is used to select applicants for identity/fraud
    verification.
        Finally, for your awareness, in July we announced some
    modifications to our verification approach to the 2021-2022 FAFSA
    processing cycle in response to the challenges and barriers resulting
    from the ongoing national emergency by focusing solely on identity and
    fraud. We continue to evaluate potential approaches for upcoming cycles
    to ensure that they are balanced and equitable.
        Question. What percentage of students chosen for verification, did
    not complete, and failed their verification during the last award year
    under model?
        Answer. FSA uses the receipt of either a Pell Grant or Subsidized
    Direct Loan as a measure of whether an applicant successfully completes
    verification once selected. Of those selected for verification during
    the 2020-21 FAFSA cycle, 64.5 percent received either a Pell Grant or a
    Subsidized Direct Loan. Some students that submit a FAFSA do not enroll
    in an institution of higher education for a variety of reasons, so we
    would not expect this percentage to equal 100. Therefore, to understand
    the impact of the verification process on student enrollment, the
    Department compares this rate to the population not chosen for any type
    of verification. The rate for those not selected for verification
    receiving either a Pell Grant or a Subsidized Direct Loan is 56.8
    percent. Please note this data is as of July 28, 2021 and may change
    slightly as Award Year 2021 aid is finalized.
        Question. We have a student debt crisis that isn't going to resolve
    itself. Currently 45 million Americans hold more than $1.7 trillion in
    student loan debt. Student debt is larger than credit card debt in our
    nation. It is second only to mortgages when it comes to consumer debt.
    The average debt per student borrower is more than $37,000. Most of
    this is in Federal student loans. The student debt crisis is limiting
    young people's life and career choices. Americans are putting off
    starting a family and buying a home because of student debt. And it's
    not just young people. More than 8 million Americans over age 50 have
    student loan debt. For years, I have introduced legislation to fix the
    absurd way that the bankruptcy code treats student debt. If a person
    overextends himself on his credit card or goes into debt buying a car
    or a boat or a luxury watch, he can address those debts in bankruptcy.
    But the bankruptcy code provides no meaningful relief for student loan
    debt. In 1998, Congress put Federal student loans in the category of
    nondischargeable debts, along with alimony, child support, overdue
    taxes, and criminal fines. Right now, the only way a student borrower
    can get bankruptcy relief for student loans is if she can demonstrate
    ``undue hardship.'' This standard is not defined in law, and courts
    have interpreted it to make it nearly impossible to meet. But,
    Secretary Cardona, you have the ability to help this situation. The
    Department of Education can set internal standards for when it views an
    undue hardship as being met, and can direct its contractors and
    servicers not to challenge those undue hardship claims in bankruptcy
    court. For years, I have urged previous Secretaries of Education to use
    this authority and to issue undue hardship guidance for its guaranty
    agencies and contractors. There are categories of debtors where undue
    hardship can be presumed--for example, debtors who suffer from certain
    disabilities, or who have had a low income for a number of consecutive
    years. If the Department would use this authority, it would create an
    option of last resort for student debtors who truly have nowhere else
    to turn. Will you commit to issue guidance on the Department's views of
    when an undue hardship claim can be met?
        Answer. The Administration is committed to ensuring that student
    loan borrowers have options to make the burden of student loans more
    manageable . The consequences of delinquency and default on Federal
    student loans can be substantial, particularly for borrowers who are
    suffering from other economic hardships, including many who ultimately
    file for bankruptcy relief on their debts. We have already taken
    initial actions to support borrowers; but we recognize that more work
    remains to be done.
        To that end, the Department is committed to reviewing its 2015
    guidance on undue hardship student loan discharges in bankruptcy
    proceedings, as well as other policies related to such proceedings to
    assess the types of changes that might better protect borrowers. We
    hope to have more to share on this soon.
        Question. A recent report by the National Student Loan Defense
    Network, entitled ``The Missing Billion,'' highlights the aggressive
    tactics the Department uses to collect from struggling borrowers--
    including challenging claims of undue hardship in bankruptcy. At the
    same time, the report finds that the Department has failed to collect
    on more than $1 billion owed to taxpayers by for-profit institutions
    and executives. Please comment on the findings of this new report.
        Answer. The National Student Loan Defense Network's (NSLDN's)
    report, ``The Missing Billion,'' compares the differences in the
    Department's collection of liabilities owed by institutions and its
    collection of student loans owed by individual borrowers in default.
    This difference primarily comes from statutory provisions that make it
    difficult to hold individual owners liable for the corporate debts of
    the institutions, in contrast to provisions that substantially limit
    any bankruptcy relief under an ``undue hardship'' standard. See 11
    U.S.C. Sec. 523(a)(8). The ``undue hardship'' standard applies to
    educational debts when individuals seek bankruptcy protection. In
    seeking to enforce that standard uniformly, the Department considers as
    a factor the availability of several student loan repayment plans that
    can take a borrower's circumstances into account to reduce a borrower's
    scheduled loan installments to a more affordable monthly payment.
        The Department uses oversight measures as provided in the
    Department's regulations to identify institutions that are financially
    weak and institutions with impaired administrative capability. These
    measures include monitoring the numeric composite score of financial
    responsibility, requiring institutions with failing financial scores to
    provide letters of credit (LOCs), using Heightened Cash Monitoring
    (HCM) methods of payment, and provisional certification to monitor
    schools' compliance with the Department's requirements to mitigate
    risk.
        Frequently, LOC amounts, HCM requirements, and provisional
    certification are linked to an institution's performance under the
    Department's financial responsibility requirements and an institution's
    numeric composite score determined by financial analysis of the
    institution's annual financial statements in accordance with the
    Department's regulations. Consistent with the Department's regulations,
    LOC amounts are indexed to an institution's annual Title IV, HEA
    funding. The proceeds of LOC collections can be applied towards an
    institution's unpaid debts after any related appeals are fully
    resolved. When the Department perceives increased financial or
    administrative risk, the Department may require institutions to comply
    with more stringent requirements, such as raising the amount of
    financial protection an institution must provide and increasing the
    level of scrutiny applied to payment requests through the HCM2 method
    of payment. The Department also considers risks associated with
    increased compliance requirements. One outcome of stringent enforcement
    and oversight can be that an IHE may close if it is unable to fully
    comply with more rigorous requirements, such as a posting a larger LOC.
        The Department's Office of Finance and Operations collects debts
    owed to the Department and follows applicable Federal debt collections
    laws, including the Debt Collection Improvement Act of 1996, when
    collecting debts and when referring delinquent debts for collections.
    If an institution files for bankruptcy, it immediately loses
    eligibility to participate in the Title IV, HEA programs. The
    Department is bound to follow applicable bankruptcy law and pursues
    debt recovery from the institution's estate through the bankruptcy
    court. Institutions that close often do so with a lot of debt and
    limited assets to be distributed among the creditors. Collection of
    liabilities against an institution is generally limited to the direct
    owner corporate entity unless there is litigation to ``pierce the
    corporate veil,'' which often proves difficult. Litigation to recover
    liabilities against individuals can only be brought by the U.S.
    Department of Justice and requires piercing the corporate veil in order
    to hold individuals personally accountable. The Department has taken
    steps to prevent individuals with unpaid school debts or bad track
    records running schools from operating other schools. The Department's
    past performance regulations can bar school owners who owe unpaid debts
    from owning or exercising substantial control over other schools until
    their outstanding debts are paid.
        We are reviewing the report to determine if there are any
    outstanding actions that need to be resolved for currently
    participating schools. While the report is critical of the Department's
    administration of debts owed by institutions, an initial reading also
    indicates the report contains unfounded conclusions and inaccurate
    claims because it fails to take into account the requirements to
    establish liabilities against institutions. The report also appears to
    misinterpret the data provided to NSLDN via the Freedom of Information
    Act (FOIA).
        As an example, the report is critical of the Department's
    administration of debts owed by institutions owned by Zovio, Inc, and
    claims the Department failed to collect a $883,613 liability amount
    assessed against the University of the Rockies (owned by Zovio, Inc.).
    In actuality, the Department's efforts to collect this liability
    (arising from a final close-out audit determination) have been
    suspended in accordance with 34 C.F.R. Part 668, Subpart H--Appeal
    Procedures for Audit Determinations and Program Review Determinations
    because an appeal is currently pending resolution with the Department's
    Office of Hearings and Appeals. The suspension of collections is
    required under the Department's regulations at 34 C.F.R.
    Sec. Sec. 668.23(f)(1); (g)(1)(i)-(ii); and 668.123. These regulations
    provide that an institution must repay an audit liability within 45
    days of the date of the Department's notification, unless the
    institution files a timely appeal or unless a longer repayment period
    is permitted. A liability may be established but not paid in full
    because an institution is repaying the liability owed under a repayment
    agreement. The Department monitors institutional compliance with
    repayment requirements. Failure to comply with these repayment
    requirements is a violation of the Department's financial
    responsibility standards, as described above.
        The report suggests that Department improperly issued a Program
    Participation Agreement to Ashford University (also owned by Zovio,
    Inc.) while Ashford owed a $32,965 liability. The Department's Federal
    Student Aid office received confirmation on Oct. 5, 2016, that Ashford
    University had fully repaid the $32,965 liability to the Department on
    Sept. 9, 2016. The Department would not dispute that the $32,965
    receivable erroneously included in the records provided to NSDLN
    through the FOIA request was the result of a recordkeeping error.
    However, before the Department provided a Program Participation
    Agreement to Ashford University on Oct. 20, 2017, the Department had
    determined that Ashford had fully paid the liability.
        As another example, the report states ``The Department has asserted
    a $283,782,751 claim in the bankruptcy proceeding against ITT Technical
    Institute, plus an additional $1,544,738 against the school due to its
    ownership and operation of Daniel Webster College. Yet the Department's
    list of unpaid debt only includes approximately $343,000 from ITT and
    nothing with respect to Daniel Webster College.'' In this instance, the
    Department did not issue final determinations associated with the debts
    identified in the proof of claim to avoid violating the automatic stay
    provisions of the Bankruptcy Code.
        The NSLDN report unfortunately misinforms its readers that ``[t]he
    Department's inaction has irrevocably cost at least $218 million
    because the statute of limitations on collections has expired'' by
    misconstruing 28 U.S.C. Sec. 2462. The NSLDN report cites as support 28
    U.S.C. Sec. 2462 and the Lincoln University case (Docket 13-68-SF),
    April 25, 2016, in Footnote 35. A reading of 28 U.S.C. Sec. 2462
    undermines the notion that there is a statute of limitations on
    collections. Rather, 28 U.S.C. Sec. 2462 establishes a statute of
    limitations for commencing actions to assess civil fines, etc. which
    must be commenced within 5 years from the date when the claim first
    accrued. In Lincoln University, the Department asserted on Oct. 25,
    2013, fines for Clery Act violations which occurred on Oct. 1, 2006,
    and were repeated annually on that date until 2009 under the
    Department's regulations at 34 C.F.R. Part 668, Subpart G--Fine,
    Limitation, Suspension and Termination Proceedings (Subpart G). The
    question was whether the Sec. 2462 statute of limitations for these
    violations had elapsed based on the date the violation occurred. After
    close review of Sec. 2462, the Subpart G hearing official held in the
    initial decision dated March 16, 2015 that the statute of limitations
    barred the Department's fines for the 2006, 2007, and 2008 Clery Act
    violations, but that the fines for the 2009 violations were not barred.
    There is however no discussion in the Lincoln University decisions to
    support the assertion that a fine is uncollectable under Sec. 2642
    simply because the debt is asserted or continues to exist more than 5
    years after the claim first accrued. Indeed, the initial and remand
    decisions ordering payment of fines in Lincoln University were dated
    more than 5 years after the violation. To assert otherwise implies that
    those who are subject to a civil penalty or fine action can evade and
    self-discharge their payment obligation after 5 years of making no
    payments. Additionally, 28 U.S.C. Sec. 2462 only applies to civil
    fines, penalties and forfeitures; it does not apply to repayment
    liabilities. Funds owed back to the Title IV program are not subject to
    any statute of limitations.
        Question. Two decades ago, a CDC study came out that changed the
    way we think about public health. It was called the Adverse Childhood
    Experiences or ``ACEs'' study and it established the link between
    exposure to trauma--things like witnessing violence or an overdose--and
    our long-term health, education, and economic outlook. We now
    understand how trauma and ACEs harm brain development and how having
    multiple of these emotional scars can reduce life expectancy by up to
    20 years make you two times less likely to graduate high school and
    make you 10 times more likely to attempt suicide. Prior to COVID-19, we
    already had an epidemic of gun violence, suicides, and overdoses--all
    of which exacerbate and stem from the root issue of trauma. But the
    pandemic has magnified this problem, with a recent CDC study finding a
    50 percent increase in suicide attempts by teenage girls. Senator
    Capito of West Virginia and I teamed up in 2018 to pass legislation to
    increase funding and coordination across the Departments of Education
    and HHS to promote this understanding of trauma in more Federal grant
    programs. Specifically, we authorized a $50 million trauma and mental
    health services grant program for schools, which we have not yet been
    able to fund. This grant program--Section 7134 of the SUPPORT Act--
    would support schools in adopting trauma-informed practices, training
    more staff, engaging families, and forging partnerships with clinical
    mental health professionals. I know the Biden Administration is
    proposing $1 billion to support more counselors in schools--sign me up
    for that. Would you also support appropriations for this already
    authorized program to address the breadth of trauma needs in schools--
    setting up comprehensive plans, trainings, and partnerships, beyond
    just adding school psychologists or counselors?
        Answer. COVID-19 has had a devastating impact on many families,
    contributing to significant trauma resulting from isolation, economic
    stress, housing insecurity, and the loss of loved ones, among other
    traumatic events. Prior to COVID-19, many of these kinds of traumas and
    others already existed and were only further exacerbated by the
    pandemic. A significant number of students, predominantly students from
    low-income backgrounds, rely on their schools for access to mental
    health services and other services that are intended to meet their
    physical, social, emotional, and mental health needs. The need for all
    students, especially those most underserved, to have access to these
    critical services is why the Department requested $1 billion to double
    the number of school counselors, nurses, social workers, and school
    psychologists over the next decade. It is also why we requested $250
    million for IDEA, Part D Personnel Preparation to support the pipeline
    into the profession , including mental health service providers, and
    their preparation, development, and support. The Department is also
    requesting $443 million to support Full Service Community Schools--
    schools which have in place the kinds of comprehensive plans and
    partnerships you describe to support students and families. We also
    call for increased investments in the Promise Neighborhoods, School
    Safety National Activities, and Student Support and Academic Enrichment
    Grants programs, all in effort to provide a comprehensive set of
    investments intended to mitigate the impact of traumatic experiences
    and help our students heal from the trauma, develop, and thrive. We
    look forward to working with you to make these kinds of critical
    investments in existing programs and identify additional opportunities
    for targeted and increased investments.
        Question. Multiple Congressionally mandated Department of Education
    studies of the D.C. Opportunity Scholarship program--the only
    federally-funded voucher program--have found that the program does not
    improve the academic achievement of students in the program. In fact,
    two recent Department of Education studies of the program found that
    students using vouchers have performed worse academically than their
    peers not in the voucher program. And, previous studies have indicated
    that many of the students in the voucher program are less likely to
    have access to key services such as ESL programs, learning supports,
    special education supports and services, and counselors than students
    who are not part of the program. Moreover, a study from the Urban
    Institute found that receiving a voucher does not increase D.C.
    students' college enrollment rates. Given these troubling findings, do
    you support continuing Federal support for the program?
        Answer. The Administration seeks to phase out the D.C. Opportunity
    Scholarship Program while providing scholarships to students currently
    participating in the program through 12th grade. Accordingly, the
    Administration has requested level funding for fiscal year 2022 to
    continue funding scholarships for continuing students in school year
    2022-2023.
                                     ______

                    Questions Submitted by Senator Jack Reed
        Question. PSLF and Military Service Members--Earlier this year, the
    Government Accountability Office (GAO) issued a report finding that 94
    percent of the Public Service Loan Forgiveness (PSLF) applicants in
    military service or Department of Defense (DoD) civilian jobs were
    denied. Additionally, the GAO recommended that the Department of
    Education could take additional steps to improve information sharing
    about PSLF with DoD about military service members and DoD civilian
    personnel seeking to participate as well with potential beneficiaries.
    According to the GAO, as of February 17, 2021, 178,215 active-duty
    service members had direct loans eligible for PSLF, and another 16,195
    active-duty service members had Federal loans that could be
    consolidated into new qualifying direct loans. These statistics offer
    just a small snapshot of the full scope of eligible military borrowers
    who should be benefiting from the protections of PSLF since borrowers
    first became able to secure forgiveness through the program in 2017.
        Using the Department of Defense's DMDC website, please provide the
    total number of active duty service members (and veterans) with Federal
    student loans who have served since PSLF launched on October 1, 2007
    and who continue to be in repayment on Director Loans and/or FFELP
    loans.
        Answer. FSA is working to produce such an analysis, in
    collaboration with the Department's Office of the General Counsel and
    the Department of Defense.
        Question. Please provide information on the Department's efforts to
    implement the GAO recommendations. Also please include information
    about the Department's plans to use any other authority, such as
    authorities under the HEROES Act of 2003, to ease the process and
    expand access to PSLF for military service members.
        Answer. The Government Accountability Office (GAO) made two
    recommendations for the Secretary of Education in its recent report,
    ``Public Service Loan Forgiveness: DoD and Its Personnel Could Benefit
    from Additional Program Information (GAO-21-65).'' The other three
    recommendations in the report were addressed to the Department of
    Defense (DoD).
        First, the GAO recommended that Federal Student Aid (FSA)
    collaborate with officials in DoD's Office of the Under Secretary of
    Defense for Personnel and Readiness to share information about the
    Public Service Loan Forgiveness (PSLF) Program, including current
    information on program participation and eligibility, as well as
    program requirements. The Department concurred with the recommendation
    and has already begun this collaboration with DoD. For example, FSA had
    already begun discussions with DoD about enhancements to our digital
    toolsets and is actively working with DoD on providing more and
    improved information to employees interested in PSLF.
        Second, the GAO recommended that FSA update the student loan guide
    for service members to provide information on applying for PSLF and
    TEPSLF, as well as the steps borrowers can take to count their annual
    payment from DoD's student loan repayment program as multiple
    qualifying payments for the PSLF program. The Department again
    concurred with the recommendation and intends to update the next
    version of the student loan guide for service members to reflect the
    new combined PSLF form, which no longer requires borrowers to
    separately apply for TEPSLF. In addition, FSA currently makes
    information available on lump sum payments made by DoD for service
    members through StudentAid.gov. We agree this information should be
    included in the next version of the student loan guide for service
    members. FSA will work with DoD to ensure there are clear instructions
    for borrowers participating in DoD's student loan repayment program to
    earn qualifying payments for the PSLF Program.
        On October 6, 2021, the Department of Education announced a set of
    actions that, over the coming months, will restore the promise of PSLF.
    We will offer a time-limited waiver so that student borrowers can count
    payments from all Federal loan programs or repayment plans toward
    forgiveness. This includes loan types and payment plans that were not
    previously eligible. We will pursue opportunities to automate PSLF
    eligibility, give borrowers a way to get errors corrected, and make it
    easier for members of the military to get credit toward forgiveness
    while they serve. We will pair these changes with an expanded
    communications campaign to make sure affected borrowers learn about
    these opportunities and encourage them to apply.
        The Department is working hard to eliminate barriers for military
    service members to receive PSLF. The Department will allow months spent
    on active duty to count toward PSLF, even if the service member's loans
    were on a deferment or forbearance rather than in active repayment.
    This change addresses one major challenge service members face in
    accessing PSLF. Service members on active duty can qualify for student
    loan deferments and forbearances that help them through periods in
    which service inhibits their ability to make payments. But too often,
    members of the military find out that those same deferments or
    forbearances granted while they served our country did not count toward
    PSLF. This change ensures that members of the military will not need to
    focus on their student loans while serving our country. Federal Student
    Aid will develop and implement a process to address periods of student
    loan deferments and forbearance for active-duty service members and
    will update affected borrowers to let them know what they need to do to
    take advantage of this change.
        Finally, the Department is working to automatically help service
    members and other Federal employees access PSLF. Military service
    members and other Federal employees devote themselves to serving the
    United States, and we should make it as easy as possible for them to
    receive PSLF. Next year, the Department will begin automatically giving
    Federal employees credit for PSLF by matching Department of Education
    data with information held by other Federal agencies about service
    members and the Federal workforce. To date, approximately 110,000
    Federal employees and 17,000 service members have certified some
    employment toward PSLF. These matches will help the Department identify
    others who may also be eligible but cannot benefit automatically, like
    those with FFEL loans.
        Question. Restarting Student Loan Repayment--Payments on Federal
    student loans have been paused for over a year due to the pandemic,
    with borrowers currently expected to begin repaying their student loans
    on October 1 of this year. There are indications that the restart will
    trigger unprecedented outreach to servicers, with survey data showing
    that servicers could field inquiries from more than 9 million
    borrowers. There have been indications that it will take approximately
    2-4 months for servicers to rehire, train, and obtain background checks
    for their workforce.
        As the U.S. Department of Education and its student loan servicers
    prepare for the repayment restart, what are the essential steps that
    the Department is considering to ensure a seamless return to repayment?
    What is the timeframe for implementing these steps so that the Office
    of Federal Student Aid and servicers have sufficient time to implement
    this plan so that both borrowers and servicers can prepare? What is the
    Department's monitoring plan for servicers on their implementation of
    the restart of repayment?
        Answer. The Department's goal is to achieve a smooth transition
    that minimizes borrower harm due to confusion, lack of awareness, and
    insufficient servicing capacity. To this end, the Department has
    produced a comprehensive plan that combines elements of borrower
    outreach, servicer hiring, training and preparation, and vendor and
    process oversight to ensure borrowers have the resources they need to
    effectively manage the process of returning to repayment.
        From an outreach perspective, in March 2020, FSA launched an
    ongoing communications and engagement campaign to provide borrowers
    clear, concise messaging related to available CARES Act benefits and
    the eventual transition to repayment. Since then, FSA has engaged in
    continuous communication efforts to encourage student loan borrowers to
    take actions to put them on the best repayment plan for their economic
    situation before payments resume. From July 2020 until the end of
    February 2021, FSA sent over 220 million emails to borrowers,
    supplemented by multiple paid media campaigns.
        FSA has also posted information on StudentAid.gov to assist
    borrowers in preparing for payments to resume, specifically
    recommending that borrowers update their contact information with their
    loan servicer and in their StudentAid.gov profile, use Loan Simulator
    to find a repayment plan that meets their needs and goals, and consider
    applying for an income-driven repayment plan. As we approach the end of
    the forbearance period, outreach to borrowers will increase and include
    broad campaigns aimed at increasing general awareness of payment
    resumption and options to address ability to repay, as well as targeted
    outreach to at-risk borrowers.
        To ensure our servicers are prepared for the restart of repayment,
    FSA engaged in ongoing conversations with loan servicers about their
    preparations and staffing levels since the CARES Act was passed in
    March 2020. During the payment pause, FSA has clearly communicated
    expectations for how loan servicers should engage with borrowers. FSA
    is continually analyzing historical, current, and projected future loan
    servicer staffing levels against several customer service metrics to
    ensure servicers are ready for payments to resume. As we prepare for
    borrowers to enter repayment, FSA will provide detailed communications
    ``playbooks'' for loan servicers to follow. To ensure loan servicers
    are held accountable for customer service performance during the return
    to repayment effort, FSA plans to add explicit return-to-repayment
    performance expectations, called service level agreements (SLAs), to
    the servicers' existing contracts. Proposed SLAs would focus on call
    center performance, such as abandon rates and Average Speed to Answer,
    to ensure borrowers have prompt, easy access to information. As
    borrowers exit the payment suspension period, FSA will expand our
    monitoring to include all aspects of return to repayment. Vendors who
    fail to adhere to any statutory, regulatory, or contractual standards
    will be held accountable through appropriate corrective actions, which
    may include financial penalties.
        On Aug. 6, 2021, the Department announced a final extension of the
    payment pause until Jan. 31, 2022. The Department is already working
    diligently to ensure a smooth transition back to repayment for all
    borrowers
        The pause on student loan repayment will end on January 31, 2022,
    and we are planning around that date. The Department's priority is to
    ensure students and borrowers get the service they deserve. We are
    committed to ensuring that student loan borrowers are able to
    transition smoothly into repayment. The Department has established
    timelines with key deadlines related to returning student loans to
    repayment. Those plans include substantial communications and outreach
    to make borrowers aware of the resumption of loan payment obligations.
    FSA also continues to communicate with servicers about return to
    repayment as information becomes available. Additionally, the
    Department plans to collaborate with Federal and state regulators to
    ensure our oversight of Federal student loan servicers is as effective
    as possible, and are working to ensure the tools available to the
    Office of Federal Student Aid are used to the fullest extent possible.
        Question. FFEL and Repayment Relief--In April, Senator Murkowski
    and I sent you a letter asking you to address the over 5 million FFEL
    and the roughly 1.7 million Perkins loans borrowers who have been left
    out of the CARES Act relief and the subsequent extensions of the pause
    on student loan repayment.
        What steps is the Department taking to ensure that all Federal
    student loan borrowers have equal access to any current or proposed new
    relief and benefits?
        Answer. We have taken steps to assist those FFEL borrowers that
    have defaulted during the national emergency. In March 2021, the
    Department announced that the payment pause on interest and collections
    would be extended to all defaulted FFEL loans, protecting more than
    800,000 borrowers from debt collection activity such as wage
    garnishment and seizure of tax refunds. FFEL loans on which borrowers
    defaulted since March 13, 2020, the start of the national emergency,
    are being restored to good standing, and the record of default removed
    from their credit reports. The Department continues to explore
    additional opportunities to aid all Federal student loan borrowers,
    whether they hold FFEL, Perkins, or Direct Loans, and to ensure that
    their payments remain affordable, particularly during a period that has
    been challenging for so many borrowers.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. I want to once again thank you for working with myself
    and Senator Murkowski on getting out the first tranche of the American
    Rescue Plan funding for homeless children and youth in an expedited
    manner, so we could ensure that homeless children and youth are
    identified and are able to access summer programming and wrap-around
    supports they need in light of the COVID-19 Pandemic. In the
    Department's initial announcement surrounding this funding, you
    indicated that the second tranche of this funding could be available as
    soon as June, to help states and school districts prepare for the fall.
    This is critical as we expect to see even greater numbers of
    homelessness and higher level of service needs, as communities return
    to in person learning.
        Can you tell me if those plans for the release of the second
    tranche of homelessness funding are on schedule, and will be out this
    month?
        Answer. The awards for the second tranche of American Rescue Plan
    funding for homeless students were made on July 27, 2021.
        Question. In the final fiscal year 2021 spending package, I was
    able to secure language urging the Department to ensure that local
    educational agencies (LEA's) set aside adequate amounts of Title I Part
    A funds for students experiencing homelessness and use those resources
    effectively.
        Can you tell me what the Department has done to date to implement
    this request and does this budget proposal do anything to implement
    that language further?
        Answer. In July 2018, the Department sent a letter to State
    educational agencies (available at: https://oese.ed.gov/files/2020/02/
    letterforessatitleialeahomelesssetaside-1.pdf) that highlights the
    requirement that an LEA reserve sufficient funds under Title I, Part A
    to provide services for students experiencing homelessness. This
    clarification was included in an update in August 2018 to the non-
    regulatory guidance for the Education for Homeless Children and Youth
    (EHCY) program and it is also part of the monitoring protocol for the
    EHCY program. The Department asks the States that it is monitoring to
    provide a list of all Title I, Part A set-asides by LEA. These are
    compared with the latest available homeless student enrollment counts,
    which usually lag by 1 year. The SEA is asked to explain if any LEAs
    had homeless students enrolled but did not set aside a reservation from
    Title I, Part A to serve them. We also correlate a per-pupil amount to
    look for statewide patterns of insufficiency. The EHCY State
    Coordinator Handbook developed by the National Center for Homeless
    Education (NCHE) has a Summary of EHCY Performance Management Pilot
    Monitoring, fiscal year 2015-18 that summarizes which States had
    findings or recommendations in this area (Indicator 3.3). For fiscal
    year 2022, due to the American Rescue Plan funds for homeless children
    and youth, the Department will expand its monitoring of States for
    homeless education programs, including the Title I, Part A LEA set-
    aside.
        In addition, NCHE also provides technical assistance concerning
    Title I, Part A requirements for serving students experiencing
    homelessness (see https://nche.ed.gov/legislation/title-1-part-a/).
        The key proposal in the fiscal year 2022 request that would support
    stronger implementation of Title I requirements related to meeting the
    needs of homeless students is the additional $20 billion for Title I,
    which would more than double funding for Title I districts and schools,
    direct more funds to LEAs with the greatest concentrations of poverty,
    and help close equity gaps for all students, including homeless
    students.
        Question. Student loan disclosure forms are essential in helping
    students and families understand the costs and terms of their student
    loans, but as currently written they are filled with unhelpful legal
    jargon, are complicated. lengthy, and don't show the true cost
    associated with taking out the loans leading to excess borrowing,
    further contributing to the nation's student debt crisis.
        What is the Department doing to address this issue and simplify
    student loan disclosure forms? Is there anything in this budget
    proposal to help with this?
        Answer. We are regularly looking at ways to help students,
    families, and borrowers better understand and support their efforts to
    meet their student loan obligations. For instance, we continue to
    promote use of the College Financing Plan, which provides a
    standardized financial aid offer letter so students can understand and
    compare their options for paying for college. If there are additional
    improvements you have in mind, my staff would be grateful to have them
    for consideration.
                                     ______

                    Questions Submitted by Senator Roy Blunt
                             student loan servicing
        Question. Mr. Secretary, your budget requests $2.1 billion, which
    is an increase of $200 million from the fiscal year 2021 level, to
    administer the student aid programs. Yet the budget provides very few
    details about how those funds would be used on student loan servicing
    activities aside from mentioning a ``long-term servicing solution.''
    Can you provide the Subcommittee additional details on your plans for
    the long-term servicing solution?
        Answer. The Department is currently working on its long-term
    servicing plans and looks forward to sharing more information in the
    future.
        Question. For the last several years the Labor/HHS bill has
    included appropriations language requiring the allocation of Federal
    student loans to servicers based on the quality of their performance to
    encourage the Department to leverage competition among student loan
    servicers. The budget request proposes to strike this language because
    the requirement will be included in FSA's ``long-term servicing
    solution'' despite the fact that no information is included in the
    request on what the long-term solution will look like. How will you
    continue to hold the Federal student loan servicers to performance-
    based allocations as required by years of appropriations laws
    regardless of what a future long-term servicing solution may look like?
        Answer. The Department currently allocates loan volume based on
    servicer performance. We will continue this practice going forward
    under the two-year extensions of servicer contracts (as outlined in the
    appropriations language), as well as in the future under the final
    servicing solution.
        Question. The Department has struggled to complete the contracting
    process to fully implement its Next Generation Financial Services
    Environment. In light of that prolonged struggle, what are your plans
    for using the current five Business Process Operations contractors,
    which were awarded in June 2020, in the servicing of student loans
    moving forward?
        Answer. As you are aware, the Consolidated Appropriations Act, 2021
    included several provisions related to the future state of loan
    servicing, including provisions directly applicable to the Interim
    Servicing Solution (ISS) solicitation and Business Process Operations
    (BPO) contracts. Specifically, the language prohibited the use of ISS
    as a transitional servicing solution and called for an accelerated BPO
    implementation that would make it possible for BPO providers to perform
    the full suite of loan servicing activities upon migrating accounts to
    the ISS platform. After reviewing the change in the solicitation's
    requirements as a result of the appropriations provisions, Federal
    Student Aid (FSA) decided to cancel the ISS solicitation.
        FSA is using this opportunity to work with our new leadership in
    the Biden-Harris Administration to refine our long-term strategy for
    loan servicing, with the first priority being to ensure student loan
    borrowers have a stable, reliable, and accountable solution that meets
    their needs. In developing this long-term solution, FSA will continue
    to build on the newly modernized systems, tools, and resources for
    customers. In particular, FSA expects to leverage the new
    StudentAid.gov, the myStudentAid mobile app, and enhanced systems that
    allow FSA to improve how we collect and analyze data, offer more self-
    service options, provide better customer service, and communicate
    directly with students, parents, and borrowers.
        In addition, FSA will continue its work to bring BPO vendors online
    in preparation for a fall 2021 migration of all non-servicing contact
    center work. This work includes taking on FSA's legacy contact center
    functions, including the Federal Student Aid Information Center,
    Student Loan Support Center, Feedback Center, FSA Ombudsman, borrower
    defense hotline, and Office of Inspector General fraud referral. The
    BPO vendors will handle much of FSA's direct communication with
    customers and partners, including inbound and outbound calls, email,
    chat, social media inquiries, and physical correspondence. BPO vendors
    will receive training from FSA to ensure they are providing customers
    with correct and consistent information and are treating customers and
    partners equitably.
        The five-month transition to fully onboard the BPOs is expected to
    begin in November 2021 and be finalized by April 2022.
                                career pathways
        Question. Programs that provide academic and career counseling and
    exposure to postsecondary opportunities to students, as early as 8th
    grade and continuing through secondary and postsecondary education,
    have been shown to significantly increase rates of postsecondary
    enrollment and completion among rural students. To that end, the fiscal
    year 2021 Labor/HHS bill included $10 million for the Department of
    Education to improve rates of postsecondary enrollment and completion
    among rural students through development of career pathways aligned to
    high-skill, high-wage, or in-demand industry sectors and occupations in
    the region. What is the timeline for publishing a Notice Inviting
    Applications for these funds? What can you tell me about how the
    Department plans to prioritize and spend this funding this year?
        Answer. While the Department is still developing a notice inviting
    applications (NIA), we plan to make up to 7 awards to institutions of
    higher education and other public and private non-profit organizations
    and agencies for 3-year projects that would implement innovative
    approaches to improve rates of postsecondary enrollment and completion
    among rural students through development of career pathways aligned to
    high-skill, high-wage or in-demand industry sectors and occupations in
    a specific region.
        Question. The budget request proposes a new $1 billion program to
    expand career pathways for middle and high school students,
    particularly in underserved communities. This Subcommittee will only be
    considering the discretionary request, but providing students in high
    school or middle school with access to quality work-based learning
    opportunities and exposure to their full range of postsecondary college
    and career opportunities should be happening in every school. How will
    additional funding for CTE help meet that goal?
        Answer. Additional funding under both the Career and Technical
    Education (CTE) State Grants formula program and CTE National Programs
    would support opportunities to provide high school or middle school
    students with access to quality work-based learning opportunities and
    exposure to postsecondary college and career opportunities, albeit in
    different in ways. The reauthorization of the Perkins Act in 2018 added
    provisions and requirements pertaining to work-based learning and
    including students in middle school in certain CTE activities. However,
    States and local grantees have been expected to implement these and
    other new requirements with relatively small increases in funding.
    After more than a decade of relatively flat funding, the increase in
    funding for the program since fiscal year 2019 (the implementation date
    for the reauthorized Perkins program) has been approximately 5.7
    percent. Increases for this program would provide additional resources
    to State and local grantees to implement these provisions.
        Increases in funding under CTE National Programs would provide
    opportunities to quality work-based learning opportunities and exposure
    to support and evaluate targeted activities to provide high school or
    middle school students with access to postsecondary college and career
    opportunities. Under that program the Department could fund focused,
    high quality proposals for such activities and set priorities for
    funding, such as funding to high-poverty LEAs and LEAs serving a high
    percentage of students of color or a high percentage of students from
    low-income backgrounds.
                     k-12 covid-19 funding/school reopening
        Question. Mr. Secretary, you and I both agree it is crucial that we
    get kids back in the classroom to prevent further learning loss. While
    I'm encouraged to see that more and more schools are reopening for in-
    person learning, the latest data from the Department shows that only 51
    percent of 4th graders and 41 percent of 8th graders are enrolled in
    fully in-person learning and these numbers are even worse for low-
    income and minority students. Given the significant amount of COVID-19
    emergency funding that has gone to K-12 schools, I would expect these
    numbers to be closer to 100 percent. What actions have you taken to
    help states and school districts use their ESSER funds to reopen
    schools and get kids back in the classroom? Do you expect that all
    schools will be fully open for in-person learning this fall?
        Answer. We are doing everything possible to support students,
    families, teachers, staff, school leaders, and communities to in
    returning to full-time, in-person learning this fall, and the
    Administration is confident that we, as a nation, will achieve this
    goal to the greatest extent possible.
        Most recently, on August 2, 2021, the Department released the
    ``Return to School Roadmap,'' an online resource available at https://
    sites.ed.gov/roadmap/to support students, schools, educators, and
    communities as they prepare to return to safe, healthy in-person
    learning this fall and emerge from the pandemic stronger than before.
        The Roadmap includes three ``Landmark'' priorities that schools,
    districts, and communities are encouraged to focus on to ensure all
    students are set up for success in the 2021-2022 school year: (1)
    prioritizing the health and safety of students, staff, and educators,
    (2) building school communities and supporting students' social,
    emotional, and mental health, and (3) accelerating academic
    achievement. The Roadmap also includes planned releases of additional
    resources for practitioners and parents on each of these priorities and
    will highlight schools and districts that are using innovative
    practices to address these priorities. These resources also will
    explain how American Rescue Plan funds, including ESSER funds, can be
    used to address these priorities in schools and communities across the
    country.
        The Roadmap is part of the Department's broader efforts to support
    schools and districts in the safe and sustained return to in-person
    learning since the beginning of the Biden Administration. In addition
    to releasing the Roadmap, the Department has issued three volumes of
    the COVID-19 Handbook to support K-12 schools and institutions of
    higher education in their reopening efforts, prioritized the
    vaccination of educators, school staff and child care workers,
    published a Safer Schools and Best Practices Clearinghouse, which
    includes over 200 examples of schools and communities safely returning
    to in-person learning, held a National Safe School Reopening Summit,
    provided $122 billion in support through the American Rescue Plan
    Elementary and Secondary School Emergency Relief Fund for K-12 schools,
    provided over $3 billion in IDEA funds within the American Rescue Plan
    to support children and families with disabilities impacted by the
    pandemic, awarded $800 million within the American Rescue Plan to
    support students experiencing homelessness who have been
    disproportionately impacted by the pandemic, released a report on the
    disparate impacts of COVID-19 on underserved students, and launched an
    Equity Summit Series focused on addressing school and district
    inequities that were made worse by the pandemic.
                               student loan pause
        Question. Mr. Secretary, I am concerned that the Administration has
    not outlined a plan to transition borrowers back into repayment when
    the student loan pause ends this fall. Now that the pandemic is winding
    down, it is time for this pause to end. Furthermore, the extension of
    the pause beyond what was originally authorized in the CARES Act cost
    taxpayers an additional $36 billion. I understand that some borrowers
    may still be struggling, but they have access to income-driven
    repayment plans where they can pay as little as $0 per month. Will you
    commit to end the pause as scheduled at the end of this fiscal year?
        Answer. On Aug. 6, 2021, the Department announced a final extension
    of the payment pause until Jan. 31, 2022. We believe this additional
    time and definitive end date will allow borrowers to plan for the
    resumption of payments and reduce the risk of delinquency and defaults
    after restart. The Department is already working diligently to ensure a
    smooth transition back to repayment for all borrowers
        Question. Federal student loan borrowers have gone over a year
    without making a payment on their loans. It is absolutely imperative
    that the Department begins communicating with borrowers early and often
    to ensure that all borrowers understand their responsibilities and
    their repayment options when their loans come due on October 1, 2021.
        What are your plans to help ensure that borrowers are prepared to
    begin repaying their loans when the pause ends?
        Answer. In March 2020, FSA launched an ongoing communications and
    engagement campaign to provide borrowers clear, concise messaging
    related to available CARES Act benefits and the eventual transition to
    repayment. Since then, FSA has engaged in continuous communication
    efforts to encourage student loan borrowers to take actions to put them
    on the best repayment plan for their economic situation before payments
    resume. From July 2020 until the end of February 2021, FSA sent over
    220 million emails to borrowers, supplemented by multiple paid media
    campaigns.
        FSA has also posted information on StudentAid.gov to assist
    borrowers in preparing for payments to resume, specifically
    recommending that borrowers update their contact information with their
    loan servicer and in their StudentAid.gov profile, use Loan Simulator
    to find a repayment plan that meets their needs and goals, and consider
    applying for an income-driven repayment plan. As we approach the end of
    the forbearance period, outreach to borrowers will increase and include
    broad campaigns aimed at increasing general awareness of payment
    resumption and options to address ability to repay, as well as targeted
    outreach to at-risk borrowers.
        Question. How will the Department engage the Federal student loan
    servicers and provide the necessary instructions so that the return to
    repayment process goes smoothly?
        Answer. FSA has engaged in ongoing conversations with loan
    servicers about their preparations and staffing levels since the CARES
    Act was passed in March 2020. During the payment pause, FSA has clearly
    communicated expectations for how loan servicers should engage with
    borrowers. FSA is continually analyzing historical, current, and
    projected future loan servicer staffing levels against several customer
    service metrics to ensure servicers are ready for payments to resume.
    As we prepare for borrowers to enter repayment, FSA will provide
    detailed communications ``playbooks'' for loan servicers to follow.
        To ensure loan servicers are held accountable for customer service
    performance during the return to repayment effort, FSA plans to add
    explicit return-to-repayment performance expectations, called service
    level agreements (SLAs), to the servicers' existing contracts. Proposed
    SLAs would focus on call center performance, such as abandon rates and
    Average Speed to Answer, to ensure borrowers have prompt, easy access
    to information. As borrowers exit the payment suspension period, FSA
    will expand our monitoring to include all aspects of return to
    repayment. Vendors who fail to adhere to any statutory, regulatory, or
    contractual standards will be held accountable through appropriate
    corrective actions, which may include financial penalties.
        Question. Both the CARES Act and the December COVID-19
    supplemental, as well as the American Rescue Plan, provided a total of
    $161 million to FSA to prevent, prepare for, and respond to the COVID-
    19 pandemic. How much of this funding has been used and what has it
    been used for?
        Answer. As of July 30, 2021, approximately $25 million has been
    committed and obligated for the following activities: system changes
    due to COVID-19; targeted communication campaigns to notify borrowers
    of administrative forbearance; increased server capacity and support
    for telework; and personnel and compensation for approximately 38 on-
    board staff at FSA to support CARES Act related activities.
        Question. Does the Department intend to use the remaining funds to
    improve communications and outreach with borrowers about the upcoming
    end of the repayment pause?
        Answer. Yes, the remaining funds will be used to improve
    communications and outreach to borrowers, as well as any additional
    actions needed to support borrowers regarding the end of the payment
    pause.
                                charter schools
        Question. During the last school year, several states saw
    significant enrollment shifts into charter schools. For example,
    charter schools in California saw an increase of around 2.5 percent
    while districts saw a decrease of 3 percent, Colorado saw a 4 percent
    increase while districts saw the same decline. New York City charter
    schools had an influx of 10,000 students--a 7 percent increase. And yet
    the President's budget does not request new funding for the Charter
    Schools program. Given the demand we are seeing at the state level, why
    isn't the administration requesting more funds for the Charter School
    Program?
        Answer. The Administration's fiscal year 2022 request would provide
    over $210 million for new awards under the various grant components of
    the Charter Schools Program. We believe these resources will be
    sufficient to meet demand for funding.
        Question. The budget proposes prohibiting Charter School Program
    funds from being provided to schools that are substantially operated or
    managed through a contract with a for-profit entity. However, most
    public schools are utilizing the services of for-profit entities in
    some way, including for spending their COVID-19 relief funds.
        What does ``substantially operated or managed'' mean? Does it
    include contracting for services such as payroll and benefits,
    staffing, curriculum, professional development, or individual student
    services?
        Answer. We recognize that public schools, including charter
    schools, may contract with for-profit vendors for specific services
    that do not constitute management or control of operations and do not
    intend to prevent schools engaged in such procurements from accessing
    funds under the CSP or other programs.
        Question. Why are you proposing this restriction only for charter
    schools? Are you considering this requirement for other programs?
        Answer. The Administration believes that Charter Schools Program
    (CSP) funds should not support charter schools that are operated or
    managed by for-profit entities, and we urge Congress to adopt language
    that would prohibit CSP funds from supporting schools that are operated
    or managed by such entities through contractual relationships. We
    believe this is consistent with intent of the program statute, under
    which charter school developers or management organizations seeking CSP
    funds must be nonprofit.
                             title i equity grants
        Question. The budget request includes $20 billion for a new Title I
    Equity grant that proposes to create a new formula not authorized in
    statute to force State and local behavior changes related to school
    funding systems, teacher compensation, access to advanced curricula,
    and access to preschool. There have been a lot of questions and
    concerns about this proposal, specifically how funding would be
    allocated. Do you have any further details on the impact of this
    formula and where the money would be allocated?
        Answer. The Administration remains committed to addressing
    longstanding concerns around equity in education funding at the
    Federal, State, and local levels. However, we also recognize that
    further consultation with a wide range of stakeholders, including
    Congress, will be necessary to develop a comprehensive set of proposals
    aimed at improving education funding equity that can generate broad
    support. Consequently, the Administration supports allocating the
    proposed $20 billion increase for Title I through the authorized
    funding formulas.
        Question. Why is the Department proposing to create a new grant
    program that interferes with decisionmaking that is best left to State
    and local school districts rather than putting additional funding into
    programs we know work to increase student achievement, such as the
    Charter Schools Program, or further increasing this existing Title I
    programs or IDEA, which has long been underfunded?
        Answer. The nearly $30 billion, or 41 percent, increase for the
    Department of Education proposed by President Biden for fiscal year
    2022 provides strong support for Federal education programs across the
    board, including a $3 billion or 21 percent increase for IDEA State
    formula grant programs. However, because nearly all Federal education
    programs provide supplemental funding, the impact and effectiveness of
    that funding depends in large part on a level playing field in terms of
    the overall education resources made available at the State and local
    levels. For this reason, the Administration strongly believes that a
    key goal of any major new Federal investment in education should be to
    leverage significant improvement in equity for all students, but
    especially for students from low-income families and students of color.
    In this context, the Administration is working closely with Congress
    and stakeholders to leverage additional investments in Title I to
    improve education funding equity, support high-quality preschool,
    address teacher compensation, and enhance rigorous coursework in Title
    I schools. In that context, the Department believes the proposed $20
    billion increase for Title I would provide a meaningful incentive for
    systemic changes in the equity of our decentralized education system.
                                  naep funding
        Question. NAEP provides crucial information about what our nation's
    students know and can do in various subject areas. Ensuring we continue
    to have this information is more important than ever given the
    widespread learning loss that is expected as a result of the pandemic.
    Your budget requests an additional $15 million for NAEP in fiscal year
    2022. Will this increase ensure that the planned assessment schedule
    can remain on track?
        Answer. The $15 million proposed for fiscal year 2022, if sustained
    in future years, would support operational funding needs, including
    planned assessments, through 2024.
                                 mental health
        Question. Mr. Secretary, one of my priorities in the Senate has
    been mental health--and ensuring that a person's mental health is
    treated the same as their physical health. The Department's budget
    requests $1 billion for a new program to increase the number of health
    professionals in our public schools, including school counselors,
    nurses, school psychologists, and social workers. I share your concern
    about the well-being and mental health of our nation's students,
    particularly given the widespread disruption to school that students
    have experienced over the past year due to the COVID-19 pandemic.
    However, states and school districts have yet to spend the vast
    majority of COVID-19 funding provided to them, and one of the ways they
    can spend this money is to provide mental health services to students.
    What has the Department done to help states and school districts use
    their COVID-19 funding to support the mental health of their students?
        Answer. The Administration has recognized from the beginning of its
    response to the pandemic that students need a strong social and
    emotional foundation to excel academically. It is clear that many
    students, and especially students from low-income backgrounds and
    students of color, have suffered much over the past 18 months and
    require additional support to help them heal and recover from all the
    trauma and hardship the pandemic has brought. And we know for many
    students, schools are the only place where they can access mental
    health professionals, school counselors, nurses, and support structures
    they need--including their friends--to help them through the adversity
    of the last year. This is why we have emphasized meeting students'
    mental health needs as part of our overall effort to reopen schools for
    fully in-person learning, including through the hiring of school-based
    health professionals as well as other efforts to address social and
    emotional development needs.
        For example, the Department published Volume 2 of the ED COVID-19
    Handbook: Roadmap to Reopening Safely and Meeting All Students' Needs
    (see https://www2.ed.gov/documents/coronavirus/reopening-2.pdf), in
    April, 2021, which includes a section on Supporting Student Mental
    Health Needs that highlights examples and best practices that States
    and school districts can implement using funds provided by the American
    Rescue Plan. Additional guidance is provided in our ESSER Fund
    Frequently Asked Questions document (see Question C-14 at https://
    oese.ed.gov/files/2021/05/
    ESSER.GEER--.FAQs_5.26.21_745AM_FINALb0cd6833f6f46e03ba2
    d97d30aff953260028045f9ef3b18ea602db4b32b1d99.pdf).
        We have seen the results of these efforts in the plans that States
    have developed for using ARP ESSER funds. For example, Nevada is
    reserving ARP funds to hire 100 school-based mental health
    professionals and Alaska is using ARP funds to help social workers
    provide virtual lessons in self?care and methods to reduce student
    stress, depression, and anxiety. The New York City Department of
    Education is using ARP funding to hire over 600 mental health
    professionals to provide care as students returned back this fall. This
    means that every school will have at least one full-time social worker
    or school-based mental health clinic.
        In addition, we plan to issue guidance on using ARP funs to address
    student mental health needs in fall 2021.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. The Institute of Education Sciences (IES) funds education
    research, data collection and analysis, and a national assessment of
    student progress. The fiscal year 2016 Omnibus included a $44 million
    (8 percent) increase for IES. The budget request includes a further $76
    million (12 percent) increase. The Investing in Innovation (i3) grant
    program required that at least 20 percent of recipients be located in
    rural areas. The i3 competition has been replaced with a new grant
    program, the Education Innovation and Research program, in fiscal year
    2017. Geographic diversity in all research grant programs is important.
    From 2013 to 2015 the Department made almost 1,900 grants to
    institutions of higher education and other research organizations.
    However, those grants went to colleges, universities, and research
    organizations in only 35 states. Not one went to a school or
    organization in Mississippi and generally the same schools and
    organizations tend to get the bulk of research grants year after year.
        In my state, 92 percent of school districts and more 50 percent of
    students are rural, yet most research is conducted in urban and
    suburban communities. The Every Student Succeeds Act requires that
    schools implement evidence-based strategies to improve student outcomes
    yet most education research is conducted in urban and suburban
    settings.
        How will you ensure that education research addresses the unique
    needs of rural districts?
        Answer. Supporting education research to help understand and
    address the unique needs of rural districts is a priority for IES. We
    support education research, including on rural education, primarily
    through two funding mechanisms: (1) field-initiated research grants,
    and (2) research conducted by the Regional Educational Laboratories. We
    discuss the role of each below.
        Research Grants. As a scientific agency, funding decisions are
    based on peer reviewer's independent assessments of the scientific
    merit of applications, including the significance of the proposed
    research project, the scientific quality of the research plan, the
    skills of the personnel, and the resources available to support the
    proposed project. We hold competitions on various topics to ensure that
    the education research that we fund meets the needs of the diverse
    populations and geographic settings of our nation.
        For example, in 2021, IES launched a new research competition
    inviting State agencies to apply for funds to expand use of their State
    Longitudinal Data Systems (SLDS) for generating evidence in support of
    education policy decisions. Using SLDS as a data source ensures that
    all districts within a State can be included in their research
    activities. Of the 7 awards made, 5 are made to States with substantial
    rural populations, including Tennessee, Montana, Virginia,
    Pennsylvania, and Oregon. Mississippi received $6.6 million in 2016 for
    an NCES SLDS grant that ended 9/30/20 to enhance its SLDS system, so we
    encourage the State education agency to apply for funding under this
    program for projects using data from its SLDS for research on rural
    populations, and to reach out to IES program officers for input as they
    prepare their application.
        In addition, IES invested $20 million in two five-year research and
    development centers focused on the needs of rural education in 2019:
    The National Center for Rural Education Research Networks (NCRERN) and
    The National Center for Rural School Mental Health (NCRSMH): Enhancing
    the Capacity of Rural Schools to Identify, Prevent, and Intervene in
    Youth Mental Health Concerns. Rural districts participating in the work
    of these two centers are located in: New York, Ohio, Iowa, New Mexico,
    Wyoming, Missouri, Virginia, and Montana. Both rural centers are
    actively engaged with communities in these States and beyond and are
    developing and sharing resources for the rural education community. For
    example, NCRSMH has developed an Early Identification System (EIS)
    Intervention Hub (https://www.ruralsmh.com/intervention-hub/) designed
    to connect rural educators to resources focused on preventing and
    remediating student mental health challenges.
        In addition, 27 of our new fiscal year 2021 research awards and 16
    of our fiscal year 2020 research awards are being carried out in rural
    settings. These studies are addressing teacher retention in rural
    schools, fostering positive family-school involvement for students from
    economically disadvantaged households in rural communities,
    interventions to help special educators with behavior management, and
    web-based professional development to help teachers improve students,
    reading comprehension in rural districts.
        The Regional Educational Laboratories (RELs). For more than 50
    years, the REL program has worked in partnership with State, district,
    and college and university leaders to develop and use research that
    improves academic outcomes for students and their communities. REL
    Southeast serves has successfully completed a number of projects
    focused on the needs of rural communities in Mississippi, including:
      --The Improving Schools in Mississippi Research Alliance, a
            professional learning community that supports research and
            practice on rural school improvement. Partners include district
            leadership from the Vicksburg/Warren Public Schools, Durant
            Public Schools, Yazoo City Public Schools, Holmes County Public
            Schools, and Humphreys County Public Schools, as well as Alcorn
            State University and Mississippi Valley State University.
      --The Southeast School Readiness Research Alliance, which seeks to
            build the capacity of preschool teachers and administrators
            across Mississippi and the other five States in the Southeast
            region to use evidence-based emergent literacy instruction to
            support three-to five-year old children's language and literacy
            learning and to help policymakers understand the factors that
            influence access to high-quality childcare and preschool
            programs.
      --Examining School-level Reading and Math Proficiency Trends and
            Changes in Achievement Gaps for Grades 3-8 in Florida,
            Mississippi, and North Carolina, which detailed student
            achievement trajectories for Mississippi students overall and
            within student group, supporting stakeholders decisionmaking
            about how to prioritize school improvement efforts.
      --Educator Outcomes Associated with Implementation of Mississippi's
            K-3 Early Literacy Professional Development Initiative, which
            examined changes in teacher knowledge of early literacy skills
            and ratings of quality of early literacy skills instruction,
            student engagement during early literacy skills instruction,
            and teaching competencies.
      --Beating the Odds in Mississippi: Identifying Schools Exceeding
            Achievement Expectations, which identified K-12 schools that
            were performing better than would have been predicted and was
            used to inform decisionmaking on statewide school improvement
            efforts.
      --Math Course Sequences in Grades 6-11 and Math Achievement in
            Mississippi, which examined the relationship between students'
            course-taking patterns in middle- and high-school and their
            subsequent performance on college admission tests, supporting
            local and State college readiness efforts.
        Question. In awarding research grants, how will you ensure that the
    Department considers the geographic distribution of research projects
    and geographic disparities in education research funding? How will you
    ensure funding is going to colleges, universities, and research
    institutions in under-researched and underserved areas?
        Answer. IES is required by law, under the Education Sciences Reform
    Act, to base our funding decisions on the independently assessed
    scientific merit of applications. In all of our grant competitions, we
    explicitly seek to broaden participation in our research studies and to
    expand the populations and geographic settings within which our studies
    are taking place. We are currently supporting a research project at the
    University of Southern Mississippi (grant award R305A200185) and two
    projects that are collaborations between Arizona State University and
    Mississippi State University (grant awards R305A180261 and
    R305A180144). IES also periodically holds competitions with a specific
    focus on addressing the unique needs of rural America, such as the two
    R&D Centers on rural education awarded in 2019. It is important to
    stress that these are competitive grant programs which are funded based
    on the scientific merit of the applications submitted. We do not
    include the State or geographic region in which the applicant
    institution is located in the selection criteria for our education or
    special education research grant programs.
        We also actively seek to broaden participation in our applicant
    pool through our research training programs. For example, our Pathways
    to the Education Science Research Training program was established to
    develop a pipeline of talented education researchers who bring fresh
    ideas, approaches, and perspectives to addressing the issues and
    challenges faced by the nation's diverse students and schools. These
    grants are awarded to minority-serving institutions (MSIs) and their
    partners. In the initial two rounds of competitions, IES made awards to
    7 institutions and their partners. IES is currently accepting
    applications for a new program: Early Career Mentoring Program for
    Faculty at Minority Serving Institutions that seeks to prepare faculty
    at MSIs to conduct high-quality education research that advances
    knowledge within the field of education sciences and addresses issues
    important to education policymakers and practitioners.
        Question. President Biden's campaign included a Plan for Rural
    America. That plan opened with the statement ``Rural America is home to
    roughly 20 percent of Americans, but we are all connected to rural
    communities in many ways. Rural Americans fuel us and feed us. Rural
    lands provide us with places to spend time outdoors with friends and
    family and relax.'' This statement suggests an attitude that rural
    people and places exist to provide for and serve more populated urban
    and suburban areas. The current version of the plan, available here
    https://joebiden.com/rural-plan/contains some of the same language but
    has been revised. It will be important that the administration move
    beyond metro-centric policy making to ensure rural schools are treated
    equitably.
        How will you ensure that policies and practices in the Department
    recognize and value the strengths and unique contexts of rural schools
    and communities?
        Answer. The Department is committed to educational opportunity and
    academic achievement for all students throughout the nation, including
    those in rural areas. Our Rural Education Achievement Program, for
    example, recognizes the need of many rural school districts for
    additional funding, as well as flexibility around the use of Federal
    education funds, to address their unique circumstances. Similarly, many
    of our discretionary (competitive) grant programs include rural set-
    asides to ensure that rural applicants receive an equitable share of
    grant funds, and we also use grant priorities for rural and new
    applicants that help level the playing field and ensure that rural
    applicants can compete successfully for Federal funds.
        Question. In 2018, the Department released the Section 5005 Report
    on Rural Education in response to a provision in the Every Student
    Succeeds Act that called on the Department to critically examine its
    policies and procedures in related to rural education. The 2018 report
    touted some things the Department is doing to ensure the needs of rural
    schools and students are met, and also listed steps the Department
    intended to implement to address the needs of rural schools. To date,
    not all of those seven steps have been accomplished, most notably, NCES
    has not updated its 2007 report on the status of rural education. In
    2019 this analysis by Devon Brenner (of MSU) of the Section 5005 report
    summarized the reports findings and plans or implementation and
    critiqued the report, saying ``it falls short of the 5005 mandate to
    self-assess and determine actions to be taken. The Department engaged
    in listening sessions and sought feedback from rural stakeholders, but
    does not seem to have incorporated feedback from key stakeholder
    organizations (e.g., AASA and Rural School and Community Trust, The
    University Council for Educational Administration (UCEA), the National
    Indian Education Association (NIEA), and the National Association of
    federally Impacted Schools). The Department commits to increasing
    listening sessions and improving communication but is not clear that
    rural input is or will be ``baked into'' the system to ensure that
    rural communities are considered in every facet of the Department's
    work, particularly rulemaking.'' See https://
    journals.library.msstate.edu/index.php/ruraled/article/view/535/501.
        How will you ensure that the Department completes these commitments
    to improve policies and procedures for rural schools and considers the
    needs of rural schools in the development of regulations and the
    implementation of programs?
        Answer. The Department is committed to ensuring educational
    opportunity for all students, including those in rural areas, and
    recognizes the need to account for all education settings when
    developing policies and procedures.
        To that end, in recent years, the Department's Rural Interagency
    Working Group has helped offices responsible for our programs,
    including the Rural Education Achievement Program (REAP), collaborate
    on issues such as access to broadband services which disproportionately
    impacts rural schools and communities. Department staff are examining
    how we can build upon these internal collaborations. Drawing on the
    experience of other Federal agencies, the Department also plans to
    collaborate more closely with the Departments of Agriculture, Interior,
    and Health and Human Services to better support and serve students in
    rural communities.
        The Department interacts regularly with REAP grantees and
    organizations advancing the interests of rural schools. The Department
    appreciates input from rural stakeholders and is working toward being
    responsive to that feedback. For example, in order to reduce burden on
    rural local educational agencies (LEAs), the Department has simplified
    the application process for the Small, Rural School Achievement (SRSA)
    grant, under which OESE awards over 4,000 LEA grants annually. OESE
    plans to increase its outreach to REAP grantees and its participation
    in events organized by rural advocacy organizations such as the
    National Rural Education Association (NREA). Additionally, the
    Department has recently been in contact with the Organizations
    Concerned about Rural Education (OCRE) regarding issues affecting rural
    schools and communities and emphasizing collaborative efforts to
    support rural schools.
        The Department will continue to rely on local leaders and rural
    stakeholders for their expertise and knowledge of rural schools, with
    those conversations informing plans to support student achievement in
    all settings.
        Question. Across the nation, equitable access to effective teachers
    remains an issue. Rural schools, especially, often struggle to recruit
    and retain talented teachers and school leaders. Previous programs such
    as the Transition-to-Teaching grant program provided for scholarships
    for teacher preparation programs to meet the needs of schools with
    demonstrated teacher shortages. In Mississippi, Transition-to-Teaching
    grants awarded in the last decade led to the successful licensure of
    hundreds of new teachers in the past 5 years, addressing the needs of
    rural schools.
        Please discuss how you envision the that the Department can
    explicitly addresses inequitable distribution of effective teachers,
    particularly in rural areas.
        Answer. The Administration's fiscal year 2022 request provides both
    flexible ESEA formula grant funding and competitive opportunities that
    can help States and school districts carry out strategies aimed at
    putting effective teachers in front of every classroom:
      --The $20 billion increase proposed for the Title I program would
            more than double the formula grant funding available to help
            address under-resourced school districts while helping to
            ensure that teachers in Title I schools, including thousands of
            rural Title I schools, are paid competitively.
      --The $2.1 billion requested for Title II will support ongoing State
            and local efforts to improve teacher and principal
            effectiveness and help ensure that all students have equitable
            access to well-prepared, qualified, and effective teachers and
            principals. In particular, States may use Title II-A funds for
            programs that provide alternative routes for State
            certification of teachers in areas where the State experiences
            a shortage of educators, similar to the previously authorized
            Transition to Teaching program.
      --The $250 million request for IDEA Personnel Preparation, an
            increase of nearly $160 million, would help ensure that there
            are adequate numbers of personnel in underserved rural schools
            with the skills and knowledge necessary to help children with
            disabilities succeed educationally, including enhanced support
            for beginning special educators.
      --The $80 million requested for Supporting Effective Educator
            Development (SEED) would support evidence-based educator
            preparation and development efforts that can serve as models
            for similar efforts across the country; new projects could have
            a stronger focus on building and enhancing the instructional
            skills of a more diverse educator workforce.
      --The $200 million requested for Teacher and School Leader (TSL)
            Incentive grants would support reforms to human capital
            management systems and performance-based compensation systems;
            the statue requires that priority be given to applicants that
            support teacher and leaders in high-need schools; in addition,
            consideration is given to ensuring an equitable geographic
            distribution of grants, including equitable distribution
            between urban and rural areas.
      --The $30 million requested for first-time funding (since
            reauthorization) of the School Leader Recruitment and Support
            program would support grants for high-quality professional
            development for principals, other school leaders, and aspiring
            principals and school leaders. Under the first competition for
            the program since the reauthorization of the ESEA, projects
            would focus on ensuring that the nation's most underserved
            schools have resources to improve school leadership.
      --The $132.1 million request for the Teacher Quality Partnership
            program, an increase of $80 million, supports projects that
            improve the preparation of teachers, including through teacher
            residencies and ``grow your own'' programs that can be
            especially valuable in rural communities.
      --The $20 million request for first-time funding of the Hawkins
            Centers of Excellence program would support diversifying the
            educator workforce, including in rural areas, by increasing the
            number of high-quality teacher preparation programs at Minority
            Serving Institutions.
        Question. Rurally located and rural serving public colleges and
    universities have an important role to play in the economic and social
    recovery from the COVID-19 pandemic. Public institutions of higher
    learning are important economic anchors in their communities and
    provide important access to educational opportunities that drives rural
    economies. However, rural colleges and universities are often
    underfunded compared to more urban and suburban institutions of higher
    learning, and students face particular challenges including geographic
    access and access to broadband Internet and technology. This report on
    the role that rural serving institutions play and Federal policy
    solutions to strengthen rural anchor institutions https://
    www.regionalcolleges.org/project/ruralanchor.
        How will you work to enact policies and practices that strengthen
    rural serving and rurally located public colleges and universities,
    including HBCUs and other minority serving institutions, and the
    communities they serve?
        Answer. The Department, in general, provides funding to
    institutions of higher education (IHEs) through two primary vehicles:
    (1) formula-based institutional capacity-building grants, and (2)
    discretionary competitive grants. For the Department's formula-based
    institutional capacity-building grants, such as HBCUs, HBGI, PBIs, and
    HBCU Masters, the Department has little flexibility given statutory
    requirements to provide additional funding to rural IHEs. For
    discretionary competitive grants, unless specifically prohibited by
    statute, the Department generally can give priority to particular types
    of institutions.
        More broadly, rural-serving postsecondary institutions, include
    HBCUs, would benefit significantly from key mandatory programs proposed
    as part of the American Families Plan and now included in the Building
    Back Better Act. These include Free Community College, which would
    provide $108.5 billion over 10 years to create a new partnership with
    States, territories, and Tribes to make 2 years of community college
    free for first-time students and workers wanting to reskill,
    potentially allowing up to 5.5 million students to pay zero in tuition
    and fees for 2 years of community college; the Advancing Affordability
    for Students program, which would award $39 billion over 10 years for
    eligible 4-year HBCUs, TCUs, or MSIs to provide 2 years of subsidized
    tuition for students from families earning less than $125,000; and
    Completion Grants, which would provide $62 billion over 10 years for
    grants to States and Tribes to support completion and retention
    activities designed to ensure postsecondary success for low-income and
    underserved students in high-need institutions.
                                     ______

                Questions Submitted by Senator Patrick J. Leahy
        Question. Even before the COVID-19 pandemic, Vermont was facing a
    mental health crisis in its schools. Many students have been
    irrevocably impacted by the opioid epidemic, losing parents and
    caregivers. This trauma has had a negative impact on their mental and
    behavioral health, leaving many teachers and school staff struggling to
    deal with the consequences. This is why I am so pleased to see the new
    $1 billion fund proposed by the administration to help schools hire
    more counselors, nurses, and mental health professionals.
    Unfortunately, Vermont is plagued with a severe shortage not only of
    teachers but of mental health professionals. As of May 2021, there were
    780 staffing vacancies among our mental health agencies in the state.
    The number of kids seeking inpatient mental healthcare in Vermont
    tripled between 2010 and 2019, as a dearth of community-based resources
    has led many families no choice but to turn to the Emergency Room as a
    last resort.
        How does the administration propose to help schools, particularly
    schools in rural areas, utilize this fund to hire school based health
    staff in areas where there are community, or even statewide, shortages
    of mental health professionals?
        Answer. The School-Based Health Professionals proposal recognizes
    the challenges to hiring such professionals in areas facing shortages,
    and would allow State educational agencies to reserve up to 15 percent
    of their allocations to address shortages of health professionals by
    establishing partnerships with institutions of higher education to
    recruit, prepare, and place graduate students in school-based health
    fields in high-need LEAs and to complete required field work, credit
    hours, internships, or related training as applicable for the degree,
    license, or credential program of each health-based candidate. SEAs
    also may use a portion of these funds for review and revision of State
    licensure standards to promote mobility of health professionals into
    school settings.We look forward to working with both chambers to ensure
    this proposal provides adequate support for both hiring these key-staff
    and developing the pipeline.
        Question. I strongly support the administration's goal to increase
    equity in public education funding. The COVID-19 pandemic has
    particularly laid bare the systemic inequalities that exist in our
    nation's schools. Vermont has many small and rural schools that have
    historically struggled to close both the equity gap and the digital
    divide due to a lack of resources. The proposed $20 billion for a new
    Title I equity grant program would represent the most significant
    Federal investment the program has ever seen. It is vital that this
    grant program is an option for all schools that need it around the
    country.
        How will you ensure that these equity grants are distributed among
    geographically diverse areas, particularly rural areas?
        Answer. State educational agencies would allocate funds to school
    districts based on existing Title I formulas, ensuring that virtually
    all school districts--urban, suburban, and rural--receive significantly
    more Title I funding to help close equity gaps in teacher compensation,
    access to rigorous coursework, and access to preschool.
        Question. TRIO and GEAR UP are vital student assistance programs
    that helps first generation, disabled and low income college students
    in Vermont succeed in all aspects of college life. These programs have
    proven effective in increasing postsecondary enrollment and graduation
    rates, as well as helping to address workforce shortages in the state.
    Unfortunately, both the COVID-19 pandemic and a historical lack of
    Federal funding for the programs has meant that many of the grant
    application cycles have become highly competitive. For example, the
    fiscal year 2020 TRIO Student Support Services (SSS) competition faced
    a significant increase in applicants. Separated by mere percentage
    points, 80 longstanding SSS programs were defunded, among more than 600
    un-funded applicants. This left nearly 15,000 high-need students
    without access to services provided by the program.
        How does the administration propose to allocate the increase in
    fiscal year 2022 funding for TRIO and GEAR UP? Will any of the funding
    become eligible to programs that were defunded in the fiscal year 2020
    SSS cycle?
        Answer. The Administration recognizes that limited resources under
    the TRIO and GEAR UP programs have historically resulted in an
    inability to fund all high-scoring applicants. This is why the
    increased funding proposed for TRIO in fiscal year 2022 would be
    allocated, in part, based on historical trends in the programs
    scheduled for competition in fiscal year 2022. Specifically, the
    Administration reviewed peer review scores on all applications
    submitted for fiscal year 2017 competitions under Upward Bound, Upward
    Bound Math and Science, Veterans Upward Bound, and McNair
    Postbaccalaureate programs (the last year in which competitions were
    held under these programs also scheduled for competition in fiscal year
    2022), and proposed to allocate additional funds to each program based
    on the number of high-scoring unfunded applicants from that year to
    ensure that funding more appropriately met demand. In addition, the
    Administration has proposed to provide all grantees under the Student
    Support Services program a 10 percent supplemental award to support the
    critical services they provide our students. However, at this time
    there are no plans to make additional Student Support Services awards
    to applicants that were unsuccessful in the fiscal year 2020
    competition.
        Question. The Public Service Loan Forgiveness (PSLF) Program
    forgives Federal student loan debt of borrowers who work for at least
    10 years in qualifying public service employment. The program has been
    plagued by complicated eligibility criteria and ongoing administrative
    problems that have resulted in a dismal approval rate. I was pleased to
    see the administration recently announce a regulatory review of PSLF
    and other Federal student loan relief programs to understand how they
    can better serve the needs of our nation's borrowers. However, the
    President's Budget proposes a decrease in funding for PSLF.
        Could you explain the justification for a 50 percent budget
    decrease for PSLF? What progress has the agency made in addressing the
    issues that have resulted in such a low approval rate for loan
    forgiveness?
        Answer. The Department recognizes that there are PSLF areas for
    improvement and we are committed to addressing them as quickly as
    possible so that our public servants receive the benefits they have
    worked hard to earn. We have already made some improvements to make it
    easier for eligible borrowers to access relief through administrative
    actions and others are in store. For instance, the Department has
    launched and updated the PSLF Help Tool, is now allowing lump sum and
    prepayments to count as qualifying payments, and created a single
    application for PSLF, Temporary Expanded PSLF (TEPSLF), and Employment
    Certification Forms (ECFs). However, we recognize more needs to be
    done. To that end, we recently announced that PSLF is among the topics
    we intend to revisit through an upcoming rulemaking process. We also
    recently issued a Request for Information, inviting feedback on
    borrower experiences and possibly policy solutions with the PSLF
    program, to identify broader areas for improvement.
        At the same time, Congress has provided funds annually toward
    TEPSLF so borrowers who may have made payments in a repayment plan not
    previously eligible for PSLF could still qualify for relief. Though
    these funds have remained largely unspent to-date, the Department still
    requested additional funds for fiscal year 2022 in recognition of the
    importance of this program to public servants. The additional $25
    million the Administration requested will ensure even more borrowers
    can access the program and receive relief under the TEPSLF program. In
    addition to those funds, we are also working to improve administration
    of the TEPSLF program and streamline access to its benefits; we believe
    those improvements will lead to these funds being more easily awarded
    to borrowers in the future.

                              SUBCOMMITTEE RECESS

        Senator Murray. With that, this hearing is adjourned.
        [Whereupon, at 11:31 a.m., Wednesday, June 16, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

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

                                  ----------

                            WEDNESDAY, JULY 14, 2021

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10 a.m. in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Reed, Shaheen, Merkley, Baldwin,
    Blunt, Kennedy, and Braun.

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    STATEMENT OF HON. MARTIN J. WALSH, SECRETARY OF LABOR

                   OPENING STATEMENT OF SENATOR PATTY MURRAY

        Senator Murray. Good morning. The Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies will come to order.
        Today we are having a hearing on the Biden administration's
    fiscal year 2022 budget request for the Department of Labor.
    Senator Blunt and I will each have an opening statement. Then I
    will introduce our witness, Secretary Walsh.
        After his testimony, Senators will each have 5 minutes for
    a round of questions. While we are unable to have this hearing
    fully open to the public, or media for in-person attendance,
    live video is available on our committee website. And if you
    need accommodations, including closed captioning, you can reach
    out to the Committee of the Office of Congressional
    Accessibility Services.

               VISION OF THE FISCAL YEAR 2022 PRESIDENT'S BUDGET

        You know, a budget is a reflection of values and through
    our hearings on President Biden's budget for the Department of
    Health and Human Services, and the Department of Education, we
    have seen a welcome change in values from the previous
    administration, and the budget proposal for the Department of
    Labor is no exception.
        This budget is a message to workers across the country;
    President Biden is fighting for you. Workers are the backbone
    of our economy. When we invest in workers, in keeping them
    safe, strengthening their rights, providing pathways for their
    development, ensuring their financial security, and more, we
    are investing in a stronger economy and a country for everyone.
        And that is exactly what this budget, which proposes
    increasing funding for the Department of Labor by 14 percent,
    does. When it comes to workers' safety, this past year has been
    a painful lesson on how important it is for every person to
    have a safe workplace. But even before the pandemic, our Nation
    saw 5,000 workplace deaths a year, one every 99 minutes. And
    on-the-job deaths have disproportionately spiked for Black and
    Latino workers since 2016, increasing 8 percent and 25 percent
    respectively, compared to just 3 percent overall. And while we
    know the economic cost of these deaths, a substantial $250
    billion a year, the loss to families is immeasurable.

                       PROTECTING WORKERS AND THEIR WAGES

        That is why the Occupational Safety and Health
    Administration was founded 50 years ago, with the mission to
    protect worker health and safety. President Biden's budget
    would help us recommit to that mission by increasing OSHA's
    (Occupational Safety and Health Administration) funding level
    by 73 million from last year, and that will help the agency
    hire more staff, provide more assistance to workers and
    businesses, hold employers accountable to providing safe,
    healthy workplaces, and ultimately save lives.
        In addition to protecting workers' lives, this budget also
    includes funding to protect their wages. It would provide
    $276.5 million to the Wage and Hour Division, an increase of
    $30 million. This agency investigates employer wage theft and
    illegal compensation practices used to cheat people out of
    their hard-earned wages, something which most commonly happens
    to women, workers of color, and foreign-born workers. The Wage
    and Hour Division recovers, on average, $1,120 per affected
    employee. And they do it with a staff of barely 1,300 people
    covering 148 million workers at over 10 million workplaces.
        The funding in this budget would help them expand their
    capacity, and put even more money back in the pockets of even
    more workers who have been cheated by their employer. And
    President Biden's budget not only invests in accountability for
    employers in our country, but also in accountability for our
    trading partners. So workers in Washington State, or Missouri,
    or across the country, don't pay the price for unfair labor
    practices across the world.
        This budget increases funding for the International Labor
    Affairs Bureau (ILAB) by over a quarter, including $19.16
    million for ILAB to expand monitoring and enforcement of worker
    rights under our trade agreements and preference programs, and
    critical new investments to fight forced labor and child labor.
        This budget also provides support to help workers
    struggling in light of the economic crisis caused by COVID-19,
    including the millions who have lost jobs, and especially
    women, workers of color, and others who have been most set back
    by it.

                          TRAINING AMERICA'S WORKFORCE

        President Biden's budget would increase funding for
    registered apprenticeships by $100 million, an increase well
    over half of what its budget was last year.
        These are proven apprenticeship models and lead to good-
    paying jobs in high-demand fields. Funding for them will help
    address long-standing inequities in apprenticeships, and change
    the fact that women and workers of color are historically
    underrepresented in these apprenticeship programs, and in the
    careers that they lead to.
        The budget would also increase funding throughout the
    workforce training system, including with the $203 million
    increase for workforce development State grants, which help
    States make investments in career pathways for youth, and
    support adults and dislocated workers, including those most
    affected by the pandemic, and a new National Youth Employment
    Program, and Veterans Clean Energy Training Initiative.
        Secretary Walsh, I look forward to hearing more about your
    plans here.

                   MODERNIZING UNEMPLOYMENT INSURANCE SYSTEMS

        And finally, this budget includes funding to administer and
    improve State unemployment insurance systems. This COVID-19
    pandemic made really clear what a lifeline that support can be,
    and how outdated and inadequate some of our systems are. This
    budget would help modernize our unemployment insurance system,
    and address vulnerabilities, inefficiencies, and other issues
    with processing these critical benefits, so families can get
    the support they need faster.
        Of course, the need for better unemployment insurance
    systems, workforce training programs, and workplace safety are
    just a few of the many issues we have to tackle in the wake of
    this pandemic.

                          EMPOWERING AMERICA'S WORKERS

        If we want a stronger economy, if we want a stronger
    country it all starts with stronger rights for workers. We also
    need to make sure workers are safe from pandemics, sexual
    assault, and harassment, and more. We need to make sure workers
    have paid family, sick, and medical leave, quality, affordable
    childcare, a livable minimum wage of $15 an hour, without
    exceptions, and a secured retirement.
        We need to make sure workers are not disadvantaged by pay
    inequality. We need to address the inequities in our economy
    that makes things so much harder for women, workers of color,
    workers with disabilities, and others.
        And we need to defend and strengthen the right to form and
    join a union, a right, which allows workers to secure better
    pay and benefits, and safer working conditions. This budget is
    a bold step in the right direction. And my colleagues and I
    have proposed other steps as well.
        Secretary Walsh, I look forward to working with you and
    President Biden in the months ahead to support workers in our
    country.
        With that, I will turn it over to Senator Blunt for his
    opening statement.

                         STATEMENT OF SENATOR ROY BLUNT

        Senator Blunt. Thank you, Senator Murray.
        Good morning, Secretary Walsh. Welcome to the committee. I
    look forward to your testimony today, and the chance to talk
    about the Department's budget request for the coming year.
        You know, the past 18 months have been challenging for our
    country. The COVID-19 pandemic put unprecedented strain on the
    economy, on its workforce, and on families who suddenly were
    dealing with issues they hadn't expected to deal with, and that
    families hadn't dealt with in the same way before.
        Prior to the COVID-19 Public Health Emergency Declaration,
    the unemployment rate was 3.5 percent. That was the lowest
    since the late 1960s. I think you have to assume from that,
    that some of the things that we are doing that were different,
    were making a difference. But at the height of the pandemic, in
    April of 2020, our unemployment rate exceeded 14 percent. While
    we have made great strides in bringing our unemployment rate
    back down since that point, I am concerned we won't reach the
    3.5 percent pre-pandemic number due to, frankly, some misguided
    Federal policies, specifically the additional $300 in Federal
    supplemental unemployment payments that have unintentionally
    incentivized unemployed individuals to remain exactly that,
    unemployed.
        In May of this year, the weekly--the average weekly
    unemployment check in the country was $318. That is a bigger
    check than a lot of people had taken home before, and you
    didn't have the expenses of going to work. And so frankly, a
    lot of people did not go to work. While businesses in America
    have been searching for workers, this benefit has really
    misaligned the workforce needs across the Nation.
        And in Missouri recently, I continue, to see ``Help
    Wanted'' signs all across the State, and in my hometown of
    Springfield, these help wanted signs often included hiring
    bonuses, and pay well above the $10.30 minimum wage in our
    State. Missouri, like many States across the country, has
    decided to end the Federal supplemental payment to increase the
    level of participation in the economy.
        I believe that it is beginning to work, but I also believe
    it is now time for Congress to recognize the importance of
    balancing, providing a safety net when you need it, and
    ensuring that our labor needs are met. We need to create an
    environment for Americans to thrive, where people want to go
    back to work, where they are encouraged to go back to work, and
    where people who can't go back to work have a basic
    unemployment benefit.
        However, I am concerned that some of the components of the
    Department's budget request, and particularly some of the
    increases, don't consider this, or the very real needs of local
    communities, and the needs for a workforce to be more actively
    engaged. Really, too much of this budget is driven by the
    politics of the administration. Now every administration
    should, and has every reason to make some changes. I think this
    budget makes way too many changes, in way too short a time.
        For example, instead of focusing funding on flexible
    workforce training, determined by States to meet their own
    unique employment needs, the administration is tying training
    funds in many, many cases to green jobs. I am not opposed to
    green jobs. I am just opposed to the Federal Government
    deciding how States approach the needs they have right now.
        According to the analysis of the U.S. Energy and Employment
    Report, and the Department of Labor's Bureau of Labor
    Statistics, when compared to jobs in fossil fuels, jobs in
    solar, and wind power, employ a larger share of individuals in
    their construction, rather than more permanent roles, as plant
    managers, and other jobs. These jobs don't pay enough, and are
    unionized at lower rates.
        Mr. Secretary, I agree with you, and we have talked about
    this, that we really need to target funding to the workforce of
    the future. However, I think it is unlikely that the Federal
    Government alone will be able to figure out what that workforce
    of the future should look like. And we need to have more
    involvement from States, communities, and local economies.
        Now, we are going to disagree on some things in this
    budget, but I am encouraged to see things we are going to agree
    on. For instance, the increase of the apprenticeship program, I
    think this has been, and needs to continue to be a successful
    tool to allow workers to get paid while they train. And
    frankly, to find out as early as possible, if what they think
    they want to do is not meeting their expectations. So they
    don't get way too far down a line before they realize, this is
    not what I want to do.
        This budget supports programs that are targeted to the
    hardest hit parts of the country. For instance, the Appalachian
    and the Lower Mississippi Delta regions have challenges there.
    And I think your budget does what it needs to, to begin to
    allow us to look at those challenges; there is support here for
    veterans transitioning to civilian workforce, one of the key
    priorities of this committee, and I think of this Congress.
        Mr. Secretary, we are in a challenging environment. It is
    going to be a difficult year. I believe we can work toward
    consensus with the Department's budget, but frankly, as I have
    said at our other budget hearings this year, I think this can
    only be achieved by more parity between the defense and
    nondefense funding. The President's budget request did not
    achieve that goal. However, I remain confident that the final
    appropriations bill will.
        And Mr. Secretary, I am glad that you plan to be in St.
    Louis tomorrow. I know we were told yesterday a couple of the
    things you would be talking about: one, promoting vaccines, and
    the other, the Job Corps. On the vaccine front, I was talking
    about this at our leadership stakeout yesterday. I have talked
    about it I think in every event I have been in in Missouri
    since we started the Warp Speed effort to try to get vaccines
    available more quickly.
        Vaccines are a necessary, an absolutely necessary part of
    us creating an environment where this virus can't continue to
    replicate itself and change in new ways, and the variants are
    going to be the future enemy. Vaccine is the answer to those
    variants.
        On Job Corps, Senator Murray, and I, and the committee have
    worked together the last 6 years to increase that funding. I
    know those programs continue to be programs that we can do more
    with and, can look for reforms in. And I look forward to your
    leadership in that area.
        So again, thank you for your time here today. I look
    forward to working together, as we try to be sure that
    Americans, working families, have the opportunities they need,
    and that our economy continues to grow. Thank you, Senator.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Thank you, Chair Murray. Good morning and welcome, Secretary Walsh.
    I look forward to your testimony on the Department of Labor's fiscal
    year 2022 budget request.
        The past 18 months have been challenging for our nation. The COVID-
    19 pandemic put unprecedented strain on our economy and its workforce.
    Prior to the COVID-19 public health emergency declaration, the
    unemployment rate was at 3.5%, the lowest since the late 1960s. At the
    height of the pandemic, in April 2020, our unemployment rate exceeded
    more than 14%. While we have made great strides in bringing our
    unemployment rate back down since that point, I'm concerned that we
    won't reach that 3.5% pre-pandemic number due to misguided federal
    policies.
        Specifically, the additional $300 in federal supplemental
    unemployment payments have unintentionally incentivized unemployed
    individuals to remain exactly that: unemployed. While so many
    businesses in America are searching for workers, this excessive benefit
    seems misaligned with the workforce needs across the nation.
        When I was in Missouri recently, I saw ``help wanted'' signs across
    the state. In my home town of Springfield, these ``help wanted'' signs
    included hiring bonuses and pay well above the $10.30 minimum wage in
    the state. Missouri, like many states across the country, has decided
    to end the federal supplemental payment to increase the level of
    participation in our state's economy. And I believe it is now time for
    Congress to recognize the importance of balancing providing a safety
    net, when needed, with ensuring that our labor needs are met.
        We need to create an environment for Americans to thrive--where
    people want to go back to work, where they are encouraged to go back to
    work, and where people who can't go back to work have a basic
    unemployment benefit. However, I am concerned that some components of
    the Department of Labor's budget request, and particularly some of the
    increases don't consider this or the very real needs of the local
    communities. Instead, too much of the budget is engrossed in the
    politics of this Administration.
        For example, instead of focusing funding on flexible workforce
    training determined by states to meet their own unique employment
    needs, the Administration is tying training funds to ``green jobs.''
    Yet, according to an analysis from the U.S. Energy and Employment
    Report and the Department of Labor's Bureau of Labor Statistics, when
    compared to jobs in fossil fuels, jobs in solar and wind power employ a
    larger share of individuals in their construction rather than in more
    permanent roles as plant operators; these jobs also don't pay as much,
    and are unionized at lower rates.
        Mr. Secretary, I agree with you that we should target funding to
    the workforce of the future. However, I think it's wrong for the
    federal government to dictate what that workforce should look like, and
    for bureaucrats in Washington, DC to determine the speed at which we
    get there. That should be left up to states, to communities, and to
    local economies.
        While we may disagree on this point, there are many components of
    the budget request on which we do agree. I'm encouraged to see an
    increase for the Apprenticeship Program--which has been a successful
    tool to allow workers to get paid as they train--support for programs
    targeted to the hardest hit parts of our country--in the Appalachian
    and Lower Mississippi Delta regions--and support for our veterans
    transitioning to the civilian workforce.
        Mr. Secretary, we are in a challenging environment and this is
    going to be a difficult year. I believe we can work toward consensus
    with the Department's budget, but as I have said at other FY2022 budget
    hearings this year, this can only be achieved when there is parity
    between defense and non-defense funding. The President's budget request
    did not achieve this goal. However, I remain confident that final
    appropriations bills will.
        Thank you for your time here today. I look forward to working with
    you to strengthen our nation's workforce and create a more prosperous
    economy for all Americans. Thank you.

        Senator Murray. Thank you, Senator. Thank you.
        And with that, we will turn to Secretary Walsh. Welcome to
    our committee. And you may begin your testimony.

                   SUMMARY STATEMENT OF HON. MARTIN J. WALSH

        Secretary Walsh. Thank you very much, Chairwoman Murray, I
    appreciate it; and Ranking Member Blunt, and the members of the
    subcommittee, thank you for having me today.
        I look forward to aligning the Biden-Harris
    administration's version of the Department of Labor's fiscal
    year 2022 budget and beyond. And I am excited to be here in
    person. This is my second in-person hearing. My first was my
    confirmation. So if I make some mistakes, bear with me until I
    get used to this process. So I truly appreciate it.
        I want to just start by saying how humbled and honored I am
    to be here, as the son of Irish immigrants, and a member--my
    father was a member of the Labors Union in Boston, to lead the
    Department of Labor. Just to think about their journey to
    America, and having their son sitting in front of Congress--in
    front of the Senate today.
        I also believe, as the President says, we are at an
    inflection point in our Nation's history right now. We are
    coming out, as was mentioned a couple of times, of a pandemic
    that has taken over 600,000 American lives. And it has pushed
    working people to the breaking point in so many different ways,
    in so many different corners of our country.
        The President and Congress worked together to pass the
    American Rescue Plan. It changed the course of the pandemic. It
    delivered relief to the American people, and it certainly set
    us on a pathway to recovery. At the Department of Labor, the
    team over there is working hard to implement this plan, from
    strengthening our unemployment systems to fully subsidizing the
    corporate premiums, to protecting workers' health and safety.
        But there is certainly much more work to be done. We need
    to build back better. That means putting workers at the center
    of a more resilient, more inclusive, and ultimately more
    competitive economy as a country. That is what the President's
    economic vision is all about.
        The Bipartisan Infrastructure Framework negotiated with
    members of the Senate would rebuild our communities and create
    millions of good jobs all across this country. And the Build
    Back Better agenda would make historic investments in working
    people through job training, and education, which I think we
    can all agree on, the CARES economy, and paid family leave, and
    medical leave, and workers' rights and protections.

                               BUDGET INVESTMENTS

        Building on that vision, the Department of Labor's fiscal
    year 2022 budget request proposes an investment of $14.2
    billion. That is, as the Chairwoman mentioned, a 14 percent
    increase over 2021 enacted levels. That includes $3.7 billion
    in Workforce Innovation and Opportunity Acts, and the Wagner
    Peyser state formula grants. It is an increase of 6 percent.
    That is about creating more pathways to good-paying jobs for
    workers who need them the most. And we have seen it with people
    unemployed now, and underemployed, the opportunity to make
    those investments.
        This budget also would invest $285 million in registered
    apprenticeship programs. That is an increase of $100 million
    that would allow us to expand and diversify a model of economic
    mobility that has proven to produce results for both workers
    and employers all across this country.
        For unemployment insurance, we would fully fund and update
    the formula for what States receive to administer UI
    (Unemployment Insurance), it is the first update, quite
    honestly, in decades. We also request $100 million for
    technology solutions to prevent fraud and ensure access to UI
    benefits for all people that need them.
        For our worker protection agencies, this budget requests
    $2.1 billion, a 17 percent increase. We need to rebuild and
    strengthen our capacity to protect workers, wages, benefits,
    and rights, and safety on the job sites.
        This budget also requests $100 million for the multiagency
    POWER Plus Initiative that is aimed at empowering displaced
    workers in coal communities with new--with new skills and new
    job opportunities. And it requests $20 million for a new
    program to help veterans. The ranking member mentioned this. It
    is transitioning services for members and military spouses to
    get good careers in clean energy.
        It was developed with the Department of Labor--with the
    Department of Labor's Department of Veterans Affairs. Across
    the Department of Labor's work, this budget invests in those
    who have been shut out of economic opportunities in the past,
    from women, and people of color, to rural Americans, and
    veterans, to at-risk youth, justice-involved adults, and people
    with disabilities.
        The pandemic proved that the systems failing some workers
    end up failing all workers, and failing our country,
    ultimately. But we have an opportunity to do better now, coming
    out of the pandemic. We can empower all American working
    people. It is a moment in history when we need to move forward
    together, we need to come together.
        Madam Chairwoman, Ranking Member, thank you for the
    opportunity; I know that we will have many more conversations,
    and we will work together to support the economic recovery that
    works for all American workers.
        I look forward to discussing the budget proposals and
    requests with you and the committee today. And I am happy to
    respond to any questions that you have. And if I do not have an
    answer to your question, I guarantee you our team will get back
    to you in the next couple of days with questions--answers that
    I don't have today. So thank you.
        [The statement follows:]
                     Prepared Statement of Martin J. Walsh
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee, thank you for the invitation to testify today. I am
    pleased to appear before this Subcommittee for the first time and to
    outline the Biden Administration's vision for the Department of Labor
    in Fiscal Year (FY) 2022 and beyond. I am honored and humbled to lead
    the Department in its critical work.
        The Department's mission is to foster, promote, and develop the
    welfare of the wage earners, job seekers, and retirees of the United
    States; improve working conditions; advance opportunities for
    profitable employment; and assure work-related benefits and rights.
    This mission is personal to me and my family's story. My father's
    participation in the Laborers Union, Local 223 in Boston, was the
    pathway to a fair wage, so my family was not worried about housing
    insecurity. My parents had a safe workplace, so I never knew the fear
    of them not returning from work. The job came with a pension, so my
    parents could retire with dignity. And the job included health
    insurance, so that when my parents experienced the worst nightmare of
    having a child diagnosed with cancer, they had health insurance so that
    I could be treated and recover.
        Years later, I followed my father into construction and joined the
    same union, and experienced those same benefits of having a safe
    workplace, health insurance, a fair wage, and a pension. These are not
    abstract policies--these are life-changing rights. I have spent my
    career fighting for the rights of working people as a State
    Representative, as General Agent for the Metro Boston Building Trades
    Council, and as Mayor of Boston. I feel privileged to continue this
    work as the Secretary of Labor.
                              american rescue plan
        As a former Mayor, I know that our communities--and our families--
    have been hit hard by the COVID-19 pandemic. That's why it was so
    important that Congress worked with President Biden to pass the
    American Rescue Plan (ARP) to change the course of the pandemic and
    deliver immediate relief for American workers. In terms of jobs, not
    only did the ARP extend unemployment insurance benefits for our friends
    and neighbors who lost their jobs during this pandemic, but it also
    laid the groundwork for shoring up and modernizing our unemployment
    insurance system to help workers get the benefits they deserve when
    they need them. The ARP also helps workers who lost their jobs or had
    their hours reduced pay for health insurance by fully subsidizing COBRA
    premiums for eligible individuals from April 1 through September 30 of
    this year. And it provides additional funding for the Department to
    help keep vulnerable workers healthy and safe. Finally, ARP also
    distributes more than $360 billion in emergency funding for state,
    local, territorial, and Tribal governments to ensure that they are in a
    position to keep front line public workers on the job and paid, while
    also effectively distributing the vaccine, scaling testing, reopening
    schools, and maintaining other vital services. We appreciate this
    landmark law, and we are working hard to ensure that this law is
    implemented in the way that Congress and the President intended to
    reopen our economy.
                               american jobs plan
        As a former construction worker, I know a good job can change your
    life. One of the most important things we do at the Labor Department to
    improve the economy and strengthen the workforce is help people pursue
    training that leads to good jobs and helps close racial and gender
    equity gaps throughout the economy. The President's American Jobs Plan
    is a historic investment in the working people of America. It will
    create millions of good paying, family sustaining jobs that rebuild the
    middle class by empowering our workers to build America's future.
        The President's plan provides funding for sector-based training
    programs focused on growing, high-demand sectors, such as clean energy,
    manufacturing, and caregiving, helping workers of all kinds to find
    good-quality jobs in an ever-changing economy. In addition, the plan
    provides for a new Dislocated Workers Program that provides
    comprehensive supports for workers who have lost jobs through no fault
    of their own, to ensure they are able to successfully participate in
    training that can prepare them for in-demand jobs. The plan will
    prioritize workforce development opportunities for underserved
    communities and ensure job opportunities are open to, and support,
    women, people of color, people with disabilities, and people impacted
    by the criminal justice system, among other disadvantaged groups.
    Further, subsidized jobs programs will support unemployed and
    underemployed workers who have faced significant barriers to employment
    to gain a key foothold in the labor market. Additional investments to
    establish more pathways to good jobs include creating up to two million
    new registered apprenticeship slots, while strengthening access for
    women, people of color, and individuals with disabilities; creating
    career pathway programs in middle and high schools, including those
    that increase access for underrepresented students to computer science
    and other STEM sectors; and supporting community college partnerships
    that build capacity to deliver job training programs that lead to good
    jobs. The plan also makes key investments in expanded career services
    and adult literacy programs to equip job seekers with the tools,
    information, and foundational skills they need to be successful in the
    labor market.
        The plan provides critical funding to strengthen the capacity of
    our labor enforcement agencies to prevent discrimination, protect wages
    and benefits, enforce health and safety rules, and strengthen health
    care and pension plans. In addition to these investments, the President
    is calling for increased penalties when employers violate workplace
    safety and health rules, which have proven inadequate to address
    serious violations.
     fy 2022 budget: supporting america's workers through the pandemic to
                                    recovery
        Building on the American Rescue Plan and the American Jobs Plan,
    the Department's FY 2022 budget proposes investments in workers and in
    our country's future: a future of opportunity and shared prosperity, a
    future of robust job growth and a thriving middle class, a future where
    workers nationwide get the skills and training that leads to jobs that
    pay a fair wage without risking their health or safety. The
    Department's budget requests an investment of $14.2 billion in
    discretionary resources, which is a 14 percent increase above the FY
    2021 enacted level.
        The budget includes resources to expand training opportunities,
    supporting workers and building a better future. There is no single
    path to a good-paying job, and the country's future growth and
    prosperity depend, in part, on ensuring workers have multiple pathways
    to high-quality, good-paying jobs. To that end, the budget requests
    $3.7 billion, a six-percent increase, for the Workforce Innovation and
    Opportunity Act and Wagner Peyser state formula grants to make
    employment services and training available to more dislocated workers,
    low-income adults, and disadvantaged youth hurt by the economic fallout
    from the COVID-19 pandemic.
        The budget also invests additional resources in programs that serve
    marginalized groups, such as justice-involved individuals, at-risk
    youth, and vulnerable veterans. While higher-income earners have
    recovered many of the jobs lost, workers in low-wage industries have
    experienced persistent net loss. As seen in the June 2021 Employment
    Situation, disparities among workers continue, and over 5.7 million
    jobs that existed last February are yet to return. While the overall
    unemployment rate was 5.9 percent, the African American unemployment
    rate was 9.2 percent and the Hispanic rate was 7.4 percent, compared
    with 5.2 percent for Whites. For individuals with disabilities, the
    unemployment rate was 10.9 percent. Due in large part to the impact of
    the pandemic, there are roughly 3.4 million fewer women working now
    than there were in February 2020--and many women have had to reduce
    their hours, often in response to caregiving demands. Women,
    particularly women of color, continue to face barriers to good jobs
    with equal pay. The budget prioritizes investments in these communities
    of color, with a goal of increasing success for all groups, because
    systems that are failing these populations are failing us all.
        The Department will continue to invest in proven approaches, such
    as expanding the Registered Apprenticeship model by investing $285
    million, an increase of $100 million, which will allow the Department
    to create a more balanced apprenticeship portfolio, support states'
    efforts to implement a reauthorized National Apprenticeship Act, and
    further the development of youth apprenticeship and pre-apprenticeship
    opportunities, all while increasing equity for under-represented
    populations. Registered Apprenticeships provide a pathway to good-
    paying jobs, and as Secretary of Labor, I am committed to expanding
    these opportunities across the United States, in order to help rebuild
    the middle class and create millions of new opportunities for workers
    to enter into relevant, high quality training that both protects
    workers' rights and propels workers into career paths that provide a
    sufficient and fair wage. Registered Apprenticeships produce strong
    results for both employers and workers. The Department's investments in
    Registered Apprenticeship will work to address the systemic disparities
    that have impacted women, people of color, and other under-served and
    under-represented populations.
        This last year has again demonstrated that Unemployment Insurance
    (UI) is an essential social insurance program and economic stabilizer,
    and it has been a lifeline to millions of workers and to the economy
    throughout the pandemic. Yet the pandemic uncovered longstanding
    problems in the UI system, including the challenges facing states'
    administration of their UI systems. These systems, in part as a result
    of persistent underfunding and inadequate technology, have been plagued
    by delays and obstacles that disproportionately affect workers of
    color. When benefits are slow to reach workers who have lost their
    jobs, it delays both their recovery and negatively impacts the country.
    To address these challenges, the budget provides resources to ensure
    States can better handle higher volumes of claims and be better
    prepared for future crises or high unemployment levels. The budget
    request fully funds and updates the formula for determining the amount
    states receive to administer UI--the first comprehensive update in
    decades. In addition, the budget requests $100 million to support the
    development of information technology solutions that can be deployed in
    states to ensure timely and equitable access to benefits. The $100
    million increase will further support and complement the resources the
    Department was appropriated under the American Rescue Plan to prevent
    fraud, promote equitable access, and ensure timely payment of benefits.
        The Biden-Harris Administration has taken stock of the challenges
    the unemployment system faces and developed a set of high-level
    principles that should guide future efforts to reform the UI system.
    Those principles include ensuring adequate benefit levels and duration
    for unemployed workers; ensuring the UI system can ramp up quickly and
    automatically in response to recessions; addressing the lack of access
    to UI for workers misclassified as independent contractors, low-income
    and part-time workers, and workers with non-traditional work histories;
    shoring up UI trust funds; and improving UI program access and
    integrity.
        The budget request includes $2.1 billion--a 17 percent increase in
    funding--for our worker protection agencies, enabling the Department to
    conduct the enforcement and regulatory work needed to ensure workers'
    wages, benefits, and rights are protected, address the
    misclassification of workers as independent contractors, and improve
    workplace safety and health. These are the staff who recover back wages
    owed, help prevent fatalities and life-altering injuries or illnesses,
    respond to whistleblower complaints, reduce exposure to cancer-causing
    agents, help ensure retirees get their benefits, and address pay
    inequities.
        Over the past four years, the Department's worker protection
    agencies have lost 14 percent of their staff. A lack of enforcement
    makes workers more vulnerable to workplace violations. The President's
    budget reverses this trend by proposing $304 million in additional
    funding for the Department's worker protection agencies, including $73
    million for the Occupational Safety and Health Administration, $67
    million for the Mine Safety and Health Administration, $35 million for
    the Office of Federal Contract Compliance Programs, $31 million for the
    Wage and Hour Division, and $37 million for the Employee Benefits
    Security Administration.
        The budget continues the President's commitment to tackling the
    climate crisis. For the Department, the request includes an additional
    $100 million investment in an initiative as part of the new Interagency
    Working Group on Coal and Power Plant Communities and Economic
    Revitalization, aimed at reskilling and reemploying displaced workers
    in legacy energy communities. The request also includes $20 million for
    a new discretionary program, developed in collaboration with the
    Department of Veterans Affairs, which is focused on helping
    transitioning service members, veterans, and military spouses to pursue
    careers in clean energy, which will help combat climate change, while
    preparing this population for good-paying jobs.
        I know we will have a lot of conversations, as we collaborate on
    the American Jobs Plan and the FY 2022 Budget. I look forward to those
    collaborations and partnering with you all to invest in the nation's
    economic recovery. The Department plays an important role in expanding
    opportunity.
        Madam Chairwoman, Ranking Member, thank you for the opportunity to
    testify. I look forward to discussing our budget request with the
    committee, and I am happy to respond to any questions you may have.

        Senator Murray. Thank you very much, Mr. Secretary. We will
    now begin a round of 5-minute questions of our witness. I ask
    our colleagues to please keep track of your clock and stay
    within your allotted time.

                   OSHA INCREASES IN THE AMERICAN RESCUE PLAN

        I appreciate that the budget addresses the need to rebuild
    and strengthen the capacity of the occupational safety and
    health administration. Under the previous administration, OSHA
    didn't do more than issue non-binding guidance on how employers
    could protect workers from COVID-19. And that left a lot of
    workers exposed, as we witnessed thousands of deaths and
    illnesses of workers in healthcare, and meat packing, and other
    essential industries.
        Now, the Biden administration recently issued an Emergency
    Temporary Standard, but it does not yet cover all frontline
    workers. And as you know, OSHA received $100 million in the
    American Rescue Plan, which it plans to use to support more
    than 80 compliance and safety health officers, among some other
    priorities. But as the economy continues to reopen, and more
    contagious COVID variants emerge, workers need OSHA to be fully
    engaged in its job of making sure employers provide a safe
    workplace for their employees, and their workers.
        So I wanted you to describe for the committee this morning,
    your plans to use those ARP (American Rescue Plan) funds to
    hire the staff OSHA needs to do its job, and how quickly do you
    expect to get these staff on the job.
        Secretary Walsh. Thank you very much, Madam Chair. OSHA is
    one of the areas that, when I was sworn in, work had already
    begun there, due to the help of the American Rescue Plan, and
    investments in staffing up. They were severely understaffed to
    be able to make sure that we keep our workplaces safe in
    America. Certainly, we have a difficult time keeping up with
    the average volume of business, but if you throw COVID-19 and
    the atrocities of some of the workplaces in our country with
    COVID-19, it made it very complicated.
        We are currently in the process of hiring up and staffing
    up in OSHA so that we can have more inspectors to go out to job
    sites. Quite honestly, I would love OSHA, at some point--we are
    asking for an increase in this budget--I would love OSHA at
    some point to get to a point where we are not responding to
    accidents on the job site, that we are actually being proactive
    working with businesses, in how do we create better, safer work
    conditions, and work sites.
        We are not at that point right now, so we are at the point
    where we are still looking to staff up, and hire up. And also
    just--and I have spent many, many hours on Zooms with the OSHA
    employees across the country, just thanking them for their
    work, because throughout the pandemic OSHA employees went to
    work every day. They didn't have the luxury of sitting home on
    a Zoom and doing their job. They had to be on a job site. They
    had to be touring facilities, and they had to see some of the
    toughest situations out there. So I look forward to working
    with this committee and continuing the staffing up of OSHA.

                    OSHA INCREASES IN FISCAL YEAR 2022 BUDGET

        Senator Murray. Well, the budget requests an increase of
    $73 million for OSHA in fiscal year 2022. Can you describe why
    those funds are needed in addition to the ARP funds that were
    provided?
        Secretary Walsh. Yes, because--thank you. With the ARP
    funds as it just--it restores us back to where we were pre-5-
    years-ago. What the new funds allow us the opportunity to do is
    expand the office and to get into some of the other work that
    we want to do. People should not be, businesses should not look
    at OSHA as a burden. People should be looking at OSHA as a
    partner, and being able to create opportunities to help create
    safe work environments.
        When I was a young person working on construction sites,
    and OSHA came on the job, they would come on the job to
    investigate, but they were not investigating after an accident
    happened, they were not investigating after a tragedy happened,
    they were making sure that there were proper procedures in
    place there to make sure that workplaces are safe.
        We need to do work around this country to make sure that
    our workplaces are safe, that workers are safe. And that we
    collectively work with businesses as well as we move forward
    here. So that additional revenue will go into continuing to
    hire up in OSHA, and to create better opportunities to
    training, and to have the best prepared--OSHA inspectors we
    have in the country.
        Senator Murray. You didn't mention whistleblower
    complaints, but I understand that last year the inspector
    general reported a significant increase in complaints, and
    insufficient staff to investigate those complaints. What are
    you going to do to address that issue?
        Secretary Walsh. Again, it is about the staffing when--I
    might have the numbers wrong--let me just get the numbers here
    for you. We are going to double the number of inspectors by the
    end of the administration, the first administration, Biden-
    Harris administration, the first term, we are about--we were at
    about 360 inspectors in the country, inspecting about 170
    million workers in our country. That certainly is not going to
    do the job.
        So what we are doing here is making sure that we have
    enough inspectors out there that when an employee calls the
    office with a complaint, we are able to respond to that, and
    not have it sit in a pile, or sitting in an inbox somewhere.
    And again, it is about when you think about whether it is OSHA,
    Wage and Hour, the Department of Labor was down about 3,000
    employees to where it was 4 years ago.
        And when you are down employees in the Department of Labor,
    the Department of Labor is an agency, as you know, that is out
    there protecting workers. If we don't have the staff and don't
    have the employees to protect the workers, then we can't be on
    the job sites, we can't be checking Wage and Hour, we can't be
    making sure that people are working in safe conditions.
        So our intention, with this investment that we are asking
    for today, and with the intention of the American Rescue Plan,
    to staff back up, to build back pre-4-years-ago level, but also
    enhance that.
        Senator Murray. Okay. I have a number of other questions,
    and I am going to ask them at the end, so our other committee
    members can have their time.
        I will turn to Senator Blunt.

                       CREATING A WELL-PREPARED WORKFORCE

        Senator Blunt. Thank you, Chair. Let me start with a
    question that is really going to be more of a question I will
    follow up with later, but I want to be sure we cover this. You
    and I have talked about this before, Mr. Secretary, the idea
    that people don't get the information they need early enough to
    decide what kind of job is out there, what their personal sense
    of job satisfaction would be, and what those jobs pay.
        A few years ago I went with the Secretary of Labor to the
    Carpenter Training facility in St. Louis, and as we visited
    individually, the people, at the end of that visit, they were
    all in their late-20s; they all had a similar story, and it was
    sort of that lost decade of not knowing what they wanted to do,
    or not having information about the importance of benefits, the
    importance of job satisfaction.
        And we have looked at that as sort of a lost decade that we
    would like to avoid. It is hard to recover, frankly, from that
    lost decade. You ask for $10 million to continue to pursue that
    in your budget. The Secretary of Education didn't ask for the
    $10 million education had last year. We put $10 million in both
    budgets.
        At some point when you have had time to think about this
    more, I am going to ask you, I will be asking the Secretary of
    Education what the two of you are doing to try to close that
    gap between getting the information you need. If you want to
    talk about the importance of knowing what jobs are out there
    sooner rather than later. Just let me let you do that for a
    moment.
        Secretary Walsh. No. Thank you, ranking member. And to be
    quite honest with you, I want to ask--add another component to
    that: the Secretary of Commerce. So the Secretary of Commerce,
    Gina Raimondo; the Secretary of Education, Secretary Cardona,
    and myself, have had conversations. And when you think about
    the jobs of the future, the three of us, the three of our
    departments catch people--catch employers in educational
    opportunities to prepare people for the future.
        So what we are doing is, we are working collectively
    together to make the investments. Gina Raimondo is working with
    the business community as well as I am, to find out where the
    gaps are, where they need employers--employees now, and in the
    future, working with education on how do we create those
    programs in our primary schools, in our high schools? How do we
    create those opportunities in community college moving forward?
        And the Department of Labor is offering--obviously has the
    workforce development grants, and the workforce grants to be
    able to fund those jobs. So it really has to be real
    intentional work that we are doing here to make sure that this
    money that we are asking for today, and the money through the
    rescue plan, and potentially, through the CARES Economy Plan,
    that this investment is preparing workers of the future.

               ADAPTING TRAINING PROGRAMS TO MEET INDUSTRY NEEDS

        You just said it yourself. I mean, when you think back and
    look at the history of this country, and you look at the
    investments that were made in the '50, and '60s and '70s, lots
    of schools around America had training--had Vo-Tech schools,
    and they were doing Vo-Tech training, and young people that
    were going to those programs were going into the trades. That
    would become an electrician, plumber, carpenter, laborer, and
    mechanic, what have you.
        Many of those programs are very different today. And I
    think we are at a moment in time, coming out of a pandemic, or
    getting through a pandemic, I should say--we are not out of it
    yet--that we have an opportunity right now to retrain and
    reskill workers, young people, as well as some older workers as
    well, into those careers. But it has to be a coordinated
    effort, it has to be the secretaries of commerce, labor, and
    education, and it has to be Democrats and Republicans, quite
    honestly.
        Senator Blunt. All right. I am going to run out of time
    here. I agree with that, but the component I want to be sure we
    continue to add is like those Vo-Tech programs.
        I was at a great new facility in Buffalo, Missouri, the
    other day that they are building, and being focused again,
    people need to know, sooner rather than later, what jobs are
    out there, what those jobs pay. A lot of jobs that have that
    kind of training actually produced greater satisfaction and
    more income than jobs that you have a college degree for. And
    sharing all that information early is important.
        One way to create an early sense of what you want to do are
    apprenticeships. Missouri, where you will be tomorrow, is
    ranked second in the United States in apprenticeships. We are
    working toward a goal in our State of having 20,000 active
    apprenticeships by 2025. The one thing left out of that, it
    appears to be the nontraditional industries and what we can do
    to develop apprenticeships outside of the well-run trade union
    programs, and other programs. For instance, like healthcare,
    cybersecurity, even finance. What can we be doing to think
    about how we expand that apprenticeship opportunity to new
    fields?
        Secretary Walsh. Well, what I have been doing, and what we
    are going to continue to do is talk to companies, the tech
    companies as well. We have opportunities in tech, and biotech,
    and high-tech, and even pharmaceuticals. So having
    conversations with those industries on how we create pathways
    into those industries would be important. Those are good-paying
    jobs, and they are looking for people.
        And quite honestly, we have a huge opportunity right now in
    this country to really think about those apprenticeships, and
    how do we create more apprenticeships; and the beauty is--I
    know my time is over--the beauty is, is the apprenticeships you
    are paying while you are learning. And that is the difference
    between workforce development and job training. You are
    actually getting paid in the apprenticeship while you are
    learning on the job.
        Senator Blunt. Right.
        Secretary Walsh. And that allows a person that might be
    unemployed or underemployed right now, to get on-job
    experience, real-life experience moving forward.
        Senator Blunt. Thank you, Secretary. I will have some more
    questions also later, Chairwoman. And thank you for the time.
        Senator Murray. Thank you.
        Senator Reed.

                        SHORT-TERM COMPENSATION PROGRAM

        Senator Reed. Thank you very much, Madam Chairwoman.
        And congratulations, Secretary Walsh, I am glad you are
    there in the Department. Let me raise the first question about
    the Short-Term Compensation Program, or otherwise known as
    ``work sharing''. After the last recession in 2010/2009, it is
    estimated that we saved 570,000 jobs. And I know Congress and
    the Biden administration stepped up and they are providing
    fiscal support for this program, and it is saving tens of
    thousands of jobs.
        And as you know, what it does is it basically provides 1 or
    2 days on unemployment compensation while the individual works
    at the facility. Can you explain how, and if you will continue
    to support this program, and try to extend it to every State in
    the union?
        Secretary Walsh. Thank you very much, Senator. And thank
    you for raising this issue. Work sharing certainly is an
    important and innovative tool. I agree with you, and I wished
    that we had seen it across the States, and we want to see it
    across the States. I think it is going to be very important for
    the future of our workforce. It is important that we continue
    to explore that. I am going to, as Secretary of Labor; our
    Department is. The Department is certainly committed to
    promoting State adaptation of this program.
        And we are going to continue to find ways to increase
    awareness and participation in the program. We have seen--you
    have seen the benefit of it, and I think that--and workers are
    seeing the benefit of it. And I think that those are
    opportunities for us throughout the United States of America
    for other States, and other workers, more honestly, to see the
    benefit as well.
        So I know that, Rhode Island, they have been a leader on
    this, and I want you to know that I want to continue to work
    with you, and maybe some of the other members of the Senate, in
    governance, quite honestly, around the country to expand the
    program.

                        DEMAND-DRIVEN TRAINING PROGRAMS

        Senator Reed. Thank you, Mr. Secretary. Switching gears a
    bit, I secured about $28 million in the Defense Appropriations
    Bills for a submarine, industrial-based support of workers, and
    of training, and education initiatives. And I think you have
    seen one of these when you visited Westerly, Rhode Island, and
    saw our training program, where our Department of Labor,
    together with Electric Boat collaborates. And I think this is
    another example of what Senator Blunt was getting at. This
    demand-driven model for training, it is not the old-fashioned:
    We turn out X, we have always done that. It is: What does
    business need?
        And up in our place where Electric Boat, over the next
    several years, is going to have to hire 17,000 people, many of
    them machinist, welders, et cetera. So how are you going to
    continue to work with the Department of Defense to support
    programs like this, and with other agencies to support demand-
    driven programs?
        Secretary Walsh. Well, first of all, thank you for your
    work on this. Ranking Member Blunt talked about this as well. I
    think first I want to say is that, the jobs that you work with
    your hands are now computer jobs, meaning that you have to have
    not just the skill to be able to be the craft person working
    with your hands, but you need to be able to learn and read off
    a computer because the work has gone so technical.
        The Department of Labor has just awarded the State of Rhode
    Island a $3 million--$3.9 million grant to expand registered
    apprenticeship opportunities. I think that this is one of the
    areas that we have such a great opportunity. Electric Boat is a
    great example. I was in Connecticut; we went through Rhode
    Island to get to Connecticut. I know there is facility in Rhode
    Island, as well, and the expansion that was going on there, and
    the opportunity for employees.
        I guess the best way I can sum it up is what I am going to
    do about it is make sure that these investments are there, and
    that we work with companies like Electric Boat, but the human
    side of it. When I was at Electric Boat, I was talking to a
    couple of apprentices that were standing there next to me, and
    I got to talking with them.
        And I am like: What are you doing? You know, did you go to
    college? One kid went to college a little while, dropped out.
    It wasn't for him. I told them my story. I dropped out of
    college after a-year-and-a-half.
        He is now on a pathway to a career. He is on a pathway to
    working on submarines for the United States of America. He is
    on a pathway to doing some amazing work. He is proud of his
    work. He is happy with what he does. He told me he is earning
    good money. He is making a living. He is able to raise a
    family.
        That is the type of stories that we need to continue to
    happen. So I think it is incumbent upon us. If I do anything as
    Secretary of Labor, it is making sure that the money in the
    workforce development grants, in the apprenticeship program,
    money that we get, we get out in the street because that, that
    is going to be the fundamental, biggest game changer in the
    United States of America, to get workers retrained, or workers
    trained, and the ability to raise and get into the middle-
    class. That is what we can do. That is the one thing. If I
    accomplish anything and I do that, I will be happy.

                           COMBATING LITERACY ISSUES

        Senator Reed. Well, thank you very much, Mr. Secretary.
    Just a final point, not a question; as I was sitting down with
    adult educators in Rhode Island a few weeks ago, they pointed
    out that one of the problems is literacy; that they have a
    significant number of adults who walk in and they want jobs,
    they want to work, but they have very poor literacy, and very
    poor numeracy and, digital skills too.
        And I will just, not a question, but I assume, and I know
    you will follow up with the Department of Education to try to
    collaborate, to see how we can integrate our literacy programs,
    as well as our training programs. And I will then--I won't
    follow up with additional question. I will just, thank you.
    Thank you, ma'am.
        Senator Murray. Thank you.
        Senator Kennedy.
        Senator Kennedy. Thank you, Madam Chair.

                                BUDGET INCREASES

        Mr. Secretary, welcome. I agree with you, by the way, for
    what it is worth, about getting the money out on the streets,
    literally. So I am looking at your budget here. Your current
    budget is $12.5 billion. You are asking for $14.2 billion. Does
    that sound about right?
        Secretary Walsh. Yes.
        Senator Kennedy. That is a 14 percent increase. You want an
    extra $1.7 billion?
        Secretary Walsh. Yes.
        Senator Kennedy. Okay. Explain to me why the American
    people would be better off giving you $1.7 billion, than taking
    that $1.7 billion and spending it on infrastructure? I did a
    little math and for $1.7 billion, we can resurface a four-lane
    highway from Washington to Denver. So why are the American
    people better off giving you more money than putting it on
    infrastructure?
        Secretary Walsh. Well, thank you very much, Senator. And
    thank you for the question. It is a great question. And I think
    the way I would think about it is the $1.7 billion increase to
    my--to the budget, my budget is an investment in infrastructure
    as well. It is an----
        Senator Kennedy. It is what? I am sorry?
        Secretary Walsh. Infrastructure investment as well. It is
    an infrastructure investment in the American worker in this
    country. It is an opportunity for us to look at, as I think
    about the Department of Labor----
        Senator Kennedy. Would you believe every--excuse me for
    interrupting--I am sorry, Mr. Secretary.
        Secretary Walsh. No problem.
        Senator Kennedy. We don't have much time. Do you believe
    that every expenditure by the Federal Government is an
    investment?
        Secretary Walsh. This----
        Senator Kennedy. What is the difference between an
    investment and an expenditure?
        Secretary Walsh. An investment is an investment in the
    future of workers, and expenditure is an expenditure in
    building a bridge.
        Senator Kennedy. Okay. Well, you have a union background,
    which I respect and admire. If we took $1.7 billion that you
    say you need, you need more to run your Department, and we
    spent that on infrastructure. That is going to create a lot of
    union jobs. Isn't it?
        Secretary Walsh. It is going to create a lot of jobs, but
    we are also not going to be able to educate the workforce that
    needs those new jobs that are going to be created off of that
    infrastructure investment of new bridges.
        Senator Kennedy. But they are already educated. The people
    building the roads are already educated. They are good at what
    they do.
        Secretary Walsh. Well, Senator Reed just mentioned of--an
    issue around literacy in this country. So again, it is an
    investment in helping people to be able to be retrained and
    trained in the jobs of the future. I come out of construction.
    I worked construction as well. The construction industry that I
    worked on in the early-'90s and late-'90s is different than the
    construction industry of today.

                     TAX INCREASES FOR INFRASTRUCTURE BILL

        Senator Kennedy. Yes, sir. Let me stop you for a second. I
    don't want to get too far afield here into a history of the
    construction industry. I used to work construction too.
        Let me be sure I understand what you are saying. When my
    constituents call me and they say, look, you are being asked to
    raise taxes to pay for infrastructure. Why, instead of putting
    $1.7 billion in extra taxes on us, why did you give $1.7
    billion to the Department of Labor? Why didn't you use that for
    infrastructure? Am I just supposed to say, because the
    Department of Labor says they are going to make an investment?
        What metrics are you going to use this time next year to be
    able to prove to this Congress that your investment paid off
    better than $1.7 billion in infrastructure?
        Secretary Walsh. Before I answer that, let me just quickly
    go back to the tax question. I think the beauty for your
    constituents is that the infrastructure bill that is being
    negotiated right now does not raise taxes on the average
    American who earns under $400,000. So the average American is
    not paying for that.
        Senator Kennedy. That is not true.
        Secretary Walsh. Okay. Well, that is not why I am here
    today.
        Senator Kennedy. We just have to agree to disagree.
        Secretary Walsh. It really----

                          DEPARTMENT OF LABOR SURVEYS

        Senator Kennedy. Let me move on, because I have got one
    minute left, and I like to stay within my time. Does your
    agency conduct surveys?
        Secretary Walsh. As far as employee surveys?
        Senator Kennedy. Any surveys.
        Secretary Walsh. We do, yes.
        Senator Kennedy. Okay. Do you pay people?
        Secretary Walsh. Pay the people who do the surveys?
        Senator Kennedy. No, to take the survey.
        Secretary Walsh. I actually don't know the answer to that.
        Senator Kennedy. Well, here is why I am asking. And I am
    not trying to----
        Secretary Walsh. I will get back. I don't know. I don't
    know the answer to that.
        Senator Kennedy. I need your help finding something. One of
    my constituents got this in the mail. It is a letter--I know it
    is not under your jurisdiction--from the Bureau--Census Bureau.
    And they asked him to fill out a form on children's health, and
    he opened it up, and look what fell out, a five-dollar bill.
    And there is no reference in the letter to the $5 in cash he
    got from the Federal Government. What is this all about?
        Secretary Walsh. I have no idea. I will look into----
        Senator Kennedy. Can you help me find out?
        Secretary Walsh. I will help you find out.
        Senator Kennedy. I took the----
        Secretary Walsh. I didn't get one of those letters.
        Senator Kennedy. Well, I filled out my census, my survey. I
    want five bucks.
        Secretary Walsh. I do, too.
        Senator Kennedy. And I understand that under the Biden
    administration is also sending people $40 gift cards.
        Secretary Walsh. I doubt that is from the Biden
    administration. But I will look into it.
        Senator Kennedy. I looked it up, it is on the Internet. It
    must be true.
        Secretary Walsh. I will look into it with you, my friend.
        Senator Kennedy. Would you?
        Secretary Walsh. I promise.
        Senator Kennedy. Thank you, Mr. Secretary.
        Secretary Walsh. All right, sir.
        Senator Murray. Senator Shaheen.

                      IMPORTANCE OF THE JOB CORPS PROGRAM

        Senator Shaheen. Well, thank you, Madam Chair.
        And congratulations, Mr. Secretary, we are delighted to
    have you in your current role, and it is nice to have a New
    Englander who I can understand.
        You were talking earlier about the need to have more
    nontraditional apprenticeships, and the potential for doing
    that for organizations to make that possible. One of those
    organizations in New Hampshire is the Job Corps where they have
    a number of training programs that train people for healthcare
    roles, for dental assistants, for some of the things that have
    been nontraditional.
        Can you speak to the importance of the Job Corps and why it
    is a great opportunity for young people who may not have
    another alternative?
        Secretary Walsh. Absolutely, Senator. Thank you for that.
    You know, prior to my being here, I did not have, per se, a Job
    Corps Center in the City of Boston, but we had lots of
    workforce development programs. My first Job Corps visit was in
    Memphis, Tennessee, where I got a chance to tour the Job Corps
    facility there. And I saw first-hand the unbelievable potential
    of creating pathways for so many young people in America.
        And then I started to look into it, and realize the amount
    of young people that go through Job Corps. Job Corps, there is
    no question in my mind, that everybody today who brought up the
    question with me so far, Job Corps should be a main stay in
    Opportunity For Economic Development and Job Growth.
        I think that we need to continue--I am going to continue to
    partner with Job Corps. I am going to do everything I can. I
    have asked for a budget increase for Job Corps. I am also going
    to do everything I can to make sure that Job Corps all across
    this country is successful.
        I know your Job Corps in New Hampshire. I know it is
    successful, and we want to take those models and make it
    successful. So I am spending, you know--again not to kind of
    get off the beaten path here--but I know when I became
    Secretary of Labor, you know, people talk about OSHA,
    unemployment insurance, and all of the--kind of the bigger
    ticket items, Job Corps is as important as any of these, if we
    do it right and continue to create pathways.
        Senator Shaheen. Well, thank you. I worked for 20 years,
    first as governor, to get that Job Corps, with a lot of other
    people who supported it. So it is really nice to see it be
    successful. And I appreciate the support from--your support for
    Job Corps.

                                   H-2B VISAS

        Something that has not been so positive this year has been
    the challenges with finding workers in New Hampshire, as
    everyone has spoken to already. And one of those issues in New
    Hampshire has been the access for H-2B visa workers. You and I
    talked about this last spring. But we have a lot of seasonal
    businesses that rely on H-2B visa workers to fill those
    temporary jobs. When we don't have workers in New Hampshire who
    are willing to take those jobs, and we have an unemployment
    rate that is now back to under 3 percent.
        Congress charged the Secretary of Homeland Security and
    you, as Secretary of Labor, with the responsibility of
    collaborating to determine the appropriate number of additional
    H-2B visas to release for this fiscal year. I was disappointed
    to see the administration's ultimate decision to release just
    22,000 additional visas. And just 16,000 of those were set
    aside for returning workers. They were fully applied for less
    than 2 weeks after being made available.
        So can you tell us how the administration determined that
    22,000 number, and why only 16,000 of those should be available
    for returning workers?
        Secretary Walsh. Yes. I can. First and foremost, it was, as
    somebody who was literally on the job about 3 weeks at that
    particular moment, I sat with Secretary Mayorkas, and we were
    looking at different numbers. He had a very high number--a much
    higher number than that. And we were looking at the consistency
    of what the past practice has been, and what the average number
    of additional visas have been; 22,000--well, let me, 16,000 of
    the traditional ones is about the average of the last 3 years,
    not including last year, what the average was.
        The 6,000 that were added was for the Northern Triangle of
    Central America and Southern America. So we have made--my
    office and Homeland Security's office is coming up with a
    better formula for how we operate and move forward next year.
    And I think that, certainly, your office, I spoke to you
    directly, and Senator Hassan called me, and many Senators from
    around the country called me as well, from all over the
    country, really concerned about this.
        We got the number out late. And so what we want to do now
    is prepare for next year as we move forward so this same thing
    doesn't happen. I know that in New Hampshire, Maine, and other
    places, the tourism industry is in desperate need of these
    workers, and other parts of the country, the fishing industry
    is desperately in need of these workers.
        And then we are also looking at the H-1B program as well
    for the farmers. So I don't have a great answer for you, how we
    came up with that number, other than we sat down and had a
    compromise, a conversation. But I can tell you this: you have
    my commitment that next year we will not be dealing with this
    at the last minute. We will have this conversation beforehand,
    and may be even an opportunity for me to visit with you and
    talk to some of the workers that are in your State, to talk
    about the importance of that program.
        Senator Shaheen. Well, thank you very much. I appreciate
    that.

                       ADDRESSING THE WORKFORCE SHORTAGE

        And I know I am out of time, Madam Chair. But I would just
    remind us all that we are dealing with an aging workforce in
    this country. And if we expect to fill the jobs that we are
    creating, we need to get more older workers into the workplace,
    and we need to get more immigrants into the workplace. And I
    understand that is a charged political issue, but it is one we
    need to face if we are going to address our workforce shortage.
    Thank you.
        Senator Murray. Thank you.
        Senator Baldwin.
        Senator Baldwin. Thank you, Chair Murray.

                    PARTNERS ACT APPRENTICESHIP LEGISLATION

        Secretary Walsh, I am going to join the chorus here as a
    big supporter of apprenticeship programs. And I plan to shortly
    re-introduce my apprenticeships legislation, known as the
    PARTNERS Act, in the near future. That is focused particularly
    on collaboration between smaller work places, and technical
    colleges, and workforce Boards to sometimes create novel
    apprenticeships, but to assist, especially, smaller businesses,
    in standing up apprenticeship programs.

                      DIVERSITY IN APPRENTICESHIP PROGRAMS

        Anyways, I was pleased to see that your budget requested a
    $100 million increase for apprenticeship programs, along with a
    commitment to increase access to apprenticeships for,
    historically underrepresented groups. I wanted to call your
    attention to my home State of Wisconsin, where in Milwaukee we
    learned that the number of Black apprentices decreased by
    nearly 22 percent over the last year. That is a deeply
    disturbing statistic.
        And so I am interested in learning how the Department will
    use the appropriated funds to attract more racially-diverse
    apprentices. And what strategies you have to prevent the sort
    of numbers that we have seen in Wisconsin, and Milwaukee in
    particular?
        Secretary Walsh. No. Thank you. I was in Milwaukee about 3
    weeks ago, or with the Mayor, and we were on a job site,
    replacing lead pipes, they were replacing lead pipes in one of
    the neighborhoods in Milwaukee. And prior to that I was at a
    roundtable with the Building Trades, I think that there are two
    things we have to do.
        Number one is, I think the people that we have to--that
    want to get access to these apprenticeship programs, that there
    are people of color, African-American, Latino. People want to
    get in. It is about, you have to be real intentional about
    reaching out to the community and creating open-door
    opportunities for these programs. I have done it in the city as
    a head of the Building Trades. I have done it as the Mayor of
    the City of Boston.
        And I think that we have a unique opportunity right now in
    the--you know, at the Department of Labor equity is kind of at
    the core of everything that we are doing, and we need to make
    sure, if we want to really come back and build back better, it
    has to be built back better for all people, it cannot just be
    build back better for some communities.
        And so I think we--number one, to answer your question, at
    the Department of Labor, when we start to think about putting
    RFPs (Request for Proposals) out, we start to expand these
    apprentice programs, we also have to put in some
    recommendations on how, and explain to people, how do you get
    people that don't have access to these programs, access.
        So you just got to be intentional about it, bottom line. I
    mean, in Boston, it has worked. I mean, are the numbers great?
    No. Are the numbers better? Yes. So we have to be better than
    we were.

                       IT SOLUTIONS FOR AGING UI SYSTEMS

        Senator Baldwin. During the pandemic Wisconsin's Department
    of Workforce Development really struggled to make timely
    unemployment insurance payments because of outdated computer
    systems.
        Secretary Walsh. Yes.
        Senator Baldwin. And they were a product of years of
    neglect, and frankly, partisan attacks on the unemployment
    insurance program to begin with. I am encouraged to see that
    your budget will provide, again, $100 million specifically for
    IT solutions that can be deployed in the State. And this money,
    I think will be well spent in Wisconsin. But I was also
    interested in learning more about the first comprehensive
    update in decades to the formula that determines the funding
    States received to administer unemployment.
        Can you provide more information on the proposed changes to
    the formula? And is this something that the Department expects
    to undertake administratively? Or do you think you are going to
    need changes to authorizing language?
        Secretary Walsh. Well, first of all, thank you for bringing
    this up. Because as I was prepping for this hearing, most of my
    prep was about--around unemployment insurance, so I thank you
    for bringing it up. I think that a lot of what we can do,
    Department of Labor, is working, going to be working with
    States and territories to be able to look at what investments
    are needed in those different areas.
        We are using the funds that--through the American Rescue
    Plan to tackle the most acute problems that the systems have
    been facing for a long time. There are kind of four key
    priorities, which I will touch upon: one is sending teams to
    States to provide intensive technical assistance that is first
    and foremost, really finding out, because every State system is
    a little different on how they operate, and their computer
    systems are completely different. We are going to provide
    States with direct assistance and experts, to learn about the
    challenges, and to begin to help immediately on what we need to
    do. So that is one space.
        Second is a focus on ID verification, and looking in that
    area. A third is modernizing technology, probably one of the
    biggest things that we have an issue with is technology, and
    States are running on incredibly antiquated systems that they
    have had for 30, 40, 50 years; and then a direct grant to
    States to help them solve the challenges that they have in the
    system.
        I mean, reforming the united system will do a lot. Number
    one, as you mentioned at the very beginning, at the beginning
    of the pandemic people had problems accessing the benefit. They
    couldn't get in. They were waiting, and they were waiting on
    Zoom, they were waiting in the line, they were waiting and they
    couldn't get through.
        So creating a platform, a system, when somebody needs
    unemployment, they can either sign up online, or get a phone
    call. They can get in; number one.
        Number two; it is also the fraud piece of it. Lots of--
    there was lots of organized crime and fraud with the UI system
    where millions and billions of dollars were taken that should
    have gone to people. Again, that will address the fraud.
        So we are going to have a comprehensive approach moving
    forward. We are being very, very, focused on how we administer
    this program, and how we move forward.
        Senator Baldwin. Okay. And if you can follow up with some
    more information about the formula changes that are being
    undertaken, that would be great.
        Secretary Walsh. Yes. I will get back to you. Thank you.
        Senator Murray. Thank you very much.

              BUDGET INCREASES FOR WORKFORCE DEVELOPMENT PROGRAMS

        Mr. Secretary, the budget request includes significant
    increases in funding across the workforce development program,
    and like COVID itself, the economic impacts of the pandemic
    issue now have fallen disproportionally on the most vulnerable,
    including women, workers with low incomes, workers of color; so
    the investments in this budget would help our economic
    recovery, but also address changing workforce needs that were
    apparent actually long before COVID; such as the transition to
    clean energy, and the development of other in-demand industries
    and sectors.
        Can you talk to us about why the increases in workforce
    development programs are so important right now, and
    specifically what this budget does to address inequities in our
    workforce programs?
        Secretary Walsh. Yes. Let me try and do a better job than
    the first time I was asked the question. Most people here today
    that have asked me a question have discussed either, the
    underemployment of people, or the lack of ability to get into a
    better paying job. What the pandemic--we have known this before
    the pandemic--but what the pandemic has really shown is that we
    are in a crossroad in our country, and we have an opportunity
    to create a platform for people to get into the middle-class.
        President Biden's ``Build Back Better'' plan, not the plan,
    but build back better, the words ``build back better'' when he
    talked about in the very beginning before there were any plans
    associated with that, was about creating opportunities and
    pathways into the middle-class, that people wouldn't have to
    live in poverty, people wouldn't have to worry about
    unemployment, people wouldn't have to worry about not having
    healthcare, and child's care, daycare, education, all of that.
        And what our workforce investments are--what we are asking
    for in this budget, and what we want to do with our workforce
    investments in the Department of Labor, in this budget, is to
    continue to advance what the President's agenda is, what we all
    want to do moving forward. And so for every dollar that we
    spend, with all due respect to one of the Senators today, for
    every dollar that we spent in workforce development, it is an
    investment in the future of America's workforce. And it is an
    opportunity.
        Ranking Member Blunt mentioned new emerging tech--new
    emerging industries, those industries right now, a lot of them,
    are just for college graduates. They are going into cities like
    Boston, and they are grabbing up college graduates, but they
    have more opportunities than they have people to work in those
    jobs. And when I--when you talk to those CEOs, and the people
    that create those companies, what they say is that we can train
    the workforces to work in those industries. We don't need to
    have a college degree, or a Ph.D, or a law degree.
        So we have a unique opportunity right now. So the
    investments that I am asking this committee to support, and I
    am going to be asking the Full Senate and Congress to support,
    are investments we are making in the future of American
    workers.
        We don't want the same-old, same-old Department of Labor,
    where we are going to be giving grants to States and States
    will be taking the money and maybe doing something with it.
    What we want to do is make sure that these investments are
    going in the right places so we can continue the opportunity to
    get our--your constituencies, my constituents into good-paying
    jobs.
        That is the opportunity in front of us at this particular
    moment in time. And I think that nobody wants to go back to the
    old way. I think it is important for us, we continue to make
    investments in American people for those jobs.

                              COMBATING WAGE THEFT

        Senator Murray. Okay. There are workers around the country
    right now, as you well know, trying to support their families,
    make ends meet, but they are being denied the unacceptable--or
    the unacceptably low Federal minimum wage, overtime pay, or
    both. And it is clear more needs to be done to ensure workers
    received the wages that they actually earn. And it is the Wage
    and Hour Division's job, as you know, to investigate these
    cases and recover back wages and damages on their behalf. Can
    you talk to us about how your Department would use the $30
    million increase that you have requested for Wage and Hour, to
    address wage theft or increased back pay recovery, particularly
    for our vulnerable workers?
        Secretary Walsh. Yes. First and foremost I want to--again,
    I wanted to just thank you for the American Rescue Plan because
    we have made some investments there as well in Wage and Hour,
    and we are building back up where we were a previous--to
    previous levels. The investments that we want to invest there,
    again it goes back to thinking about the Department of Labor in
    a different way, as far as, the way I view the Department of
    Labor is we represent workers in the morning, in the afternoon,
    and at night.
        And we represent workers in all different levels, whether
    it is security on the job site, safe retirement, and safe
    working conditions. So what we want to do in Wage and Hour is
    make sure that we truly make an opportunity for people that are
    being shortchanged or not getting their wages that they earn
    and deserve, that we have the proper opportunity for
    investigation to go in and investigate any cases out there, so
    we are able to follow up, and get people's back wages.
        If you look at the Department of Labor's website, every day
    we have another case where we are able to recoup benefits of
    people that lost their money.
        Senator Murray. Thank you.
        Senator Blunt.
        Senator Blunt. Thank you. Thank you, Chair.

       ALLEVIATING LICENSING RESTRICTIONS FOR MILITARY WORKERS AND THEIR
                                    SPOUSES

        The President on Friday released an executive order that
    encourages the FTC (Federal Trade Commission) to ban
    unnecessary occupational licensing restrictions. I have been
    particularly involved in that as it related to returning
    veterans who bring skills back with them, or veteran spouses or
    military spouses who are going from one State to the next. What
    are you doing? And what do you think we can do to encourage
    more cross-State collaboration in licensing, and to eliminate
    needless barriers for licensing, particularly for those people
    who in some way have either been in the military, or have
    spouses in the military?
        Secretary Walsh. Yes. I don't have a direct answer for you
    to that question, but my past understanding of being in the
    legislature, or in the City of Boston as the mayor, it is a
    concern because people would come to our city and they would
    want to work in a certain industry, and the license was not
    recognized in the City of Boston.
        And there was an ability at the State level to get a
    waiver, but it is something that I don't have enough
    information on, and I will look into it. But I definitely think
    that, particularly military families, as military families they
    are not in--I have a cousin that is in the Coast Guard. In the
    last 10 years he has spent time in San Diego, up in Portland,
    Maine, he has been all over the country because he gets shifted
    from base to base every 3 years.
        Senator Blunt. Right.
        Secretary Walsh. So again, you know, if he had a career
    that, a side career that had a license, he needed to get that.
    So let me--I will work on that with you. I don't have the
    direct answer for you on that.
        Senator Blunt. Let us work on that. I think the executive
    order clearly heads in the right direction, but let us work on
    what we can do now. That is largely a State and a local
    determination. Up until this point many of the States,
    including Missouri, are moving in the direction of making it
    much easier. We just, I think our first military spouse that
    got an immediate license when she came to this State, was a
    lawyer, who, within a few days of moving to Missouri with her
    husband who was at Fort Leonard Wood was practicing law. And
    the more of that sort of thing, whether it is a lawyer, or a
    beautician, or an electrician, or----
        Secretary Walsh. A teacher.

                             INCREASE IN H-2B VISAS

        Senator Blunt [continuing]. A commercial truck driver,
    whatever those licenses are, I want to work with you on that.
        In another area, I was pleased to see the Department, in
    conjunction with the Department of Homeland Security, announce
    the availability of an additional 22,000 H-2B visas, provided
    for in the 2021 Omnibus Bill. You know, these H-2B visas are, a
    lot of them in hospitality, and landscaping, in timber.
        In our State, I see those generally as jobs that actually
    protect the other jobs that are there, coming in, filling a
    part-time gap that allows the full-time Missouri resident
    employees to have a job that they wouldn't have, if the hotel
    couldn't be open, or that they wouldn't have if all of the
    landscaping work that needs to be done at a given time,
    couldn't be done.
        I don't want a detailed answer from you here today, but I
    would like you to commit to working with this subcommittee to
    guarantee that the program has sufficient returning workers to
    meet the seasonal needs of our small businesses, and our local
    industries. And fishing would be one of those industries in
    coastal areas. Senator Mikulski and I used to work closely on
    this particular issue.
        Would you be willing to continue to work with us on this,
    Secretary?
        Secretary Walsh. Yes. There is no question about that. And
    not only that, I think that this program also benefits the
    people that are coming here, working and taking back home, the
    revenue back home to their families. And I think that that also
    is a kind of a win-win for all sides. So I certainly will
    continue to work with you on that.

               FUNDING FOR THE APPALACHIAN AND DELTA COMMISSIONS

        Senator Blunt. Another area I mentioned in my opening
    comments was that your budget request included a $35 million
    set aside to serve workers in the Appalachian and Lower
    Mississippi Delta regions, that we began funding in 2018. I was
    the Chairman of the committee at the time, and Senator Murray
    was the ranking member, and that funding has created, and will
    create employment opportunities by providing reemployment and
    training assistance in areas where they are needed.
        Can you speak to the success of the grants in this area,
    these regional commissions, like the Appalachian Regional
    Commission, and the Delta Regional Commission?
        Secretary Walsh. Certainly. I mean, there is no question
    that these grants are beneficial to those areas of the country
    and, you know, I hear, the feedback I get from the Department
    of Labor, from the workforce development side of it, is that a
    lot of these different areas want increased grants, and
    opportunity to access to grants. So it is beneficial. And that
    is why the additional revenue that I am looking for in some of
    this workforce development and grant money will allow us the
    opportunity to make more investments in those areas.
        Senator Blunt. Thank you, Secretary.
        Chair, I think that I will have some more questions for the
    record. But I believe those are, at this point, at least all
    the questions I have for the hearing today.
        Senator Murray. Very good.
        Senator Braun.

                        OSHA ENFORCEMENT BUDGET INCREASE

        Senator Braun. Thank you, Madam Chair.
        And good to see you, Mr. Secretary, enjoyed our
    conversations in the past. And, you know, I come from the
    business world, and especially small business, and I have been
    able to see our business grow over the years, and interface
    with all the things you have to do with government. And I have
    always felt an inherent responsibility to do things right, keep
    your employees safe, that that is part and parcel of growing an
    enterprise.
        I noticed where there is a request for $350 million
    increase in enforcement funding, and would be curious, I tried
    to get the information what that is on top of already, and is
    it related to. I know maybe during the Trump administration,
    which I welcomed, a lot of easing up on certain stuff that
    maybe was in overdrive, still acknowledging that many things
    need to be in place to keep a safe environment, to keep a safe
    workplace.
        Has there been an uptick in OSHA-related cases that would
    warrant that kind of increase that would be targeted towards
    enforcement?
        Secretary Walsh. That is a great question. The problem we
    have with OSHA is that we have seen an increase in cases, and
    we have also seen a decrease in OSHA inspectors. So I guess the
    answer is: that we are seeing increased potential problems, and
    we have fewer people to go out and investigate those problems.
    So we have a lot of our cases that are going kind of, I guess,
    unchecked, if you will.
        Again, as I said earlier, before you came in Senator, this,
    I would like to get OSHA to a point where it is not just going
    out and seen as a ``gotcha'' organization. I mentioned, when I
    was a younger person, I worked on construction, and OSHA would
    come out to the job site, and not because they are out there
    because of an accident, they are out there to make sure that
    there was proper safety procedures in place in construction,
    which is dangerous, as you know.
        I would like to get OSHA back where we are doing a lot more
    collaboration of working with businesses to make sure we create
    work--safe work sites across America, rather than having to
    respond to a tragedy. And we are not there yet. So the increase
    that we are looking for is to build back the OSHA Department,
    and build back the Department of Labor to pre--you know, the
    last 5 years we are down, the lowest amount of inspectors, I
    believe, in the history since the beginning of the Department
    of Labor, we are at the lowest number right now.
        Senator Braun. So what I would like, and you can get that
    to our office, would be: what the number of enforcement issues
    have been from 5 years ago to the present, what the funding
    levels were each year, to make sure it might get related to
    that in some fashion.

             OSHA ENFORCEMENT IN LARGE BUSINESS VS. SMALL BUSINESS

        And then also I would want to bring up the distinction
    between large business and small business. And NFIB (National
    Federation of Independent Business Inc.) has been out there
    with so many stats that have shown that small businesses have
    been decimated, challenged with COVID, some of the things they
    had to do there that was on top of what they have to normally
    do to move forward and prosper. And I have also been an
    observer there. The smaller your business is, normally, the
    more intimate that relationship is with your employees.
        So again, I would like to know whether the Department
    currently differentiates between how it looks at enforcement
    among big businesses versus small businesses. And to see if
    there is a distinction in how you carry out those functions.
        Secretary Walsh. Yes. Let me get back to you on that one. I
    don't have the answer for you.
        Senator Braun. Yes.
        Secretary Walsh. But I understand here what you are saying.
    And when you talk about small businesses, you are not
    necessarily talking about the three-person mom-and-pop store,
    you are talking about the 200-person store and----
        Senator Braun. I would give it 500 and fewer.
        Secretary Walsh. Yes.
        Senator Braun. And it is that----
        Secretary Walsh. So let me get back to you on that.
        Senator Braun. Yes.
        Secretary Walsh. Because I understand, I recognize the fact
    that there is a big difference between a small business and a
    corporation.
        Senator Braun. Especially 50 and under.
        Secretary Walsh. Yes.
        Senator Braun. But let us take the common definition, and
    whatever is being done in the future, I would want to make sure
    it is based upon the need to do it, number one, especially in
    the context of scarce resources. So much of what we are doing
    today and not just after the Biden administration took over,
    because we do it on borrowed money on anything that we do
    enhance in a budget. And I think that will come into question
    in the long run as well.
        So if you could get back to my office on those two
    particular pieces of information, I would appreciate it.
        Secretary Walsh. I definitely will.
        And I was at the Indy 500 the other day, I went around the
    track, it was pretty amazing.
        Senator Braun. Yes. And that is a kind of, I guess, a big
    version of a small business.
        Secretary Walsh. Yes. It certainly is.
        Senator Braun. Right in my home State.
        Secretary Walsh. It certainly is. It was interesting. It
    was fun.
        Senator Braun. Yes. Okay. Thank you.
        Secretary Walsh. Thank you, Senator.
        Senator Murray. Thank you very much.
        That will end our hearing today, Mr. Secretary; and our
    hearings on President Biden's Budget Proposal for fiscal year
    2022.
        I want to thank all of our fellow committee members for
    their participation.
        Secretary Walsh, thank you for your very thoughtful
    answers. I look forward to continuing to work together with you
    to fight for workers, and build a stronger, fair economy for
    everyone.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due Friday, July 23 at 5 p.m.
    The hearing record will also remain open until then for members
    who wish to submit additional materials for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                  Questions Submitted to Hon. Martin J. Walsh
                  Questions Submitted by Senator Patty Murray
                     whistleblower complaints and staffing
        Question. I'd like to follow-up on my question about OSHA's
    whistleblower program. Last year's Inspector General report described
    the significant increase in complaints and insufficient staff to
    investigate those complaints during the pandemic.
        Please describe the impact of complaints not being timely and
    effectively investigated and the steps planned and being taken to
    address this issue.
        Answer. Over the past several years, OSHA has experienced a
    significant increase in new whistleblower complaints being filed, while
    the level of staffing has remained steady. This, coupled with new
    whistleblower statutes added to the agency's growing portfolio,
    including statutes unrelated to worker safety and health, has resulted
    in a significant increase in the inventory of outstanding
    investigations, with many going on for extended periods of time
    (overage/backlog cases). These factors have created a lag time in
    completing investigations and making agency determinations based on the
    merits of the complainants' allegations. With the onset of the
    coronavirus pandemic (with more than 5,500 COVID-19-related
    whistleblower complaints filed so far), the additional increase in new
    filings and subsequent backlog inventory have limited the agency's
    ability to complete investigations in a timely manner. If OSHA does not
    have sufficient resources to meet quality and efficiency standards for
    its whistleblower investigations, and is unable to review all
    complaints alleging workplace retaliation, the agency cannot properly
    protect employees' rights to engage in protected activity and prevent
    retaliation.
        OSHA has taken many steps to address the challenge of achieving a
    reasonable balance between an investigation's timeliness and quality in
    order to handle its whistleblower inventory more efficiently and
    effectively. First, the agency instituted a pilot program whereby the
    agency conducted two rounds of assignments of complaints across
    regional boundaries, allowing for regions with a lesser workload to
    assist regions with a higher workload, focusing on establishing a more
    reasonable workload balance nationwide. OSHA is actively exploring
    other avenues to address backlogged inventory, both nationally and
    regionally. Second, the agency is overhauling the Whistleblower
    Investigations Manual (WIM) to streamline procedures without
    compromising case quality. OSHA instituted a new Pilots Directive that
    allows for innovative ideas and suggestions to be `tested' to see if
    added efficiency is gained and successful pilots are incorporated into
    the WIM and made national policy. Third, OSHA developed an
    investigative checklist to ensure that key investigative steps are
    followed, establishing clear and effective case monitoring during the
    final stages of an investigation, and thus ensuring that the quality of
    the investigation is maintained. Finally, OSHA is actively hiring
    additional whistleblower staff to assist not only in addressing the
    inventory of backlogged cases but also the total inventory of cases, by
    promptly processing and investigating new complaints so they don't
    become overaged. The agency's fiscal year 2022 budget request also
    includes a requested increase 63 FTE and $5.3 million to provide
    additional whistleblower staff to meet the workload demands.
        OSHA will also continue to engage its stakeholders with meetings
    throughout the year. These meetings provide a forum for the public to
    offer suggestions and comments on ways the agency can improve the
    whistleblower program. This will allow OSHA an opportunity to go beyond
    the protection of individual whistleblowers by increasing outreach
    efforts through the Whistleblower Outreach Plan in an effort to educate
    employers about their responsibilities and employees on their rights
    afforded under the statutes OSHA enforces. The agency will focus its
    outreach efforts on industries with the highest, as well as the fewest
    number of complaints filed, whistleblower protection provisions of the
    newest statutes enacted, and vulnerable populations least aware of
    worker protections while also continuing to promote the ``Recommended
    Practices for Anti-Retaliation Programs'' guidance for employers. This
    document outlines the steps recommended for employers to establish a
    workplace where employees feel comfortable raising concerns, without
    fear of retaliation. In turn, the employer benefits from improved
    employee morale and productivity, as well as the likelihood of fewer
    whistleblower complaints being filed by its workers.
        Question. How would the American Rescue Plan Act funds, additional
    funds requested in the fiscal year 2022 budget and policy changes
    address a recommendations made by the Office of Inspector General to
    more equitably distribute whistleblower complaints amongst
    investigators, and provide consistent enforcement of whistleblower
    rights among the regions.
        Answer. OSHA will use the funding received under the American
    Rescue Plan Act to address COVID-19 related whistleblower complaints.
    OSHA published the COVID-19 National Emphasis Program, which
    prioritizes investigating employers that retaliate against workers for
    complaints about unsafe or unhealthy conditions, or for exercising
    other rights protected by Federal law. OSHA plans to spend $13,079,000
    to support 32 FTE in the Whistleblower budget activity, including 25
    investigators over the course of the three-year supplemental. Funding
    would also support seven national and regional whistleblower staff to
    address evolving policy issues, and provide required high level review
    of the growing number COVID-19 retaliation claims received by the
    agency, with more than 5,500 COVID-19-related whistleblower complaints
    filed so far.
        In fiscal year 2022, OSHA is requesting $24,999,000 and 185 FTE,
    which includes a program increase $4,100,000 and 50 FTE for
    whistleblower investigators to effectively enforce 25 whistleblower
    statutes, including the recently added Criminal Antitrust Anti-
    Retaliation Act and the Anti-Money Laundering Act. In addition to
    investigators, OSHA is requesting a program increase of $1,243,000 and
    13 FTE to support the Alternative Dispute Resolution (ADR) Program,
    policy development and review, and appropriate management support for
    the Whistleblower Protection Program (WPP). As part of the effort to
    build a stronger whistleblower program and have the necessary level of
    resources to support the significant number of whistleblower statutes
    the agency has been mandated to enforce, OSHA will make sure that every
    worker, especially those in vulnerable and underserved communities,
    knows about their rights and what to do if they believe their safety
    and health is not being protected. The agency is committed to ensuring
    that every worker is protected and feels empowered to raise concerns
    when they feel their workplaces are unsafe.
        The additional investigators requested in fiscal year 2022 will be
    distributed throughout the agency's regional offices with a focus on
    preventing an increase in the backlog of complaint investigations while
    also reducing the overall inventory of pending investigations. The
    requested resources will help OSHA keep up with the high demand, and
    ensure that workers' concerns are properly and thoroughly processed and
    responded to as expeditiously as possible.
        OSHA has taken many steps to address this challenge of achieving a
    reasonable balance between an investigation's timeliness and quality in
    order to handle its whistleblower inventory more efficiently and
    effectively. First, the agency instituted a pilot program whereby the
    agency conducted two rounds of assignments of complaints across
    regional boundaries, allowing for regions with a lesser workload to
    assist regions with a higher workload, again, focusing on establishing
    a more reasonable workload balance nationwide. OSHA is actively
    exploring other avenues to address backlogged inventory, both
    nationally and individually by Region. Second, the agency is
    overhauling the Whistleblower Investigations Manual (WIM) to streamline
    procedures without compromising case quality. OSHA has instituted a new
    Pilots Directive that allows for innovative ideas and suggestions to be
    `tested' to see if added efficiency is gained--those successful pilots
    are incorporated into the WIM and made national policy. Third, OSHA
    developed an investigative checklist to ensure that key investigative
    steps are followed, establishing clear and effective case monitoring
    during the final stages of an investigation, and thus ensuring that the
    quality of the investigation is maintained. Lastly, the agency is
    actively hiring additional staff to assist not only in addressing the
    inventory of backlogged cases but also the total inventory of cases, by
    promptly processing and investigating new complaints so they don't
    become overaged.
        In addition, with new fully trained staff in place, along with new
    staff requested in the fiscal year 2022 Budget Request, OSHA will
    continue to streamline its processes by developing alternative
    procedures through piloted programs and strategies that are evaluated,
    found to be effective, and implemented nationwide. Specific focus will
    continue to be placed on backlog reduction strategies to reduce the
    inventory of overaged cases. Additionally, OSHA will continue its
    efforts to expand the use of the Alternative Dispute Resolution (ADR)
    Program, which has proven to be an effective strategy to efficiently
    process complaints/cases in a timely manner and with positive results.
    With the delegation of two additional whistleblower laws in fiscal year
    2021, the Anti-Money Laundering Act (AMLA) and the Criminal Antitrust
    Anti-Retaliation Act (CAARA), OSHA plans to conduct training on the
    investigative processes concerning these new laws for its staff in
    fiscal year 2022, as done with the Taxpayer First Act (TFA) in fiscal
    year 2020. OSHA also plans to develop an Intranet-based Whistleblower
    Investigator (WBI) Resource Page for whistleblower personnel that will
    include technical assistance and answer a myriad of questions presented
    by the field, including those related to COVID-19, which is constantly
    evolving. This will be accessible to all Regions, ensuring nationwide
    consistency. All of the initiatives will be developed and implemented
    to assist the agency in addressing the recommendations made by the
    Office of the Inspector General.
                            davis bacon enforcement
        Question. Mr. Secretary, construction workers across this nation
    rely on the Department's Wage and Hour Division to enforce their right
    to prevailing wages on federally assisted construction projects. As a
    former construction worker, you know as well as anyone that
    construction is hard, dangerous work. These protections ensure the
    Federal Government is creating good jobs with fair pay and bringing
    countless economic benefits to local communities. The workers and
    communities who build our bridges, highways, and other critical
    infrastructure deserve the protections and the benefits prevailing wage
    provides.
        Mr. Secretary--how would your Department use the funds requested
    for the Wage and Hour Division to better enforce the Davis-Bacon Act,
    particularly with respect to working with other Federal agencies to
    ensure compliance?
        Answer. The Davis Bacon Act protects construction workers' rights
    to receive the local prevailing wage and leverages the purchasing power
    of the Federal Government to support local contractors, local workers,
    and local economies. The Department is currently engaged in a
    comprehensive review of its Davis Bacon program including outreach,
    education, compliance assistance in partnerships with contracting
    agencies and enforcement. Additional enforcement resources will allow
    the Wage and Hour Division to put more investigators into the field and
    onto construction sites to make sure workers are getting the wages they
    have earned on Davis Bacon projects.
                        ilab monitoring and enforcement
        Question. Mr. Secretary, my home state of Washington is one of the
    most trade dependent economies in the United States. That's one of the
    reasons I support trade deals with strong labor and environmental
    protections. So, I was pleased to see the budget proposes $124 million,
    an increase of more than $27 million, for the International Labor
    Affairs Bureau. This includes significant new investments for ILAB to
    expand trade-related monitoring and enforcement of labor provisions in
    our trade programs and new resources to investigate the use of forced
    and child labor in global supply chains.
        I know you have dedicated resources for work on our trade agreement
    with Mexico and Canada. However, with 150 international trading
    partners under existing free trade agreements or trade preferences,
    your budget request won't stretch far enough to conduct monitoring and
    enforcement with all of our trading partners.
        How will you prioritize countries for monitoring and enforcement
    activities?
        Answer. DOL is committed to monitoring and enforcing the labor
    provisions in all of our trade agreements and preference programs. Over
    the last year, in addition to creating a new division dedicated to
    enforcing the labor provisions of the U.S.-Mexico-Canada Free Trade
    Agreement, our Office of Trade and Labor Affairs (OTLA) within the
    Bureau of International Labor Affairs has increased the staffing level
    and resources devoted to enforcing labor provisions in the other trade
    agreements and trade programs as well. This has enabled us to intensify
    our engagement with countries with the greatest need. For example, so
    far in 2021, the Department has dramatically increased its work
    allocated to our trade agreement with Central America (CAFTA-DR),
    enabling us to integrate labor enforcement into the important work
    being led by the White House on Central America. Likewise, with the
    preference programs, we are continuing to monitor all countries
    benefiting from the Generalized System of Preferences (GSP) and the
    African Growth and Opportunity Act (AGOA) through the GSP triennial
    assessment and the annual AGOA review. Based on these processes, our
    team prioritizes and engages with key countries in an ongoing manner.
    Both the GSP and AGOA processes consider information from a broad array
    of sources, including U.S. government reporting, international and
    national labor rights organizations, and public comment mechanisms
    included in the preference programs. Our team shares the results of its
    fact-finding, along with recommendations for priority countries, with
    the Trade Policy Staff Committee (TPSC). Subsequent discussions with
    interagency partners further shape OTLA's identification of priority
    countries and inform ongoing strategies for engagement to promote
    progress towards meeting the worker rights eligibility criteria.
        Question. And, how will you partner with the State Department and
    Office of the Trade Representative to ensure the most robust
    enforcement possible of labor provisions in our trade programs?
        Answer. DOL works closely with the Department of State and the
    Office of the U.S. Trade Representative (USTR) in our goal for strong
    enforcement of labor provisions in our trade agreements and trade
    preference programs. DOL engages with key countries through bilateral
    work and is in constant communication with our interagency partners,
    trade partner country stakeholders, and the International Labor
    Organization to maximize our effectiveness in labor enforcement. In
    addition, DOL works with State and USTR in a variety of formal
    mechanisms, such as the Trade Policy Staff Committee (TPSC), labor and
    trade-related working groups such as the CAFTA-DR working groups, and
    Trade and Investment Framework Agreements (TIFAs). For example, DOL's
    Office of Trade and Labor Affairs (OTLA) collaborates with USTR's labor
    office to develop and deliver talking points on labor priorities in
    connection with TIFAs between the U.S. and parties to the TIFA. OTLA
    also convenes regular calls with USTR and State to discuss and share
    updates on priority labor issues, and ensures USTR and State's
    participation on relevant labor-related country briefings.
                                  child labor
        Question. According to the latest report on child labor produced by
    the International Labour Organization and UNICEF, the number of
    children in child labor around the world dropped from 246 million in
    2000 to 152 million in 2016. Unfortunately, this 16-year downward trend
    has been reversed over the past 4 years, increasing to 160 million
    children worldwide in 2020 with nearly half of these children engaged
    in hazardous work.
        Please describe how funds currently available to the International
    Labor Affairs Bureau will be used to contribute to a reversal of this
    increase in child labor.
        Answer. Reversing the upward trend in child labor, as reported in
    the latest ILO and UNICEF global estimates, will require a multi-
    faceted approach. A range of factors have contributed to the
    significant increase in child labor noted in some parts of the world,
    particularly Sub-Saharan Africa. ILAB is increasing its focus on a
    number of key areas where there is a great need and where we can have a
    significant impact. This includes increased focus on global supply
    chains; promoting greater access to social protection, training, and
    education opportunities for vulnerable children and families;
    confronting gender and racial inequity; and strengthening worker voice
    and workers' rights.
        ILAB's Office of Child Labor, Forced Labor and Human Trafficking is
    currently overseeing 46 projects with activities in over 40 countries.
    These projects are addressing root causes of child labor and forced
    labor through research, awareness raising, education, improved
    livelihoods, strengthening labor laws and enforcement, and by
    increasing the capacity of governments and other stakeholders to scale
    up and sustain effective practices for preventing and reducing these
    abusive labor practices. ILAB has also worked with these existing
    grantees to address urgent needs resulting from the global pandemic.
    ILAB has allocated project resources to increase vulnerable groups'
    access to information about the virus, address food insecurity, support
    remote education and training, and provide masks and hygiene resources
    to reduce exposure of vulnerable children and workers. ILAB is also
    deeply engaged in addressing child labor and forced labor in Sub-
    Saharan Africa, with over $40 million in active programming in the
    region, including more than $18 million in new programming awarded in
    2020 addressing child labor in key supply chains such as cobalt, cocoa,
    and mica. These projects include a focus on issues of gender equity and
    the need for enhanced monitoring and remediation. With fiscal year 2021
    funds, ILAB is also currently in the process of funding new projects
    that will address some of the key gaps identified in the ILO-UNICEF
    report. For example:
      --In Malaysia, ILAB is funding a $5 million project to combat forced
            labor and child labor by increasing advocacy by workers and
            civil society in the production of palm oil and garments,
            worker voice in the implementation of a social compliance
            systems, and workers access to remedies in these sectors.
      --In El Salvador, Guatemala, and Honduras, a $7 million ILAB-funded
            project will build civil society and workers organization
            capacity to address child and forced labor and other
            unacceptable conditions of work, promote greater gender and
            racial equity, and address the needs of some of the most
            vulnerable populations in these countries, including persons of
            African descent and indigenous communities.
        Moreover, as part of our efforts to achieve a larger and more
    sustainable reduction in child labor and forced labor, ILAB will
    actively engage with governments, the private sector, worker
    organizations, civil society actors, other donor governments, and
    international organizations to promote the replication of effective
    practices. ILAB will call on governments to mainstream child and forced
    labor elimination strategies into broader social initiatives as a way
    to take to scale strategies that can help to reduce the vulnerability
    of children, families, and workers to abusive labor practices. ILAB
    will also continue to use its flagship reports on child labor and
    forced labor to urge governments to take specific action to reduce
    these abusive labor practices.
        Question. How would resources requested in the fiscal year 2022
    budget build on and learn from prior investments?
        Answer. From more than 25 years of experience funding international
    child labor projects and contributing to significant strides in the
    fight against child labor, we have learned that our most successful and
    impactful initiatives are those that adopt a holistic approach, based
    on a broader rights-based ecosystem that places workers and vulnerable
    communities at the center. We have also learned that it is critical to
    create the right incentives for governments and businesses to take
    actions to address child labor and forced labor, particularly in global
    supply chains.
        In fiscal year 2022, ILAB will focus its programming on addressing
    the persistence of abusive labor practices in supply chains, including
    through the funding of research to trace goods through supply chains
    and targeted action to increase workers' voice in the monitoring of
    labor rights abuses. Rigorous research and reporting can help us hold
    both governments and corporations accountable for goods produced by
    forced labor and child labor throughout the supply chain. We will also
    support projects that help address decent work gaps, as child labor
    tends to persist where adult workers cannot exercise their rights at
    the workplace, especially the rights of freedom of association and
    collective bargaining. Another critical element of ILAB's approach will
    be to promote good practices and the expansion of social protection
    schemes that build social safety nets for vulnerable communities where
    labor abuses are most prevalent (e.g., in rural areas, in agricultural
    sectors). ILAB will also increase support for workers in informal
    sectors, where vulnerability to labor exploitation is more pronounced,
    as noted in the new ILO-UNICEF global child labor estimates, including
    through support for informal worker organizations. ILAB's increased
    focus in these areas will be particularly important in addressing the
    significant increase in child labor in Sub-Saharan Africa, as well as
    the persistence of child labor in other parts of the world. Finally,
    ILAB will partner with other donors and organizations to leverage our
    resources and experience and support our goal for the replication and
    scaling up of good practices to achieve the broader impact needed.
        ILAB will continue to use evidence to inform action, drawing upon
    our own research and reporting on forced and child labor as well as
    lessons learned from past and current projects. ILAB's research serves
    as an essential knowledge base for ILAB's technical cooperation
    projects, helping ILAB focus its technical assistance in areas where it
    is most needed and where it can have the greatest impact. ILAB also
    relies on external evaluations of our projects, which systematically
    assess the relative effectiveness of different approaches or
    combination of approaches. ILAB uses good practices, identified through
    project experience and project evaluations, as a way to leverage
    learning to promote greater impact in the countries where we work. The
    following are just a few examples of the impact of ILAB's strategic
    approach:
      --In Uzbekistan, our strategy of consistent, multi-year diplomatic
            engagement coupled with programming on a broad labor rights/
            decent work agenda helped achieve a radical reduction in the
            country's use of forced labor in the cotton sector;
      --In Honduras, we have used a multidisciplinary approach--research on
            labor issues, monitoring, and technical assistance and
            cooperation--to holistically and sustainably advance labor
            rights, including child labor, freedom of association,
            collective bargaining, minimum wages, hours of work, and
            occupational safety and health (OSH). With support from an
            ILAB's project, three Honduran cooperatives that export coffee
            to the United States implemented a sustainable social
            compliance system to reduce the prevalence of child labor in
            their supply chain.
      --In Mexico, we have focused research and technical assistance
            efforts in the agriculture sector and on goods where there is
            high risk of child labor, forced labor, and other labor
            violations. ILAB has used strategic engagement to empower
            workers and civil society organizations to advocate for
            increased access to education and social protection services
            for children at risk of child labor, their families, and
            migrant workers.
        Question. What are the specific plans to address the worst forms of
    child labor in the cocoa supply chain in West Africa and build on prior
    investments made toward this objective?
        Answer. The recent release of the ILAB-funded, NORC (formerly the
    National Opinion Research Center at the University of Chicago) report
    on child labor in cocoa-growing areas of Cote d'Ivoire and Ghana
    underscores the significant challenges remaining in the sector. ILAB
    recognizes that moving toward large-scale reduction of child labor in
    the cocoa supply chain will require securing a commitment to broader
    action by the two West African governments and the International
    Chocolate and Cocoa Industry, including to improve labor monitoring,
    better regulate the sector, and expand remediation efforts. Current
    ILAB programming is supporting efforts to build the capacity of cocoa
    cooperatives to enhance child labor monitoring in the cocoa supply
    chain and facilitate enforcement of child labor laws. ILAB is also
    funding programming to help law enforcement, private sector due
    diligence monitors, social service and civil society organizations, and
    workers themselves to prevent, detect, and eliminate forced labor and
    labor trafficking in supply chains.
        During the most recent meeting of the Child Labor Cocoa
    Coordinating Group (CLCCG)--a group established in 2010 under the
    Declaration and Framework-- in May 2021, the Governments of Cote
    d'Ivoire and Ghana, the International Chocolate and Cocoa Industry and
    ILAB agreed on the need to continue to coordinate on joint efforts to
    reduce child labor in the cocoa sector. ILAB is currently engaged in
    dialogue with the two governments and industry on ways to (1) expand
    this partnership to include other donor governments (e.g., the E.U.)
    and organizations; (2) promote more active engagement with worker
    organizations and civil society actors; (3) expand the scope of efforts
    to include a greater focus on forced labor and human trafficking and
    the advancement of decent work; (4) take good practices to scale and
    increase support to children and families in more remote areas where
    NORC research found the most significant increase in child labor; and
    (5) increase transparency and develop and report more regularly on
    indicators of progress.
        ILAB will also continue to report on child labor and forced labor
    in Cote d'Ivoire and Ghana in its three flagship reports--the Findings
    on the Worst Forms of Child Labor, the List of Goods Produced by Child
    Labor or Forced Labor, and the List of Products Produced by Forced or
    Indentured Child Labor. In addition, ILAB continues to engage in active
    dialogue with other U.S. government agencies, such as the State
    Department, USAID, USDA, MCC, and DHS/CBP on efforts to combat child
    and forced labor in the cocoa sector and potential opportunities for
    enhancing interagency coordination and collaboration.
                               ofccp enforcement
        Question. Mr. Secretary, the Department of Labor plays a unique and
    vital role in Federal contracting policy through the Office of Federal
    Contract Compliance Programs to protect workers' rights on jobs created
    by Federal contracting. These critical protections ensure the Federal
    Government is creating a fair and safe workplace when it does business
    with the private-sector. And I'm pleased to see that the Biden
    Administration has placed such a substantial emphasis on these
    protections, including a guarantee of a $15 an hour minimum wage.
        Mr. Secretary--how would your Department use the funds requested
    for OFCCP to vigorously enforce anti-discrimination, safety, pay, and
    other important protections for workers on Federal contracts?
        Answer. OFCCP would use the $140,732,000 in funds requested for
    fiscal year 2022 to rebuild its workforce, strengthen its enforcement
    to remove systemic barriers to equal opportunity, advance workplace
    equity, increase contractor accountability, and invest in its
    technological infrastructure. An investment of critically needed
    resources will enable OFCCP to play a powerful role in advancing
    President Biden's commitment to equity by addressing employment
    inequities that have denied opportunities to vulnerable workers.
    Rebuilding Workforce
        The fiscal year 2022 OFCCP funding request is $140,732,000 and 639
    FTE. This includes a program increase in the amount of $34,756,000 and
    188 FTE to rebuild OFCCP's workforce. Over the past 4 years, OFCCP's
    staffing levels have dropped significantly. In fiscal year 2020, OFCCP
    operated with a staffing level of 452 full-time equivalents (FTE)
    compared to 755 in fiscal year 2011.
    Strengthening Enforcement
        Specifically, the agency will focus on identifying ways to
    strategically allocate our limited resources on comprehensive
    compliance evaluations that identify and remedy systemic issues
    including in hiring and pay, especially as our economy begins to
    rebuild. Our approach has often been data driven to identify
    disparities, but OFCCP is interested in developing strategic approaches
    to identify issues that do not lend themselves to the same kinds of
    statistical analysis, such as discrimination against workers with
    disabilities and LGBTQ+ workers.
        OFCCP will also focus on reinvigorating its compliance program for
    Federal construction contractors and subcontractors and federally
    assisted construction contractors and subcontractors. This effort will
    be instrumental for the Department to ensure equal employment
    opportunity for good jobs in the construction industry. OFCCP plans to
    launch an outreach and education campaign to advance equity in
    construction contractor workplaces and to educate workers of their
    rights under the mandates enforced by OFCCP.
        On its regulatory agenda, OFCCP listed its intention to modernize
    its supply and service regulations. OFCCP is interested in updating its
    requirements to align them with the realities of today's workforce and
    how employers operate. The agency is considering how it can streamline
    its processes and reduce unnecessary burdens on contractors while
    ensuring OFCCP can comprehensively address indicators of discrimination
    across all its authorities.
    Workplace Equity Initiative
        The funding request would support OFCCP developing a comprehensive
    initiative to advance all forms of equity at work. President Biden has
    made a historic commitment to advancing equity, prioritizing it as a
    key pillar of his Administration. OFCCP has a critical opportunity to
    work with a broad coalition of stakeholders in the pursuit of a common
    goal--to eliminate discrimination in the workplace and proactively
    advance equality of opportunity for all workers, including women,
    people of color, LGBTQ people, people with disabilities, veterans, and
    people belonging to multiple protected classes.
        The purpose of this initiative is to identify promising practices,
    evidenced-based research, and innovative initiatives that can lead to
    more diverse, equitable, and inclusive workplaces that increase equity
    in employment opportunities. In particular, the initiative will focus
    on examining employment practices that have been effective in closing
    pay gaps, increasing the recruitment and hiring of underrepresented
    workers, and facilitating the promotion of underrepresented workers
    into senior-level and executive positions.
    Technology Modernization
        In fiscal year 2022, OFCCP will continue to prioritize expediting
    the modernization of its technology to promote greater employer
    compliance while maximizing the efficiency of agency staff. This
    includes completing OFCCP's Compliance Management System (CMS)
    development and deploying the Notification Construction Award Portal
    (NCAP), which allows Federal procurement officers, States, and
    construction contractors and subcontractors to electronically notify
    OFCCP of constructions awards valued at $10,000 or more. This IT
    modernization effort centralizes the notification process in the
    national office, increasing field efficiencies by relieving staff from
    having to manage contract award notifications
        Question. Please describe your hiring plans for the proposed
    investments in OFCCP included in your budget request.
        Answer. This funding request specifically supports the hiring,
    retention, and training of a highly qualified and diverse workforce to
    support OFCCP in advancing its mission through enforcement, outreach
    and education, stakeholder engagement, and compliance assistance while
    emphasizing efficiency, productivity, and accountability throughout the
    organization. The support for additional staff will enable OFCCP to
    strengthen its capacity to conduct compliance evaluations, and identify
    and resolve instances of systemic discrimination in hiring and pay.
        OFCCP is actively hiring to fill critical vacancies the agency lost
    over the course of several years, especially compliance officers. OFCCP
    is strengthening its internal capacity to support the hiring surge by
    filling the vacant HR Branch Chief position and hiring additional
    management analysts to support the agency's hiring and employee
    engagement needs. To expedite the hiring process, OFCCP is utilizing
    standardized position descriptions, single vacancy announcements for
    multiple positions at various locations, and an array of hiring
    authorities, including the Recent Graduate authority for entry level
    positions. In addition, OFCCP encourages its employees to share
    announcements through their professional and social networks. OFCCP is
    also working with OHR to reach a diverse talent pool for its vacancy
    announcements.
        OFCCP is developing several new training courses and resources for
    its compliance officers. With the recent OMB approval of the
    construction scheduling letter and the upcoming release of the
    construction scheduling list, OFCCP will ensure that its compliance
    officers are fully trained to handle construction compliance
    evaluations in the most efficient and effective manner. This training
    is scheduled to commence prior to the release of the scheduling list.
        OFCCP is also developing training for new compliance officers. The
    training will cover the foundational topics a new compliance officer
    must know in order to successfully start performing their job, such as
    relevant legal authorities, policies, enforcement authorities,
    compliance evaluations, complaint processing, and compliance
    assistance. This training will be ongoing for all cohorts of new
    compliance officers as the agency continues to hire.
        The training OFCCP provides to its compliance officers allows them
    to communicate agency standards and processes through compliance
    assistance and apply those standards and processes during compliance
    evaluations and complaint investigations. A uniform training program
    ensures consistency in training across the regional offices, which is
    critical in following OFCCP's regulations, processes, and procedures
    and carrying out the agency's mission. OFCCP will continue to
    prioritize investing in compliance officer training as the agency
    rebuilds and hires.
                             osha farmworker safety
        Question. Under a longstanding appropriations rider of more than 40
    years, farms with fewer than 10 employees at all times during the prior
    year and no temporary labor camp within the previous 12 months are
    exempt from enforcement of all rules and requirements of the
    Occupational Safety and Health Act. Yet, according to the National
    Institute of Occupational Safety and Health, agriculture ranks as one
    of the most dangerous industries, with farmers at a very high risk for
    fatal or non-fatal injuries. Any worksite fatality is unacceptable and
    every step must be taken to avoid such tragic loss of life.
        How would the Occupational Safety and Health Administration (OSHA)
    use Federal funds to improve farmworker safety if Congress removed this
    rider in the fiscal year 2022 appropriations bill for the Department of
    Labor? Please describe compliance assistance it would undertake, as
    well as how farms would be factored into planned enforcement
    activities, including any emphasis programs or directives.
        Answer. The existing appropriations rider has precluded OSHA from
    conducting enforcement activities at a farming operation if it: (1)
    employs 10 or fewer non-family member employees currently and all times
    during the preceding twelve months and (2) has not had an active
    temporary labor camp during the preceding twelve months. If Congress
    removes the rider, OSHA can respond to imminent danger situations at
    currently exempt farming operations and remove employees from those
    dangers. The agency would also be able to respond to employee
    complaints regarding workplace safety and health hazards, and
    investigate fatalities (such as from grain engulfment) and severe
    injuries. Lastly, OSHA would include small farming operations in
    programmed or planned inspections, such as national, regional, and
    local emphasis programs, that are aimed at specific high-hazard
    industries.
        While the appropriations rider has significant implications for
    OSHA's enforcement activity, it should first be noted that it has not
    prevented the agency from developing and distributing workplace safety
    and health resources for agricultural settings, including those where
    OSHA is unable to conduct enforcement. For example, OSHA maintains an
    Agricultural Operations Safety and Health Topics Page with information
    about hazards related to grain bins and silos, hazard communication of
    chemicals, noise, musculoskeletal injuries, heat, and others. OSHA also
    has a plethora of publications in both English and Spanish that are
    relevant to agricultural operations that may be printed from the
    agency's website directly or ordered free of charge from our
    Publications Office.
        The agency also conducts significant outreach to the agricultural
    industry as a whole, and engages with agricultural industry
    stakeholders whose target audiences include small agricultural
    workplaces and family-operated farms. For example, following a
    significant increase in fatal grain engulfments between fiscal year
    2015 and fiscal year 2016, OSHA's Regions 5, 6, 7, and 8 launched a
    ``Stand-Up for Grain Engulfment Prevention'' event in fiscal year 2017.
    That same year, OSHA signed an Alliance with the National Grain and
    Feed Association, which helped to expand the Grain Stand-Up. Two
    additional organizations, the Grain Elevator and Processing Society
    (GEAPS) and Grain Handling Safety Coalition (GHSC), have since joined
    the Alliance and lent their resources to expanding this initiative.
    GHSC, in particular, has played a key role in ensuring the Grain Stand-
    Up reaches smaller growers/producers over which OSHA does not have
    jurisdiction.
        If the rider were removed, and funds became available, OSHA could
    greatly expand its outreach to smaller agricultural employers and
    workers. Staff could pursue new relationships with Federal and state
    farm associations, and proactively establish alliances for the express
    purpose of conducting outreach, developing educational materials, and
    providing workplace safety and health training opportunities to smaller
    farm owners, operators, and employees. Removal of the rider would also
    enable OSHA to expand its On-Site Consultation Program to provide no-
    cost workplace safety and health services to smaller agricultural
    operations who were previously not eligible for these services.
    Information collected during OSHA's inspections (e.g., regarding types
    and location of fatalities in smaller farm operations) could also be
    used to strengthen, and more effectively target, outreach and
    compliance assistance.
        Question. How would OSHA use Federal funds to improve farmworker
    safety if Congress were instead to modify the rider by allowing the
    fiscal year 2022 appropriation to be used only to investigate
    fatalities on such small farms and provide associated compliance
    assistance necessary to decrease the likelihood of a similar injury or
    fatality?
        Answer. Farming operations experience workplace fatalities from a
    variety of hazards, including from grain engulfment, falls from
    structures, entanglement in grain moving machinery, and electrocution.
    Researchers with the Agricultural Safety and Health Program of Purdue
    University publish a report yearly, showing trends in the number of
    grain entrapments and associated fatalities. Because small farming
    operations are exempt from OSHA enforcement activities, OSHA cannot
    investigate such incidents and determine the root causes to prevent
    recurrence of such incidents. If Congress modifies the rider, OSHA can
    inspect and thoroughly investigate the fatalities, and provide
    necessary abatement methods and hazard recognition training to
    employers engaged in small farming operations.
        We assume that the provision of the direct compliance assistance
    would be limited to the employers involved in the fatalities
    investigated, and focused on decreasing the likelihood of a similar
    injury or fatality at that facility. In this case, the agency would
    continue the outreach it already engages in (noted above) but could not
    meaningfully expand proactive outreach and compliance assistance to
    smaller farm operations. In many instances, when OSHA responds to a
    fatality in an agricultural operation and determines that it has no
    enforcement jurisdiction (e.g., where an incident is voluntarily
    reported), the responding staff will nevertheless advise them that
    there is important safety and health information on the OSHA website
    that could help them to decrease the likelihood of a similar injury or
    fatality. However, the agency could enhance this effort by using the
    findings gathered through any resulting investigations to augment
    existing compliance assistance materials and share them broadly through
    its outreach efforts. The agency may also be able to engage with the
    individual employers through the On-site Consultation program; this
    would need to be evaluated at the time the rider is issued.
                      multilingual worker protection staff
        Question. The missions of worker protection agencies of the
    Department of Labor include coverage of and assistance to all workers,
    including those who speak languages other than English.
        Please provide current counts of the number of multilingual staff
    for the Wage and Hour Division (WHD) and Occupational Safety and Health
    Administration (OSHA) in total and by region.
        Answer. OSHA has a total of 111 staff who are multilingual. The
    breakout by region is shown in the table below.

    ------------------------------------------------------------------------
                          OSHA Multilingual Staff 2021
    -------------------------------------------------------------------------
                   Region                               Staff
    ------------------------------------------------------------------------
                                1                                    4
    ------------------------------------------------------------------------
                                2                                    4
    ------------------------------------------------------------------------
                                3                                    8
    ------------------------------------------------------------------------
                                4                                   14
    ------------------------------------------------------------------------
                                5                                   38
    ------------------------------------------------------------------------
                                6                                   14
    ------------------------------------------------------------------------
                                7                                   16
    ------------------------------------------------------------------------
                                8                                    0
    ------------------------------------------------------------------------
                                9                                    7
    ------------------------------------------------------------------------
                               10                                    4
    ------------------------------------------------------------------------
                  National Office                                    2
    ------------------------------------------------------------------------
                            Total                                  111
    ------------------------------------------------------------------------

        These data were provided by the Office of the Assistant Secretary
    for Administration and Management and includes positions that may
    require a foreign language capability.
        In total, WHD has 573 employees who are multilingual and speak 21
    different languages.
        By Region, the Northeast Region has 136 multilingual staff, the
    Midwest Region has 87 multilingual staff, the Southeast Region has 107
    multilingual staff, the Southwest Region has 117 multilingual staff,
    and the Western Region has 126 multilingual staff.
        Question. How will the Department use resources in the current
    fiscal year and requested for fiscal year 2022 to recruit and hire
    multilingual, qualified candidates for roles as investigators,
    inspectors and other critical positions where language barriers could
    prevent an agency from fulfilling its statutory mission? How will the
    Department assess such language gaps and plan to meet its language
    needs in carrying out the missions of its agencies?
        Answer. OSHA plans to recruit and hire multilingual qualified
    candidates for investigators, inspectors and other positions by working
    with organizations such as Historically Black Colleges and
    Universities, Hispanic Serving Institutions, the Asian American Network
    and other organizations so that the agency's workforce has the
    multilingual capabilities that reflects the communities that OSHA
    serves. By reaching the most hazardous worksites and facilities, the
    agency not only helps secure safe and healthy workplaces and reduce
    workplace injuries, illnesses, and deaths, but also protects at-risk
    workers in marginalized communities, who are less likely to have the
    protections and training to work safely in high-hazard workplaces.
        The Wage and Hour Division (WHD) utilizes targeted recruitment
    strategies to attract a diverse pool of highly qualified candidates for
    WHD positions. WHD routinely includes language requirements when hiring
    to ensure that investigators can successfully communicate with workers
    and employers about their rights and responsibilities under the law.
    Currently, WHD has more than 570 multilingual staff.
        In fiscal year 2022 WHD will continue to assess hiring needs
    through a data-driven approach that will help to identify gaps in
    services and resource allocation to particular communities. WHD is
    implementing plans to increase recruitment and outreach to Minority
    Serving Institutions and community based organizations to continue to
    reach diverse applicants and ensure a pipeline of investigators who
    reflect the communities they serve. Finally, WHD is opening positions
    in remote, low-wage, underserved communities nationwide and increasing
    flexibility in telework to serve these areas.
        Question. Please describe how the WHD and OSHA will work with
    stakeholders, including community-based organizations in reaching
    worker populations such as those with language access barriers and
    other factors that may contribute to a decreased likelihood of filing
    of a complaint for a violation of labor law protections.
        Answer. OSHA remains committed to working with and engaging its
    whistleblower stakeholders. The agency has been conducting two
    stakeholder meetings per year, some targeting specific industries,
    seeking input and suggestions from them on a myriad of issues, such as
    how to provide better customer service and how to conduct better
    outreach to the public. The agency also listens to their concerns
    regarding how the coronavirus pandemic has affected their workplaces.
    The agency reviews each and every comment and suggestion from these
    meetings and has implemented a number of them.
        As a result of the most recent stakeholder meeting in May 2021,
    OSHA is reaching out to migrant worker groups who provided comments, to
    more fully understand their concerns, and to work with them on enhanced
    ways to reach out to the people they represent. In addition, the
    agency's whistleblower website, www.whistleblowers.gov, contains many
    outreach documents that provide information to workers who may have
    been retaliated against for engaging in protected activity. Much of the
    information is available in English and Spanish.
        The agency is committed to not only inform workers of their rights,
    but also to remind employers of their responsibilities under these
    laws. Moreover, OSHA is actively promoting its Recommended Practices
    for Anti-Retaliation Programs guidance document, which focuses on
    assisting employers in creating an effective anti-retaliation program
    in their workplaces, where workers feel comfortable reporting concerns
    without fear of retaliation, and without the need to file a
    whistleblower complaint in the first place.
        OSHA continues to prioritize outreach to vulnerable worker
    populations. For example, OSHA translated its educational and outreach
    materials into Spanish \1\ and more than 30 other languages.\2\ These
    resources are printable from OSHA's website and print copies may be
    shipped at no cost upon request. Several focus specifically on
    workplace rights \3\ and OSHA created a video on filing a complaint
    that is available in both English \4\ and Spanish,\5\ which is shared
    along with its publications through the agency's outreach efforts.
    ---------------------------------------------------------------------------
        \1\ https://www.dol.gov/newsroom/releases/odep/odep20200429-0.
        \2\ https://www.osha.gov/publications/bylanguage.
        \3\ https://www.osha.gov/publications/bytopic/workers'-rights-
    outreach.
        \4\ https://www.youtube.com/watch?app=desktop&v=k70Ln7gRWDE.
        \5\ https://www.youtube.com/watch?app=desktop&v=zgv-Fuqx3K4.
    ---------------------------------------------------------------------------
        OSHA's Labor Liaisons \6\ maintain communication with organized and
    unorganized workers, Committees on Occupational Health and Safety,
    worker centers and coalitions, helping them navigate OSHA's
    organizational structure and complaint procedures, and assisting them
    in developing and updating health and safety programs.
    ---------------------------------------------------------------------------
        \6\ https://www.osha.gov/workers/liasons.
    ---------------------------------------------------------------------------
        The agency maintains regular communication with worker advocacy
    organizations such as the National Council for Occupational Safety and
    Health (National COSH), to ensure that safety concerns workers have
    about their jobs are heard and addressed. On June 23, 2021, Acting
    Assistant Secretary Jim Frederick participated in a bilingual town hall
    meeting where he responded directly to questions from farm, poultry
    plant, nursing home and other workers. Topics included the urgent need
    to protect workers from heat exposure and the COVID-19 Emergency
    Temporary Standard for healthcare. The recording is available in
    English here \7\ and in Spanish here.\8\
    ---------------------------------------------------------------------------
        \7\ https://drive.google.com/file/d/
    1HFikHihuIMbB69LGgdNsRsVkWCINtOXG/view.
        \8\ https://drive.google.com/file/d/1gbM7sdTTonaNEGaMP-
    PVO3Itdpf3uoH4/view.
    ---------------------------------------------------------------------------
        OSHA has numerous regional and area office alliances with
    Consulates \9\ of Mexico and other Latin American countries through
    which the agency shares information in English and Spanish about
    workplace safety and health hazards and workers' rights, including use
    of the OSHA complaint process. OSHA's Region 5 Regional Office also has
    an Alliance with the Consulate of the Philippines in Chicago.
    ---------------------------------------------------------------------------
        \9\ https://www.osha.gov/alliances/byemphasis#consulate-alliances.
    ---------------------------------------------------------------------------
        OSHA Compliance Assistance Specialists participate in regional task
    forces and committees established to protect migrant farmworkers in
    both the midwest and southeastern United States. Each August, OSHA and
    WHD collaborate in supporting Labor Rights Week, a joint initiative
    between the governments of the United States and Mexico to increase
    awareness in the Mexican and Latino communities about the rights of
    workers, including immigrant workers.
        WHD is currently engaged in the Essential Workers, Essential
    Protections initiative, which includes collaborating with stakeholders
    nationwide to train them in protections for the most vulnerable, at-
    risk worker populations as we emerge from the pandemic. Efforts to date
    include conducting hundreds of educational webinars, reaching more than
    26,000 participants; training advocates on how to file complaints;
    producing and continuing to air television and radio public service
    announcements in English and Spanish; and producing and placing
    workers' rights posters in local stores to reach marginalized
    populations. A nationwide series of listening sessions is now underway
    to hear directly from stakeholders in contact with these workers how we
    can better reach them. These efforts are designed to strengthen
    relationships with community based organizations who are trusted
    resources for the most vulnerable workers and can refer workers, file
    third-party complaints, and amplify WHD's enforcement efforts.
                                subminimum wage
        Question. The budget requests $42.7 million, an increase of $3.7
    for the Office of Disability Employment Policy (ODEP). The budget notes
    a priority for ODEP to advise Federal agencies and assist states and
    employers in transitioning workers away from sub-minimum wage
    employment currently authorized under 14(c) of the Fair Labor Standards
    Act to competitive, integrated employment. My home state of Washington
    recently enacted legislation ending a similar authority for issuing
    certificates to pay workers with a disability less than the state
    minimum wage generally as of July 31, 2023.
        Please identify the Federal agencies involved and describe the
    planned advisements that ODEP has for this and next year.
        Answer. ODEP works with multiple Federal agencies to advance
    competitive integrated employment (CIE) in order to reduce reliance on
    Section 14(c) certificates. CIE is employment that pays at least the
    Federal minimum wage (or state minimum wage when higher) and allows an
    employee with a disability to interact with people without disabilities
    to the same extent able-bodied employees interact with one another. The
    main Federal agencies ODEP collaborates with include:
      --AbilityOne
      --Department of Labor (DOL), Office of Federal Contract Compliance
            Programs (OFCCP)
      --DOL, Employment and Training Administration (ETA)
      --DOL, Employee Benefits Security Administration (EBSA)
      --DOL, Veterans' Employment and Training Services (VETS)
      --DOL, Wage and Hour Division (WHD)
      --Department of Education (ED), National Institute on Disability
            Independent Living, and Rehabilitation Research (NIDILRR)
      --ED, Office of Career Technical and Adult Education (OCTAE)
      --ED, Office of Special Education and Rehabilitation Services (OSERS)
      --ED, Office of Special Education Programs (OSEP)
      --ED, Rehabilitation Services Administration (RSA)
      --Department of Health and Human Services (HHS), Administration for
            Community Living (ACL)
      --HHS, Centers for Medicare and Medicaid Services (CMS)
      --HHS, Substance Abuse and Mental Health Services Administration
            (SAMHSA)
      --Social Security Administration (SSA)
      --Department of Veterans Affairs (VA), Veterans Health Administration
            (VHA)
      --VA, Veterans Readiness and Employment (VRE)
        ODEP planned activities and advisements for this year and next year
    to promote CIE: In fiscal year 2021, ODEP is investing significant
    effort \10\ to advance national and state-level policy promoting CIE to
    reduce reliance on Section 14(c) certificates. ODEP maintains a list of
    state ``Employment First'' policies and initiatives aimed at phasing-
    out Section 14(c). The list is readily available to share with Federal
    agencies, state partners and other stakeholders on request. ODEP
    maintains a learning library of webinars and resources focused
    specifically on advancing CIE and has worked directly in over 27 states
    to align state policy, funding and service strategies to incentivize
    integrated over segregated employment. ODEP remains a resource for
    Federal agencies and state/local systems on use of best practices for
    achieving CIE, such as supported and customized employment, and
    reasonable accommodations. In designing activities to advance CIE and
    eliminate Section 14(c) employment, ODEP organized the recommendations
    of the Advisory Committee on Increasing Competitive, Integrated
    Employment for Individuals with Disabilities (ACICIEID) into 10
    critical areas. These 10 areas are needed for employment service
    providers and systems to transform their systems from segregated to
    competitive integrated business models and provide the overarching
    framework for ODEP's work. Based on this framework, ODEP created a
    Transformation Guide for states to assist in organizing the multiple
    aspects of transformation needed across policy, funding and practice to
    achieve CIE.\11\ Specific ODEP activities and advisements for fiscal
    year 2021-2022 include:
    ---------------------------------------------------------------------------
        \10\ https://www.dol.gov/agencies/odep/program-areas/integrated-
    employment.
        \11\ http://drivedisabilityemployment.org/employment-first-
    resources/e1st-state-transformation-guide.
    ---------------------------------------------------------------------------
      --National Expansion for Employment Opportunities Network (NEON):
            ODEP's NEON project assists provider agencies to increase CIE
            outcomes and thus reduce reliance on Section 14(c) employment.
            In fiscal year 2020, NEON selected and worked with five
            national provider organizations (NPOs): ACCESS, the American
            Network of Community Options and Resources (ANCOR), the
            Association of People Supporting Employment First (APSE), the
            Arc US and SourceAmerica. ODEP helped the NPOs create national
            strategic plans for their employment provider networks to
            transition away from Section 14(c) strategies and increase CIE
            outcomes. Through NEON, ODEP also supported 19 local provider
            organizations (LPOs) transition to CIE in fiscal year 2020. In
            fiscal year 2021, NEON is assisting 48 providers in 19 states,
            including Washington state. ODEP is also working through NEON
            to create a National Plan to Increase CIE within the provider
            community (anticipated for release in late 2021). In addition,
            ODEP manages a monthly Community of Practice bringing national
            experts, promising practices and real-life examples of provider
            transformation to the over 2,700 participants from every state.
            In fiscal year 2022, NEON will support up to 75 LPOs with
            transition to CIE, and will provide support and technical
            assistance to implement the NEON National Plan to Increase
            CIE.\12\
    ---------------------------------------------------------------------------
        \12\ https://www.dol.gov/newsroom/releases/odep/odep20200429-0.
    ---------------------------------------------------------------------------
      --Advancing State Policy Integration for Recovery and Employment
            (ASPIRE): Established in fiscal year 2021, ODEP's ASPIRE
            initiative provides technical assistance to seven states to
            help them develop and align policies, funding and service
            strategies to increase CIE for people with mental health
            conditions. Each state is required to involve key systems that
            provide employment service and support including: Vocational
            Rehabilitation, Mental/Behavioral Health, Medicaid and
            Workforce Development. ASPIRE's goal is to coordinate policy,
            funding and service strategies to increase availability of
            evidence-based supported employment opportunities for people
            with mental health conditions in the state. A technical working
            group (TWG) composed of national mental health stakeholder
            organizations, mental health national experts and intermediary
            associations of state and local government agencies provide
            ongoing information and assistance to ASPIRE states. In
            addition, a supported employment learning community meets
            monthly to bring cutting-edge information on key issues in
            supported employment implementation to ASPIRE states. In fiscal
            year 2022, ODEP will expand the number of states included in
            ASPIRE, and will utilize its State Exchange on Employment and
            Disability (SEED) to increase state policy alignment across
            systems to increase CIE for people with mental health
            conditions.\13\
    ---------------------------------------------------------------------------
        \13\ https://www.dol.gov/agencies/odep/initiatives/aspire.
    ---------------------------------------------------------------------------
      --ODEP's work with VA and DOL VETS on CIE for Veterans with
            Disabilities: In fiscal year 2021, ODEP partnered with the VA's
            VRE and VHA and DOL's VETS to develop and release two videos to
            raise awareness about customized employment as an effective
            strategy to help veterans with disabilities move from sheltered
            employment or unemployment into CIE. Released in February 2021,
            the videos are available at: Customized Employment Works for
            Veterans: A Job That I Love \14\ and Customized Employment
            Works for Veterans: A Win-Win Strategy.\15\
    ---------------------------------------------------------------------------
        \14\ https://www.youtube.com/watch?app=desktop&v=xIsekJpeyiw.
        \15\ https://www.youtube.com/watch?app=desktop&v=5CFjKwJtXqc.
    ---------------------------------------------------------------------------
      --ODEP work on Rate Rebalancing to Incentivize CIE: In May 2021, ODEP
            released a comprehensive policy guide on state rate
            reimbursement restructuring titled ``Value-Based Payment
            Methodologies to Advance Competitive Integrated Employment: A
            Mix of Inspiring Examples from Across the Country''. Guidance
            on rate reimbursement restructuring is critical to increasing
            CIE for people with significant disabilities. Many existing
            rate structures are based on the assumption that some people
            with disabilities are incapable of work, rather than on an
            Employment First framework that assumes all people are capable
            of work if given the necessary supports, accommodations and
            work environment. ODEP developed three webinars on rate
            restructuring in which relevant state agencies (Medicaid,
            Vocational Rehabilitation, Mental/Behavioral Health) and
            providers discuss how adjusting service rates enabled them to
            incentivize CIE over segregated work models. This is important
            because some state systems may reimburse providers higher
            amounts for segregated outcomes. These systems could instead
            elect to include services necessary for CIE in their list of
            covered services and incentivize their use through higher
            reimbursement rates. The webinars providing examples from
            multiple states and multiple different systems include: (1)
            Value, Outcome and Performance-Based Payment Methodologies to
            Advance Competitive Integrated Employment in State Medicaid
            Long-Term Services and Supports (LTSS) Systems and Managed Care
            LTSS Systems; (2) Supporting Employment Service Providers to
            Succeed and Prosper by Partnering to Advance Competitive
            Integrated Employment: Applying Value, Outcome and Performance-
            Based Payment Methodologies; and (3) Advancing Competitive
            Integrated Employment: Value, Outcome and Performance-Based
            Payment Methodologies in State Vocational Rehabilitation and
            Behavioral Health Systems.
      --Financial Literacy and Benefits Planning through the Lifespan:
            Financial Literacy Toolkit: ODEP also worked with DOL's EBSA to
            develop a toolkit for youth and adults with disabilities to
            assist with their finances as they consider employment,
            retention and advancement. It also shows them how they can
            build savings. This toolkit provides valuable information for
            all phases of employment, including consideration of the impact
            on benefits from working as people with disabilities move from
            sheltered settings to CIE. It provides information in essential
            areas such as work incentives, Achieving a Better Life
            Experience (ABLE) accounts, and other areas of financial
            literacy essential for people with disabilities. For example,
            one important resource is the new fact sheet on the Medicaid
            buy-in, developed by ODEP in collaboration with ACL and CMS
            (see Medicaid Buy-In Q&A Medicaid ``Buy-In'' Q&A
            (dol.gov)).\16\ ODEP will continue to develop new resources in
            this area and add them quarterly. On July 27, ODEP and EBSA
            hosted a webinar, Secure Your Financial Future: A Toolkit for
            Individuals with Disabilities,\17\ to launch this new financial
            literacy toolkit.\18\ I provided welcoming remarks for the
            webinar.
    ---------------------------------------------------------------------------
        \16\ https://www.dol.gov/sites/dolgov/files/odep/topics/
    medicaidbuyinqaf.pdf.
        \17\ http://leadcenter.org/webinars.
        \18\ https://www.dol.gov/agencies/ebsa/secure-your-financial-
    future.
    ---------------------------------------------------------------------------
      --Workforce Innovation and Opportunity Act (WIOA) Workforce
            Development System: ODEP efforts to expand access to CIE
            includes leveraging the services and connections available
            through the American Job Centers (AJC) system operated under
            WIOA. AJCs can register to become Employment Networks (ENs)
            under the Ticket to Work (TTW) program. ENs are reimbursed for
            employment services on a milestone basis for successfully
            assisting people with disabilities into CIE employment.
            Consequently, ODEP worked to expand the impact of the TTW/EN
            program by connecting providers of CIE employment services to
            ENs. The goal was to leverage additional support in achieving
            CIE for people with disabilities who are eligible Social
            Security recipients under TTW. To assist in this effort, on May
            2021, DOL released a Ticket to Work: Operating a Workforce EN
            Planning Guide and Workbook to promote the benefits of
            operating as a workforce EN and to enhance awareness of
            available resources to help in this process, including guidance
            and promising practices. ODEP, ETA and SSA developed this
            technical guide with input from 19 workforce systems currently
            operating as ENs. The planning guide and workbook assist state
            and local area workforce leadership in the process of becoming
            and operating as a workforce EN. It includes a set of
            activities (e.g., checklists, discussion questions and
            exercises) to help walk through the process to make an informed
            decision, and serve as an operational resource for existing
            workforce ENs. ODEP also held a webinar on May 26, 2021,
            Practices in Workforce Employment Network Operation--New
            Technical Guidance,\19\ which provided highlights from the
            technical guide, promoted the advantages this opportunity
            provides to local workforce systems and shared the experiences
            of three current workforce systems from the workforce EN
            operators.
    ---------------------------------------------------------------------------
        \19\ https://www.workforcegps.org/events/2021/03/23/13/16/
    Practices-in-Workforce-Employment-Network-Operation-New-Technical-
    Guidance.
    ---------------------------------------------------------------------------
      --Advisement to Federal State and Local Governments, Providers and
            Individuals with Disabilities on Current Federal Investments to
            Advance CIE: In July 2021, in recognition of the 31st
            anniversary of the Americans with Disabilities Act, ODEP
            released a new fact sheet, ``Recent Funding Opportunities to
            Expand Access to Competitive Integrated Employment (CIE) for
            Individuals with Disabilities'', developed in collaboration
            with the HHS' CMS, ACL, SAMHSA; ED's RSA and OSEP; and SSA. The
            fact sheet highlights new funding and flexibilities which
            provide significant opportunities to increase access to CIE for
            youth and adults with disabilities. The increased funding and
            flexibilities are provided under the Coronavirus Aid, Relief
            and Economic Security Act (CARES), the American Rescue Plan Act
            of 2021 (ARP), the Coronavirus Response and Relief Supplemental
            Appropriations Act (CRRSA), the Further Consolidated
            Appropriations Act of 2020 (FCAA), and through the work of
            multiple Federal agencies providing services to individuals
            with disabilities. The CIE fact sheet is located on the ODEP
            web page at: Recent Funding Opportunities to Expand Access to
            Competitive Integrated Employment (CIE) for Individuals with
            Disabilities.\20\
    ---------------------------------------------------------------------------
        \20\ https://www.dol.gov/sites/dolgov/files/ODEP/pdf/
    508_odep_cie_07152021.pdf.
    ---------------------------------------------------------------------------
      --Disability Innovation Fund: ED's RSA and ODEP are discussing RSA's
            2020 and 2021 Disability Innovation Fund, which currently has
            approximately $110 million in fiscal year 2020 available
            funding, resulting from unused Federal vocational
            rehabilitation funding returned by states. Congress directed
            RSA to consult with DOL regarding the use of fiscal year 2021
            funds. For the fiscal year 2021 funds, Congress stipulated that
            the funds be used to award competitive grants to improve
            opportunities for CIE for individuals with disabilities. ODEP
            is working with WHD, RSA, ACL and CMS to design the next set of
            grants.
        Question. How does ODEP plan to assist states and employers in such
    transitions?
        Answer. ODEP remains committed to helping states and employers
    transition from segregated Section 14(c) employment to CIE outcomes.
    ODEP's most critical activities include NEON, ASPIRE, and a new
    collaboration between ODEP's SEED initiative with ASPIRE and NEON.
      --National Expansion for Employment Opportunities Network (NEON): As
            described above, ODEP's NEON project assists provider agencies
            to increase CIE outcomes and thus reduce reliance on Section
            14(c) employment. In fiscal year 2022, NEON will increase the
            number of providers developing and implementing transformation
            plans and assist states in the critical task of rebalancing/
            aligning their service funding in support of CIE. ODEP is also
            developing multiple NEON tools for release. These include, but
            are not limited to: an Employment First statewide strategic
            planning manual to assist states in organizing their statewide
            strategic planning efforts to effectively engage stakeholders
            and implement Employment First systems change and a state self-
            assessment tool for increasing CIE to assist states in
            evaluating current policies, practices and infrastructures in
            each of the Ten Critical Areas to Increase Competitive
            Integrated Employment. The 10 sections of the assessment tool
            are based on the recommendations of the final report of the
            Advisory Committee on Increasing Competitive Integrated
            Employment for Individuals with Disabilities. Additional focus
            in NEON fiscal year 2022 activities will assist providers in
            implementing the NEON National Plan to Increase CIE (expected
            release late 2021).
      --Advancing State Policy Integration for Recovery and Employment
            (ASPIRE): As described above, ODEP's ASPIRE initiative is
            assisting states and providers with aligning policy, funding
            and service strategies across systems This is needed to expand
            access to evidence-based supported employment throughout
            participating states. In fiscal year 2022, ODEP will expand the
            number of states included in ASPIRE, and will collaborate with
            ODEP's SEED initiative to increase state policy alignment
            across systems in other states to increase CIE for people with
            mental health conditions.
      --State Exchange on Employment and Disability/ASPIRE/NEON
            partnership: ODEP's SEED works through state intermediary
            organizations such as the National Conference of State
            Legislatures (NCSL), the National Governors Association (NGA),
            and the Council of State Governments (CSG) to assist state
            legislatures and governors in developing more inclusive
            workforce policies that promote disability employment. Since
            transitioning away from subminimum wage is a priority for DOL
            and an increasing priority for states, SEED and its
            intermediaries will actively promote legislative and
            administrative policy options for consideration by all of the
            states, as well as share examples of recently passed or enacted
            legislation. In fiscal year 2022, SEED and its intermediaries,
            including NGA, will work with ODEP's ASPIRE and NEON
            initiatives to establish a policy collaborative that will focus
            on assisting those states supporting CIE and the phase-out of
            Section 14(c). States with more mature CIE policy in place will
            participate as CIE leaders to assist states with less developed
            CIE policy, and subject matter experts will work directly with
            participating states to develop CIE transformation plans.\21\
    ---------------------------------------------------------------------------
        \21\ https://www.dol.gov/agencies/odep/state-policy.
    ---------------------------------------------------------------------------
                                    bls move
        Question. The last two Department of Labor Appropriations Acts have
    appropriated a total of $40 million requested for the move of the
    headquarters of the Bureau of Labor Statistics (BLS). The Congressional
    Budget Justifications for fiscal years 2020 and 2021 both identified
    this amount as the share of total project costs that BLS would
    contribute to the move, with the General Services Administration (GSA)
    paying for the remainder of construction and real property costs of
    nearly $50 million. The fiscal year 2022 BLS budget requests $28.5
    million for a portion of these real property costs and indicates the
    remaining costs would be initially financed by the GSA and repaid by
    BLS over time after the move is complete.
        Why has GSA backed out of paying its share of project costs?
        Answer. The fiscal year 2020 Budget, released in March 2019,
    announced that the BLS headquarters would move to the Suitland Federal
    Center. At the time, based on a high-level assessment of the project,
    the Budget estimated a total project cost of $89 million. The personal
    property costs of $40 million were assigned to BLS, and GSA was
    assigned the real property costs at $49 million. These estimates were
    done in advance of a detailed building assessment study which expanded
    the scope of the renovation project resulting in a new cost estimate
    and a detailed assignment of costs between BLS and GSA. The fiscal year
    2022 BLS budget request for $28.5 million reflects this revised cost
    estimate and an updated determination that BLS would fund tenant
    improvement costs, the costs to be borne by the agency consistent with
    the publicly posted GSA pricing guide, through a combination of
    appropriated dollars (paid up front) and a tenant improvement allowance
    (repaid over time through the rent stream). GSA's fiscal year 2022
    budget also reflects increased renovation costs with a request of $20
    million in fiscal year 2022. GSA continues to fund all renovation costs
    consistent with the pricing guide while BLS is funding the tenant
    related costs consistent with projects in GSA owned facilities.
        Question. What actions has DOL taken to secure the GSA contribution
    that DOL stated in prior Congressional Budget Justifications GSA would
    provide?
        Answer. Throughout the project, DOL has worked closely with GSA to
    refine cost estimates and clarify funding mechanisms. This has involved
    numerous and regular meetings with GSA executives within the National
    Capital Region, in consultation with the Office of Management and
    Budget.
        Question. Please describe how the $28.5 million requested for costs
    that GSA was going to cover could instead be used to strengthen BLS
    programs for measuring labor market activity, working conditions,
    productivity and other critical information for understanding the
    economy of the United States? What about the additional $23.8 million
    in costs that would need to be repaid in the future?
        Answer. As mentioned above, the fiscal year 2022 BLS budget request
    for $28.5 million reflects the revised cost estimate to realize the
    move with the associated reduced footprint and the long-term rent
    savings for the BLS National Office. The Department strongly supports
    the move, as it will produce considerable savings and efficiencies that
    will contribute to BLS' achievement of its mission. If the BLS
    appropriation for fiscal year 2022 instead directed the $28.5 million
    in additional funding for base programs, the BLS could fund work on
    additional statistical program improvements that have been of interest
    to Congress, such as improving the Job Openings and Labor Turnover
    Survey (JOLTS) and Consumer Expenditure (CE) program poverty
    measurement. However, without this funding, the BLS Suitland move would
    be interrupted and the project timeline would be prolonged.
    Additionally, it is critical for work to proceed in a timely fashion as
    the $40 million appropriated to date for the move expires September
    2024. Once the BLS National Office is located at Suitland, rental
    savings are expected, which could be used to cover the tenant
    improvement costs to be repaid over time and future program
    improvements.
        The $23.8 million in estimated costs to be paid to GSA in the
    future are intended to take place over the course of several years in
    the form of a tenant improvement allowance. As such, the payments will
    be part of the BLS rent bill at the Suitland Federal Center (SFC) and,
    at that level, will reduce the expected rent savings at the SFC by
    approximately $2.5 million per year.
                           whd and osha foia requests
        Question. With over 1,700 Freedom of Information Act requests
    backlogged at the Wage and Hour Division and more than 800 backlogged
    at the Occupational Safety and Health Administration as of the second
    quarter of fiscal year 2021, it's clear more needs to be done to timely
    process these requests.
        Please identify the funding and staffing level dedicated to this
    work at each of these agencies in the current fiscal year and the
    amounts and staffing level in the fiscal year 2022 request.
        Answer. OSHA's FOIA program is decentralized, with designated staff
    performing FOIA work largely as an additional duty in the national
    office and field offices across the country, and does not have a
    designated budget line item. The funding and staffing for OSHA's FOIA
    work is calculated based on a survey on the number of staff involved
    and amount of time spent working on the program. In fiscal year 2020,
    eight FTE worked full-time on FOIA. Staff working on FOIA as an
    additional duty accounted for the equivalent of 54 FTE, for a total of
    62 FTE working on the FOIA program at a cost of $6.4 million.
        In fiscal year 2021, the Wage and Hour Division had nine FTE at an
    approximate cost of $1.1 million performing work related to the Freedom
    of Information Act. In fiscal year 2022, the Wage and Hour Division
    expects staffing levels to be 11 FTE for approximately $1.3 million to
    perform this work.
        Question. What steps are these agencies taking and planning to
    timely process FOIA requests?
        Answer. OSHA acknowledges that there is room for improvement in the
    FOIA program and is working to address the backlog of requests and to
    improve the timeliness of responses to new requests. OSHA processes
    approximately 9,000 FOIA requests every fiscal year. This accounts for
    approximately 60 percent of all FOIA requests that come into the
    Department of Labor. OSHA's FOIA program is decentralized and consists
    mainly of staff working on FOIA requests as an additional duty. OSHA's
    Office of Communications (OOC) coordinates the agency's FOIA program
    and routinely coordinates with staff working on FOIA throughout the
    country to address any issues, share information, and provide necessary
    training. OOC continuously looks for ways to improve the effectiveness
    and efficiency of the FOIA program. For example, OOC has conducted two
    pilots to evaluate potential changes to the program's structure in
    order to streamline and improve overall efficiency, consistency and
    quality of the agency's FOIA process. The agency is evaluating the
    results of the pilots and is considering next steps.
        During fiscal year 2021, the Wage and Hour Division has reduced its
    FOIA back log from 530 outstanding requests at the end of fiscal year
    2020 to 285 as of July 30, 2021. WHD has accomplished this by
    recruiting and retaining FOIA leadership and staff as well as
    leveraging technological tools to speed processing requested records
    within WHD.
                            ebsa consolidated budget
        Question. The budget request for the Employee Benefit
    Administration (EBSA) requests a consolidated employee benefits
    security programs budget activity in place of separate budget
    activities for enforcement and participant assistance, policy and
    compliance assistance, and administration.
        How would this new structure better enable EBSA to achieve its
    statutory mission?
        Answer. EBSA seeks to aggregate and consolidate program budget
    activities for enforcement and participant assistance, policy and
    compliance assistance, and program oversight.
        By restructuring these three budget activities into a single
    activity for Employee Benefits Security Programs, EBSA can simplify
    agency performance reporting and streamline agency performance and
    operating plan development and implementation.
        Question. How would EBSA continue to provide transparency and
    oversight of its spending for each of the eliminated budget activities?
        Answer. EBSA believes that restructuring its budget activities will
    facilitate the allocation and redistribution of resources from lesser
    performing and lower priority strategies/programs to better performing
    and higher priority strategies/programs. The restructured budget
    activities will create a responsive organization that facilitates
    results-based management. Additionally, the restructured budget
    eliminates artificial lines between activities, all of which are aimed
    at a single outcome--employee benefits security. While this
    restructuring would promote the more efficient allocation of resources,
    it would not have any negative impact on EBSA's ability and
    responsibility to report responsibly to Congress on how it expends
    appropriated funds or on the agency's resulting performance.
                        research and evaluation funding
        Question. The budget proposes new evaluation funding flexibility
    for the Chief Evaluation Officer and Bureau of Labor Statistics at the
    Department of Labor, as well as for certain offices within the
    Department of Health and Human Services.
        Please describe how each of the new authorities requested would
    better advance research, evaluation and statistical purposes at the
    Department of Labor.
        Answer. High-quality evaluations, research, and statistical surveys
    are essential to building evidence about what works, why, and for whom.
    They are also inherently complicated, dynamic activities, with
    uncertainty about the timing and amount of work required to design,
    implement, and complete the studies. Further, we often want to know
    about the outcomes for workers both in the short- and longer-term. This
    usually requires information collections spanning five or more years
    beyond the particular intervention or program under study. The proposal
    allows flexibility to strategically plan evaluations over time by
    extending the obligation period to 5 years, rather than constraining
    obligation within 1-2 years (as current authorities for BLS or the
    Chief Evaluation Office allow). In addition, the currently available
    procurement vehicles lack the flexibility needed to match the dynamic
    nature of these evidence-building projects. Some studies provide high
    quality information useful across DOL sub-agencies or across Federal
    agencies; the proposed authority to use a single Treasury account for
    such activities, when multiple originating appropriations are used,
    enables efficiencies for awarding contracts to evaluate DOL programs
    when portions of funding from several DOL accounts are needed to
    sufficiently fund the project, or when cosponsoring research across
    Federal agencies. The proposed flexibilities enable DOL to maximize the
    use of evaluation resources, reduce burden to the public, and mitigate
    duplication of Federal efforts.
        Further, evaluation and research projects often encounter
    unexpected circumstances due to their dynamic nature. The proposed
    authority would permit unexpended funds to be repurposed for another
    research, evaluation, or statistical project, which is often not
    currently possible because of the time-limited and inflexible nature of
    these funds. This would allow the funds to be used efficiently for
    their original intent. In order to streamline these procurement
    processes, improve efficiency, and make better use of existing
    evaluation resources the Budget proposes to provide the Department of
    Labor with expanded flexibilities to spend funds over a longer period
    of time through the ``Evaluation Funding Flexibility'' outlined in
    General Provision, Section 521. This request is part of a provision
    which includes the Departmental Program Evaluation activity in the
    Departmental Management appropriation and the Bureau of Labor
    Statistics; as well as the Department of Health and Human Services'
    Assistant Secretary for Planning and Evaluation and the Office for
    Planning, Research and Evaluation in the Administration for Children
    and Families. These flexibilities will allow agencies to meet the
    collective aim of efficient government investment in evidence-building
    with embedded adaptability to reflect changing circumstances on the
    ground.
                            wcf unobligated balances
        Question.The budget proposes to increase the transfer authority
    from unobligated balances available to the Secretary in fiscal year
    2022 to the Working Capital Fund (WCF) from $18,000,000 to $36,000,000.
    The budget also proposes to create a multi-year funding authority for
    building space optimization within the WCF.
        Please identify the additional investments that could be supported
    by the increased transfer authority and describe the cost avoidance and
    risk reduction expected to be achieved through these additional
    projects.
        Answer. The Department will use these funds to modernize a host of
    legacy agency applications. DOL's 27 agencies have developed and
    maintained distinct, customized systems and applications to meet the
    unique requirements of their respective missions, but many of these
    systems and applications are outdated and quite cumbersome by modern
    standards. These legacy applications are costly to maintain,
    inefficient for both Federal staff and the public to use, and are less
    secure than modernized alternatives.
        The Department is well prepared to modernize these systems thanks
    to investments in the centralized IT platform made through the IT
    Modernization appropriation. By investing in and promoting DOL's
    centralized IT platform, the Department has established common
    foundational components that are being leveraged across the Department
    to ensure scalability, reliability, innovative development and minimum
    time to deployment. DOL's platform and standardized process to
    consolidate disparate and outdated systems, enables data sharing and
    component re-use--allowing DOL to be forward-focused and on the
    forefront of innovation with capabilities such as data analytics, case
    management, artificial intelligence and machine learning, and Robotic
    Process Automation. In addition to access to this standardized process
    and best practices, agencies have access to optimized infrastructure in
    a hyper-converged, hybrid-cloud data center environment and
    technologies that facilitate design of an overall improved user
    experience to allow employees to focus on mission work instead of
    technology. The cloud-based platform has helped achieve DOL-wide
    operational efficiencies in support of mission-driven IT applications
    resulting in consolidated resources, eliminated redundancies,
    accelerated modernization, and enhanced security.
        While DOL has made significant progress in investing in the IT
    platform, there is still an extensive list of legacy systems requiring
    modernization overhauls. By applying a set of common criteria, DOL
    prioritized legacy systems for modernization. DOL has been working to
    address the top 50 systems and is making progress in this multi-year
    effort. Based on DOL's FITARA's score, DOL has a proven track record of
    making the right investment decisions to streamline technologies and
    garner efficiencies for its IT, but budget limitations impede progress.
    Consolidating, integrating, and updating DOL's legacy systems improves
    DOL's security posture with capabilities such as standardized PIV-based
    application access, multi-factor authentication, Continuous Diagnostics
    & Mitigation (CDM) for cyber incident detection and response, and real-
    time vulnerability and threat monitoring. Investing in information
    technology provides significant public-impacting benefits in many
    policy areas, including mine safety, visa processing, grants
    management, and retirement benefits assurance, among many others. This
    authority will enable DOL to modernize systems to ease public access to
    DOL services, improve accessibility for users with disabilities,
    mitigate security issues due to legacy technologies, and reduce the
    increasing costs of supporting incompatible and obsolete technologies.
    Each effort will improve reliability and accessibility for the public
    to the Department's programs for employment, worker safety and health,
    and benefits.
        The investments that can benefit by the increased budget authority
    include (but are not limited to):
      --OLMS--Electronic Labor Organization Reporting System (e.LORS)
            Investment: OCIO has identified e.LORS as one of the highest
            priority systems in the Department for modernization due to
            inherent risks associated with this outdated legacy technology
            which has no vendor support nor is it supportable by DOL's
            cloud-based enterprise platform infrastructure. Modernization
            is projected to provide initial annual cost savings of
            approximately $600,000 the year following initial deployment.
            After the system is fully deployed, OLMS expects to experience
            a 15 percent savings in annual IT cost due to a reduction in
            costs for maintenance of the new system versus the old.
      --OSHA--Information Management System Investment: The data
            modernization and Transparency Initiative will help with the
            Agency's ability to store data, retrieve it in the most
            applicable form for operational use, and provide it in the most
            user-friendly format for the public. Internally, easier
            accessibility, paired with standardized data output from the
            OSHA systems, will result in more efficient searches and better
            ability for staff to analyze the data to lead to swifter
            decisionmaking. Improvements in data retrieval and analysis
            could also provide OSHA staff with insight into the types of
            violations they might find at a facility, or enable a
            compliance assistance specialist to provide best practices to
            abate hazards most likely to be found at the worksite. These
            efficiencies will lead to improved performance and cost savings
            will be realized in the higher utilization by OSHA data
            stakeholders of standardized reports with reliable information.
      --WHD--Wage Determination System Investment: Modernizing the agency's
            technology infrastructure is critical to WHD's success and a
            key factor in mitigating risk across the agency. With the
            recent implementation of the Electronic Case File (ECF), WHD is
            realizing the ways in which streamlined business processes and
            more agile technology can revolutionize and bring value to the
            agency's work. In doing so, WHD improves its abilities to be
            good stewards of taxpayer money and to provide the best
            possible service and results to those the agency is here to
            serve. Cost savings will be achieved in the following areas:
            (1) a shift to the cloud will minimize the need for WHD to pay
            for expensive O&M resources, which will yield an estimated
            savings of $3 million per year; (2) elimination of paper record
            keeping costs associated with case files storage and
            administration once ECF is fully rolled out, will yield an
            estimated savings of $500,000 per year which equates to
            1,557,000 pages transferred between offices and to record
            centers per year; and (3) automated ingestion of data through
            the new WDS customer portal will yield a reduced need for
            contractor support on data entry and processing of paper
            records and provide an estimated savings of $300,000 per year
            in actual contract costs. This represents total costs impacts
            of $4 million per year, which can be readily redirected towards
            mission-critical enforcement staff and activities.
      --OFCCP--Case Management System Investment: The Affirmative Action
            Verification Initiative (AAVI) is modernization need that would
            allow OFCCP to ingest and process its administrative data in a
            more uniform digital format. It will also allow staff to
            retrieve and store data in a central repository that will
            improve operations and enforcement by driving efficiency and
            increasing the number and depth of analytical assessments
            performed by the scheduling, policy, and enforcement branches.
            Once development is completed, the ongoing costs will be
            operations & maintenance, and a fraction of the help desk
            service. The total operating cost is anticipated to be reduced
            by approximately 65 percent, assuming no further development
            efforts.
        Question. How will the Department assure that unobligated balances
    for the WCF are only generated from unexpected balances rather than the
    delay of spending on the original purpose of the Congressional
    appropriation?
        Answer. The Department has a robust program to ensure that
    unobligated balances are only generated from unexpected balances. The
    Office of the Chief Financial Officer meets regularly with agencies to
    review budget execution data and, in coordination with the Performance
    Management Center, tracks the percent of discretionary appropriations
    canceled after the five-year period of obligation authority has
    expired. The results are reported in the Congressional Budget
    Justification. In fiscal year 2020, the Department targeted 1.9 percent
    in canceled appropriations and outperformed this target with a
    cancellation rate of only 1.6 percent.
                      learning agendas and evaluation plan
        Question. The ``Foundations for Evidence-Based Policymaking Act of
    2018'' includes key provisions related to developing a multi-year
    learning agenda, evaluation plan, improving coordination of data
    government at the Department, and improving accessibility of labor
    data. The Department has indicated it plans to release an updated
    learning agenda and Capacity Assessment for Research, Evaluation,
    Statistics, and Analysis in February 2022.
        Please describe stakeholder consultations that have occurred or
    will occur during the development of these plans.
        Answer. The Department has engaged with a wide range of
    stakeholders external to DOL to understand evidence production, use,
    and future needs. For example, given the critical role of the
    Department in supporting the public workforce system across the
    country, DOL targeted early engagement with the workforce development
    field. From November 2020 to April 2021, the Department sponsored
    unstructured group discussions and individual conversations with 104
    individuals representing 53 organizations spanning the U.S. workforce
    development system. The objectives of the meetings were to encourage
    participants to discuss what research, information, or evidence would
    be most useful to them to improve the services they provide, and to
    identify future research topics related to employment programs and
    services and the future of work.
        In addition to this broad-based engagement, the Department convened
    an 11-member panel of highly qualified experts in the workforce
    development field, including representatives from workforce boards,
    academics, nonprofit organizations that partner with or study the
    workforce system, and labor unions. The panel provided DOL with
    targeted input on high-priority research topics related to WIOA
    programs and services that could build on the current evidence base,
    fill key knowledge gaps, and could be potentially suitable for rigorous
    evaluation. A summary of the findings from these engagements will be
    available on the Department's Chief Evaluation Office website later
    this year.
        DOL has also sought input on our evidence-building agenda from
    Congressional stakeholders. On July 29, 2021, DOL's Office of
    Congressional and Intergovernmental Affairs sponsored a Congressional
    outreach session, which included a high-level briefing on the
    Department's strategic and evidence-building planning approach.
    Further, it allowed Congressional aides from both appropriations and
    authorizations committees to ask questions and to provide direct
    comments and reactions on the Department's activities.
        Looking to the future, the Department will gain insights from
    additional activities. For example, the responses to the equity RFI
    issued by OMB on May 5, 2021 will be helpful to all Federal agencies,
    including the Department, in evidence-building plans.\22\ Further, the
    Department will engage in further targeted stakeholder feedback, to
    support ongoing evidence development and dissemination activity. As
    evidence building evolves to meet emerging needs, the Department
    anticipates refining activities based on future stakeholder inputs. DOL
    is especially interested in ensuring perspectives from a diverse array
    of stakeholders who represent the communities our programs serve.
    ---------------------------------------------------------------------------
        \22\ The full text on the OMB RFI, Methods and Leading Practices
    for Advancing Equity and Support for Underserved Communities Through
    Government, can be found here: https://www.govinfo.gov/content/pkg/FR-
    2021-05-05/pdf/2021-09109.pdf.
    ---------------------------------------------------------------------------
        Question. What has the Department learned from its prior
    evaluations and how has the information been used in decisionmaking and
    its programs, policies and operations? How will it inform future
    decisions on programs, policies and operations?
        Answer. The Department has learned a great deal from its
    evaluations, data analytics efforts, surveys, and other rigorous
    research projects to help improve our work on specific programs and
    topics, and also to better understand how to best help specific
    populations, especially populations facing barriers to full
    participation and inclusion in the labor market. Specifically, the
    Department has used the results from its evaluations and rigorous
    research to expand and scale proven training strategies, to better
    target enforcement and worker protection activities, to identify
    underrepresented populations for tailored outreach, and even to improve
    internal employee engagement, among other outcomes.
        As decision-makers develop policies and programs to support workers
    with job training and other employment supports, they have used the
    results of evaluations to effectively target future investments. One
    important example comes from evaluations of the Registered
    Apprenticeships (RA) program. DOL funded a large-scale impact study of
    RAs across 10 states, which was published in 2012. That study found
    that RA participants had substantially higher short- and long-run
    earnings than did non-participants and that the broader benefits of the
    RA program for apprentices, government agencies, and society greatly
    outweighed program costs. RA participants earned an average of $5,839
    more than similar nonparticipants. Further, the completers of RA
    programs earn over $300,000 more in salary and benefits during their
    careers than similarly situated individuals who do not complete such
    programs. This study is regularly cited by researchers, program
    administrators, and policymakers as evidence for the return on
    investment to RAs.
        In part on the basis of those findings, both Congress and the
    Department have pursued expansions of the RA program. In partnership
    with the Department's Employment and Training Administration, the Chief
    Evaluation Office is now actively evaluating these new investments in
    the RA program, including studying efforts to expand apprenticeships to
    underrepresented populations, as well as assessing the effectiveness of
    expanding apprenticeships into high-growth and high-paying industries,
    such as information technology.
        Another important area of ongoing evidence-to-practice is related
    to building the capacity of the nation's community colleges' education-
    to-employment pipeline to meet 21st century demands. Based on the
    results of a national evaluation of the DOL capacity-building grant
    program, Trade Adjustment Assistance Community College and Career
    Training (TAACCCT), the Department identified a range of promising
    practices for future adoption including accelerated learning/career
    pathways, persistence and completion strategies, and learning-based
    connections to employment. The national evaluation generated these and
    a wealth of other findings based primarily on a synthesis of 71
    evaluation reports completed by grantees' third-party evaluators.
    Evidence-based practices and insights from these studies' findings are
    being applied to the Strengthening Community Colleges Training Grants
    (SCCTG) Round 2 Funding Opportunity Announcement and future DOL
    investments.
        The Department has also helped states and local areas in their
    efforts to build strong evaluation capacity, such as with the
    Reemployment Services and Eligibility Assessment (RESEA) program.
    Beyond funding and broadly disseminating findings from the largest
    evaluation of the RESEA predecessor program, Reemployment and
    Eligibility Assessment (REA) program, the Department has developed a
    suite of resources to support states in implementing and leveraging
    insights from the evidence base, as they build, pilot, and evaluate new
    RESEA program components. The Department has provided evaluation
    technical assistance resources, including webinars and other tools and
    templates to help states understand, build, and use evidence.\23\
    ---------------------------------------------------------------------------
        \23\ The Department has developed a number of dedicated web-based
    resources for states, including https://clear.dol.gov/reemployment-
    services-and-eligibility-assessments-resea and https://
    rc.workforcegps.org/resources/2016/10/03/06/29/RESEA.
    ---------------------------------------------------------------------------
        Other research efforts with notable impact on Departmental
    operations include the Family and Medical Leave Act (FMLA) surveys of
    workers and businesses. Fielded in 1995, 2000, 2012, and 2018, these
    large-scale nationally representative surveys represent a primary
    source of credible information about workers' leave needs, patterns of
    usage, reasons for leave, awareness of leave benefits, among many other
    factors. In addition, the size of the survey sample permits
    disaggregation and analysis by geography and a variety of demographic
    groups. The results of these surveys have helped the Department improve
    and target educational campaigns on Federal leave worker protections,
    as well as to provide technical assistance to businesses with
    administration of this benefit as part of compliance and enforcement
    efforts. The surveys have also been very important to Federal, state,
    and local policymakers interested in understanding gaps in worker leave
    needs and designing potential leave program proposals.
        Question. What are the Department's plans for increasing the
    investment in evaluation and evidence-building activities authorized by
    the annual evaluation transfer provided in the Department of Labor
    Appropriations Acts which significantly decreased from more than
    $22,000,000 in fiscal year 2016 to $2,000,000 in fiscal year 2020?
        Answer. The Department is committed to supporting a robust research
    and evaluation portfolio, including the capacity to develop and deploy
    evidence across agency management activities. Doing so is consistent
    with this Administration's priorities, as reflected in the President's
    Memorandum on Restoring Trust in Government through Scientific
    Integrity and Evidence-Based Policymaking and through the Office of
    Management and Budget's guidance to Federal agencies on the
    implementation of the Evidence Act (OMB M-21-27). Bolstering the
    Department of Labor's research and evaluation activities is reflected
    in our fiscal year 2022-2026 strategic plan, which includes a
    management goal to ``strengthen the Department's commitment and
    capacity for evidence-based decisionmaking.''
                                     ______

                    Questions Submitted by Senator Jack Reed
                           wioa and public libraries
        Question. Workforce Innovation and Opportunity Act and Public
    Libraries.--Public libraries are critical but often under-resourced
    partners in the workforce development system supported under the
    Workforce Innovation and Opportunity Act. As the nation continues to
    recover from the COVID-19 emergency, libraries will play a critical
    role in helping people access benefits and get back to work.
        What are the Department's plans to build and strengthen
    partnerships between the one-stop system and public libraries and
    ensure that public libraries have the resources necessary to provide
    these workforce development services?
        Answer. States have used WIOA funding for partnerships with public
    libraries to conduct digital and financial literacy education
    activities; educate library staff about available in-person and virtual
    employment and workforce development resources; provide resume writing,
    interview preparation, and other adult education programs; use the
    libraries' space to provide career assistance and host job fairs; and
    share workforce and labor market information. As an example,
    California's Library Workforce Partnership Initiative (LWPI) recently
    announced a funding opportunity for ten California public libraries to
    partner with local Workforce Development Boards to build staff skills
    and knowledge about workforce development and enhance workforce
    development efforts in their communities. Local Boards in California
    will work with public libraries, and together they will promote
    employment, career development, and skill-building for job seekers.
        The Department has partnered with the Institute of Museum and
    Library Services (IMLS) for several years and continues to collaborate
    with libraries since the passage of the Workforce Innovation and
    Opportunity Act. This collaboration has included webinars to ensure
    both libraries and the workforce development system know about the
    assets and services they each have available to support jobseekers. The
    Department published guidance to the workforce system reiterating the
    importance of library partnerships and continues to make the workforce
    system aware of the resources available in libraries to support
    workforce development (See Training and Employment Notice 35-15,
    ``Encouraging Collaborations between the Workforce Investment System
    and Public Libraries to Meet Career and Employment Needs'').
        Other ongoing collaborative work with IMLS includes the Performance
    Partnership Pilot (P3) authorized in 2014, in which pilot sites can
    test innovative strategies to achieve significant improvements in
    education, employment, and other key outcomes for disconnected youth.
    P3 gives the Departments of Education, Labor, Health and Human Services
    (HHS), and Justice (DOJ), the Corporation for National and Community
    Service (CNCS), and IMLS authority to waive Federal statutory and
    regulatory requirements that inhibit access to assistance and effective
    service delivery for disconnected youth provided certain conditions and
    requirements are met.
        Public libraries play an integral role and are a crucial resource
    in communities for job seekers. The Department will continue working
    with libraries and promoting libraries as key partners in the workforce
    system.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
                              black lung benefits
        Question. Black lung is a terrible disease caused by inhaling coal
    dust and mainly affects coal miners. After years of dedication to
    providing our nation with energy, America's coal miners continue to
    face the devastation of black lung disease. We are seeing more and more
    cases of black lung--particularly in younger miners who have spent less
    time working in the mines. Today, more than 25,000 coal miners and
    their dependents rely on the Black Lung Disability Trust Fund to pay
    for critical medical treatments and basic expenses. The Black Lung
    Disability Trust Fund is financed primarily by an excise tax on coal
    produced and sold domestically. In both 2019 and 2020, Congress passed
    1 year extensions to ensure revenue streams for the Trust Fund did not
    plummet. Current rates are set to expire on December 31, 2021, putting
    an indebted Trust Fund in a precarious financial situation.
        How can we ensure these benefits are protected and that our coal
    miners continue to get the help they need?
        Answer. President Biden has consistently expressed his
    understanding of the harms to individuals and communities impacted by
    black lung disease. He has also expressed his belief that coal mine
    companies must be responsible for the occupational harms incurred by
    their workers.
        When the Government Accountability Office evaluated options for
    improving the Trust Fund's financial condition in May 2018, it examined
    different options and noted that permanently increasing the excise tax
    on coal to at least $1.38 per ton for underground-mined coal and $0.69
    for surface-mined coal (25 percent higher than the current rates),
    could keep the Trust Fund solvent through 2050. The Administration is
    committed to ensuring coal miners continue to receive their benefits in
    any case, and without a legal change, the Trust Fund will continue to
    borrow from Treasury in order to finance the benefits. Without
    increased funding, the GAO estimated that the Trust Fund will
    accumulate $15 billion of debt by 2050. That debt would be shouldered
    by taxpayers instead of the responsible coal mine companies. The
    Administration is eager to work with Congress to protect these critical
    benefits and ensure that the Black Lung Disability Trust Fund is
    solvent.
                                silica dust rule
        Question. The extraction, refining, and transportation of coal
    generates significant amounts of coal dust, which contains silica.
    While coal dust is hazardous to miners' health on its own, silica is
    classed as a carcinogen and is substantially more dangerous. Excessive
    exposure to silica has been linked to black lung, silicosis, and the
    most lethal type of black lung, progressive massive fibrosis (PMF). The
    U.S. Department of Labor's Office of Inspector General (OIG) produced
    an audit report last year critical of the Mine Safety and Health
    Administration's (MSHA) inadequate efforts to safeguard coal miners
    from crystalline silica exposure. The Inspector General's report found
    that MSHA needs to update its regulations to: (1) Lower the legal
    exposure limit to silica, (2) Improve the ability of the agency to
    issue citations and fines for excess exposure to silica, and (3)
    Increase sampling protocols where were found to be too infrequent to
    protect miners adequately. These findings are extremely troubling--
    especially while we continue to grapple with the COVID-19 pandemic.
        How far along is the agency in creating a silica dust standard for
    underground coal mines?
        Answer. The Notice of Proposed Rulemaking for MSHA's Respirable
    Crystalline Silica standard is scheduled for January 2022. MSHA is in
    the process of developing the proposed rule including the preamble and
    supporting documentation. Under Section 101 (a) of the Federal Mine and
    Safety and Health Act of 1977, the proposal must go through the notice
    and comment process, which includes solicitation of comments from
    stakeholders. This allows the public opportunity to submit both written
    comments and to present testimony at public hearings, if requested. The
    substance of the final rule would take into consideration the comments
    and testimony received during the rulemaking process.
        Question. When do you anticipate releasing a new rule?
        Answer. The Notice of Proposed Rulemaking for MSHA's Respirable
    Crystalline Silica standard is scheduled for January 2022.
                        miners and covid-19 protections
        Question. In March 2021, the Mine Safety and Health Administration
    issued Federal guidance for mine operators, but fell short of issuing
    an enforceable standard that would apply to mines and miners. Last
    month, the Occupational Safety and Health Administration issued an
    Emergency Temporary Standard for healthcare workers, which set
    requirements to protect workers from contracting COVID-19 in healthcare
    settings. I introduced a bipartisan bill in February, the COVID-19 Mine
    Worker Protection Act, which would require you as the Secretary of
    Labor to issue an Emergency Temporary Standard to requires mine
    operators to protect their workers from COVID-19. This would include
    development and implementation of a comprehensive infectious disease
    exposure control plan, provide PPE to miners, and a framework for
    documenting data. Mining is a dangerous business, we in West Virginia
    know this all too well. But we should take all appropriate steps to
    ensure miners are protected against COVID-19, something we know is
    continuing to spread in our country.
        Secretary Walsh, can you provide an update on what are you doing to
    protect miners from COVID-19 exposure in and around mining sites?
        Answer. On March 10, 2021, the Mine Safety and Health
    Administration issued worker safety guidance to help mine operators and
    mine workers implement a coronavirus protection program and better
    identify risks that could lead to exposure. ``Protecting Miners: MSHA
    Guidance on Mitigating and Preventing the Spread of COVID-19'' provides
    updated guidance and recommendations, and outlines existing safety and
    health standards. The guidance details key measures for limiting the
    coronavirus's spread, including ensuring infected or potentially
    infected miners are not in the workplace, implementing and following
    physical distancing protocols and using surgical masks or cloth face
    coverings. It also provides guidance on use of personal protective
    equipment, improving ventilation, good hygiene and routine cleaning.
    MSHA announced the guidance to more than 450 stakeholders during a
    quarterly meeting and answered questions from the mining community.
        Question. Will you work with me on this proposal to protect miners
    from COVID-19 exposure?
        Answer. We need to take all appropriate steps to ensure miners are
    protected from COVID-19. The state of the pandemic is in constant flux
    and MSHA will follow the science. If it becomes necessary, we will
    issue an Emergency Temporary Standard for COVID-19 for the mining
    industry.
                        addiction and returning to work
        Question. As the opioid epidemic continues to take its toll, there
    are more and more men and women who face severely limited job
    opportunities after serving their time for crimes committed as a result
    of addiction. To help fix this problem, I reintroduced a bill called
    the Clean Start Act that seeks to help former addicts with criminal
    records seal those records if they complete a comprehensive addiction
    treatment program and show that they have turned their lives around.
    West Virginia has now enacted its own version of the Clean Start Act.
        What are some of the key ways the Department of Labor can help in
    getting those struggling with addiction to get back to work?
        Answer. The public workforce system complements health, law
    enforcement, and social service agencies to address the impact of
    opioid addiction and other substance use disorders. Since 2018, the
    Department has issued three grant opportunities addressing the
    workforce impacts of opioid addiction and other substance use
    disorders. Under these programs, grantees provide reemployment services
    for individuals impacted by the crisis; train individuals to transition
    into professions that can impact the crisis, such as alternative pain
    management, mental health treatment, and addiction treatment; and
    create temporary employment opportunities for peer recovery counselors
    and other positions that have a direct impact on the crisis. States and
    eligible applicants can continue to apply for National Health Emergency
    (NHE) Dislocated Worker Grants (DWGs) at www.grants.gov. ETA encourages
    State Workforce Agencies, local Workforce Development Boards, outlying
    areas, and tribal organizations to develop comprehensive partnerships
    to creatively align and deliver career, training, and supportive
    services that will best serve workers impacted by substance use
    disorders and opioid addiction. The services that the public workforce
    system offers complement evidence-based treatment for substance use
    disorders.
        DWG grantees use two main approaches to strengthen enrollment and
    services for individuals with substance use disorders: bringing
    individuals into the American Job Center for tailored services, and
    bringing American Job Center services to providers of behavioral health
    services. DWG grantees have also reported that courts and justice-
    related agencies are strong partners. These may include juvenile and
    family courts, drug courts, as well as prison and probation offices.
    The workforce system can connect individuals who have been involved in
    the juvenile and/or adult justice system to Reentry Employment
    Opportunities grant programs (where available) to receive services and
    resources. These partnerships help to bridge the gap between recovery
    services and employment and self-sufficiency.
        For further information, ETA issued Training and Employment Notice
    2-21, Serving Individuals and Communities Impacted by Opioid Addiction
    and Other Substance Use Disorders, July 23, 2021. This is in addition
    to a series of virtual programs in 2021 to train professionals in the
    workforce system on serving individuals impacted by substance use
    disorder.
        Question. What programs and initiatives, in your experience, will
    be most effective in assisting former offenders rejoin the workforce?
        Answer. The Department's Reentry Employment Opportunities (REO)
    program, which includes current reentry grants Reentry Projects,
    Pathway Home, and Young Adult Reentry Partnerships, align with
    evidence-based practices that result in people involved in the justice
    system getting employment. Our grant programs include flexibility to
    support the individualized needs of participants. Supportive services
    such as transportation, housing, mental health and substance abuse
    counseling, and assistance with gaining identification necessary for
    employment are crucial to initial and long-term stable employment for
    this population. Without these basic supports, it is hard for
    participants to succeed in training that leads to better employment
    outcomes. People connected to the justice system also need mentors,
    especially mentors with similar lived experiences, who can support them
    through the transition from incarceration to reenter the community. The
    use of Work Opportunity Tax Credits and the Federal Bonding Program can
    also increase employers' hiring of previously incarcerated individuals.
        Moreover, connecting participants to work that is legally available
    to them after release is imperative. Sometimes local or state licensure
    laws present barriers to employment. The Department is currently
    developing a tool that will help individuals re-entering their
    communities learn how license/certification laws align with their
    employment goals. The tool will be available on https://
    www.careeronestop.org/.
        The Department has used existing evidence to support current
    initiatives, building off the Linking Employment Activities Pre-Release
    (LEAP) implementation study to develop the 2020 and 2021 Pathway Home
    grants. The LEAP pilots provided pre-release services through jail-
    based American Job Centers and linked participants to post-release
    services. The study documented effective approaches to serving
    individuals in jails. The Pathway Home grants further test the
    identified concepts and link participants in jails and prisons to the
    workforce system while still incarcerated. Additionally, the
    participants maintain the same case manager pre- and post-release for
    seamless reentry into the community. Federal Bonding is also an
    important tool to help justice-involved individuals overcome existing
    prejudice and stigma that may prevent potential employers from hiring
    them due to perceived risks.
        The Reentry Projects and Pathway Home initiatives are currently
    being rigorously evaluated, which will further support the evidence
    base for connecting people involved with the justice system to gainful
    employment. Learnings from these projects will inform future grant
    models for continuous improvement and refinement of reentry employment
    projects.
                  unemployment insurance and returning to work
        Question. Mr. Secretary, it's no question that the COVID-19
    pandemic has had a tremendous impact on our country since the start of
    2020. Among many actions that were taken to respond to its effects, I
    was proud to work with my colleagues here in Congress to provide
    Americans with unprecedented relief in the form of unemployment
    insurance benefit programs, which has been a needed source of income
    for many West Virginians and Americans during these trying times.
    However, we are noticing that in some states and localities, despite
    our economy steadily returning to full, pre-pandemic capacity,
    unemployment rates still remain high. This trend is, of course,
    concerning, especially given the fact that the U.S. economy is adding
    jobs at rates seen before the COVID-19 pandemic set in. My
    understanding is that this combination of still elevated unemployment
    and elevated job growth has led many states, including my state of West
    Virginia, to end the pandemic unemployment assistance program before
    its expiration on September 4, 2021. Like many of my colleagues, I want
    to ensure that folks in my state and our country can return to work and
    can do so safely. I remain willing to work with anyone and through any
    means to do so.
        Do you believe that the enhanced unemployment insurance programs
    Congress has implemented have contributed to the inability of some
    employers to fill employment vacancies?
        Answer. I am not aware of evidence that enhanced unemployment
    insurance programs have contributed to the inability of some employers
    to fill employment vacancies. The President has said: ``I think people
    who claim Americans won't work, even if they find a good and fair
    opportunity, underestimate the American people. So we'll insist that
    the law is followed with respect to benefits. But we're not going to
    turn our backs on our fellow Americans.'' And I agree.
        Question. What can we do in Congress to support the economy and our
    returning workforce as we return to pre-pandemic output levels and
    activity?
        Answer. The COVID-19 pandemic created widespread economic
    disruption and further highlighted pre-existing deficiencies in the
    availability of opportunities for all Americans to find good-paying,
    safe employment. While existing WIOA funding amounts to states are set
    by a statutory formula, the fiscal year 2022 Budget reflects the
    Department's continued commitment to help American workers and job
    seekers, particularly those from disadvantaged communities, get back on
    their feet, access job training, and find pathways to high-quality jobs
    that can support a middle-class life. The fiscal year 2022 Budget
    requests $3.7 billion for WIOA programs, a $203 million increase over
    the fiscal year 2021 funding. The Budget includes increases of
    approximately $37 million for the Adult Program, $94 million for the
    Dislocated Worker Formula Program, $100 million for Dislocated Worker
    Grants (DWG), and $43 million for the Youth Program. This request will
    make employment services and training available to more dislocated
    workers, low-income adults, and disadvantaged youth who have been hurt
    by the economic impacts of the COVID-19 pandemic.
        The fiscal year 2022 Budget also includes the American Jobs Plan,
    an investment that will create millions of high-quality jobs and
    rebuild our country's infrastructure. This includes investments in
    American workers--providing people with the skills they need to
    succeed, strengthening the pathways to success, and ensuring that the
    jobs that are created are high quality. Structural racism and
    persistent economic inequities have undermined opportunity for millions
    of workers, and these investments will prioritize underserved
    communities and communities negatively impacted by the transforming
    economy. The United States currently spends just one-fifth of the
    average that other advanced economies spend on workforce and labor
    market programs.
        The Department included legislative proposals to implement the
    American Jobs Plan, totaling $81.5 billion over 10 years, to address
    these multiple challenges. This investment in proven workforce
    development models includes:
      --Creating and expanding sector-based training programs;
      --Providing comprehensive support for dislocated workers to enable
            their participation in high-quality training programs;
      --Expanding Registered Apprenticeship and pre-apprenticeship
            opportunities;
      --Building community colleges' capacity to deliver high-quality job
            training programs;
      --Expanding access to evidence-based intensive, staff-assisted career
            services;
      --Providing subsidized jobs to workers with barriers to employment;
      --Expanding workforce development services for justice-involved
            individuals; and
      --Phasing out the subminimum wage provided to workers with
            disabilities while expanding their access to competitive,
            integrated employment opportunities.
        The Administration also has requested $100 million in the next
    fiscal year to enable states to overcome the loss of legacy industries
    or persistent employment challenges and work towards a clean energy
    economy, helping to ensure steady employment opportunities into the
    future.
        Question. Are there any lessons to be learned with how our
    unemployment systems have responded over the last year to better
    prepare them if faced with another economic crisis in the future?
        Answer. The Unemployment Insurance system has served as a critical
    lifeline over the last year, helping nearly 53 million workers stay
    afloat during the pandemic and the resulting economic crisis infusing
    over $800 billion into the economy--staving off an even deeper
    recession. At the same time, this crisis only further exposed
    longstanding challenges in the UI program. While states mobilized
    quickly to implement new crucial pandemic unemployment programs, they
    were hamstrung by outdated technology and a lack of resources that made
    them vulnerable to fraud from international crime rings. State
    administrative funding was at a historic low. Recent policy changes in
    state law are designed to make it more difficult to access UI. These
    challenges made it difficult for states to quickly and equitably
    deliver benefits to unemployed workers. Even as economic conditions
    continue to improve, states face significant backlogs that have delayed
    benefits to workers, and they have struggled to address fraud
    perpetrated by sophisticated crime rings that persist in using new
    techniques to attack UI systems.
        The Department welcomes the $2 billion that Congress provided in
    the American Rescue Plan Act and agrees that UI technology and
    infrastructure modernization are urgently needed. State systems must
    operate on a high-quality technology infrastructure that enables them
    to administer their UI programs equitably and efficiently, so all
    eligible unemployed workers have timely and meaningful access to this
    vital benefit. The Administration is fully engaged in developing
    detailed plans to achieve the goals and purposes set in the American
    Rescue Plan Act and will keep Congress informed of those plans and
    progress on the implementation of this important project.
        The Department has engaged with states on this topic. The
    Department conducted an initial webinar with state UI agencies on June
    22, 2021, to share some of the current plans and approach on pursuing
    UI information technology modernization. The webinar also solicited
    states for engagement and partnership in these activities. Since then,
    seven states have begun working with the U.S. Department of Labor (DOL)
    and the U.S. Digital Service in research partnerships designed to help
    fill in research gaps and provide input on the current and future
    stages of UI modernization. Also, there have been follow-up virtual
    office hours offered to states for further conversations on this topic.
        All states should benefit from the funding provided in the American
    Rescue Plan Act. As a state modernizes its IT system, there may be
    opportunities to take advantage of the central, modular, open
    technology solutions developed through this DOL/state partnership. DOL
    is also deploying teams of experts, initially to six states, on a
    voluntary basis to help identify process improvements that can speed
    benefit delivery, address equity, and fight fraud (i.e., Tiger Teams).
    The Tiger Teams can provide support, including funding, as states like
    West Virginia look at business processes through a fraud-fighting and
    equity lens in the course of modernization. Additionally, DOL is making
    grants to states available to promote equity and fight fraud. These
    grants will be designed to help states improve worker access to the UI
    system, while helping states make system improvements that will
    safeguard them against fraud.
                                     ______

                    Questions Submitted by Senator Roy Blunt
                 apprenticeships and nontraditional industries
        Question. As Chairman of the Subcommittee in fiscal year 2016, I
    began funding for the Apprenticeship program. I note that while the
    Administration is requesting an increase of $100 million for the
    program, the Department is no longer pursuing Industry Recognized
    Apprenticeship Programs (IRAPs)--which would allow third-party entities
    to apply for awards without being registered by the Department of
    Labor. The previous Administration argued that IRAPs are intended to
    supplement the current system, not replace or weaken it. IRAPs would
    also allow non-traditional apprenticeship programs to thrive alongside
    of the more traditional apprenticeships.
        During a period when our nation is recovering from the
    unprecedented strain of COVID-19 on our workforce, it is paramount that
    we provide the most opportunities to get our country back to work.
        How will you work with non-traditional industries to bring them
    into the Apprenticeship program?
        Answer. The Department supports industry-driven and employer-led
    innovation in the Registered Apprenticeship System, a key strategy to
    increase the representation of non-traditional industries in Registered
    Apprenticeship. In fact, expanding Registered Apprenticeship into non-
    traditional industries has been a Departmental priority for the past 10
    years, and we've seen incredible growth due to numerous investments and
    promotional activities. Since 2015, the number of Registered
    Apprenticeships in non-traditional industries (non-construction) has
    grown by over 43 percent.\24\
    ---------------------------------------------------------------------------
        \24\ https://www.dol.gov/agencies/eta/apprenticeship/about/
    statistics/2020.
    ---------------------------------------------------------------------------
        Industry designs and operates Registered Apprenticeship programs.
    The Department works in partnership with industry to provide technical
    assistance to support and ensure programs meet minimum quality
    standards for apprentice safety, welfare, and equal opportunity. This
    approach ensures that Registered Apprenticeship programs are employer-
    led, industry-driven, of high quality, responsive to the changing needs
    of employers, and capable of producing highly skilled workers that can
    compete in a highly-competitive global economy.
        Over the past 6 years, the Department has made significant
    investments to support apprenticeship and work-based learning in non-
    traditional industries. Investments include recent awards to support
    state-led expansion, equity and innovation grants, innovative
    approaches to developing consistent standards in non-traditional
    occupations through competency-based occupational frameworks, as well
    as the establishment of new Registered Apprenticeship (RA) Technical
    Assistance (TA) Centers of Excellence. This includes a dedicated RA TA
    Center to support the development of Registered Apprenticeship Program
    frameworks (competency-based, hybrid, and other innovative models),
    national standards including those that include industry-recognized
    credentials, and supporting industry in meeting Registered
    Apprenticeship Program design and development requirements in
    compliance with 29 C.F.R. Part 29, Subpart A.
        The Department has also supported employer-led innovation in
    Registered Apprenticeship through the following mechanisms:
      --Industry Intermediaries: Since 2016, DOL has funded industry
            associations, also referred to as ``industry intermediaries''
            to develop National Apprenticeship Programs to meet critical
            industry needs and lead the expansion of Registered
            Apprenticeship across a wide range of industries. The most
            recent round of industry intermediary awards included a focus
            on expanding registered apprenticeship into non-traditional
            industries.
      --Growth of National Programs: To better support national employers
            and industry-led efforts, the Department has enabled
            significant growth in the number of organizations that have
            registered as National Apprenticeship Programs. This growth has
            nearly doubled over the past several years. Between January
            2019 and May 2021, the Department registered approximately 70
            National Apprenticeship Programs. These National Apprenticeship
            Programs allow employers to quickly and easily adopt industry
            vetted and Departmental-approved Registered Apprenticeship
            programs into their organization through a simple employer
            acceptance agreement, reducing paperwork and program
            duplication.
        Question. What resources are needed to ensure that all
    opportunities for apprenticeships are considered at the Department?
        Answer. Dedicated resources for Registered Apprenticeship are
    critical to expand the program. I urge Congress to enact the
    President's Budget and the American Jobs Plan. Within the fiscal year
    2022 President's Budget, the Administration proposes increasing
    apprenticeship funding by $100 million, for a total of $285 million.
    The Department will prioritize investments that expand the
    apprenticeship model to new sectors and occupations and increase access
    for historically underrepresented groups, including people of color,
    women, individuals with disabilities, and justice-involved individuals.
    The American Jobs Plan provides another opportunity for Congress to
    ensure support for apprenticeship. The Administration proposes
    investing $10 billion over 10 years to create between one and two
    million new Registered Apprenticeship slots.
                                   green jobs
        Question. The budget request includes an increase of $100 million
    within the Dislocated Worker National Reserve for a new initiative that
    will target investments for training and employment opportunities in
    communities for new industries, including those supporting ''green
    jobs''.
        Additionally, the budget request includes an increase of $20
    million for a new competitive grant program to prepare eligible
    veterans, transitioning service members, and their spouses for careers
    in ``green jobs.'' This new competitive grant program is proposed to be
    housed within Training and Employment Services, as opposed to within
    the Veterans' Employment and Training Service program.
        I'm concerned with the notion that the Federal Government is
    dictating the future of our workforce by tying training dollars to
    ``green jobs.'' Specifically, the new Power initiative will impose
    significant restrictions on local economies to focus only on green
    jobs, and not necessarily jobs their local economy may need. The
    Department already spends millions of dollars to train workers for jobs
    that are needed in local communities because of the partnership with
    state and local workforce boards. Therefore, why is the Federal
    Government simultaneously determining what industries can prosper in
    local economies through this new initiative?
        Answer. The $100,000,000 requested is part of a new Interagency
    Working Group on Coal and Power Plant Communities and Economic
    Revitalization. The Working Group is not an attempt by the Federal
    Government to determine which industries can prosper. Rather, it is an
    initiative that will complement other targeted Federal investments to
    assist workers and transform local economies in communities
    transitioning into new, sustainable industries, including those
    supporting new or sustainable energy sources. This targeted program
    will help energy industry workers who have been adversely impacted by
    changes in the economy prepare for jobs in demand in states and local
    communities that choose to apply. The initiative will build on the
    success of the original POWER initiative and expand beyond the coal
    industry. It will address changes in the energy economy, and other
    legacy industries, through strategic planning, partnership development,
    and reskilling and reemployment activities aligned with longer-term
    economic transformation efforts. It will support community-led
    workforce transition, layoff aversion, job creation, and other
    strategic initiatives designed to ensure economic prosperity for
    workers and job seekers in the coal, oil, gas, and other industries in
    decline.
        Question. I'm encouraged to see an increase for veterans' programs
    in the budget request. Many service members leave the military with
    significant training that can translate to the civilian workforce, and
    it should be a priority to ensure that our veterans have the resources
    necessary to transition to civilian life. Our workforce system should
    be flexible to allow these workers to succeed. However, I'm concerned
    about the proposal for a new, $20 million program to train our nation's
    heroes for ``clean energy'' jobs, only. I do not think we should tie
    our training dollars to specific jobs, especially jobs for our
    veterans, nor should the Federal Government be in the position to pick
    winners and losers in the economy. Why does the Department think that
    it can better dictate workforce opportunities for our transitioning
    service men and women, as opposed to our local economies and the local
    job creators that truly understand the workforce needs of our
    communities?
        Answer. The Veterans' Clean Energy Training Program will be a new
    competitive grant program to prepare eligible veterans, Transitioning
    Service Members (TSMs), and their spouses for careers in the clean
    energy sectors of the energy industry. This program does not dictate
    workforce opportunities but, instead, allows states and local
    communities, based on their local workforce needs and in partnership
    with local businesses, to help veterans prepare for jobs that are in
    demand. Clean energy job opportunities are expected to grow between now
    and 2029. Certain occupations are expected to grow rapidly in the next
    several years or have large numbers of job openings. A skilled
    workforce is foundational to achieving the President's goal of having
    100 percent carbon-free electricity by 2035 while creating a more
    resilient energy grid, lowering energy bills for middle-class
    Americans, and improving air quality and public health outcomes. The
    Department's Employment and Training Administration will develop and
    implement the program collaboratively with the Department's Veterans'
    Employment and Training Service and the Department of Veterans Affairs
    to identify appropriate state, Federal, and industry partners to
    deliver the education, training, and job placement of program
    participants.
        Grantees will use effective outreach, media, and engagement to
    recruit a diverse cohort of participants for job training. Grantees
    will use robust, comprehensive work-based learning strategies, such as
    On-the-Job Training, customized training, Incumbent Worker Training,
    Registered Apprenticeship, pre-apprenticeship programs that matriculate
    to Registered Apprenticeship programs and paid work and internships.
    Other allowable approaches will include classroom, including
    competency-based, and technology-based training strategies, culminating
    in the attainment of an appropriate industry-recognized certificate or
    credential.
        Grantees will also provide technical assistance to this network of
    employers to successfully employ and retain veterans, TSMs, and
    military spouses. In addition, grantees will provide participants with
    supportive services, such as transportation and childcare, to enable
    them to participate in activities authorized under the program.
        The program will engage a wide array of employers, large and small,
    including Veteran-Owned Small Businesses and Service Disabled Veteran
    Owned Small Businesses in the adoption and deployment of training and
    work-based learning. These will be public-private partnerships engaging
    employers across clean energy sectors, which will help empower local
    communities and ensure that we are training workers for occupations
    that are in demand.
        The program will develop new or expand existing successful industry
    sector partnerships and build off of lessons learned from the
    Department of Energy's Solar Ready Vets program. These partnerships of
    multiple employers, educational institutions, economic development
    agencies, workforce development entities, and community-based
    organizations will identify and collaboratively meet the workforce
    needs of the growing clean energy sector within a given labor market,
    incorporating career pathway strategies by aligning education and
    training programs with industry needs.
                              joint employer rule
        Question. In June 2021, DOL sent its proposed rescission of the
    previous Administration's Joint Employer rule to the Office of
    Information and Regulatory Affairs for final rule. I am concerned that
    the Department is moving to rescind the previous Administration's Joint
    Employer rule and potentially issue another new rule. This
    Administration's steps will further burden small and local businesses,
    who are the economic drivers of our economy. As our nation recovers
    from COVID-19, we need to be encouraging job growth and job creation,
    not stifling it with further regulations and complicated, ambiguous
    standards.
        What are the Department's substantive plans and timeframe with
    respect to this rulemaking?
        Answer. The Department issued a final rule rescinding the previous
    Administration's Joint Employer rule on July 30, 2021. The rescission
    will be effective October 5, 2021.
                     covid-19 emergency temporary standard
        Question. The Occupational Safety and Health Administration (OSHA)
    published an emergency temporary standard (ETS) relating to COVID-19
    protections in the workplace. The requirements of the ETS apply to
    ``all settings where any employee provides healthcare services or
    healthcare support services.'' I am concerned that there's ambiguity
    regarding who and what are exempt from the emergency rule. While retail
    pharmacies have a blanket exemption, walk-in medical clinics, doctor's
    offices, dental practices, and other ``non-hospital ambulatory care
    settings'' may qualify for exemptions depending on their screening
    policies and the type of care performed. To qualify for an exemption,
    the employer must limit the number of entrances to a facility and have
    a screening process where people are checked at the entrance or outside
    of the facility. ``Screening'' is defined as ``asking questions to
    determine whether a person is COVID-19 positive or has symptoms of
    COVID-19.'' Testing is optional.
        Workplaces and employers that are not exempt from this emergency
    rule must develop and implement a COVID-19 plan; provide and ensure the
    wear of facemasks for employees; provide respirators and other Personal
    Protective Equipment to employees; ensure social distancing when
    possible; install physical barriers where social distancing cannot take
    place; and clean and disinfect all workplace areas in accordance with
    CDC guidelines.
        While I appreciate that hospitals and nursing homes must comply
    with the provisions of this emergency temporary standard, as those are
    the settings in which there's an increased risk of coming into contact
    with an infected person, I am worried that there's too much ambiguity
    as to who and what are exempt outside of those facilities. Further, the
    provisions of this emergency standard place a burden on the employer,
    and I'm concerned that certain workplaces that could be exempt from
    these provisions may not realize it. Can you detail what settings are
    exempt from this standard, and will these settings be subject to an
    OSHA inspection?
        Answer. The COVID-19 ETS applies to employers in settings where any
    employee provides healthcare services or healthcare support services.
    This includes: Employees in hospitals, nursing homes and assisted
    living facilities; emergency responders; home healthcare workers; and
    employees in ambulatory care facilities. The focus of the ETS is on
    protecting healthcare workers in settings where suspected or confirmed
    COVID-19 patients are treated. Thus, the standard targets healthcare
    settings where OSHA has found the elevated risk associated with care of
    persons with confirmed and suspected COVID-19, and associated
    activities, constitute a grave danger. Accordingly, it exempts out
    settings where this elevated risk does not exist.
        Paragraph (a)(2) of the standard serves to limit the applicability
    of the ETS and provides that the ETS does not apply to the following:
    (i) The provision of first aid by an employee who is not a licensed
    healthcare provider; (ii) the dispensing of prescriptions by
    pharmacists in retail settings; (iii) non-hospital ambulatory care
    settings where all non-employees are screened prior to entry and people
    with suspected or confirmed COVID-19 are not permitted to enter those
    settings; (iv) well-defined hospital ambulatory care settings where all
    employees are fully vaccinated and all non-employees are screened prior
    to entry and people with suspected or confirmed COVID-19 are not
    permitted to enter those settings; (v) home healthcare settings where
    all employees are fully vaccinated and all non-employees are screened
    prior to entry and people with suspected or confirmed COVID-19 are not
    present; (vi) healthcare support services not performed in a healthcare
    setting (e.g., off-site laundry, off-site medical billing); or (vii)
    telehealth services performed outside of a setting where direct patient
    care occurs.
        The agency has developed numerous compliance assistance materials
    to help employers understand and apply the ETS to their workplace.
    These materials can be found at the OSHA website.\25\ In particular,
    the agency has developed a flow chart to help employers determine
    whether and how their workplace is covered by the COVID-19 Healthcare
    ETS. The flow chart is available on the website.\26\ The agency has
    also provided responses to many Frequently Asked Questions (FAQs),
    several of which address scope issues.\27\
    ---------------------------------------------------------------------------
        \25\ https://www.osha.gov/coronavirus/ets.
        \26\ https://www.osha.gov/sites/default/files/publications/
    OSHA4125.pdf.
        \27\ https://www.osha.gov/coronavirus/ets/faqs.
    ---------------------------------------------------------------------------
        Employers that are covered by the ETS can consult the Inspection
    Procedures for the COVID-19 Emergency Temporary Standard \28\
    compliance directive for information about inspection procedures and
    enforcement policies for the ETS. It should be noted that upon opening
    a COVID-19 related inspection where the ETS could potentially apply,
    the agency's enforcement personnel are specifically directed to
    determine if any of the exemptions outlined in sections 29 CFR
    Sec. 1910.502(a) apply to the whole facility or to well-defined
    portions to ensure that the ETS is not inappropriately applied to an
    employer who may be exempt.
    ---------------------------------------------------------------------------
        \28\ https://www.osha.gov/sites/default/files/enforcement/
    directives/DIR_2021-02_CPL_02.pdf.
    ---------------------------------------------------------------------------
        Employers not covered by the ETS can consult the Updated Interim
    Enforcement Response Plan for Coronavirus Disease 2019 (COVID-19) \29\
    for more information about how OSHA is handling COVID-19-related
    complaints, referrals, and severe illness reports in these workplaces.
    All employers can also consult the Revised National Emphasis Program--
    Coronavirus Disease 2019 (COVID-19) \30\ for more information about how
    OSHA is targeting specific high-hazard industries or activities where
    COVID-19 hazards are present in its enforcement activities.
    ---------------------------------------------------------------------------
        \29\ https://www.osha.gov/laws-regs/standardinterpretations/2021-
    07-07.
        \30\ https://www.osha.gov/sites/default/files/enforcement/
    directives/DIR_2021-03_CPL_03.pdf.
    ---------------------------------------------------------------------------
                          restoration of dol staffing
        Question. The fiscal year 2022 budget request includes an increase
    of $1.7 billion over the fiscal year 2021 level for the Department.
    Included in that increase is an increase of an additional 1,949 full-
    time equivalents (FTE) for the Department, increasing total FTE levels
    from 14,906 to 16,855. The vast majority of the increases are within
    Worker Protection components, which will ultimately increase the number
    of enforcement actions against businesses.
        The budget includes an additional 1,949 full-time equivalents for
    the Department. 362 of those are for OSHA alone, increasing the number
    of employees by over 13 percent. Most of those personnel won't focus on
    training individuals to renter the workforce, which is arguably the
    most important part of the Department's mission, especially as we
    recover from the unprecedented strain on our economy from COVID-19. Why
    is the Department not prioritizing training programs over increasing
    Federal bureaucracy?
        Answer. In addition to a much-needed restoration of staffing levels
    in Worker Protection activities, the fiscal year 2022 Budget renews
    DOL's commitment to help American workers and job seekers, particularly
    those from disadvantaged communities, get back on their feet, access
    job training, and find pathways to high-quality jobs that can support a
    middle-class life. Significant investments in training include:
      --Apprenticeship: The Budget requests $285 million, a $100 million
            increase above the fiscal year 2021 enacted level, to expand
            Registered Apprenticeship (RA) opportunities while increasing
            access for historically underrepresented groups, including
            people of color and women, and diversifying the industry
            sectors involved.
      --Workforce Innovation and Opportunity Act State Grants: The fiscal
            year 2022 Budget also requests $3.7 billion, a $203 million
            increase over the fiscal year 2021 enacted level, for Workforce
            Innovation and Opportunity Act State Grants. This request will
            make employment services and training available to more
            dislocated workers, low-income adults, and disadvantaged youth
            hurt by the economic fallout from the pandemic.
      --Training displaced coal workers: The Budget requests a $100 million
            investment for DOL's role in the new multi-agency POWER+
            Initiative, aimed at reskilling and reemploying displaced coal
            workers in Appalachian communities. This request would
            complement other targeted Federal investments in POWER+ to
            assist workers and transform local economies in communities
            transitioning away from fossil fuel production.
      --Veterans: The VETS Budget prepares America's veterans, service
            members, and their spouses for meaningful careers, provides
            them with employment resources and expertise, protects their
            employment rights, and promotes their employment opportunities.
            The Budget provides funding for the Veterans' Employment and
            Training Service's (VETS) core programs, which help improve
            skills and provide employment opportunities for veterans across
            the country. The request also provides the Employment and
            Training Administration (ETA) $20 million for a new program,
            developed in collaboration with VETS and the Department of
            Veterans Affairs, focused on helping veterans shift to careers
            in clean energy, which would help combat climate change while
            preparing veterans for good-paying jobs.
                  cares act and american rescue plan spending
        Question. The Department of Labor received $385 million in
    discretionary and mandatory supplemental funds through the CARES Act
    that was passed in March 2020 and more than $2.2 billion in mandatory
    funds through the American Rescue Plan (reconciliation bill) that was
    passed in March 2021.
        As of June 30th, a little more than $270 million has been obligated
    and only $91 million has been drawn-down from the $385 million provided
    in CARES. Further, of the $2.2 billion provided in the American Rescue
    Plan, less than $25 million has been obligated and only $5.6 million
    has been drawn-down. What is the delay in spending this funding and how
    long will it take you to expend these dollars?
        Answer. The CARES Act appropriated to the Department with $345.0
    million for National Dislocated Worker Grants (DWGs) and $15.0 million
    for the Departmental Management account to prevent, prepare for, and
    respond to coronavirus, including enforcing worker protection laws and
    regulations. In addition, the CARES Act appropriated $25.0 million to
    the Office of Inspector General (OIG) for oversight of the unemployment
    provisions enacted in the CARES Act.
        The Department issued guidance to States explaining how to apply
    for Disaster Recovery DWGs and Economic Recovery DWGs. The Department
    accepts applications on a rolling basis. Based on the anticipated large
    volume of funding requests across the nation, the Department approved
    reduced initial funding amounts to address the critical community needs
    in areas hardest impacted by the COVID-19 public health emergency. The
    amount initially provided was 33 percent of the grant amount requested
    or a set initial award amount correlated to a severity rating. The
    Department typically funds DWG awards on an incremental basis, although
    on rare occasions, it may award funds in full or in larger-than-typical
    increments, depending on factors such as the severity of the disaster
    and the viability of a proposed project.
        The Department has awarded nearly $398 million in Disaster Recovery
    and Economic Recovery DWGs related to COVID-19. Of this total,
    approximately $143 million was obligated from the Program Year 2019
    appropriation; the remainder was obligated from the supplemental funds
    appropriated under the CARES Act. ETA determines the amount to award
    for subsequent funding opportunities on a recipient's justification for
    the additional funds and continued demonstrated need, as evidenced by
    productive performance, enrollments and expenditures. ETA has
    traditionally considered requests for subsequent funding opportunities
    when expenditures have reached approximately 70 percent of the total
    DWG funds awarded to date. ETA works closely with states in determining
    their needs and identifying when additional resources may be warranted.
        Of the $15.0 million appropriated to the Departmental Management
    account, $1.0 million was transferred to OIG, as required. OIG's funds
    are available without fiscal year limitation. The remaining $14.0
    million was allocated between the Occupational Safety and Health
    Administration ($5.5 million); the Employment and Training
    Administration's Program Administration account ($4.0 million); the
    Wage and Hour Division ($2.5 million); the Employee Benefits Security
    Administration ($1.0 million); and the Office of the Solicitor ($1.0
    million). These funds are available for obligation until September 30,
    2022.
        As of July 31, 2021, the Department has obligated approximately
    $11.0 million and $9.9 million has been expended. The Department will
    obligate the remaining $4.0 million over the remainder of fiscal year
    2021 and fiscal year 2022 and expend the funds shortly thereafter.
        Of OIG's $25.0 million CARES Act appropriation, as of July 31,
    2021, OIG has obligated approximately $9.5 million and expended
    approximately $5.1 million. These funds are available for obligation
    until expended. The OIG indicated that it has allocated its CARES Act
    appropriation to support audits and investigations related to the
    expansion of the UI program during the pandemic, to include the hiring
    of more than 50 criminal investigators to combat unprecedented levels
    of fraud in the program. The OIG's funding will cover activities,
    salaries, and benefits through the end of fiscal year 2022.
        The American Rescue Plan Act (ARPA) appropriated $2.0 billion to
    detect and prevent fraud, promote equitable access, and ensure the
    timely payment of benefits with respect to the unemployment
    compensation program, $8.0 million to carry out Federal activities
    related to the administration of unemployment compensation programs,
    and $200.0 million to carry out COVID-19 related worker protection
    activities.
        The unemployment insurance (UI) system provided a critical lifeline
    for millions of workers during the pandemic. The pandemic also exposed
    longstanding challenges in the UI system. The funds appropriated under
    ARPA are critical to helping states address the most acute challenges
    they have faced this past year. The Department will be using the funds
    to tackle these acute problems facing the system in the short-term
    while also working to address long-term challenges. The Department is
    currently focusing on four key areas: sending multidisciplinary teams
    to states to provide intensive technical assistance; a comprehensive
    approach to implementing identify verification; modernizing technology;
    and directing grants to states to help solve some of these challenges
    immediately. Regarding the worker protection funding, the Department
    has set up a website \31\ that outlines the planned use of funds for
    the worker protection activities and a quarterly status of obligations.
    ---------------------------------------------------------------------------
        \31\ https://www.dol.gov/general/american-rescue-plan/worker-
    protection-supplemental-appropriation.
    ---------------------------------------------------------------------------
            unemployment insurance and consumer finance applications
        Question. In your testimony, you stated that you have two key goals
    for unemployment insurance: decreasing fraud and increasing access to
    benefits. You mentioned that the Department will have a four-pronged
    approach to bolstering unemployment insurance, including modernizing
    technology.
        What are your thoughts on utilizing consumer finance applications
    to assist states in modernizing their unemployment insurance systems
    and preventing fraud?
        Answer. The pandemic has only underscored states' desperate need
    for technological support and improvements. Many state systems are
    operating on outdated technology, which made it difficult for them to
    rapidly respond to changes in law and economic conditions. Part of our
    plan for the $2 billion appropriated under the American Rescue Plan Act
    is to address this problem by centrally developing open, modular
    technology solutions that states may adopt as part of ongoing
    modernization and improvement efforts. Shared IT solutions will be
    designed to integrate with state systems and will focus on the needs
    that are shared across states, while supporting states to implement and
    continue operating state specific elements. DOL's vision is to provide
    software to support end-to-end administration of UI, including benefit
    delivery, employer tools, and appeals. As part of this effort, DOL will
    consider all possible IT solutions that will assist states in
    modernizing their systems and preventing fraud, including consumer
    finance applications. DOL will work with the IT staff in the States to
    develop and execute a plan that builds resilience in the UI systems
    across the country.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
                       funding for west virginia grantees
        Question. The Employment and Training Administration, an agency
    within your Department, is the leading agency responsible for providing
    job training and workforce development. My home state of West Virginia
    has one of the highest rates of unemployment in the nation, and yet we
    receive a minimal amount of ETA grant funding to retrain workers in
    emerging industries as we unfortunately shift away from a coal-
    dominated economy.
        Why is it that we are missing out on this funding and how will you
    ensure that states like West Virginia, which have a clear need for
    investment in our workforce development, are adequately supported?
        Answer. The Employment and Training Administration (ETA) provides
    grant awards to eligible entities to carry out a public purpose for the
    direct benefit or use of the United States Government. Many of these
    programs are funded through formula grants whereby the law specifies or
    allows ETA to determine the formula to distribute funding to the
    recipients. These grants include funding under Title I of the Workforce
    Innovation and Opportunity Act (WIOA), Unemployment Insurance
    Administrative Awards, Foreign Labor, Employment Service, and Trade
    Adjustment Assistance grants to states and territories. The allocation
    formula and funding allotments for these programs are published in ETA
    guidance and are made available publicly.\32\
    ---------------------------------------------------------------------------
        \32\ https://wdr.doleta.gov/directives/all_advisories.cfm.
    ---------------------------------------------------------------------------
        In addition to formula-funded programs, some legislation provides
    discretionary funding for the Department to improve operations,
    performance, or knowledge. These competitive grants are typically
    awarded to eligible entities to create or expand innovative workforce
    development programs for workers and employers. The Department develops
    grant competitions and formally issues Funding Opportunity
    Announcements (FOAs) that convey the application requirements and
    evaluation considerations. These FOAs are published on the Grants.gov
    website and provide prospective applicants with the framework for
    preparing a grant application. The Department will often host a webinar
    or other event to discuss new FOAs for prospective applicants during
    the open period. A Technical Review Panel, composed of Federal staff
    and other workforce development experts, evaluates FOA applications.
    Reviewers evaluate and score applications based solely upon the
    evaluation criteria in the published FOA. The ranked application scores
    serve as the primary basis for the Department's selection of funding
    applications.
        During fiscal year 2020, ETA awarded more than $83.33 million in
    grant funding to West Virginia, including $78.67 million for formula
    programs and an additional $4.66 million in discretionary grants. These
    awards included two grants under the Workforce Opportunities for Rural
    Communities (WORC) program that enables communities within the
    Appalachian and Delta regions that have been hard-hit by economic
    transition, with slow recovery, to develop local and regional workforce
    development solutions that align with economic development strategies.
    ETA anticipates making a third round of WORC awards this Fall.
        Question. On that same note, I was disappointed to learn two
    YouthBuild programs weren't selected for continued funding. I'd love to
    learn more about why, this program has helped so many young adults get
    back on track for a career.
        Answer. The Department issues the YouthBuild Funding Opportunity
    Announcement (FOA) each year. This FOA is a competition open to both
    previously-funded applicants and entities that never received an award.
    Since this is a competitive process, not all applicants are selected
    for funding. Of the 130 applications reviewed this year, due to limited
    funds available, only 68 were selected. All applicants are contacted
    with the results of the competition and provided guidance on how to
    receive evaluative feedback related to their application. This feedback
    often helps applicants submit a more competitive application in the
    future.
                                     ______

                   Questions Submitted by Senator Mike Braun
                    dol freedom of information act requests
        Question. The Freedom of Information Act (FOIA), codified at 5
    U.S.C. Sec. 552, provides public access to certain Federal agency
    information.
        Please provide the Committee with the Department of Labor's (DOL)
    budget request specifically for continued administration of and
    compliance with FOIA requests.
        Answer. The DOL's FOIA processing is a decentralized operation such
    that each of the Agency's components account for their own expected
    FOIA processing costs within their individual budget requests. In the
    Agency's last annual FOIA report, completed for fiscal year 2020, DOL
    reported a total of 120.5 Equivalent Full-Time FOIA Employees and spent
    $19,103,622 in FOIA related processing costs for the DOL's 23
    decentralized FOIA components,
        While DOL's President's Budget for fiscal year 2022 does not
    include a specific request for the aggregate cost of FOIA processing
    and administration, DOL is able to identify certain items included
    within its budget request that relate specifically to FOIA processing
    and administration. First, for fiscal year 2022, the DOL has projected
    a cost of $1,170,000 for its Office of Information Services (OIS),
    which supports the statutorily mandated functions of the Department's
    Chief FOIA Officer (currently the Solicitor) in carrying out
    Department-level responsibilities under the Freedom of Information Act.
    5 U.S.C. Sec. 552. In addition, DOL's Office of the Chief Information
    Officer (OCIO) has projected fiscal year 2022 FOIAXpress System cost to
    be $1,121,576, to include $891,210 for FOIA System Costs (Licensing and
    Hosting), $155,366 for FOIA.
        Question. Pertaining to the January 1, 2021 to July 15, 2021
    timeframe, please also provide:
          1. An update on the volume of FOIA requests;
          2. The average time the agency took to fulfill such and the
            volume of FOIA requests outstanding; and
          3. How many requests the agency has utilized a statutory
            exemption to deny fulfillment of a FOIA request.
        Answer.
          1. An update on the volume of FOIA requests

    ------------------------------------------------------------------------
    Total Number of Initial FOIA Requests Received.............      7,632
    Total Number of Initial FOIA Requests Processed............     8,442
    ------------------------------------------------------------------------
    ``Total Number of Initial FOIA Requests Processed'' includes requests
      received prior toP January 1, 2021.

          2. The average time the agency took to fulfill such and the
            volume of FOIA requests outstanding:

    ------------------------------------------------------------------------
    Average Number of Days to Process (Simple Queue)...........       45.8
    Average Number of Days to Process (Complex Queue)..........       72.2
    Average Number of Days to Process (Expedited Queue)........       79.1
    Total Number of Pending Requests (outstanding) request.....      2,296
    Total Number of Backlogged Requests (20 workdays or older).     1,503
    ------------------------------------------------------------------------
     ``Simple Queue'' is based on low volume and/or simplicity of records
      requested and ``Complex Queue'' is based on high volume and/or
      complexity of records requested.

          3. How many requests the agency has utilized a statutory
            exemption to deny fulfillment of a FOIA request: 2
        Question. Please also provide a comparison of such FOIA volume and
    related fulfillment to calendar year 2020.
        Answer.
          1. An update on the volume of FOIA requests

    ------------------------------------------------------------------------
    Total Number of Initial FOIA Requests Received.............     15,820
    Total Number of Initial FOIA Requests Processed............     15,645
    ------------------------------------------------------------------------

          2. The average time the agency took to fulfill such and the
            volume of FOIA requests outstanding:

    ------------------------------------------------------------------------
    Average Number of Days to Process (Simple Queue)...........         39
    Average Number of Days to Process (Complex Queue)..........       53.3
    Average Number of Days to Process (Expedited Queue)........       18.8
    Total Number of Pending Requests (outstanding).............      2,589
    Total Number of Backlogged Requests (20 workdays or older).      1,714
    ------------------------------------------------------------------------

          3. How many requests the agency has utilized a statutory
            exemption to deny fulfillment of a FOIA request: 0
                payroll audit independent determination program
        Question. In the Trump Administration, the Department of Labor's
    Wage and Hour Division (WHD) saw both record-breaking enforcement
    numbers, and record-breaking outreach efforts. Despite these incredible
    outcomes for workers, the Biden Administration ended a voluntary
    compliance program called PAID (Payroll Audit Independent
    Determination). Will you commit to reviewing and reestablishing the
    PAID program?
        Answer. The Department ended the Payroll Audit Independent
    Determination (PAID) program in January 2021. Between 2018 and 2021,
    approximately 70 employers participated in the PAID program. The
    Department continues to provide outreach and education resources for
    employers. Employers may continue to contact any of our 200 Wage and
    Hour Division offices to confidentially discuss their compliance
    questions, or to self-report violations they would like to resolve.
                                  teleworking
        Question. How many of DOL's approximately 15,279 Full Time
    Equivalent (FTE) person workforce in Washington, D.C. is currently
    teleworking either (1) part-time or (2) full-time?
        Answer. Based on data from the end of July 2021, 99.1 percent of
    DOL and PGBC employees are teleworking either on a part-time or full-
    time basis.
        Question. For part-time staff, what proportion of their time is
    spent teleworking, on average?
        Answer. Pre-pandemic, part-time employees spent 21 percent of their
    time teleworking. During the maximum telework posture, part-time
    employees spent 92 percent of their time teleworking.
        Question. What has such teleworking done to decrease commuting and
    parking reimbursements, energy consumption, and other expenditures
    compared to years prior to the pandemic?
        Answer. Transit subsidy costs have decreased and these funds have
    been reinvested by agencies in their program activities. There have
    been some savings in energy consumption related to the reduction in on-
    premises staff. To comply with safety recommendations from the Centers
    for Disease Control and Prevention in response to the COVID-19
    pandemic, however, the Heating, Ventilation and Air Conditioning system
    is now run 24 hours a day to increase ventilation in the building. This
    has increased energy usage overall from prior years.
                              secretary's calendar
        Question. Previous administrations posted the calendars of their
    agency head for public inspection. As of July 23, 2021, there is no
    calendar information available to the public to understand your daily
    efforts on the public's behalf.
        Will you commit to begin sharing your calendar information with the
    public on the DOL website? Can you provide a date on which your
    calendar detailing the first several months of your tenure will be
    published publicly?
        Answer. No later than September 29, 2021, Secretary Walsh's
    calendar will be available at https://www.dol.gov/general/foia/
    readroom.\33\ This will include the Secretary's calendar dating back to
    March 23, 2021 through July 31, 2021. Moving forward the calendars will
    be updated on a monthly basis.
    ---------------------------------------------------------------------------
        \33\ https://www.dol.gov/general/foia/readroom.
    ---------------------------------------------------------------------------
           unemployment insurance and third-party income verification
        Question. Pandemic Unemployment Assistance (PUA) has brought
    Unemployment Insurance (UI) eligibility to a significant number of
    ``gig'' or 1099 workers. These workers often face the greatest lag
    between income loss and access to benefits.
        Some have suggested using consumer finance applications (apps) to
    reduce processing overhead, decrease fraud, and enable automation
    resulting in streamlined access to benefits.
        Do you believe that states should use available funds to modernize
    UI systems and prevent fraud by creating partnerships with such
    consumer finance apps?
        Answer. The pandemic has only underscored states' desperate need
    for technological support and improvements. Many state systems are
    operating on outdated technology, which made it difficult for them to
    rapidly respond to changes in law and economic conditions. Part of our
    plan for the $2 billion appropriated under the American Rescue Plan Act
    is to address this problem by centrally developing open, modular
    technology solutions that states may adopt as part of ongoing
    modernization and improvement efforts. Shared IT solutions will be
    designed to integrate with state systems and will focus on the needs
    that are shared across states, while supporting states to implement and
    continue operating state specific elements. DOL's vision is to provide
    software to support end-to-end administration of UI, including benefit
    delivery, employer tools, and appeals. As part of this effort, DOL will
    consider all possible IT solutions that will assist states in
    modernizing their systems and preventing fraud, including consumer
    finance applications. DOL will work with the IT staff in the States to
    develop and execute a plan that builds resilience in the UI systems
    across the country.
        Question. Is the Department of Labor considering issuing guidance
    in regard to the ability of the states to use third-party income
    verification technology to accurately verify 1099 and gig worker income
    distribution?
        Answer. Within the scope of the temporary Pandemic Unemployment
    Assistance (PUA) program authorized by the Coronavirus Aid, Relief, and
    Economic Security (CARES) Act, as amended, DOL has advised states
    through webinars and individual technical assistance requests regarding
    the use of third parties when obtaining documentation to verify 1099
    income distribution for purposes of eligibility. Because the Department
    has already provided information to states on using third parties to
    verify income for PUA claimants and the program will end shortly, the
    Department does not plan on issuing guidance on using third party
    income verification technology.
                                     ______

                Questions Submitted by Senator Patrick J. Leahy
                    unemployment insurance it modernization
        Question. The COVID-19 pandemic highlighted the cracks in the
    foundation of many critical support systems across all levels of
    government, including the unemployment insurance system. After 15 very
    long months, Vermont is finally back to its pre-pandemic unemployment
    levels of 2.6 percent. The State has reinstated its work search
    requirements, and plans to allocate Federal unemployment benefits
    through the summer.
        In April, your Department contacted the Vermont Department of Labor
    requesting that they re-process thousands of Federal unemployment
    benefit claims. During this difficult and unprecedented time, the state
    was trying to get money out the door to people in need as fast as they
    could. I, along with the rest of the Vermont congressional delegation,
    wrote you in late April about the need for flexibility when it came to
    the reprocessing of unemployment insurance claims given to claimants
    for the ``able and available'' eligibility criteria.
        While the response from your Department recognized the strain under
    which state UI programs are operating, and stated that you will
    continue to provide the state with technical assistance to fulfill the
    Department's request, the Vermont delegation did not receive a response
    to our inquiry until last week, on July 7. I appreciate your
    Department's willingness to work with the state, but this was a long-
    delayed response. I hope the Department will keep me and my staff
    updated on this issue, as the state is doing, and in the future, I hope
    the responses to my office will be received in a timelier manner.
        One issue highlighted by the pandemic is how many smaller, rural
    states including Vermont lack adequate, modern unemployment insurance
    technology. While trying to process thousands of new unemployment
    claims, the Vermont Department of Labor, for example, had to work with
    a 50-year-old computer mainframe that repeatedly froze and crashed the
    system at the beginning of the pandemic in the spring of 2020. I
    appreciate your Department's request for $100 million to bolster state
    Department of Labor's IT systems to administer unemployment, which is
    on top of the $2 billion committed in the American Rescue Plan for the
    same purpose.
        How will your Department work to ensure that departments of labor
    with older unemployment insurance IT systems, such as Vermont's 50-
    year-old mainframe, are prioritized when administering UI modernization
    funding?
        Answer. The Department welcomes the $2 billion that Congress
    provided in the American Rescue Plan Act and agrees that UI technology
    and infrastructure modernization is urgently needed. It is critical
    that state systems operate on a high-quality technology infrastructure
    that enables them to administer their UI programs equitably and
    efficiently, so all eligible unemployed workers have timely and
    meaningful access to this vital benefit. Formulating large scale
    spending plans across the UI system, which is comprised of 53 different
    programs operated by the states, the District of Columbia, Puerto Rico,
    and the U.S. Virgin Islands, requires multiple complex considerations.
    The Administration is fully engaged in developing detailed plans to
    achieve the goals and purposes set in the American Rescue Plan Act and
    will keep Congress informed of those plans and progress on the
    implementation of this important project.
        The Department has engaged with states on this topic. The
    Department conducted an initial webinar with state UI agencies on June
    22, 2021, to share some of the current plans and approach on pursuing
    UI information technology modernization. The webinar also solicited
    states for engagement and partnership in these activities. Since then,
    seven states have begun working with the U.S. Department of Labor (DOL)
    and the U.S. Digital Service in research partnerships designed to help
    fill in research gaps and provide input on the current and future
    stages of UI modernization. Also, there have been follow-up virtual
    office hours offered to states for further conversations on this topic.
        All states should benefit from the funding provided in the American
    Rescue Plan Act. As a state modernizes its IT system, there may be
    opportunities to take advantage of the central, modular, open
    technology solutions developed through this DOL/state partnership. DOL
    is also deploying teams of experts, initially to six states, on a
    voluntary basis to help identify process improvements that can speed
    benefit delivery, address equity, and fight fraud (i.e., Tiger Teams).
    The Tiger Teams can provide support, including funding, as states like
    Vermont look at business processes through a fraud-fighting and equity
    lens in the course of modernization. Additionally, DOL is making grants
    to states available to promote equity and fight fraud. These grants
    will be designed to help states improve worker access to the UI system,
    while helping states make system improvements that will safeguard them
    against fraud.
                              workforce shortages
        Question. Even as Vermont's unemployment rate has fallen back to
    pre-pandemic levels, workforce shortages remain and no sector has been
    spared. Businesses in smaller, more rural states like Vermont, have
    struggled for decades to address skilled workforce shortages--whether
    it is in the healthcare, education, child care, or manufacturing
    industry. Your Department's budget requests $3.7 billion, a 6 percent
    increase, for the Workforce Innovation and Opportunity Act and Wagner
    Peyser state formula grants to make employment services and training
    available to dislocated workers impacted by the COVID-19 pandemic.
        How will your Department work to ensure that the DOL's workforce
    development help dislocated workers in rural states like Vermont that
    currently lack the services available to provide workers with the
    skills necessary to re-enter the post-pandemic economy?
        Answer. The Department is working to ensure that all American
    workers and job seekers, including those in Vermont, have access to the
    services needed to make them ready for good jobs with family-sustaining
    wages. The COVID-19 pandemic created widespread economic disruption and
    further highlighted pre-existing deficiencies in the availability of
    opportunities for all Americans to find good-paying, safe employment.
    While WIOA funding allotments to states are set by a statutory formula,
    the fiscal year 2022 Budget reflects the Department's continued
    commitment to help American workers and job seekers, particularly those
    from disadvantaged communities, get back on their feet, access job
    training, and find pathways to high-quality jobs that can support a
    middle-class life. The fiscal year 2022 Budget requests $3.7 billion
    for WIOA programs, a $203 million increase over the fiscal year 2021
    funding. The Budget includes increases of approximately $37 million for
    the Adult Program, $94 million for the Dislocated Worker Formula
    Program, $100 million for Dislocated Worker Grants (DWG), and $43
    million for the Youth Program. This request will make employment
    services and training available to more dislocated workers, low-income
    adults, and disadvantaged youth who have been hurt by the economic
    impacts of the COVID-19 pandemic.
        The fiscal year 2022 Budget also includes the American Jobs Plan,
    an investment that will create millions of high-quality jobs and
    rebuild our country's infrastructure. This includes investments in
    American workers--providing people with the skills they need to
    succeed, strengthening the pathways to success, and ensuring that the
    jobs that are created are high quality. Structural racism and
    persistent economic inequities have undermined opportunity for millions
    of workers, and these investments will prioritize underserved
    communities and communities negatively impacted by the transforming
    economy. The United States currently spends just one-fifth of the
    average that other advanced economies spend on workforce and labor
    market programs.
        The Department included legislative proposals to implement the
    American Jobs Plan, totaling $81.5 billion over 10 years, to address
    these multiple challenges. This investment in proven workforce
    development models includes:
      --Creating and expanding sector-based training programs;
      --Providing comprehensive support for dislocated workers to enable
            their participation in high-quality training programs;
      --Expanding Registered Apprenticeship and pre-apprenticeship
            opportunities;
      --Building community colleges' capacity to deliver high-quality job
            training programs;
      --Expanding access to evidence-based intensive, staff-assisted career
            services;
      --Providing subsidized jobs to workers with barriers to employment;
      --Expanding workforce development services for justice-involved
            individuals; and
      --Phasing out the subminimum wage provided to workers with
            disabilities while expanding their access to competitive,
            integrated employment opportunities.
        There are several current funding sources that may be able to
    support rural communities in addressing workforce transition.
        First, each state may reserve up to 15 percent of their WIOA
    funding for statewide activities and an additional 25 percent of the
    Dislocated Worker formula allotment for Rapid Response activities. Both
    statewide and Rapid Response activities can be focused on prioritizing
    business engagement activities and layoff aversion efforts. Business
    engagement helps to develop long-term relationships with the business
    community. It enables the public workforce system to partner with
    businesses to play a more significant part in understanding their
    workforce needs, both currently and in the future. Statewide resources,
    or other WIOA resources, can then be used to train workers in the
    specific skills these businesses need.
        Second, state or local workforce areas may request additional
    funding from the Department through the National Dislocated Worker
    Grant (DWG) program when qualifying events occur, including large
    layoffs or a number of smaller layoffs that add up to a larger impact.
    DWG funds supplement the regular WIOA formula resources and allow
    states to provide critical workforce services to more unemployed
    workers than would otherwise be the case.
        Lastly, the Department funds several other grant programs that may
    benefit rural states and communities across the country. For example,
    on June 28, 2021, the Department announced the Comprehensive and
    Accessible Reemployment through Equitable Employment Recovery (CAREER)
    DWG. CAREER DWGs are designed to fund strategies and activities to help
    reemploy dislocated workers most affected by the economic and
    employment fallout from the COVID-19 pandemic, in particular, those
    from historically marginalized communities or groups and those who have
    been unemployed for an extended period or who have exhausted UI or
    other Pandemic Unemployment Insurance programs.
        Another example is the competitive H-1B Rural Healthcare grants. In
    January 2021, the Department awarded $40 million in funding to rural
    communities through partnerships of public and private entities to
    address rural healthcare workforce shortages across the country. This
    investment is addressing a very specific need that was exacerbated
    during the pandemic. It aims to increase the number of individuals
    training in healthcare occupations that directly impact patient care
    and alleviate healthcare workforce shortages by creating sustainable
    employment and training programs in healthcare occupations serving
    rural populations.
        The Administration also has requested $100 million in the next
    fiscal year to enable states to overcome the loss of legacy industries
    or persistent employment challenges and work towards a clean energy
    economy, helping to ensure steady employment opportunities into the
    future.
                        regional apprenticeship program
        Question. A primary focus of the Department of Labor's budget
    request for fiscal year 2022 is a significant increase of Federal
    funding for the Registered Apprenticeship Program of $100 million,
    totaling $285 million for the program, which is a 154-percent increase
    from fiscal year 2021. Apprenticeship programs add to the important
    workforce development role in helping people succeed in learning for
    the jobs of today and tomorrow. Many states, including Vermont, must
    connect jobseekers to better paying jobs that are in high-demand in
    order to continue to have a healthy economy. More than 90 percent of
    apprentices find employment after completing their programs, with
    graduates earning an average starting salary of more than $60,000.
        The fiscal year 2022 budget request highlights the need for the
    Registered Apprenticeship Program to focus on expanding access to the
    model for historically underrepresented groups, including women and
    people of color, and in high-growth sectors where apprenticeships are
    underutilized. Despite the need for innovative programs to stem the
    demographic trends of aging and shrinking rural areas, small rural
    states such as Vermont have struggled with meeting some of the criteria
    for the Department's Apprenticeship program. Expanding the Department's
    partnership with regional commissions would ensure that small rural
    areas can also build long-term community capacity and increase economic
    competitiveness.
        What is the Department's plan for ensuring that the increased
    funding request for the Registered Apprenticeship Program also benefits
    people who live in small rural states where the program's criteria has
    historically been a barrier to access?
        Answer. The Department is acutely aware of the need for improving
    conditions in rural areas and reaching underserved populations and has
    previously invested in the expansion of Registered Apprenticeships in
    states, including small rural states, and is committed to continuing
    these efforts through future grant funding.
        Previously, the Department awarded several grants supporting
    efforts to address access barriers to Registered Apprenticeship
    Programs in rural areas. These include Registered Apprenticeship grants
    awarded to states in 2016, 2018, 2019, and 2020 \34\ to support
    building state capacity to expand Registered Apprenticeship. The
    Vermont Department of Labor was a recipient of these awards in each of
    those 4 years. Since 2016, according to the Department's records the
    State of Vermont has seen a nearly 70 percent increase in the number of
    active apprentices in Registered Apprenticeship programs, including
    over 2,600 new apprentices during this period. In addition, in January
    2021, the Department awarded nearly $40 million in grants as part of
    the H-1B Rural Healthcare grant program, focused on addressing
    healthcare workforce shortages by creating sustainable employment and
    training programs in healthcare occupations serving rural populations.
    This funding opportunity allowed applicants to propose a wide range of
    training models, including Registered Apprenticeship Programs (RAPs)
    to, meet the healthcare workforce needs of rural areas.
    ---------------------------------------------------------------------------
        \34\ https://www.apprenticeship.gov/investments-tax-credits-and-
    tuition-support/active-grants-and-contracts.
    ---------------------------------------------------------------------------
        Most recently, the Department awarded more than $99 million to
    states as part of the State Apprenticeship Expansion, Equity, and
    Innovation \35\ grants to bolster states' efforts to expand programming
    and inclusive recruitment strategies to attract a diverse workforce.
    The awards include more than $85 million for states that demonstrated a
    commitment to increasing their diversity, equity and inclusion efforts.
    These grants also aim to develop partnerships with new industries and
    non-traditional occupations, including industry sectors hardest hit by
    the pandemic, and align Registered Apprenticeships with other work-
    based learning opportunities within state education and workforce
    systems. In addition, to ensure this funding opportunity could support
    the diverse needs of small rural states, medium-sized, and large states
    the funding opportunity allowed for a broad funding request range (from
    $2 million up to $10 million) with performance outcome targets that
    were commensurate with the amount of funding requested.
    ---------------------------------------------------------------------------
        \35\ https://www.apprenticeship.gov/investments-tax-credits-and-
    tuition-support/active-grants-and-contracts.
    ---------------------------------------------------------------------------
        Further, to better facilitate the expansion of Registered
    Apprenticeship, including in rural areas, the Department also awarded
    nearly $31 million through cooperative agreements to establish four
    Registered Apprenticeship (RA) Technical Assistance (TA) Centers of
    Excellence \36\ to provide technical assistance to key apprenticeship
    stakeholders. These RA TA Centers of Excellence will provide technical
    assistance on a national scale focused on: (1) diversity and inclusion;
    (2) strategic partnership and system alignment; (3) apprenticeship
    occupations and standards; and (4) data and performance best practices.
    Rural areas, as well as all states, will benefit from the technical
    assistance being provided by these centers.
    ---------------------------------------------------------------------------
        \36\ https://www.apprenticeship.gov/investments-tax-credits-and-
    tuition-support/active-grants-and-contracts.
    ---------------------------------------------------------------------------
        A focus of all of the Department's investments awarded in 2021 is
    to fund opportunities to support innovation in Registered
    Apprenticeship expansion efforts allowing states maximum flexibility
    for determining where they should target resources. Such efforts may
    include creating access for underrepresented populations; developing
    distance learning approaches; identifying promising practices with
    employer incentives that could bring employers on board, especially in
    rural areas; and ensuring industries or occupations negatively impacted
    by the COVID-19 pandemic are supported.
        In fiscal year 2022, the Department will prioritize investments
    that continue to expand the capacity of states to build and expand the
    apprenticeship model to new sectors and occupations, increase access
    for historically underrepresented groups; and address access barriers
    to Registered Apprenticeship Programs in rural areas. The Department
    will continue looking for additional opportunities to further these
    efforts.
        Question. Has the Department considered further utilizing its
    partnerships with regional commissions and authorities to expand access
    to vital workforce development programs such as the Regional
    Apprenticeship Program? How can these partnerships best be utilized?
        Answer. The Department believes partnerships that support workforce
    system integration are critical to expand access to Registered
    Apprenticeship Programs. This includes building partnerships with
    governors, workforce agencies, workforce development boards, and
    interdepartmental Federal leaders to further align registered
    apprenticeship with other work-based learning opportunities within
    state education and workforce systems.
        As these partnerships are critical to expanding access to
    Registered Apprenticeship Programs, the Department has and will
    continue to fund activities that support building strategic
    partnerships and system alignment. Most recently, the Department
    awarded more than $99 million to states as part of the State
    Apprenticeship Expansion, Equity, and Innovation \37\ (SAEEI) grants to
    bolster states' efforts to expand programming and inclusive recruitment
    strategies to attract a diverse workforce. Under these grants, states
    must explore new and expanded opportunities with industry, employers,
    education and training providers, the workforce system, state and local
    governments, labor organizations, and other entities, to better
    coordinate and maximize resources and assistance across Federal, state
    and local funding streams, as well as from the private sector
    enrollment in and access to apprenticeship opportunities that support
    workforce system integration.
    ---------------------------------------------------------------------------
        \37\ https://www.apprenticeship.gov/investments-tax-credits-and-
    tuition-support/active-grants-and-contracts.
    ---------------------------------------------------------------------------
        Additionally, the Department also awarded nearly $31 million
    through cooperative agreements to establish four Registered
    Apprenticeship (RA) Technical Assistance (TA) Centers of Excellence
    \38\ to provide technical assistance to key apprenticeship
    stakeholders. One of the RA TA Centers funded will support strategic
    partnerships and system alignment. Specifically, this center will focus
    on establishing, building, and sustaining partnerships that support
    system alignment of the national workforce and education systems to
    accelerate Registered Apprenticeship Program adoption and expansion.
    This RA TA Center of Excellence will provide technical assistance on a
    national scope to Registered Apprenticeship Program sponsors, and will
    also support state and local workforce development boards, American Job
    Center programs and operators, governors and other essential
    stakeholders that drive and inform economic and workforce development
    policies and programs.
    ---------------------------------------------------------------------------
        \38\ https://www.apprenticeship.gov/investments-tax-credits-and-
    tuition-support/active-grants-and-contracts.
    ---------------------------------------------------------------------------
        The Department is constantly striving to find new and better ways
    to connect with the workforce system and its partners.

                               SUBCOMMITTEE RECESS

        Senator Murray. With that, the subcommittee is adjourned.
        [Whereupon, at 11:12 a.m., Wednesday, July 14, the hearings
    were concluded, and the subcommittee was recessed, to reconvene
    subject to the call of the Chair.]

      DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2022

                                  ----------

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

                             DEPARTMENTAL WITNESSES

        Prepared Statement of America's Public Television Stations and
                        the Public Broadcasting Service
        On behalf of America's 158 public television licensees, we
    appreciate the opportunity to submit testimony for the record on the
    importance of federal funding for local public television stations and
    PBS (Public Broadcasting Service). We urge the Subcommittee to support
    $565 million in two-year advance funding for the Corporation for Public
    Broadcasting (CPB) in FY 2024, $20 million for the Public Broadcasting
    Interconnection System in FY 2022 and $30 million for the Ready To
    Learn program at the Department of Education in FY 2022.
          corporation for public broadcasting: $565 million (fy 2024)
                            two-year advance funded
        Public television plays a key role in educating our children;
    providing job training; preserving our diverse, dynamic culture and
    democracy; and keeping Americans informed, safe and healthy. Public
    television's essential services have never been more critical than
    during the COVID-19 pandemic, when local public television stations in
    all 50 states provided enhanced educational services and content to
    help support students, families, teachers, and schools with the sudden
    challenge of virtual learning.
        Federal funding for CPB is essential to making these services
    available to all Americans, including those in rural and underserved
    areas, and this funding enjoys the overwhelming support of the American
    people. At about $1.40 per person per year, this funding provides an
    enormous return on investment for all Americans.
        Yet these vital community-based services were level-funded at $445
    million for a decade--resulting in an approximate $100 million in lost
    purchasing power.
        Recognizing this loss, we appreciate that Congress increased the
    forward funded CPB appropriation by $20 million for FY 2022 and an
    additional $10 million for FY 2023.
        While public broadcasting is grateful for these increases, The
    public broadcasting system is still about $75 million, in inflation-
    adjusted dollars, behind where the system was 10 years ago, at a time
    when it is bearing the costly expense of providing access to content on
    ever emerging platforms and stations continue to offer more and more
    essential services to their communities.
        Public broadcasting respectfully requests that Congress take
    another substantial step toward securing our current and future public
    service goals in the FY 2022 appropriations process.
        The $565 million that public broadcasting is requesting in FY 2022
    for FY 2024 will help restore lost purchasing power and enable local
    stations to leverage advancements in technology and make investments in
    the future that will educate more children and adults, provide
    additional critical resources and capabilities to teachers and schools,
    further enhance public safety and expand the civic leadership work of
    local stations.
        Given the success of public media, and its potential to do so much
    more for so many, it is sound public policy to increase federal funding
    for this valuable service that provides an exceptional return on
    investment.
    Education
        Public media is committed to education and service for all
    Americans. Public broadcasting allows people at all income levels and
    from all parts of the country-rural and urban-to have access to
    consistent, high-quality, diverse content for free. This educational
    programming is readily available to children, parents, teachers, senior
    citizens, those pursuing their high school equivalency degrees, and
    many others.
        Since last spring, as schools across the country shifted to remote
    learning in the face of the COVID-19 pandemic, local public television
    stations rolled out new education initiatives, including curated At-
    Home Learning broadcasts, airing instructional lessons created by
    teachers, and educational datacasting pilots to serve students without
    internet connectivity. These resources provided critical support to
    schools, teachers, and parents and helped bridge the digital gap for
    rural and underserved students. This extraordinary response by public
    television stations, many of which partnered with state and local
    education agencies, has provided much needed educational resources and
    support in communities across the country.
        Public television's educational broadcast content has helped more
    than 90 million pre-school age children get ready to learn and succeed
    in school. Beyond the iconic, proven educational programming, PBS, in
    partnership with local public television stations and school districts
    provides additional content directly to classrooms and homes through
    PBS LearningMedia--which provides access to tens of thousands of State
    curriculum-aligned digital learning objects--including videos,
    interactives, lesson plans and more--for use in K-12 classrooms and at
    home. Content is sourced from the best of public television in addition
    to material from the Library of Congress, National Archives, NASA and
    other high-quality sources. PBS LearningMedia provided teachers and
    students with critical resources and digital content and the number of
    users grew by 240% during the pandemic.
        Additionally, local public television stations throughout the
    country have partnered with PBS to bring a first-of-its kind, free PBS
    KIDS 24/7 channel and live stream to their communities--providing kids
    throughout the country with the highest level of educational
    programming, available through local stations any time, over-the-air
    and streaming. During the COVID-19 pandemic, many stations are using
    this expanded broadcast capacity to directly serve families and
    students from Pre-K--12 with state standards aligned educational
    content and instructional content created by teachers. Last year, 60%
    of kids ages 2-8 watched PBS KIDS content. Parents also looked to
    public television for educational resources, with PBS Parents users
    increasing by 80% during the pandemic.
        Public television stations are also leaders in adult education.
    Public television operates the largest nonprofit GED program in the
    country, helping tens of thousands of second-chance learners earn their
    high school equivalency degree. In addition, public television stations
    are leaders in workforce development, including retraining American
    veterans, by providing digital learning opportunities for training,
    licensing, continuing education credits, soft skills and more.
    Partners in Public Safety
        Public broadcasting stations throughout the country are leading
    innovators and essential partners to local public safety officers. In
    partnership with FEMA, PBS WARN uses the public television
    interconnection system and local stations' broadcast infrastructure to
    support the Wireless Emergency Alert (WEA) system that enables cell
    subscribers to receive geo-targeted text messages in the event of an
    emergency-reaching citizens wherever they are.
        The February 2019 Report from the FEMA National Advisory Council on
    Modernizing the Nation's Public Alert and Warning System specifically
    recommends, ``Encouraging use of public media broadcast capabilities to
    expand alert, warning, and interoperable communications capabilities to
    fill gaps in rural and underserved areas.''
        In addition, and separate from the WEA system, local public
    television stations' digital infrastructure and spectrum enable them to
    provide state and local officials with critical emergency alerts,
    public safety, first responder and homeland security services and
    information during emergencies through a process known as datacasting.
    Datacasting uses broadcast spectrum to send encrypted data and video to
    first responders with no bandwidth constraints.
        In partnership with local public television stations and local law
    enforcement agencies, the U.S. Department of Homeland Security (DHS)
    has conducted several successful pilots throughout the country that, in
    addition to other local initiatives, prove the effectiveness of
    datacasting in a range of use cases including: flood warning and
    response; enhanced 911 responsiveness; over-water communications;
    faster early earthquake warnings; multiagency interoperability; rural
    search and rescue; high profile, large event crowd control; and
    assistance with school safety, including in areas that lack broadband
    or LTE services.
        As a result of the successful pilots, the DHS Science and
    Technology Directorate has partnered with America's Public Television
    Stations (APTS) to maximize and promote datacasting technology and the
    opportunity to partner with local public television stations in
    communities nationwide.
        Additionally, stations are increasingly partnering with their local
    emergency responders to customize and utilize public television's
    infrastructure for public safety in a variety of critical ways, with
    many serving as their states' Emergency Alert Service (EAS) hub for
    weather and AMBER alerts.
    Providing Civic Leadership
        Public television strengthens the American democracy by providing
    citizens with access to the history, culture and civic affairs of their
    communities, their states and their country. Through the pandemic,
    public television has been providing essential front-line coverage to
    ensure Americans have the facts they need to stay healthy and local
    information on where they can turn for help if they need it.
        For the 18th year in a row, PBS was ranked the most trusted among
    national institutions. That trust is more important than ever. Over the
    last year, when inaccurate information could endanger people's lives,
    Americans could tune into their local public television station or view
    their online resources for trusted information that could help keep
    them safe.
        Local public television stations often serve as the state-level
    ``C-SPAN'' covering state government actions. As some of the last
    locally controlled media, public television stations also provide more
    public affairs programming, forums for discussion of local issues such
    as the opioid crisis, local history, arts and culture, candidate
    debates, agricultural news, and citizenship information of all kinds
    than anyone else. What truly sets public television stations apart is
    that stations treat their viewers as citizens rather than consumers.
    Public Broadcasting is a Smart Investment
        All of this public service is made possible by the federal funding
    to CPB. This federal investment sustains the public service missions of
    public television, which are distinct from the mission of commercial
    broadcasting and will not be funded by private sources, as the
    Government Accountability Office concluded in a 2007 study commissioned
    by Congress.
        The need for federal investment is particularly acute in small-town
    and rural America, where lower population density, a lack of corporate
    and philanthropic support, and challenging topography make the
    economics of local television and public service more challenging. As a
    result, public broadcasters are sometimes the only local broadcaster
    serving rural communities-and only with the help of the federal
    investment.
        For all stations, federal funding is the ``lifeblood'' of public
    broadcasting, providing indispensable seed money to stations to build
    additional support from state legislatures, foundations, corporations,
    and ``viewers like you.''
        For every dollar in federal funding, local stations raise six
    dollars in non-federal funding, creating a strong public-private
    partnership providing a valuable return on investment and supporting
    approximately 20,000 jobs across America.
        And yet, until two years ago, this critical funding remained flat
    for a decade, forcing stations to make difficult programming, staffing
    and service decisions as operational costs rose with inflation, while
    CPB funding did not. Despite this severe financial constraint, local
    public television stations have continued their deep commitments to the
    communities they serve.
        The $565 million that public broadcasting is requesting in FY 2024
    is both prudent and necessary for the continued health of local
    stations and the public broadcasting system as a whole--and for long-
    delayed enhancements of the essential education, public safety and
    civic leadership services described above.
    Two-Year Advance Funding
        Two-year advance funding is essential to the mission of public
    broadcasting. This longstanding practice, proposed by President Ford
    and embraced by Congress in 1976, establishes a firewall insulating
    programming decisions from political interference, enables the
    leveraging of funds to ensure a successful public-private partnership,
    and provides stations with the necessary lead time to plan in-depth
    programming and accompanying educational materials-all of which
    contribute to extraordinary levels of public service and public trust.
        Local stations leverage the two-year advance funding to raise
    state, local and private funds, ensuring the continuation of this
    strong public-private partnership. These federal funds act as the seed
    money for fundraising efforts at every local station, no matter its
    size. Advance funding also benefits the partnership between states and
    stations since many states operate on two-year budget cycles.
        Finally, the two-year advance funding mechanism gives stations and
    producers, both local and national, the critical lead time needed to
    raise the additional funds necessary to sustain effective partnerships
    with local community organizations and engage them around high-quality
    programs. Producers like Ken Burns, Henry Louis Gates, Jr. and Stanley
    Nelson, spend years developing programs like The Vietnam War, Country
    Music, The Black Church, Tell Them We Are Rising: The Story of Black
    Colleges and Universities and a documentary on Muhammed Ali airing this
    fall. It would be impossible to produce this in-depth programming and
    the curriculum-aligned educational materials that accompany it without
    the two-year advance funding.
                public broadcasting interconnection: $20 million
        The public television interconnection system is the infrastructure
    that connects PBS and national, regional and independent producers to
    local public television stations around the country. The
    interconnection system is essential to bringing public television's
    educational, cultural and civic programming to every American
    household, no matter how rural or remote. Without interconnection,
    there is no nation-wide public media service. The interconnection
    system is also critical for public safety, providing key redundancy for
    the communication of presidential alerts and warnings, and ensuring
    that cellular customers can receive geo-targeted emergency alerts and
    warnings.
        Congress has always provided federal funding for periodic
    improvements of the interconnection system. In FY 2018, Congress moved
    to fund interconnection for public broadcasting on an annual, rather
    than decennial, basis to enable dynamic, incremental upgrades in accord
    with increasingly rapid advances in technology. Public television seeks
    level funding of $20 million for interconnection in FY 2022.
             ready to learn: $30 million (department of education)
        The U.S. Department of Education's Ready To Learn (RTL) competitive
    grant program, reauthorized in the Every Student Succeeds Act, uses the
    power of public television's on-air, online, mobile, and on-the-ground
    educational content to build the literacy and STEM skills of children
    between the ages of two and eight, especially those from low-income
    families.
        Through their RTL grant, CPB and PBS deliver evidence-based,
    innovative, high-quality transmedia content to improve the math and
    literacy skills of high-need children. CPB, PBS, and local stations
    have ensured that the kids and families that are most in need have
    access to these groundbreaking and proven effective educational
    resources. In addition to children, this outreach focuses on adults who
    care for kids to empower and help them understand the important role
    they play in their children's educational success.
        RTL investments have supported the production and academic rigor of
    PBS KIDS series: Elinor Wonders Why, Peg + Cat, SuperWhy!, Martha
    Speaks, Odd Squad and Molly of Denali--a curious and resourceful 10-
    year-old Alaska Native girl who lives in the fictional village of Qyah,
    Alaska--and other iconic programming for children.
        But this investment does not solely rely on trusted, educational
    children's programming. CPB, PBS, and local public television stations
    employ a national-local model to reach parents, teachers, and
    caregivers on-the-ground in communities to help them make the most of
    these media resources locally. These include television, online and
    mobile apps, digital technology, mobile learning labs and on the ground
    events that provide valuable content and support to local school
    districts, county non-profits, preschools, homeschools, Head Start and
    other daycare centers, libraries, museums, and Boys and Girls Clubs,
    among others.
    Results
        RTL is rigorously tested and evaluated to assess its impact on
    children's learning and to ensure that the program continues to offer
    children the tools they need to succeed in school. Since 2005, more
    than 100 research and evaluation studies have shown RTL literacy and
    math content engages children, enhances their early learning skills and
    allows them to make significant academic gains, helping bridge the
    achievement gap. Highlights of recent studies show that:
      --Children from low-income households who were provided with RTL-
            funded Molly of Denali videos, digital games, and activities
            were better able to solve problems using informational text, -
            oral, written, or visual text designed to inform--a fundamental
            part of literacy that paves the way for future learning,
            particularly in social studies and the sciences. After only
            nine weeks of access, this impact is equivalent to the
            difference in reading skills a first-grader typically develops
            over three months.\1\
    ---------------------------------------------------------------------------
        \1\ Kennedy, J. L., Christensen, C., Maxon, T., Gerard, S., Garcia,
    E., Hupert, N., Vahey, P., & Pasnik, S. (2021).
    ---------------------------------------------------------------------------
      --Ready To Learn-funded resources from the PBS KIDS series The Cat in
            the Hat Knows a Lot About That! increased science learning in
            children from low-income households and had a positive impact
            on children's understanding of core physical science concepts
            of matter and forces-equivalent to the difference in science
            knowledge an early elementary student develops over five
            months.\2\
    ---------------------------------------------------------------------------
        \2\ (Grindal, T., Silander, M., Gerard, S., Maxon, T., Garcia, E.,
    Hupert, N., Vahey, P., Pasnik, S. (2019). Early Science and
    Engineering: The Impact of The Cat in the Hat Knows a Lot About That!
    on Learning. New York, NY, & Menlo Park, CA: Education Development
    Center, Inc., & SRI International.)
    ---------------------------------------------------------------------------
    An Excellent Investment
        In addition to being research-based and teacher tested, RTL also
    provides excellent value for our federal dollars. In the last five-year
    grant round, public broadcasting leveraged an additional $50 million in
    non-federal funding to augment the $73 million investment by the
    Department of Education. RTL exemplifies how the public-private
    partnership that is public broadcasting can change lives for the
    better.
        A funding level of $30 million is requested in FY 2022 to support
    current grantees and further enhance the discoverability and impact of
    Ready To Learn created content and the quantity and scope of local
    station outreach to the kids, families, teachers and schools that need
    it the most.
        Given the rigorous, thoughtful educational research and evaluation
    that goes into the creation of Ready To Learn content, Ready To Learn
    grants are awarded every five years and supported through annual
    appropriations. Funding in FY 2022 would provide the third year of
    funding in the latest grant round. Providing $30 million for Ready To
    Learn in FY 2022 will ensure that CPB, PBS and stations can continue to
    create the highest quality, proven-effective kids educational media,
    meeting kids, caregivers and teachers where they are on a variety of
    platforms, while expanding local, on-the-ground outreach through local
    partners.
                                   conclusion
        Americans across the political spectrum rely on and support federal
    funding for public broadcasting because we provide essential local
    education, public safety, and civic leadership services that are not
    available anywhere else. And none of this would be possible without the
    federal investment in public broadcasting.
        Federal funding is the great equalizer that ensures that the best
    of public broadcasting is available in both the urban centers of our
    great cities and in Native American communities in America's heartland
    and everywhere in between.
        Federal funding for CPB is what ensures that young children in
    Appalachia have the same access to the unparalleled PBS KIDS content as
    their counterparts in Los Angeles. And federal funding is what ensures
    that all households, regardless of their ability to pay for cable or
    streaming subscriptions have access to local programming and the best
    of NOVA, Masterpiece, NewsHour, Great Performances, and so much more.
        Public broadcasters are the only broadcasters that reach nearly 97%
    of U.S. households, and it is CPB funding that makes this possible.
        For all of these reasons we request that Congress continue its
    commitment to the highly successful, hugely popular public-private
    partnership that is public broadcasting by providing $565 million in FY
    2024 for CPB in addition to $20 million in FY 2022 for public
    broadcasting's interconnection system and $30 million in FY 2022 for
    the Ready To Learn Program.
                                     ______

                Prepared Statement of the National Public Radio
        Chairwoman Murray, Ranking Member Blunt and Members of the
    Subcommittee,
        Thank you for this opportunity to urge the Subcommittee's support
    for a robust annual federal investment of $565 million in FY 2024 in
    public broadcasting through the Corporation for Public Broadcasting
    (CPB) and $20 million in FY 2022 to continue upgrading the public
    broadcasting interconnection system and other technologies and services
    that create system efficiencies.
        As the President and CEO of National Public Radio (NPR), I offer
    this statement on behalf of the public radio system, a nonprofit public
    service media enterprise that includes NPR, more than 1,000 public
    radio stations, other producers and distributors of public radio
    programming, and many stations, large and small, that create and
    distribute content through the Public Radio Satellite System(r)
    (PRSS(r)). Every day, public radio connects with millions of Americans
    on the air, online, through smart speakers and mobile devices, and in
    person to explore current news, music, enduring ideas, and what it
    means to be human. About 98.5% of the U.S. population is within the
    broadcast listening area of one or more public radio stations.
        Federal funding provided by Congress to the CPB enables local,
    noncommercial radio stations to provide news, information, and cultural
    programming to meet the needs of local communities and offer diverse
    perspectives. This funding is the bedrock of the public broadcasting
    system. On average, for every $1 in federal grant money that a public
    radio station receives, it raises $10 locally from audiences and local
    sponsors. Public radio stations are locally owned and managed, and
    thereby accountable to the local leaders and listeners they serve.
        Many newspapers have lost circulation and advertisers, and are
    closing their doors, eliminating sources of local news. More than 3,100
    journalists at local public radio stations help to fill this need--
    bringing trusted, reliable, independent news and information of the
    highest editorial standards to keep communities connected. On May 6,
    2021, the Radio Television Digital News Association recognized this
    quality journalism by awarding public radio 277 Regional Edward R.
    Murrow Awards--80 percent of the 343 awards in U.S. radio categories.
        Continued investments in newsgathering capacities at public radio
    stations will help ensure that public media can continue to fill the
    gap for news and information in America's communities with expanded
    local and regional coverage and digital services. CPB is helping to
    fund public radio collaboration across key regions. In 2019, NPR and
    public radio stations in Texas joined together to launch the first
    regional reporting hub. In 2020, NPR and local stations launched a Gulf
    states hub covering Mississippi, Alabama, and Louisiana--one of the
    most news deprived regions in the country--as well as hubs in
    California and the Midwest. Another NPR collaboration funded by CPB--
    the Stations Investigations Team-supports local stations' investigative
    journalism, helping with technical skills such as data collection and
    analysis, as well as training. These collaborative arrangements allow
    stations to utilize resources more efficiently, increase the scope of
    regional coverage, and promote journalistic skills and mentoring.
        Public radio stations play an important role in civics--supporting
    state house coverage, reporting on local elections, and fostering
    dialogue among communities. On a broader scale, public radio seeks to
    connect Americans, including students, through coverage of national
    civics issues and questions. For example, with CPB support, New
    Hampshire Public Radio produces Civics 101: A Podcast, exploring topics
    such as types of civic action, electoral processes, fundamental rights,
    landmark Supreme Court cases, and key documents, such as the Magna
    Carta. NHPR also provides resources for educators, including teacher
    created lesson plans, to use these audio resources in the classroom. By
    inspiring audiences of all ages to engage with foundational civics
    topics, public radio can support the search for common ground across
    the political spectrum.
        Throughout the COVID-19 pandemic, public radio stations have
    provided life-saving information and documented stories of how the
    pandemic affected communities across the nation. In May 2020, a
    collaborative reporting project from NPR and The Texas Newsroom found
    that COVID-19 testing sites in four major cities in Texas were located
    in predominately white neighborhoods, and through the examination of
    available testing data, revealed that it was harder for people of color
    to find test sites near where they lived. Following this exclusive
    report, Dallas County opened two walk-up testing sites in Southern
    Dallas, and Governor Greg Abbot announced that the state would bring
    more testing to underserved communities. In 2021, NPR and reporters
    from The Texas Newsroom and The Gulf States Newsroom teamed up to
    examine the availability of COVID-19 vaccination sites, again
    identifying disparities in the location of vaccination sites in major
    cities in the Southern United States.
        At the beginning of the pandemic, as listeners transitioned to
    working and living in quarantine, public radio's digital audiences grew
    250 percent. Audiences sought insight into the nation's response to the
    coronavirus and how their local communities were affected. Public radio
    stations provided live blogs on the coronavirus, explanations of public
    health orders, and information on the development and distribution of
    vaccines. By the end of 2020, public radio station websites
    demonstrated continued audience growth, showing a 31 percent year-over-
    year growth in average monthly users and a 67 percent increase in
    monthly newsletter traffic.
        Madam Chairwoman, Ranking Member, and members of the subcommittee,
    I would be remiss if I did not thank you for the support you provided
    to public radio, and the entire public broadcasting system, through the
    Coronavirus Aid, Relief, and Economic Security (``CARES'') Act in 2020
    and the American Rescue Plan Act earlier this year. Your support during
    this crisis ensured that local public radio stations received needed
    resources to maintain essential programming and services for the
    communities that depended upon them.
        We have seen that the COVID-19 pandemic further demonstrated the
    value of public radio embracing the challenges of a multi-platform
    media marketplace, while continuing to hold a dominant position in
    traditional radio broadcasting. Public radio stations offer original
    content through a variety of platforms and channels to reach new
    audiences, including terrestrial radio, satellite radio, the web
    (desktop and mobile), smart speakers, and podcasts--and application-
    driven mobile services on iOS and Android (both phone and tablet) and
    via aggregators such as Apple Music, Facebook News, Stitcher, and
    TuneIn. The strength of this multi-platform approach is that public
    radio can reach listeners wherever they are and attract new and diverse
    listeners. For example, Southern California Public Radio--with CPB
    support--is reaching out to younger, Latino audiences by producing
    innovative, on-demand content and increasing the diversity of its on-
    air hosts, producers and production staff. NPR has also partnered with
    classrooms across the country in the annual Student Podcast Challenge,
    which invites middle school and high school students to work with their
    teachers to develop and produce a podcast for the opportunity to be
    featured on NPR; a similar challenge is available for college students.
    Thousands of students and teachers have participated across all 50
    states, utilizing resources designed to support the process in the
    classroom, develop journalism and broadcast skills, and connect public
    radio to youth audiences.
        Public radio is more than journalism. Stations offer communities
    access to innovative music, arts, entertainment, and other cultural
    programming. Public radio music-format stations play a key role in
    supporting noncommercial music in the United States, playing a broad
    collection of sounds and styles including jazz, blues, classical, folk,
    alternative, bluegrass, zydeco, roots, and other eclectic genres.
    Public radio stations make this wide variety of music accessible to
    listeners through traditional broadcasts, streaming, live performances,
    and music journalism. This programming supports discovery and
    creativity, and connects local and national audiences to a broader
    cultural conversation thus enriching both hearts and minds. Funding for
    CPB plays a key role in enabling stations and program producers to
    provide these cultural opportunities.
        Public radio would not be possible without the federal funding
    provided for the PRSS--the satellite content distribution system on
    which the public radio system--including almost all stations, networks,
    and producers--generally depends. The federal appropriation would allow
    the current satellite-and-internet delivery system to continue to be
    modernized and maintained with next-generation equipment and software.
        The PRSS is open to all public telecommunications entities,
    including independent producers; program syndicators and distributors;
    national, state, and local organizations; and public radio stations.
    Stations that receive programming distributed by the PRSS range from
    those located in remote villages in northern Alaska and on Native
    American reservations in the Southwest, to major market stations such
    as WNYC in New York City and KUSC in Los Angeles. Through almost 400
    downlinks, PRSS transmits programs distributed from NPR, other major
    content producers, and more than 100 independent radio producers and
    organizations with a variety of formats that include news, public
    affairs, documentaries, classical music, and jazz.
        CPB's support of interconnection for the PRSS facilitates the cost-
    effective and efficient distribution of high-quality, educational
    programming to this country's increasingly diverse population. As part
    of that mission, the PRSS provides free, or ``in kind,'' satellite
    transmission services to distribute programming to un-served or under-
    served audiences. Currently, full-time support is given to three
    program service groups: Native Voice One serving Native American
    listeners; Satelite Radio Bilingue, a Spanish-language service; and the
    African American Public Radio Consortium.
        The PRSS also plays a vital role in the nation's emergency alert
    system by receiving Presidential alerts (also called Emergency Action
    Notification (EAN) alerts) fed directly from FEMA, which it can
    transmit to public radio stations in the event of a nationwide crisis.
    In addition, the PRSS MetaPub service enables local public radio
    stations equipped with this technology to issue emergency text and
    graphic alerts--such as tornado and hurricane warnings, evacuation
    routes, and COVID-19 information--that are visible on screens and
    synched with over-the-air broadcasts to mobile phones, HD radios,
    ``connected car'' smart dashboards, Radio Data System displays, and via
    online audio streaming. To date, about 10 percent of interconnected
    public radio stations have the capability to issue live text alerts
    using the MetaPub system in the event of a natural or humanmade
    disaster, such as a chemical spill.
        In closing, public radio provides an essential public service for
    local communities across the nation--embracing their diversity, telling
    their stories, and keeping them informed with trustworthy, independent
    news, information, and public safety alerts upon which they rely. Your
    support for the CPB appropriation will ensure that public media can
    continue to provide these critical services and be positioned to
    embrace the future of the media landscape. Thank you for your support
    of the public broadcasting system.

        [This statement was submitted by John F. Lansing, President and
    CEO, National Public Radio.]

                           NONDEPARTMENTAL WITNESSES

         Prepared Statement of the Academy for Radiology & Biomedical
                                Imaging Research
        Madam Chair and members of the Subcommittee, I am Mitchell Schnall,
    President of the Academy for Radiology & Biomedical Imaging Research
    (Academy), and the Eugene P. Pendergrass Professor of Radiology and
    Chair of the Radiology Department at the Perelman School of Medicine at
    the University of Pennsylvania. The Academy is more than 200 academic
    research departments, patient advocacy groups, industry partners, and
    imaging societies that represents thousands of radiologists and
    researchers in all 50 states. The Academy is the only advocacy
    organization representing the broad spectrum of the imaging research
    community by collectively advocating for robust and consistent federal
    research funding.\1\ It is my pleasure to submit this testimony on
    behalf of the Academy. We strongly support the President's request of
    $52 billion for the National Institutes of Health and ask that no less
    than $46.111 billion of that be for the NIH's base program budget for
    FY2022. Investigator-initiated research continues to be the foundation
    of basic science and discovery. The latter figure represents an
    increase of $3.177 billion over the FY2021 enacted levels. Moreover,
    the Academy supports a proportional increase to the National Institute
    of Biomedical Imaging and Bioengineering (NIBIB), resulting in at least
    $441.1 million for FY2022--a $30.4 million increase over FY2021. These
    base increases reflect approximately 5% above the biomedical research
    and development price index (BRDPI). Through consistent, strong funding
    for NIH and our national research infrastructure we can continue to
    make advancements that will improve the lives of patients with a wide
    spectrum of diseases and disorders. The Academy is grateful for the
    Subcommittee's past support of NIH and encourages you to continue
    advancing biomedical research and radiology and imaging science.
    ---------------------------------------------------------------------------
        \1\ https://www.acadrad.org/about-the-academy/.
    ---------------------------------------------------------------------------
        Imaging is not limited to any one disease or condition. Instead, it
    serves as a necessary diagnostic tool that researchers and clinicians
    of all types use to help advance our understanding of biological
    systems and how best to develop and deliver treatments benefitting
    patients. By improving our imaging tools and techniques, we broaden the
    resources available to address many challenging conditions. In my own
    work as a clinician-scientist, I use state-of-the-art technologies like
    specialized magnetic resonance imaging (MRI) and 3-dimensional
    mammography (digital breast tomosynthesis) to improve the diagnosis and
    treatment of cancer types, including breast, prostate, and pancreatic,
    while also researching rare and orphan diseases.
    Imaging Innovation to Help Patients
        Imaging tools can apply to a wide range of diseases and disorders
    and can have very real impacts on patient outcomes. This results from
    Congress's sustained federal investment in biomedical research at NIH
    over the last several years. Over time, basic science advancements
    translate into a variety of clinical settings, ultimately benefitting
    patients. This Subcommittee's continued support of NIH, and
    specifically NIBIB and the other Institutes and Centers that support
    imaging research, will help generate future breakthroughs across many
    biomedical challenges. Moreover, these innovations can be translated
    into the commercial products, supporting the biotechnology industry and
    jobs. Below are examples of the community's response to the COVID-19
    pandemic, advances in detecting and treating cancer, and the role of
    imaging in detecting and treating neurodegenerative diseases.
    Medical Imaging and Data Resource Center: Merging Diagnostics and
            Machine Learning
        In the first of a two-year effort launched in 2020, the goal of the
    Medical Imaging and Data Resource Center (MIDRC) is ``to foster machine
    learning innovation through data sharing for rapid and flexible
    collection, analysis, and dissemination of imaging and associated
    clinical data...in the fight against COVID-19.'' \2\ MIDRC is an NIBIB-
    funded collaboration between the American College of Radiology (ACR),
    the Radiological Society of North America (RSNA), the American
    Association of Physicists in Medicine (AAPM), and the University of
    Chicago. These partners are building an accessible and shareable
    database that can be used to accelerate clinical diagnosis, monitoring,
    and treatment of COVID-19. Datasets are now being released for public
    use. Moreover, MIDRC is developing machine learning tools for
    evaluating medical images to determine the likelihood and future
    severity of infection, as well as the prognosis for recovery. While
    currently focused on Covid-19, the methods can be applied to any large
    set of biomedical images to analyze and identify the likelihood of
    disease or disorder. Leveraging these innovations and computational
    tools augments human evaluation. This technology, using nationwide
    data, also improves predictive tools for identifying serious conditions
    and recovery prognoses while serving as an ``early warning'' system for
    future outbreaks.
    ---------------------------------------------------------------------------
        \2\ https://www.midrc.org/.
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    Combining Diagnostics and Therapy to Treat Cancer
        Recent technological advances in imaging have transformed the
    landscape for detecting and treating many types of cancer. Today,
    diagnostics and therapeutics can be combined into one action. The
    evolving field of theranostics--therapy-diagnostics--uses imaging
    agents, called radiotracers, to simultaneously diagnose and deliver
    therapy to affected cells. These targeted molecules are engineered to
    seek out specific types of cancer cells, which may be part of primary
    tumors or circulating throughout the body as metastases. Imaging for
    prostate cancer is now 100 times more effective than it was only 15
    years ago. And now, these same agents can be loaded with radioisotopes
    designed to kill cells, becoming ``smart bombs'' aimed at cancer.
    Extensive work is underway to develop smart radiotherapy agents for
    numerous cancers including prostate cancer. Other targeted agents
    recently approved by the FDA can simultaneously seek out and destroy
    neuroendocrine cancer cells, a form of pancreatic cancer. These
    advances are helping physicians become much more effective in
    diagnosing and treating these and many other types of cancer, including
    lymphoma and thyroid cancer. Consequently, the patient receives very
    real benefits--the ability to find and treat cancer in a single action
    rather than requiring repeated visits, evaluations, and more invasive
    procedures. Theranostics, built on research funded by multiple
    institutes at NIH, has the potential to further advance society's goal
    of making cancer a treatable disease across a broad array of tumor
    types.
    Detecting Neurodegeneration to Manage Treatments
        Every American knows at least one family with a member afflicted by
    a neurodegenerative condition such as Alzheimer's disease or another
    form of dementia. The inexact and sometimes subtle symptoms of these
    conditions in their early stages, combined with the challenges of
    studying a living human brain, can make effective diagnoses
    challenging. Recent breakthroughs in imaging provide alternative, more
    precise tools physicians can use to diagnose and manage the care of
    affected patients. New imaging agents allow investigators to detect and
    quantify amyloid plaques and Tau proteins in the brains of patients--
    two leading indicators for Alzheimer's disease. This ability informs
    and accelerates the search for new treatments and methods to predict
    which patients may benefit from such therapies. In fact, a recent
    clinical trial investigated a new treatment for the removal of amyloid
    plaque from patients, an approach enabled by an approved imaging agent
    supported by an NIH grant.
        Treatment of another neurological condition, Parkinson's disease,
    has also advanced because of emerging imaging research. Patients
    suffering from essential tremor symptoms, including those with
    Parkinson's, can now benefit from therapies in which magnetic resonance
    imaging (MRI) images are used to direct sound waves--High-intensity
    Focused Ultrasound--in a non-invasive way to alter neuronal connections
    and activities. This intervention often leads to instantaneous
    improvement in patient symptoms. While not a cure, alleviation of
    tremor symptoms allows patients to continue managing their condition by
    caring for themselves through actions such as dressing, eating, and
    other activities that require fine motor skills.
                             summary and conclusion
        Sustained and robust NIH funding is crucial to advancing our
    efforts to understand and ultimately treat a myriad of diseases and
    disorders across human systems. NIH investments are also a key economic
    driver at local research institutions, and NIH funds flow to every
    state in the nation.\3\ If we are to remain a global leader in
    biomedical research and innovation, continued, strong support for NIH
    is essential. Funding NIH's base program with at least $46.111 billion
    will provide the robust support needed to sustain growth for biomedical
    research.
    ---------------------------------------------------------------------------
        \3\ https://www.unitedformedicalresearch.org/wp-content/uploads/
    2021/03/NIHs-Role-in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
    ---------------------------------------------------------------------------
        Thank you for your strong, continued support of NIH, NIBIB, and all
    the Institutes and Centers working to advance our biomedical research
    efforts and to improve the lives of patients worldwide. On behalf of
    the Academy, I urge you to continue your strong support of our nation's
    research and innovation enterprise.

        [This statement was submitted by Mitchell Schnall, M.D., Ph.D.,
    President,
    Academy for Radiology & Biomedical Imaging Research.]
                                     ______

          Prepared Statement of the Academy of Nutrition and Dietetics
        Dear Chair Murray and Ranking Member Blunt,
        The Academy of Nutrition and Dietetics appreciates the opportunity
    to submit testimony to the subcommittee for FY22 appropriations.
    Representing more than 112,000 credentialed nutrition and dietetics
    practitioners, the Academy is the world's largest organization of food
    and nutrition professionals and is committed to improving the nation's
    health with nutrition services and interventions provided by registered
    dietitian nutritionists.
        For FY22, we strongly urge you to provide funding for the promotion
    of the 2020-2025 Dietary Guidelines for Americans by the HHS Office of
    Disease Prevention and Health Promotion; the CDC Division of Nutrition,
    Physical Activity, and Obesity; and for Americans Older Americans Act
    senior nutrition programs. In the Department of Education, we support
    the Health Professionals of the Future program proposed in the
    President's budget.
    Funding: DGA Promotion by the HHS Office of Disease Prevention and
            Health Promotion--FY2022 Request: $3 million
        The 2020-2025 Dietary Guidelines for Americans were released in
    December 2020 and featured new nutrition recommendations for children
    from birth through 24 months and pregnant and lactating women. For the
    Dietary Guidelines for Americans to achieve their intended reach and
    impact, it is essential that the federal government invest in educating
    consumers and health care professionals on these new guidelines.
        The HHS Office of Disease Prevention and Health Promotion (ODPHP)
    and the USDA Center for Nutrition Policy and Promotion (CNPP) and they
    should jointly work to develop materials for comprehensive education
    campaigns aimed at: (1) educating consumers on how to use the new
    Dietary Guidelines to inform their dietary choices; and (2) health care
    professionals to align their dietary guidance with the new Guidelines.
        The campaign should be informed by scientific research on health
    behavior change, as well as input from key stakeholder groups,
    including nutrition assistance program participants and administrators,
    health care providers, community leaders, and health and nutrition
    advocates. The campaign should incorporate educational materials
    representing wide diversity of cultural food preferences and should be
    available in languages that meet the needs of populations at risk for
    diet-related disease.
    Funding: Older Americans Act Nutrition Programs (HHS ACL)
        The Older Americans Act authorizes a wide array of service programs
    that are overseen by the HHS Administration for Community Living and
    delivered through a national network of state agencies, area agencies
    on aging, and nearly 20,000 service providers.\1\ Most program
    participants have household incomes below 100% of the federal poverty
    level.\2\ In addition to directly combatting senior hunger during this
    time of uncertainty, senior meals programs have also reduced the need
    for seniors to leave their homes to get food, helping to limit their
    exposure to COVID-19. A significant increase in funding for these
    programs would not only allow more seniors to be served but would free
    up money for the nutrition assessment and educational components of
    these programs that are often sacrificed in order to reduce wait lists
    for meals.
    ---------------------------------------------------------------------------
        \1\ https://acl.gov/about-acl/authorizing-statutes/older-americans-
    act.
        \2\ https://fas.org/sgp/crs/misc/IF10633.pdf.
    ---------------------------------------------------------------------------
                Congregate Nutrition Services
        Congregate Nutrition Services funds nearly 80 million meals per
    year for 1.5 million participants and gives seniors access to
    socialization. More than one-fifth of participants have been deemed to
    be at high nutrition risk. These funds are also used to provide
    nutrition screening and counseling to seniors who may be at risk of
    malnutrition, food insecurity or other issues. For the duration of the
    COVID-19 public health emergency, service agencies have been given the
    flexibility to convert their congregate meals programs into drive-up or
    grab-and-go programs and to use any surplus funds from their congregate
    nutrition services budget to provide home-delivered meals.
                Home-Delivered Nutrition Services
        Home-Delivered Nutrition Services provides more than 145 million
    meals per year to 867,000 participants, with more than half of program
    participants categorized as being at high nutrition risk.\3\ The
    program also serves as a welfare check for isolated seniors and as a
    primary access point for other home- and community-based services. The
    demand for this crucial nutrition security program has been
    unprecedented during the COVID-19 pandemic.
    ---------------------------------------------------------------------------
        \3\ https://www.cdc.gov/nccdphp/dnpao/state-local-programs/
    funding.html.
    ---------------------------------------------------------------------------
    Funding: CDC Division of Nutrition, Physical Activity, and Obesity--
            Division of Nutrition, Physical Activity and Obesity--FY2022
            Request: $125 million
        The CDC Division of Nutrition, Physical Activity, and Obesity
    (DNPAO) oversees grant programs that provide funds to states and
    localities to address the obesity epidemic in their communities.\3\
    Adult obesity prevalence is at over 42% in 2017-2018.\4\ Obesity-
    related conditions include heart disease, stroke, type 2 diabetes and
    certain types of cancer that are some of the leading causes of
    preventable, premature death. In 2008, the annual medical cost of
    obesity in the United States was estimated to be $147 billion; the
    medical cost for people who have obesity was $1,429 higher than those
    of normal weight. Having obesity is a top risk factor for severe
    disease, hospitalization and death from COVID-19. Minority and low-
    income communities often lack access to healthful foods and safe places
    to be active, and these inequities contribute to obesity and other
    chronic disease disparities that are contributing to disproportionate
    COVID-19 morbidity and mortality.
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        \4\ https://www.cdc.gov/obesity/data/adult.html.
    ---------------------------------------------------------------------------
    State Physical Activity and Nutrition Program--FY2022 Request: $60
            million
        The State Physical Activity and Nutrition (SPAN) grant program at
    DNPAO awards competitive grants to states to implement multi-component,
    evidence-based strategies at the state and local level to improve
    nutrition and physical activity.\5\ With its current funding level,
    SPAN is only able to fund 16 states, which is does via five-year grants
    (currently FY18-22). DNPAO estimates that it would cost an additional
    $1.2 million per state to expand the program, so we are requesting $60
    million of the $125 million for DNPAO to go to SPAN to allow every
    state to receive SPAN grant funding.
    ---------------------------------------------------------------------------
        \5\ https://www.cdc.gov/nccdphp/dnpao/state-local-programs/span-
    1807/index.html.
    ---------------------------------------------------------------------------
    Funding: Health Professionals of the Future (ED)--FY2022 Request: $200
            million
        COVID-19's disproportionate impact on communities of color has made
    the need for health professional workforce diversity and culturally
    competent care more urgent than ever. Historically Black Colleges and
    Universities (HBCUs), Tribal Colleges and Universities (TCUs), and
    other Minority Serving Institutions (MSIs) have long been leaders in
    addressing health equity in America. Specifically, HBCUs graduate 43%
    of all African Americans with postsecondary degrees in STEM fields and
    roughly 15% of all African American physicians. Despite these
    successes, gaps remain, particularly among registered dietitian
    nutritionists.
        The Health Professionals of the Future proposal \6\ put forth in
    the FY22 President's budget would help close these gaps by creating and
    funding a competitive grant program that provides funding to MSIs to
    create or expand graduate programs that prepare students for high-
    skilled jobs in the health care sector and help diversify the
    healthcare sector pipeline. Authorized activities would include the
    development of a career and educational pathways exploratory system to
    assist undergraduate and graduate students in learning about career
    opportunities in these fields and connecting students to internships
    and jobs; support services to help students complete graduate programs;
    scholarships or fellowships for tuition or to support on-the-job
    training.
    ---------------------------------------------------------------------------
        \6\ https://www2.ed.gov/about/overview/budget/budget22/
    justifications/t-highered.pdf#page=147.
    ---------------------------------------------------------------------------
    Contact
        Please feel free to contact me at hmartin@eatright.org with any
    questions on these important issues. Thank you for the opportunity to
    submit our recommendations to the subcommittee.
        Sincerely.

        [This statement was submitted by Hannah Martin, MPH, RDN, Director,

    Legislative and Government Affairs, Academy of Nutrition and
    Dietetics.]
                                     ______

          Prepared Statement of the Ad Hoc Group for Medical Research
        The Ad Hoc Group for Medical Research is a coalition of nearly 400
    patient and voluntary health groups, medical and scientific societies,
    academic and research organizations, and industry. We appreciate the
    opportunity to submit this statement in support of strengthening the
    federal investment in biomedical, behavioral, social, and population-
    based research conducted and supported by the National Institutes of
    Health (NIH) through a recommendation of at least $46.1 billion for
    NIH's base program level budget in FY 2022.
        As a result of the strong, bipartisan vision of the House and
    Senate Labor-HHS-Education Subcommittees over the last six years,
    Congress has helped the agency regain some of the ground lost after
    years of effectively flat budgets. That renewed investment in NIH has
    advanced discovery toward promising therapies and diagnostics,
    reenergized existing and aspiring scientists nationwide, and restored
    hope for patients and their families. As the Subcommittee has
    recognized, to remain a global leader in accelerating the development
    of life-changing cures, pioneering treatments, and innovative
    prevention strategies, and in this time of unprecedented scientific
    opportunity, it is essential that Congress sustain long-term robust
    increases in the NIH budget.
        In FY 2022, the Ad Hoc Group for Medical Research supports at least
    $46.1 billion for the NIH base program level budget, including funds
    provided through the 21st Century Cures Act Innovation Fund for
    targeted initiatives, a $3.2 billion increase over the NIH's program
    level funding in FY 2021. This funding level, supported by nearly 400
    stakeholder organizations, would provide 5% growth in the base budget
    above inflation, expanding NIH's capacity to support promising science
    in all disciplines. We are grateful for President Biden's enthusiasm
    for medical research investments and welcome opportunities to engage
    with the Congress and the Administration regarding the proposed
    Advanced Research Projects Agency for Health (ARPA-H). Robust growth in
    the foundational research that NIH supports will be key to this vision,
    and we urge lawmakers to ensure no less than $46.1 billion for the
    NIH's base and that any additional funds for ARPA-H or other targeted
    initiatives supplement, rather than supplant, this core investment.
        We further recommend a funding allocation for the Labor-HHS-
    Education Subcommittee in FY 2022 that allows for the necessary
    investment in NIH and other agencies that promote the health of our
    nation. We believe that science and innovation are essential if we are
    to continue to meet current and emerging health challenges, improve our
    nation's physical and fiscal health, and sustain our leadership in
    medical research.
        In addition, we remain concerned about the lingering $16 billion
    impact of the coronavirus pandemic on medical research progress in all
    disease areas, and especially on the research workforce, as highlighted
    by NIH Director Dr. Francis Collins' recent testimony before this
    Subcommittee. The supplemental funding Congress has provided over the
    last year has been instrumental in advancing research on COVID-19, with
    tremendous success in the form of multiple safe and effective vaccines
    to combat SARS-CoV-2 and other advances. But the pandemic has
    threatened progress across numerous other areas, with particular
    challenges for women, minorities, and early career investigators in the
    research workforce. We continue to urge support for emergency
    resources, as outlined in the RISE Act (H.R. 869/S. 289), that will
    allow the NIH to rebuild the nation's strong and diverse research
    workforce infrastructure and continue to invest in broad and new
    research areas that will provide better health for patients in the
    future.
        NIH: A Partnership to Save Lives and Provide Hope. The partnership
    between NIH and America's scientists, medical schools, teaching
    hospitals, universities, and research institutions is a unique and
    highly productive relationship, leveraging the full strength of our
    nation's research enterprise to translate this knowledge into the next
    generation of diagnostics, therapeutics, and cures. More than 80
    percent of the NIH's budget is competitively awarded through nearly
    50,000 research and training grants to more than 300,000 researchers at
    over 2,500 universities and research institutions located in every
    state and Washington, D.C. The federal government has an essential and
    irreplaceable role in supporting medical research. No other public,
    corporate or charitable entity is willing or able to provide the broad
    and sustained funding for the cutting-edge basic research necessary to
    yield new innovations and technologies of the future.
        NIH has supported biomedical research to enhance health, lengthen
    life, respond to emerging health threats, and reduce illness and
    disability for more than 100 years. For patients and their families,
    NIH is the ``National Institutes of Hope.'' The following are a few of
    the many examples of how NIH research has contributed to improvements
    in the nation's health.
      --NIH-funded basic research laid the groundwork for the novel mRNA
            vaccine technology used in the first two FDA approved SARS-CoV-
            2 vaccines. Vaccines continue to be one of our most cost-
            effective public health tools with every $1 spent on routine
            childhood vaccinations estimated to save $5 in direct costs,
            and $11 in broader costs to society.
      --Following nearly three decades of NIH-funded research into novel
            mechanisms of drug action, breakthroughs in the treatment of
            depression came in 2019 with two new FDA-approved drugs--one
            for treatment-resistant depression and the first ever treatment
            for postpartum depression.
      --In 2007, induced pluripotent stem cells (iPSC) were discovered when
            adult cells were re-engineered into early non-differentiated
            versions of themselves. In 2019, the National Eye Institute
            launched a first-in-human clinical trial to test the safety of
            a novel patient-specific iPSC therapy to treat the most common
            form of Age-related Macular Degeneration, and the leading cause
            of vision loss in the age 65+ population.
      --NIH-supported researchers continue to work toward strategies to
            better prevent, identify, and treat pain and substance use
            disorders through the HEAL (Helping to End Addiction Long-term)
            Initiative. HEAL aims to support research into new, non-
            addictive medication and to establish public and private
            partnerships to develop best practices in communities.
      --Today, treatments can suppress HIV to undetectable levels, and a
            20-year-old HIV-positive adult living in the U.S. who receives
            these treatments is expected to live into his or her early 70s,
            nearly as long as someone without HIV.
      --The death rate for all cancers combined has declined in adults
            since the early 1990s and since the 1970s for children. Overall
            cancer death rates have dropped by 29% including a 2.2% drop
            from 2016 to 2017, the largest single-year drop in cancer
            mortality ever reported.
        Sustaining Scientific Momentum Requires Sustained Funding Growth.
    The leadership and staff at NIH and its Institutes and Centers have
    engaged the broader community to identify emerging research
    opportunities and urgent health needs and to prioritize precious
    federal dollars to areas demonstrating the greatest promise. Sustained
    robust increases in NIH funding are needed if we are to continue to
    take full advantage of these opportunities to accelerate the
    development of pioneering treatments and innovative prevention
    strategies.
        One long-lasting potential impact of investments in NIH is on the
    next generation of scientists. Sustained increases in NIH funding over
    the last six years have allowed NIH to more than double the investment
    in early stage investigators (ESIs). In 2015, NIH only funded about 600
    grants for ESIs and the career outlook for early career researchers
    seemed grim. In FY 2020, NIH was able to fund more than 1,400 grants
    for ESIs, reinvigorating the spirits of researchers in the biomedical
    workforce. Sustained increases are needed to allow NIH to continue
    support of new talent and innovation in medical research.
        Even with recent investments in NIH, nearly 4 of every 5 research
    ideas that are proposed to NIH every year cannot be funded. Additional
    funding is needed if we are to strengthen our nation's research
    capacity, ensure a medical research workforce that reflects the racial
    and gender diversity of our citizenry, and inspire a passion for
    science in current and future generations of researchers.
        NIH is Critical to U.S. Competitiveness. Our country still has the
    most robust medical research capacity in the world; however, other
    countries have significantly increased their investment in biomedical
    science, which leaves us vulnerable to the risk that talented medical
    researchers from all over the world may return to better opportunities
    in their home countries. We cannot afford to lose that intellectual
    capacity, much less the jobs and industries fueled by medical research.
    The U.S. has been the global leader in medical research because of
    Congress's bipartisan recognition of NIH's critical role. To continue
    our dominance, we must reaffirm this commitment to provide NIH the
    funds needed to maintain our competitive edge.
        NIH: An Answer to Challenging Times. Research supported by NIH
    drives local and national economic activity, creating skilled, high-
    paying jobs and fostering new products and industries, and catalyzes
    increases in private sector investment. A $1 increase in public basic
    research stimulates an additional $8.38 investment from the private
    sector after eight years. A $1 increase in public clinical research
    stimulates an additional $2.35 in private sector investments after
    three years. According to a United for Medical Research report, in FY
    2020, NIH-funded research supported more than 536,000 jobs across the
    U.S. and generated more than $91 billion in economic activity.
        The Ad Hoc Group's members recognize the tremendous challenges
    facing our nation and acknowledge the difficult decisions that must be
    made to restore our country's fiscal health. Robust funding of the NIH,
    and strengthening our commitment to medical research, is a critical
    element in ensuring the health and well-being of the American people
    and our economy. Therefore, for FY 2022, the Ad Hoc Group for Medical
    Research recommends that NIH receive at least $46.1 billion in base
    funding to advance the foundational research NIH supports and continue
    the momentum in our nation's investment in medical research.
                                     ______

                    Prepared Statement of The AIDS Institute
        Dear Chairwoman Murray and Members of the Subcommittee:
        The AIDS Institute, a national public policy, research, advocacy,
    and education organization, is pleased to offer testimony in support of
    domestic HIV and hepatitis programs in the FY2022 Labor, Health and
    Human Services, Education, and Related Agencies (L-HHS) appropriation
    measure. This year's L-HHS bill is more important than ever, as it will
    set up critical funding streams to help rebuild and reinvest in our
    nation's public health infrastructure, which has been decimated by
    COVID-19. As you craft the FY2022 L-HHS appropriations bill, we urge
    you to significantly increase funding for the Ending the HIV Epidemic
    Initiative, as well as appropriate additional funds for core public
    health programs that work to treat and prevent HIV and viral hepatitis
    in the United States. These programs, many of which are a part of the
    safety net health system, will be key tools in recovering from COVID-
    19, and ensuring those most impacted by the COVID pandemic's economic
    fallout can still access critical care.
                            hiv in the united states
        Approximately 1.2 million people are living with HIV in the U.S.
    Since the height of the epidemic, there have been tremendous
    advancements in HIV treatment and prevention. A person living with HIV
    on treatment can expect to live a near full life, and if they achieve
    an undetectable viral load, are unable to pass HIV on to a partner. The
    toolbox for HIV prevention is ever expanding, with pre-exposure
    prophylaxis (PrEP) being the newest tool that couples with traditional
    prevention techniques like condoms and syringe service programs.
    Despite these advancements, new cases of HIV have been stagnant at
    around 38,000 cases a year since 2013. Over the last year, COVID-19 has
    severely impacted HIV prevention and treatment programs, many of which
    have had to reduce services, suspend in-person testing, transition to
    telehealth, and detail staff to COVID response. These programs have
    been forced to innovate during COVID, and we hope some of the lessons
    learned can be sustained after the pandemic has ended, such as
    expansion of at-home HIV testing and increased utilization of
    telemedicine for HIV treatment and PrEP expansion. It is extremely
    important that additional funding goes to these programs this year so
    that we can again start reducing new HIV infections while allowing
    programs to refocus on core HIV prevention and treatment programs that
    are vital to making progress against this epidemic.
        Additionally, we believe that ending HIV is a racial justice issue.
    Three quarters of new HIV infections are among people of color because
    of racism and structural barriers in the healthcare system. To end HIV,
    these barriers must be broken down, and we believe people living with
    HIV and the communities they live in must be the drivers behind
    eliminating racism in healthcare.
                       ending the hiv epidemic initiative
        The Ending the HIV Epidemic Initiative (EHE), which began in 2019,
    is focused on reducing new HIV infections by 90 percent over ten years.
    In the last two years, your Committee provided $260 million and $404
    million respectively for the EHE Initiative, which is run by the CDC,
    the Health Resources and Services Administration (HRSA), and the
    National Institutes of Health (NIH). The resources were focused on 57
    jurisdictions with the greatest share of HIV incidence, enabling these
    jurisdictions to craft and implement community-specific plans to reduce
    the spread of HIV. HRSA's EHE funding for Community Health Centers has
    already shown promising results, with more than 10,000 new clients
    being treated for HIV, nearly 865,000 HIV tests administered, and
    63,000 new PrEP prescriptions for people at risk for HIV. With greater
    funding and continued commitment from the Biden Administration to grow
    the EHE Initiative, The AIDS Institute believes this nation can make
    significant progress toward the goal of ending the HIV epidemic.
        We urge you to fund year three of the EHE Initiative at the
    following levels: $371 million for the CDC Division of HIV/AIDS
    Prevention to conduct targeted testing, connection to treatment, and
    robust surveillance; $212 million for the Ryan White HIV/AIDS Program
    to increase access to high-quality HIV care and treatment; $152 million
    for HRSA's Community Health Center program to provide prevention
    services emphasizing PrEP; $16 million for NIH's Centers for AIDS
    Research to provide best practices to guide the plan; and $27 million
    for the Indian Health Service to provide HIV prevention, treatment,
    education, and hepatitis C (HCV) elimination in Indian Country. In
    order for jurisdictions to better plan for years four through ten of
    the Initiative, we urge the Committee to work with HHS, OMB and the
    White House Office of HIV/AIDS Policy to make public out-year funding
    projections for appropriations needed to accomplish the goals of the
    Initiative by 2030.
                               cdc hiv prevention
        CDC's Division of HIV/AIDS Prevention focuses resources on those
    populations and communities most affected by investing in high-impact
    prevention. One in seven people living with HIV in the United States
    are unaware of their status, so it is critical that HIV testing and
    prevention programs are in place to help connect people to care. There
    is no single way to prevent HIV, but jurisdictions use a combination of
    effective evidence-based approaches including testing, linkage to care,
    education, condoms, syringe service programs, and PrEP. We urge the
    Subcommittee to fund CDC's HIV Prevention program at $1.293 billion,
    which includes $100 million for school-based HIV prevention efforts and
    $371 million for the Ending the HIV Epidemic Plan.
                        the ryan white hiv/aids program
        The Ryan White HIV/AIDS Program provides medications, medical care,
    and essential coverage completion services to almost half of all people
    living with HIV in the United States, many of whom are uninsured or
    underinsured. The Ryan White Program successfully engages individuals
    in care and treatment, increases access to HIV medications, and helps
    over 88 percent of clients achieve viral suppression (which is critical
    for HIV prevention, because people who have achieved viral suppression
    cannot transmit HIV to others). Increased funding is required in FY2022
    because COVID-19 has strained and will continue to strain Ryan White
    programs, which have had to respond to increased demand from people
    living with HIV who lost their jobs and their health insurance because
    of the pandemic.
        The AIDS Institute requests that the Subcommittee fund the Ryan
    White HIV/AIDS Program at a total of $2.776 billion in FY2022,
    distributed in the following manner: Part A at $686.7 million; Part B
    (Care) at $444.7 million; Part B (ADAP) at $943.3 million; Part C at
    $225.1 million; Part D at $85 million; Part F/AETC at $35.5 million;
    Part F/Dental at $18 million; and Part F/SPNS at $34 million; Ending
    the HIV Epidemic Plan at $212 million.
                            minority aids initiative
        As racial and ethnic minorities in the U.S. are disproportionately
    impacted by HIV/AIDS, it is critical that the Subcommittee continue to
    fund the Minority HIV/AIDS Fund and Minority AIDS programs at SAMHSA.
    We urge the Subcommittee to appropriate $105 million for the Minority
    HIV/AIDS Fund; and $160 million for SAMHSA's Minority AIDS Initiative
    Program.
                           viral hepatitis in the u.s
        There has been significant increase in the number of new cases of
    hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) in the U.S.
    over the past decade, despite medical advances that make preventing and
    treating viral hepatitis more effective. There are highly effective
    vaccines for both HAV and HBV, yet cases of HAV have increased 1,300
    percent since 2015 and the number of new cases of HBV have remained
    stable for the past decade. There are several curative treatments for
    HCV, yet the number of new HCV cases has increased by 484 percent over
    the past decade with no signs of slowing. The increased incidence of
    viral hepatitis is largely due to increased injection drug use related
    to the opioid epidemic. Moreover, the CDC estimates that as many as
    half of the people who are living with chronic HBV and HCV (400,000 and
    1.2 million people respectively) may be unaware that they have
    contracted the conditions. Left untreated, viral hepatitis causes liver
    damage, liver disease, cancer, and death. It also contributes to or
    exacerbates other serious and chronic conditions, increasing health
    care costs. We also expect to see even greater increases in viral
    hepatitis cases when data become available for 2020, as we know that
    many state public health systems were unable to maintain outreach,
    testing, and treatment services for viral hepatitis while also battling
    COVID-19, and many harm reduction programs were also unable to operate
    at full capacity during the pandemic. We can eliminate viral hepatitis,
    but doing so will require substantially increased investment in the
    public health infrastructure for prevention, screening, and treatment.
                 infectious disease impact of the opioid crisis
        The recent explosion of opioid use has created tremendous risk for
    viral hepatitis and HIV outbreaks and increasing infection rates among
    new groups and undoing progress toward curbing transmissions. The
    COVID-19 pandemic has caused another surge in injection drug use, with
    2020 poised to have the highest overdose death total on record. The
    systems built to respond to HIV and viral hepatitis are well poised to
    conduct outreach, engagement, and early intervention services with
    individuals who use drugs. A comprehensive response to the opioid
    epidemic must include infectious disease prevention efforts to reduce
    the infectious disease consequences of the epidemic.
        Starting in FY19, Congress allocated new funding to surveil,
    prevent and treat infectious diseases commonly associated with
    injection drug use, including viral hepatitis and HIV. We urge the
    Subcommittee to appropriate $120 million for the CDC's infectious
    diseases and opioid epidemic efforts.
                         cdc viral hepatitis prevention
        The CDC's Viral Hepatitis program funding level is only $39.5
    million, which is not nearly sufficient to address the increasing scope
    of the epidemic. In 2016, the agency suggested it would need 10 times
    that amount annually to establish a comprehensive national program to
    effectively combat the spread of viral hepatitis. This year, we request
    that the Subcommittee appropriate $134 million to the CDC to address
    the rise in viral hepatitis and combat the impact of the opioid crisis.
                            syringe service programs
        Syringe service programs (SSPs) are a critical tool in the fight to
    end the opioid epidemic and eliminate viral hepatitis. These important
    public safety programs reduce the spread of infectious disease, prevent
    overdose deaths, and connect clients to treatment. The presence of SSPs
    has been associated with a 50 percent decline in new HIV and viral
    hepatitis incidence, and when combined with medication-assisted
    treatment, there is a two-thirds reduction in HIV and HCV transmission.
    Extensive research shows that these programs save money and that they
    do not increase drug use. But there are not enough SSPs to meet the
    growing need, and appropriations language prohibiting them from using
    federal funds to purchase sterile syringes makes it difficult for many
    programs to meet their biggest expense. We urge your Subcommittee to
    increase funding for SSPs and to remove all restrictions on federal
    funding for syringe service programs, including for the purchase of
    sterile syringes. The President's FY22 Budget Request and the House's
    FY21 appropriations bill both removed the restrictions for the purchase
    of sterile syringes.
                          public health infrastructure
        Decades of chronic underfunding of public health infrastructure
    programs have left the United States extremely vulnerable to public
    health disasters, as evidenced by the untold physical and economic harm
    COVID-19 has wrought on our nation, with more than 33 million Americans
    sickened and over 600,000 deaths to date. Pandemics are a threat to our
    nation's safety and health, and we urge the Committee to fund public
    health programs with the same priority as traditional defense programs.
    Billions in increased funding is needed annually to ensure that public
    health programs are modernized, fully staffed, and prepared for public
    health emergencies. Yearly appropriations have fallen far short of what
    is needed to protect America's health, which has allowed emerging
    threats like COVID-19 to wreak havoc.
        The AIDS Institute thanks Chairwoman Murray for reintroducing the
    Public Health Infrastructure Saves Lives Act (S.674), which would
    create the Core Public Health Infrastructure Program withing the CDC.
    We believe that this program, if fully funded, will start to rebuild
    and bolster critical infrastructure needed to prepare for the next
    public health threat. We thank the Committee and your colleagues for
    significant increases in emergency funding approved during COVID-19,
    but we also urge you to ensure that this funding is sustained to
    forestall future emergencies. We urge the Committee Members and your
    colleagues to support S. 674, and once signed into law, ensure that the
    authorized programs are fully funded by your Committee.
        Thank you for your consideration of this written testimony. If you
    have questions or would like to discuss these issues further, please do
    not hesitate to contact Nick Armstrong at narmstrong@taimail.org or
    Frank Hood at fhood@taimail.org.

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

                       Prepared Statement of AIDS United
        Dear Chairman Leahy, and Vice Chairman Shelby:
        As the committee continues its important deliberations on the
    Fiscal Year (FY) 2022 Labor, Health and Human Services, Education, and
    Related Agencies (Labor-HHS) appropriation bill, we thank you for your
    commitment to ending the HIV/AIDS epidemic in the United States and
    request that you increase the federal government's financial commitment
    to meet the goals of the federal ending the epidemic initiative and
    support safety net programs that protect the public health.
        Our scientific knowledge of HIV treatment, prevention and
    epidemiology has never been stronger, but progress, until recently, has
    stalled. Over the past three years, a concerted effort to target
    resources where they can be most effective has occurred through the
    Ending the HIV Epidemic Initiative (EHE Initiative), which has the goal
    of reducing new HIV infections by 90% by 2030. Additionally, the HIV
    National Strategic Plan: A Roadmap to End the Epidemic has been
    developed. We urge Congress to capitalize on the expertise developed by
    communities as part of the EHE Initiative so that we can improve and
    expand the Initiative. Ending HIV by 2030 is possible, but resources
    are needed to achieve this goal.
        The COVID-19 pandemic has shown a light on the impact of decades of
    underfunding our Nation's public health infrastructure, resulting in an
    inadequate response to an incredibly destructive pandemic. Below are
    detailed domestic HIV funding requests that we join our coalition
    partners in the Federal AIDS Policy Partnership in urging committee to
    include in the FY2022 appropriations bills. A chart detailing each
    request as well as previous fiscal year funding levels for each program
    is available here: http://federalaidspolicy.org/fy-abac-chart/.
                       ending the hiv epidemic initiative
        Over the last two years, on a bipartisan basis, Congress has
    appropriated additional funding for the Ending the HIV Epidemic
    Initiative, which sets the goal of reducing new HIV infections by 50%
    by 2025, and 90% by 2030. We ask Congress to increase funding in FY2022
    for the Ending the HIV Epidemic Initiative by at least the amounts
    listed below in the following operating divisions:
      --CDC Division of HIV/AIDS Prevention for testing, linkage to care,
            and prevention services, including pre-exposure prophylaxis
            (PrEP) (+$196 m);
      --HRSA Ryan White HIV/AIDS Program to expand comprehensive treatment
            for people living with HIV (+$107 m);
      --HRSA Community Health Centers to increase clinical access to
            prevention services, particularly PrEP (+$34.7 m);
      --The Indian Health Service (IHS) to address the combat the disparate
            impact of HIV on American Indian/Alaska Native populations
            (+$22 m); and
      --NIH Centers for AIDS Research to expand research on implementation
            science and best practices in HIV prevention and treatment.
                        the ryan white hiv/aids program
        The Ryan White Program provides comprehensive care to populations
    disproportionately impacted by the HIV epidemic. Over three quarters of
    Ryan White clients are racial and ethnic minorities, and nearly two
    thirds are under the federal poverty level. With 88% of Ryan White
    clients achieving viral suppression, the program has a proven track
    record of success.
        The Ryan White Program provides services critical to managing HIV,
    often inadequately covered by insurance, including case management;
    mental health and substance use services; adult dental services; and
    transportation, legal, and nutritional support services. Many Ryan
    White Program clients live in states that have not expanded Medicaid
    and must rely on the Ryan White Program as their only source of HIV/
    AIDS care and treatment. While increasingly clients have access to
    insurance, patients still experience cost barriers, such as high
    premiums, deductibles, and other patient cost sharing. The Ryan White
    Program, particularly the AIDS Drug Assistance Program (ADAP), assists
    with these costs so that clients can access comprehensive treatment.
        Currently ADAPs are experiencing increased demand, particularly as
    people have lost health coverage and incomes due to the economic impact
    of COVID-19 and state and local budgets have been increasingly
    stressed. We urge Congress to fund the Ryan White HIV/AIDS Program at a
    total of $2.768 billion in FY2022, an increase of $345 million over
    FY2021, distributed in the following manner:
      --Part A: $731.1 million
      --Part B (Care): $437 million
      --Part B (ADAP): $968.3 million
      --Part C: $225.1 million
      --Part D: $85 million
      --Part F/AETC: $58 million
      --Part F/Dental: $18 million
      --Part F/SPNS: $34 million
      --EHE Initiative: $212 million
                            cdc prevention programs
    CDC HIV Prevention and Surveillance
        Increasing funding for high-impact, community focused HIV
    prevention services has proven to result in a strong return on
    investment. Not only are these prevention tools effective at halting
    new HIV infections, but in the long term they result in decreased
    lifetime medical costs that are associated with HIV treatment. HIV
    prevention tools that meet the special prevention needs of these
    populations must be expanded. HIV will not be eliminated unless we
    focus resources on those most impacted.
        The CDC's Division of HIV Prevention is the federal leader in
    creating new and innovative strategies for HIV prevention. Through
    partnerships with state and local public health departments and
    community-based organizations, the CDC has expanded targeted, high-
    impact prevention programs that work to address racial and geographic
    health disparities. We urge you to fund the CDC Division of HIV
    Prevention at $822.7 million in FY2022, an increase of $67 million over
    FY2021. This is in addition to the $371 million for EHE Initiative work
    within the Division.
    CDC STD Prevention
        Our nation faces a compounded public health crisis. STI rates are
    at an all-time high for the sixth year in a row. STI data from 2018
    shows that combined cases of chlamydia, gonorrhea, and syphilis
    infections are nearing 2.4 million cases a year--up 30%. STIs have
    life-changing and life-threatening consequences that include
    infertility, cancer, ectopic pregnancy, pelvic inflammatory disease,
    and transmission of HIV. More than 17 years of level funding for STI
    programs has resulted in a more than 40% reduction in buying power. The
    STI health infrastructure is part of the public health infrastructure
    and the need to rebuild is higher than ever. While STI rates peak, the
    same people who work to prevent the spread of sexually transmitted
    diseases--contact tracers and disease intervention specialists--have
    been redeployed to address the current COVID-19 pandemic. Consequently,
    80% of sexual health screening clinics being forced to reduce hours or
    shut down because of understaffing. We urge you to fund the CDC
    Division of STD Prevention at $252.9 million to rebuild its
    infrastructure and respond to the dramatic rise in STIs across the
    country.
        Congenital Syphilis is a fully preventable disease if women are
    provided early, accessible prenatal care that includes STI testing.
    Despite this, the transmission of congenital syphilis from mother to
    child during birth increased by 185% between 2014-2018 with an increase
    more than 40% between 2017 and 2018 alone. The result: a 22% increase
    in newborn deaths. Twenty million dollars should be allocated to
    activate a new congenital syphilis elimination initiative at the CDC
    Division of STD Prevention (DSTDP)--with funds distributed to all STI-
    funded health departments--to increase prenatal outreach and screenings
    for congenital syphilis and postnatal follow up for both mothers and
    babies to ensure that congenital syphilis is detected at the earliest
    possible stage. We urge you to fund the CDC Division of STD Prevention
    at $272.9 million in FY2022, an increase of $91.1 million over FY2021.
    CDC Viral Hepatitis Prevention
        The ongoing opioid crisis and increased injection drug has
    drastically increased the number of new viral hepatitis cases in the
    U.S. The CDC estimates that between 2010 and 2017 the country
    experienced a 374% increase in new hepatitis C (HCV) infections, with
    an estimated 44,600 new cases in 2017. The number of new cases of
    hepatitis B (HBV) has also increased over the past several years, with
    22,200 new cases in 2017, ending years of declining rates. Of the more
    than 3.2 million people now living with HBV and/or HCV in the U.S., as
    many as 65% are not aware of their infection.
        The CDC's Division of Viral Hepatitis (DVH) remains the lead agency
    combating viral hepatitis at the national level by providing important
    information and funding to the states. The division is currently funded
    at only $39.5 million. This is nowhere near the nearly $393 million CDC
    estimates is needed for a national viral hepatitis program focused on
    decreasing mortality and reducing the spread of the disease. We have
    the tools to prevent this growing epidemic and the Viral Hepatitis
    National Strategic Plan for the United States: A Roadmap to Elimination
    (2021--2025). However, only with significantly increased funding can
    there be an adequate level of testing, education, screening, treatment,
    surveillance, and on-the-ground syringe service programs needed to
    reduce new infections and put the U.S. on the path to eliminate
    hepatitis as a public health threat. We urge you to fund the CDC's
    Division of Viral Hepatitis at $134 million in FY2022, an increase of
    $94.5 million over FY2021.
    CDC Infectious Diseases and Opioid Epidemic Funding
        The FY2019 budget included new funding for the CDC to combat
    infectious diseases commonly associated with injection drug use in
    areas most impacted by the opioid crisis. The United States is
    experiencing an ongoing overdose crisis and some experts have estimated
    that the U.S. surpassed 100,000 deaths from opioid overdose in 2020, a
    more than 40% increase from 2019 itself a record year. Outbreaks or
    significant spikes in infections of viral hepatitis, as well as HIV, in
    a short period of time among people who inject drugs continue to occur
    throughout the country. Syringe Services Providers (SSPs) are first
    responders to the opioid and infectious diseases crisis effectively
    help prevent drug overdoses and new HIV and hepatitis infections. They
    have the knowledge, contacts, and ability to reach people who use
    drugs; they provide naloxone and other overdose prevention resources;
    and they connect people to medical care and support, including
    Substance Use Disorder treatment. This program, which is only funded at
    $13 million, increases prevention, testing, and linkage to care efforts
    to combat increasing new infections and is strongly needed to provide a
    strong on the ground response to this crisis. These services are
    urgently needed, and adequate funding would provide a critical down
    payment for services needed to help stop the spread of opioid-related
    infectious diseases. We urge you to fund the CDC's Infectious Diseases
    and Opioid Epidemic program in FY2022 at the $120 million requested in
    the president's FY2021 budget, an increase of $107 million over FY2021.
    Syringe Services Programs
        The Department of Health and Human Services has said that syringe
    service programs (SSPs) are a proven, evidence-based, and effective
    tool in HIV and hepatitis prevention. Beyond providing access to
    sterile syringes, SSPs connect people to substance use treatment, HIV
    and hepatitis testing, and other supportive services. These cost-
    effective programs must be expanded, especially in areas hardest hit by
    the opioid epidemic. SSPs have also been providing COVID-19 related
    services to vulnerable populations during the pandemic. The FY2021
    appropriations bill continued a harmful policy rider that restricts the
    use of federal funds for the purchase of sterile syringes, which
    negatively impacts the ability of state and local public health groups
    from expanding SSPs. We urge you to remove all restrictions on federal
    funding for syringe service programs in those jurisdictions that are
    experiencing or at risk for a significant increase in HIV or hepatitis
    infections due to injection drug use.
    Minority HIV/AIDS Initiative (MAI)
        Racial and ethnic minorities in the U.S. are disproportionately
    impacted by HIV/AIDS. African Americans, more than any other racial/
    ethnic group, continue to bear the greatest burden of HIV in the U.S.
    Three out of four new HIV infections occur among people of color. While
    there have been consistent decreases in new HIV infections among
    certain populations, HIV infections are not decreasing among Black and
    Latinx gay and bisexual men.
        The Minority HIV/AIDS Fund supports cross-agency demonstration
    initiatives to support HIV prevention, care and treatment, and outreach
    and education activities across the federal government. MAI programs at
    the Substance Abuse and Mental Health Administration target specific
    populations and provide prevention, treatment, and recovery support
    services, along with HIV testing and linkage service when appropriate,
    for people at risk of mental illness and/or substance abuse. We urge
    you fund the Minority HIV/AIDS Fund at $105 million, and SAMHSA's MAI
    program at $160 million in FY2022, an increase of $49.6 million and $44
    million over FY2021 levels, respectively. We also urge you to fund
    Minority AIDS Initiative programs across HHS agencies at $610 million
    in FY2022.
        We thank you for your continued leadership and support of these
    critical programs for so many people living with HIV, and the
    organizations and communities that serve them nationwide.
        Please do not hesitate to be in touch for more information
    regarding HIV appropriations with our Vice President and Chief Advocacy
    Officer, Carl Baloney, Jr., at cbaloney@aidsunited.org.
        Sincerely.

        [This statement was submitted by Jesse Milan, Jr., President & CEO,
    AIDS United.]
                                     ______

       Prepared Statement of the Alzheimer's Association and Alzheimer's
                                Impact Movement
        The Alzheimer's Association and Alzheimer's Impact Movement (AIM)
    appreciate the opportunity to submit outside witness testimony on the
    Fiscal Year (FY) 2022 appropriations for Alzheimer's and other dementia
    research and public health activities at the U.S. Department of Health
    and Human Services. Specifically, we respectfully request a $289
    million increase for Alzheimer's research at the National Institutes of
    Health (NIH) and $20 million for implementation of the Building Our
    Largest Dementia (BOLD) Infrastructure for Alzheimer's Act (P.L. 115-
    406) at the Centers for Disease Control and Prevention (CDC).
        The Alzheimer's Association is the world's leading voluntary health
    organization in Alzheimer's care, support, and research. It is the
    nonprofit with the highest impact in Alzheimer's research worldwide and
    is committed to accelerating research toward methods of treatment,
    prevention, and, ultimately, a cure. AIM is the advocacy affiliate of
    the Alzheimer's Association, working in strategic partnership to make
    Alzheimer's a national priority. Together, the Alzheimer's Association
    and AIM advocate for policies to fight Alzheimer's disease, including
    increased investment in research, improved care and support, and
    development of approaches to reduce the risk of developing dementia.
            alzheimer's impact on american families and the economy
        Alzheimer's is a progressive brain disorder that damages and
    eventually destroys brain cells, leading to a loss of memory, thinking,
    and other brain functions. Ultimately, Alzheimer's is fatal. We have
    yet to celebrate the first survivor of this devastating disease.
        In addition to the suffering caused by the disease, Alzheimer's is
    also creating an enormous strain on the health care system, families,
    and federal and state budgets. The annual cost for all individuals with
    Alzheimer's or other dementia will total $355 billion for health care,
    long-term care, and hospice care in 2021. This does not include the
    over $250 billion in unpaid caregiver costs. The U.S. taxpayer-funded
    federal health care programs Medicare and Medicaid are expected to
    cover about $239 billion, or 67 percent, of these costs this year.
    While an estimated 6.2 million Americans age 65 and older are currently
    living with Alzheimer's, nearly 13 million Americans will have
    Alzheimer's by 2050 and costs will exceed $1.1 trillion (in 2021
    dollars). Alzheimer's and other dementia threaten to bankrupt families,
    businesses, and our health care system.
                      investing in alzheimer's treatments
        The Food and Drug Administration (FDA) recently approved the first
    treatment for Alzheimer's disease since 2003 and the first to address
    the underlying biology of Alzheimer's disease. The FDA determined there
    is substantial evidence that aducanumab (marketed as Aduhelm) reduces
    amyloid plaques in the brain and that the reduction in these plaques is
    reasonably likely to predict important benefits to patients.
        This approval represents an important step forward in Alzheimer's
    research. This new treatment is pivotal, while not a cure. This is the
    first of a number of new treatments to come. We recognize the drug may
    work differently for everyone who takes it, and may not work for some
    individuals. Importantly, aducanumab was studied in and appropriate for
    people living with early Alzheimer's dementia and mild cognitive
    impairment (MCI) due to Alzheimer's who showed evidence of a buildup of
    amyloid plaques in the brain. The therapy has not yet been tested on
    people with more advanced cases of dementia or Alzheimer's disease.
        The recent years of increased investment provided by Congress to
    NIH have been integral to this and other promising therapeutic
    approaches to treating Alzheimer's disease. For example, NIH supported
    basic science investigations behind the discovery of immunotherapies
    like aducanumab, as well as translational research for next-generation
    immunotherapies. Additionally, the selection of participants for
    aducanumab clinical trials hinged on amyloid PET imaging, a technology
    that would not exist today without the publicly-funded research
    supported by NIH. The federal commitment, combined with unprecedented
    philanthropic support, provides the foundation for an optimistic view
    of the future, which is needed because there is much work to be done.
        This is just the beginning of meaningful treatment advances.
    History has shown us that approvals of the first drug in a new category
    invigorates the field, increases investments in new treatments, and
    encourages greater innovation. We are hopeful that this drug is just
    the beginning for better treatments to come. Looking at the big picture
    of science, there is a crucial need for effective treatment options for
    diverse populations living in all stages of Alzheimer's. Alzheimer's
    must be addressed through multiple different pathways--more than just
    amyloid--with an eye toward effective combination therapies,
    pharmacological and nonpharmacological, that work at different stages
    of the disease.
        While recent NIH funding increases have laid the foundation for
    breakthroughs in diagnosis, treatment, and prevention, and enabled
    significant advances in understanding the complexities of Alzheimer's,
    there is still much left to be done. We cannot leave any stone
    unturned. Investment in Alzheimer's research is only a fraction of
    what's been applied over time, with great success, to address other
    major diseases. Between 2000 and 2017, the number of people dying from
    Alzheimer's increased by 145 percent while deaths from other major
    diseases have decreased significantly or remained approximately the
    same. It is vitally important that NIH continues to build upon
    promising research advances. An increase of $289 million in Alzheimer's
    research at NIH in FY2022 would enable scientists to conduct more
    inclusive, efficient, and practical clinical trials; increase knowledge
    of risk and protective factors in individuals and across diverse
    populations; discover better biomarkers to detect disease and monitor
    treatment response; pursue a precision medicine approach to detect the
    disease earlier and tailor treatment plans to an individual's unique
    symptoms and risk profile; and leverage emerging digital technologies
    and big data to speed discoveries. We need to continue to increase
    investment in Alzheimer's and dementia research to maximize every
    opportunity for success.
                addressing alzheimer's as a public health crisis
        As scientists continue to search for ways to cure, treat, or slow
    the progression of Alzheimer's through medical research, public health
    plays a critical role in promoting cognitive function and reducing the
    risk of cognitive decline. Now more than ever it is apparent how
    crucial it is to have an established infrastructure in place to respond
    to public health threats.
        In 2018, Congress acted decisively to address Alzheimer's as an
    urgent and growing public health threat through the passage of the
    bipartisan BOLD Act. This law authorizes $100 million over five years
    for CDC to build a robust Alzheimer's public health infrastructure
    across the country focused on public health actions that can allow
    individuals with Alzheimer's to live in their homes longer and delay
    costly long-term nursing home care. Congress appropriated $10 million
    for the first year of BOLD's implementation in FY20, which allowed CDC
    to award funding to three Public Health Centers of Excellence (PHCOE),
    focused on risk reduction, caregiving, and early detection, and 16
    public health departments across the country. These state, local, and
    tribal public health department recipients are creating statewide
    dementia coalitions, hiring dementia coordinators, and developing or
    updating Alzheimer's and other dementia strategic plans. The $15
    million Congress appropriated for the second year of BOLD's
    implementation in FY21 will help fund additional public health
    departments and expand the impact of this crucial work into more
    communities across the country.
        The Alzheimer's Association is grateful to be leading the Dementia
    Risk Reduction PHCOE, focusing on community-level actions to reduce the
    risk of developing Alzheimer's and other dementia. Researchers are
    increasingly studying the impact that lifestyle behaviors may have on
    the risk of developing Alzheimer's and other dementia. The future of
    reducing Alzheimer's could be in treating the whole person with a
    combination of drugs and modifiable risk factor interventions, as we do
    now with heart disease. The Center will work with public health
    agencies on addressing social determinants of health with respect to
    dementia risk; capacity building to enable smaller public health
    agencies to engage in dementia risk reduction activities; and
    partnering with health systems in their communities to advance risk
    reduction.
        Over 65 percent of American adults have at least one risk factor
    for dementia. Although risk factors like age, genetics, and family
    history cannot be changed, other risk factors can be modified to reduce
    the risk of cognitive decline and dementia. Examples of modifiable risk
    factors are physical activity, smoking, education, staying socially and
    mentally active, blood pressure, and diet. In fact, the 2020
    recommendations of The Lancet Commission on dementia prevention,
    intervention, and care suggest that addressing modifiable risk factors
    might prevent or delay up to 40 percent of dementia cases.
        The Alzheimer's Association is leading a five-year clinical trial
    to evaluate a two-year intervention to see whether lifestyle
    interventions that simultaneously target multiple risk factors can
    protect cognitive function in older adults at increased risk for
    cognitive decline. The U.S. Study to Protect Brain Health Through
    Lifestyle Intervention to Reduce Risk (U.S. POINTER) will evaluate the
    effects of lifestyle interventions, like physical exercise, a healthier
    diet, cognitive and social stimulation, and self-management of heart
    and vascular health, on changes in cognitive function. It is crucial
    that forthcoming findings from studies like U.S. POINTER are translated
    into public health interventions across the country. Investing now in a
    robust public health infrastructure ensures cutting edge research can
    be effectively and efficiently disseminated into local communities.
        While these BOLD implementation efforts are important steps
    forward, and we are grateful to this Subcommittee and Congress for the
    initial funding, CDC must receive the full $20 million authorized in
    the law for FY2022 to ensure the meaningful impact that Congress
    intended. The Alzheimer's Association and AIM urge Congress to include
    the full $20 million for the third year of BOLD's implementation at CDC
    in FY2022. Activities supported by the requested $20 million in FY22
    would enable CDC to award additional PHCOEs, focused on important
    priorities such as Tribal Health and avoiding preventable
    hospitalizations, and expand the number of state, local, and tribal
    public health departments across the country that receive funding for
    Alzheimer's public health activities. Finally, as Alzheimer's is one of
    the most prevalent chronic diseases facing our nation, we look forward
    to the day that the Subcommittee and CDC elevate Alzheimer's and other
    dementia to the Division level as with other major chronic diseases.
                                   conclusion
        The Alzheimer's Association and AIM appreciate the steadfast
    support of the Subcommittee and its priority setting activities. We
    urge the Subcommittee and Congress to provide an additional $289
    million for Alzheimer's research activities at NIH and $20 million for
    full implementation of the BOLD Infrastructure for Alzheimer's Act at
    CDC in FY 2022.
                                     ______

          Prepared Statement of the Alzheimer's Foundation of America
        On behalf of the Alzheimer's Foundation of America (AFA), a
    national nonprofit that unites more than 2,000 member organizations in
    the goal of providing support, services and education to individuals,
    families and caregivers affected by Alzheimer's disease and related
    dementias nationwide, I am submitting the following budget requests for
    your consideration as you prepare fiscal year (FY) 2022 appropriations
    levels for the federal budget.
        For federal programs that impact those living with dementia and
    their family caregivers, AFA recommends the following budget
    allocations for FY '22:
      --an additional $289 million for a total $3.4 billion for Alzheimer's
            disease clinical research at the National Institutes of Health/
            National Institute on Aging (NIH/NIA);
      --$560 million to fund the Brain Research through Advancing
            Innovative Neurotechnologies (BRAIN) Initiative, a trans-agency
            effort to arm researchers with revolutionary tools to
            fundamentally understand the neural circuits that underlie the
            healthy and diseased brain;
      --$46.1 billion (a $3.2 billion increase over FY '21) for total
            spending at the NIH;
      --support for President Biden's call for $6.5 billion to launch the
            Advanced Research Projects Agency for Health (ARPA-H) at NIH;
      --an additional $50 million to fund caregiver supports and services
            provided by Older Americans' Act (OAA) programs administered by
            the Administration for Community Living (ACL), including a $7.5
            million increase for the Alzheimer's Disease Program for a
            total expenditure of $35 million in FY '22; and
      --$20.5 million to support BOLD Act initiatives, including a $500,000
            increase for the Healthy Brain Initiative and $4 million for
            fall prevention at the Centers for Disease Control and
            Prevention (CDC).
    National Institutes of Health/National Institute on Aging (NIH/NIA):
        NIA sponsors and conducts the lion's share of federal aging-related
    research, including research into Alzheimer's disease and related
    dementias, and this pioneering science contributes significantly to the
    improved care and quality of life of older adults. A key NIA priority
    is translating research into better and more efficient care through the
    development of effective interventions that are disseminated to health
    care providers, patients, and caregivers. These interventions for the
    prevention, early detection, diagnosis, and treatment of disease will
    help reduce the burden of illness for older adults and lower cost of
    care.
        AFA is extremely grateful to the Subcommittee for recent increases
    in federal funding for Alzheimer's disease research at NIH/NIA.
    Additional resources for fighting Alzheimer's disease and related
    dementias at NIH have greatly increased our chances that promising
    research gets funded as we move closer to the goal of finding a cure or
    disease-modifying treatment by 2025 as articulated in the National Plan
    to Address Alzheimer's Disease.
        Yet, meaningful treatment is still some ways off and basic science
    into dementia--the type of research funded through NIH--remains vital
    to finding a cure.
        AFA asks the Subcommittee to build upon past progress and continue
    making the battle against Alzheimer's disease a national priority. To
    this end, AFA urges the Subcommittee to provide an additional $289
    million, for a total of approximately $3.4 billion for Alzheimer's
    disease clinical research at NIH in FY '22.
        The BRAIN Initiative is a large-scale effort to accelerate
    neuroscience research by equipping researchers with the tools and
    insights necessary for treating a wide variety of brain disorders,
    including Alzheimer's disease, schizophrenia, autism, epilepsy, and
    traumatic brain injury. By mapping whole brains in action, the ability
    to identify thousands of brain cells at a time and development of
    innovative brain scanners, BRAIN Initiative research advances and tools
    are needed to better understand the brain and cognitive functioning.
    AFA is asking that $560 million be allocated to conduct BRAIN
    Initiative research for FY '22.
        AFA also urges the Subcommittee to budget at least $46.1 billion
    for total NIH spending in FY '22, a $3.2 billion increase over the
    NIH's program level funding in FY '21, as recommended by the Ad Hoc
    Group for Medical Research. This funding level would allow for
    meaningful growth above inflation in the base budget that would expand
    NIH's capacity to support promising science in all disciplines. It also
    would ensure that funding from the Innovation Account established in
    the 21st Century Cures Act would supplement the agency's base budget,
    as intended, through dedicated funding for specific programs.
        AFA also supports the President's call for an additional $6.5
    billion to launch the Advanced ARPA-H at NIH. ARPA-H would leverage
    existing public sector basic science research programs along with
    private sector efforts to accelerate development of new capabilities
    for disease prevention, detection, and treatment and overcome
    bottlenecks that have limited progress in areas such as Alzheimer's
    disease. Any funding for ARPA-H, however, should not come from the
    existing programming budget for NIH and should be considered an
    additional appropriation to AFA's $46.1 billion request for all of NIH.
    Centers for Disease Control and Prevention (CDC):
        The Building Our Largest Dementia (BOLD) Infrastructure for
    Alzheimer's Act requires CDC to establish Centers of Excellence in
    Public Health Practice dedicated to promoting Alzheimer's disease
    management and caregiving interventions, as well as educating the
    public on Alzheimer's disease and brain health, will establish
    Alzheimer's disease as a public health issue, increasing American
    awareness and care training around the disease. To fund BOLD Act
    initiatives at CDC, AFA is requesting $20 million in funding for FY
    '22.
        For older adults--especially for those living with dementia--falls
    are common, costly, and often preventable. They represent the leading
    cause of injury-related death among adults age 65 years of age and
    older. CDC's National Center for Injury Prevention and Control
    developed tools for clinicians and other health care partners to
    identify and address falls and fall risk. AFA urges a continued
    investment of $4 million to continue funding fall prevention programs
    at CDC.
    Administration for Community Living (ACL):
        AFA is requesting a $50 million increase for vital ACL programming
    impacting those living with dementia, including a $7.5 million increase
    to the Alzheimer's Disease Program for a total funding of $35 million
    in FY '22. In addition, AFA is requesting that the following amounts be
    allocated to the following Older Americans' Act (OAA) programs
    administered by ACL:
      --National Family Caregiver Support Program (NFCSP): NFCSP provides
            grants to states and territories, based on their share of the
            population aged 70 and over, to fund a range of supportive
            services that assist family and informal caregivers in caring
            for those with dementia at home for as long as possible, thus
            providing a more person-friendly and cost-effective approach to
            institutionalization. AFA urges that an additional $24.5
            million (for a total of $213.6 million) be allocated in FY '22
            to support this important program.
      --Lifespan Respite Care Program (LRCP): AFA urges the Subcommittee to
            allocate a minimum of $10 million--a $2.9 million increase--to
            LRCP in FY '22. LRCP provides competitive grants to state
            agencies working with Aging and Disability Resource Centers and
            non-profit state respite coalitions and organizations to make
            quality respite care available and accessible to family
            caregivers regardless of age or disability.
      --Falls Prevention: In response to COVID, several community-based
            fall prevention interventions, supported with ACL investments,
            have transitioned to a digital environment in cases where they
            can safely be implemented in the home. AFA, therefore, urges
            $10 million, a $5 million increase over FY '21 funding, be
            allocated so ACL can continue vital fall prevention activities
            at ACL.
      --Home Delivered Nutrition Program: This vital program provides
            grants to states for nutrition services for older people,
            including many living with dementia. In addition to healthy
            meals, the programs provide a range of services including being
            an important link to in-home and community-based supports such
            as homemaker and home-health aide services, transportation,
            home repair and modification, and falls prevention programs.
            AFA calls for a $10.1 million increase, or $286.3 million, for
            home delivered nutrition programs in FY '22.
        AFA understands that during this time of crisis, Congress is
    working hard to stem fallout of both the human and fiscal toll of
    COVID-19. We are grateful for your work and urge that the Subcommittee
    continues making services and supports available to our nation's most
    vulnerable populations--including those older Americans with chronic
    conditions like Alzheimer's disease--a priority. We know that through
    determination, sacrifice and resilience, Americans will rise to the
    challenge and take the necessary steps to mitigate the fallout of this
    public health emergency.
        AFA thanks the Subcommittee for the opportunity to present our
    recommendations and looks forward to working with you and your staff
    through the appropriations process. Please contact me at
    cfuschillo@alzfdn.org or Eric Sokol, AFA's senior vice president of
    public policy, at esokol@alzfdn.org, if you have any questions or
    require further information.
        Sincerely.

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

            Prepared Statement of the American Academy of Allergy,
                              Asthma & Immunology
        Chairwoman Murray, Ranking Member Blunt, and Members of the
    Subcommittee, the American Academy of Allergy, Asthma, & Immunology
    (AAAAI) thanks you for the opportunity to submit written testimony on
    the U.S. Department of Health and Human Services (HHS) Fiscal Year (FY)
    2022 appropriations bill. AAAAI respectfully requests the subcommittee
    to include $12.2 million in funding for the Consortium on Food Allergy
    Research (CoFAR) within the National Institute of Allergy and
    Infectious Disease (NIAID) at the National Institutes of Health (NIH).
    In addition, we request report language reflecting the importance of
    NIH engaging in trans-NIH research on food allergies. Also, the AAAAI
    supports funding of $100 million for the National Healthcare Safety
    Network which enables the Centers for Disease Control and Prevention
    (CDC) to target prevention of healthcare acquired and antimicrobial
    resistant infections and improve antibiotic prescribing.
        Established in 1943, AAAAI is a professional organization with more
    than 7,000 members in the United States, Canada, and 72 other
    countries. This membership includes board certified allergist/
    immunologists, other medical specialists, allied health and related
    healthcare professionals--all with a special interest in the research
    and treatment of patients with allergic and immunological diseases.
                                 food allergies
        Food allergies affect 32 million Americans, including 6 million
    children. Each year, more than 200,000 Americans require emergency
    medical care for allergic reactions to food--equivalent to one trip to
    the emergency room every three minutes.
        The Consortium on Food Allergy Research (CoFAR) was established by
    the National Institutes of Health (NIH) within the National Institute
    of Allergy and Infectious Disease (NIAID) in 2005. Over the following
    16 years, CoFAR discovered genes associated with an increased risk for
    peanut allergy and has also identified the most promising potential
    treatments for egg and peanut immunotherapy, among many other
    accomplishments. Breakthroughs like these, scaled across other major
    food allergies, can significantly improve the quality of life for tens
    of millions of Americans. Its annual $6.1 million budget is a
    relatively small portion within NIH's almost $40 billion budget, yet
    CoFAR has been able to achieve massive strides in the study of food
    allergy prevention and treatment.
        AAAAI enthusiastically supports an increase in funding for CoFAR of
    $6.1 million, annually, bringing its yearly budget up to $12.2 million.
    With its relatively low current level of funding, CoFAR has been able
    to accomplish breakthroughs in the under-researched field of food
    allergies. It is crucial that we continue investing at proportional
    levels given the scale of this condition which impacts 10.8 percent of
    the U.S. population.
        AAAAI also requests that the Subcommittee's report accompanying the
    FY22 Labor/HHS appropriation reflects the importance of trans-NIH
    research on food allergies. AAAAI strongly supports the following NIAID
    report language submitted by Senator Blumenthal that acknowledges the
    groundbreaking work of CoFAR and encourages robust investment to expand
    its research breadth and network.

        Food Allergies.--The Committee recognizes the serious issue of food
            allergies which affect approximately eight percent of children
            and ten percent of adults in the U.S. The Committee commends
            the ongoing work of NIAID in supporting a total of 17 clinical
            sites for this critical research, including seven sites as part
            of the Consortium of Food Allergy Research (CoFAR). The
            Committee includes $12,200,000, an increase of $6,100,000, for
            CoFAR to expand its clinical research network to add new
            centers of excellence in food allergy clinical care and to
            select such centers from those with a proven expertise in food
            allergy research.
        In addition to the AAAAI, the CoFAR funding request and report
    language are supported by the American College of Allergy, Asthma &
    Immunology; Allergy & Asthma Network; Asthma and Allergy Foundation of
    America; Food Allergy & Anaphylaxis Connection Team; Food Allergy
    Research and Education; and International FPIES Association.
             antimicrobial resistance (amr) and penicillin allergy
        The growing threat of antimicrobial resistance, combined with the
    dwindling pipeline of novel antibiotic research, requires policies that
    prevent inappropriate use of antibiotics. One of the primary ways to
    combat this threat begins with penicillin--the most commonly reported
    drug allergy. According to the CDC, approximately 10 percent of the
    U.S. population report being allergic to penicillin, yet 9 out of 10
    patients reporting a penicillin allergy are not truly allergic when
    formally evaluated, such that fewer than one percent of the population
    is truly allergic to penicillin. More recently, the CDC cited the
    importance of correctly identifying if patients are penicillin-allergic
    in decreasing the unnecessary use of broad-spectrum antibiotics in its
    2018 update of Antibiotic Use in the United States: Progress and
    Opportunities. The AAAAI strongly supports more widespread and routine
    use of penicillin allergy evaluation for patients with a self-reported
    history of allergy to penicillin. Evaluation can accurately identify
    patients who, despite reporting a history of penicillin allergy, can
    safely receive penicillin.
        The AAAAI supports funding of $100 million for the National
    Healthcare Safety Network which enables CDC to target prevention of
    healthcare acquired and antimicrobial resistant infections and improve
    antibiotic prescribing. The Antibiotic Resistance Solutions Initiative
    will benefit from significant new resources to achieve the goals
    outlined in the National Action Plan for Combating Antibiotic-Resistant
    Bacteria, including strengthening antibiotic stewardship to promote
    best practices for prescribing antibiotics such as penicillin.
        AAAAI also wishes to express its appreciation to the subcommittee
    for the inclusion of language regarding the importance of penicillin
    allergy testing in the FY20 appropriations bill. The discovery of
    penicillin opened the door to medical innovation allowing surgeries to
    be performed, organs to be transplanted, as well as combat wounds and
    burn victims to be treated. AAAAI encourages more widespread and
    routine penicillin allergy evaluation for patients with a history of
    allergy to penicillin or another beta-lactam drug (e.g., ampicillin or
    amoxicillin). Penicillin allergy evaluation can accurately identify
    patients who, despite reporting a history of penicillin allergy, can
    safely receive penicillin. On behalf of the patients we serve, thank
    you for your leadership in giving penicillin allergy testing the
    attention it deserves.
        Thank you for your consideration of these FY22 appropriations
    requests. Please contact Sheila Heitzig, JD, MNM, CAE, AAAAI Director
    of Practice and Policy, at sheitzig@aaaai.org if you have any questions
    or would like additional information.
                                     ______

            Prepared Statement of the American Academy of Pediatrics
        The American Academy of Pediatrics (AAP), a non-profit professional
    organization of 67,000 primary care pediatricians, pediatric medical
    subspecialists, and pediatric surgical specialists dedicated to the
    health, safety, and well-being of infants, children, adolescents, and
    young adults, appreciates the opportunity to submit this statement for
    the record in support of strong federal investments in children's
    health in Fiscal Year (FY) 2022 and beyond.
        AAP urges all Members of Congress to put children first when
    considering short and long-term federal spending decisions, and
    supports funding levels for the following programs: $50 million for
    Pediatric Subspecialty Loan Repayment (HRSA), $50 million for Firearm
    Injury and Mortality Prevention Research (CDC/NIH), $10 million for
    Pediatric Mental Health Care Access Grants (HRSA), $12 million for
    implementation of Scarlett's Sunshine Act (CDC/HRSA), $22.334 million
    for Emergency Medical Services for Children (HRSA), $280 million for
    the National Center for Birth Defects and Developmental Disabilities
    (CDC), $271.2 million for Global Immunizations (CDC), and $15 million
    and report language for the Vaccine Awareness Campaign to Champion
    Immunization Nationally and Enhance Safety (VACCINES) Act (CDC).
    Pediatric Subspecialty Loan Repayment Program (HRSA):
        FY 22 Request: $50 Million; FY 21 Level: Never Funded.--The AAP
    requests $50 million in initial funding for the Pediatric Subspecialty
    Loan Repayment Program, a Title VII health professions program to
    improve access to care for children with special health care needs by
    offering loan repayment to pediatric subspecialists and child mental
    health providers who agree to serve in an underserved area. The United
    States' supply of pediatric subspecialists is inadequate to meet
    children's health needs. Many children must wait more than 3 months for
    an appointment with a pediatric subspecialist, and approximately 1 in 3
    children must travel 40 miles or more to receive care from a
    pediatrician certified in certain subspecialties such as developmental
    behavioral pediatrics. Spotlighting the needs of children with autism
    spectrum disorder (ASD), as an example, there are approximately 1.5
    million children with ASD but there are only about 700 practicing
    board-certified developmental-behavioral pediatricians. The national
    wait time for a pediatric developmental evaluation is 5.4 months. In
    terms of equity, ASD prevalence among Hispanic children is about 16%
    lower than among white and black children, which suggests that more
    Hispanic children with autism are not being identified. In addition,
    black children with ASD are significantly less likely than white
    children to have a first evaluation by the age of three.
    Firearm Injury and Mortality Prevention Research (CDC/NIH):
        FY 22 Request: $50 Million Total; FY 21 Level: $25 Million Total.--
    The AAP is tremendously appreciative of and applauds Congress for
    continuing to provide $25 million total, split evenly between CDC and
    NIH, for firearm injury and mortality prevention research in FY 21. In
    the midst of the COVID-19 pandemic, communities across the U.S.
    continue to suffer from the public health crisis of firearm-related
    injuries and deaths with early data showing 2020 being a record-
    breaking year for gun violence, injuries, and deaths. A public health
    approach to firearm violence prevention is urgently needed to promote
    health equity and address the disproportionate burden of this epidemic
    on communities of color. The foundation of this approach is rigorous
    research that can accurately quantify and describe the facets of an
    issue and identify opportunities for reducing its related morbidity and
    mortality. The initial investments in FY20 and FY21 are important, but
    increased funding is still needed to overcome the decades-long lack of
    federal funding that set back our nation's response to the public
    health issue of firearm-related morbidity and mortality. Over time,
    additional funding can generate research into important issues such as
    the best ways to prevent unintended firearm injuries and fatalities
    among women and children; the most effective methods to prevent
    firearm-related suicides; the measures that can best prevent the next
    shooting at a school or public place; and numerous other vital public
    health questions. Continued and expanded investments are essential to
    the success of this important work.
    Pediatric Mental Health Care Access Grants (HRSA):
        FY 22 Request: $10 Million; FY 21 Level: $10 Million.--The AAP
    appreciates the additional funds included in the American Rescue Plan
    for the Pediatric Mental Health Care Access Grants, in recognition of
    the impact of COVID-19 on child and adolescent mental health, and urges
    Congress to continue providing $10 million for FY 22 appropriations.
    This program supports the development of new statewide or regional
    pediatric mental health care telehealth access programs, as well as the
    improvement of already existing programs. Research shows pervasive
    shortages of child and adolescent mental/behavioral health specialists
    throughout the U.S. Integrating mental health and primary care has been
    shown to substantially expand access to mental health care, improve
    health and functional outcomes, increase satisfaction with care, and
    achieve costs savings.
    Activities Authorized under Scarlett's Sunshine Act (CDC/HRSA):
        FY 22 Request: $12 Million; FY 21: Level: N/A.--The AAP urges
    Congress to provide first-time appropriations of $12 million to
    implement the Scarlett's Sunshine Act. Little is known about the
    tragic, sudden and unexpected deaths of young children because of
    variations in investigations and death certifications. Enacted in
    December 2020, this law will help states better understand sudden
    unexpected infant death and sudden unexpected death in childhood,
    facilitate data collection and analysis to improve prevention, and
    support grieving families. Funds should support work at both CDC and
    HRSA's Maternal Child Health Bureau given their complementary efforts
    on this issue.
    Emergency Medical Services for Children (HRSA):
        FY 2022 Request: $22.334 Million; FY 21 Level: $22.334 Million.--
    The AAP urges the committee to maintain $22.334 million in funding for
    the Emergency Medical Services for Children (EMSC) Program in FY 22.
    EMSC is the only federal program that focuses specifically on improving
    the pediatric components of the emergency medical services (EMS)
    system. EMSC aims to ensure state of the art emergency medical care is
    available for the ill and injured child or adolescent, pediatric
    services are well integrated into an EMS system backed by optimal
    resources, and that the entire spectrum of emergency services is
    provided to all children and adolescents no matter where they live.
    National Center for Birth Defects and Developmental Disabilities (CDC):
        FY 22 Request: $280 Million; FY 21 Level: $167.8 Million.--The AAP
    requests $280 million for FY 22 for the National Center for Birth
    Defects and Developmental Disabilities (NCBDDD), including $100 million
    for Surveillance for Emerging Threats to Mothers and Babies (SET-NET).
    This would allow the program to scale nationally and serve as the
    nationwide preparedness and response network the United States needs to
    protect pregnant individuals and infants from emerging public health
    threats. According to the CDC, birth defects affect 1 in 33 babies and
    are a leading cause of infant death in the United States. NCBDDD
    conducts important research on fetal alcohol syndrome, infant health,
    autism, attention deficit and hyperactivity disorders, congenital heart
    defects, and other conditions like Tourette Syndrome, Fragile X, Spina
    Bifida and Hemophilia. NCBDDD supports extramural research in every
    State and has played a crucial role in the country's response to the
    Zika virus, as well as COVID-19.
    Global Immunization--Polio and Measles/Other (CDC):
        FY 22 Request: $271.2 Million ($176 Million for Polio and $50
    Million for Measles/Other); FY 21 Level: $226 Million ($176 Million for
    Polio and $50 million for Measles/Other).--Vaccines are one of the most
    cost-effective and successful public health solutions available. The
    CDC provides countries with technical assistance and disease
    surveillance support, with a focus on eradicating polio, reducing
    measles deaths, and strengthening routine vaccine delivery. Global
    mortality attributed to measles declined by 79% between 2000 and 2015
    thanks to expanded immunization, saving an estimated 20.3 million
    lives. Unfortunately, the gains from global immunization are in
    jeopardy. During the COVID-19 pandemic, many countries diverted
    resources set aside for polio and routine immunizations to fight the
    pandemic. To finance immunization gaps in countries and recover from
    pandemic-related disruptions requires an additional $255 million over
    the next three years. Failing to close these gaps will leave millions
    of children at risk and will compromise U.S. global health security due
    to increased possibility of importing highly infectious diseases like
    measles into the U.S.
    Activities Authorized under the VACCINES Act (CDC):
        FY 22 Request: $15 Million; FY 21 Level: N/A.--The AAP is very
    appreciative that Congress specifically included the Vaccine Awareness
    Campaign to Champion Immunization Nationally and Enhance Safety
    (VACCINES) Act as part of Section 2302 of the American Rescue Plan that
    provided $1 billion to improve vaccine confidence for both COVID-19 and
    routine immunizations. We urge Congress to include $15 million
    authorized by the VACCINES Act for CDC to research vaccine hesitancy
    and establish an evidence-based public awareness campaign to help
    improve vaccination rates across the lifespan. We also urge Congress to
    request a report on the progress of these activities at the CDC.
        There are many ways Congress can help meet children's needs and
    protect their health and well-being. Adequate funding for children's
    health programs is one of them. The American Academy of Pediatrics
    looks forward to working with Members of Congress to prioritize the
    health of our nation's children in FY 2022 and beyond. If we may be of
    further assistance, please contact the AAP Department of Federal
    Affairs at pjohnson@aap.org. Thank you for your consideration.

        [This statement was submitted by Lee Savio Beers, MD, FAAP,
    President,
    American Academy of Pediatrics.]
                                     ______

             Prepared Statement of the American Alliance of Museums
        Chairwoman Murray, Ranking Member Blunt, and members of the
    subcommittee, thank you for the opportunity to submit this testimony.
    My name is Laura Lott, and I am President and CEO of the American
    Alliance of Museums (AAM). I urge you to provide the Office of Museum
    Services (OMS) within the Institute of Museum and Library Services
    (IMLS) with $80 million for fiscal year (FY) 2022, an increase of $39.5
    million. We request that $2.5 million of this increase be directed to
    explore establishing, and to fund projects related to, a roadmap to
    strengthen the structural support for a museum Grants to States program
    administered by OMS, as authorized by the Museum and Library Services
    Act, in addition to the agency's current critical direct grants to
    museums.
        AAM--representing more than 35,000 individual museum professionals
    and volunteers, museums of all types, and corporate partners serving
    the museum field--stands for the broad scope of the museum community.
        I want to express the museum field's gratitude for the $40.5
    million in funding for OMS in FY 2021, and we applaud the bipartisan
    group of 41 Senators who recently wrote to you in support of FY 2022
    OMS funding. We also applaud the President's budget proposal for
    additional funding for OMS for the grants program authorized by the
    African American History and Culture Act and the grants program
    authorized by the National Museum of the American Latino Act as steps
    in the right direction. OMS is a vital investment in protecting our
    nation's cultural treasures, educating students and lifelong learners
    alike, and bolstering local economies. During the COVID-19 pandemic,
    OMS has provided critical leadership to the museum community through
    its CARES Act grants. For example, the agency has been providing
    science-based information and recommended practices to reduce the risk
    of transmission of COVID-19 to staff and visitors engaging in the
    delivery of museum services.
        Through the IMLS CARES Act Grants to Museums and Libraries, IMLS
    awarded $13.8 million to 68 museums and libraries to support their
    response to the coronavirus pandemic. IMLS received 1088 applications
    from museums but was only able to fund 39 awards, fewer than 4 percent
    of the applications, for a total of $8.28 million--far below the $261.5
    million requested. Unfortunately, none or very little of the $200
    million allocated to IMLS in the American Rescue Plan is expected to be
    awarded to museums.
        Museums are a robust and diverse business sector, including African
    American museums, aquariums, arboreta, art museums, botanic gardens,
    children's museums, culturally-specific museums, historic sites,
    historical societies, history museums, maritime museums, military
    museums, natural history museums, planetariums, presidential libraries,
    public gardens, railway museums, science and technology centers, and
    zoos.
        Museums are economic engines and job creators: According to Museums
    as Economic Engines: A National Report, pre-pandemic U.S. museums
    supported more than 726,000 jobs and contributed $50 billion to the
    U.S. economy per year, including significant impact on individual
    states. For example, the total financial impact that museums have on
    the economy in the state of Washington is $1.01 billion, supporting
    14,145 jobs. For Missouri it is a $852 million impact, including 13,653
    jobs. Nationally, museums spend more than $2 billion yearly on
    education activities and the typical museum devotes 75% of its
    education budget to K-12 students.
        IMLS is the primary federal agency responsible for helping museums
    connect people to information and ideas. OMS supports all types of
    museums--from art museums to zoos--by awarding grants that help them
    better serve their communities. OMS awards grants in every state to
    help museums digitize, enhance, and preserve collections; provide
    teacher professional development; and create innovative, cross-
    cultural, and multi-disciplinary programs and exhibits for schools and
    the public. Congress reauthorized IMLS at the end of 2018, with wide
    bipartisan support. OMS grants to museums are highly competitive and
    decided through a rigorous peer-review process. In addition to the
    dollar-for-dollar match generally required of museums, grants often
    spur more giving by private foundations and individual donors.
        There is high demand for funding from OMS. In FY 2020 OMS received
    784 applications requesting nearly $146 million, but current funding
    has allowed the agency to fund only a small fraction of the highly
    rated grant applications it receives. $80 million would allow OMS to
    double its grant capacity for museums, funds that museums will need to
    help recover from the pandemic and continue to serve their communities.
    This substantial funding increase would still be greatly shy of the
    high demand of $146 million in highly rated grant applications. A
    Grants to States program administered by OMS, in addition to the
    agency's current direct grants to museums, would merge federal
    priorities with state-defined needs, expand the reach of museums, and
    increase their ability to serve their communities, address underserved
    populations, and meet the needs of the current and future museum
    workforce.
        Museums are vital to our nation's recovery from this pandemic, and
    after sudden and long-term closures, they will require financial
    assistance to reopen, maintain their staffs, provide educational
    programs to communities, and assist in rebuilding local tourism
    economies. PPP 1 and PPP 2, and Shuttered Venue Operators Grants
    (limited to museums with theatres with fixed seating) have and will
    provide a critical lifeline for many museums. But the museum field will
    need robust ongoing support from IMLS, especially as not all museums
    were eligible for pandemic relief funds. According to a report by
    McKinsey and Company, the arts, entertainment, and recreation sectors
    will not fully recover from this public health crisis and muted economy
    until 2025.
        Recent survey data confirmed that the dire economic harm to museums
    caused by the COVID-19 pandemic will result in a long road to recovery
    for the field. Three-quarters of museums (76 percent) report that their
    operating income fell an average of 40 percent in 2020 while their
    doors were closed to the public for an average of 28 weeks due to the
    pandemic. Museums have largely been unable to offset losses by cutting
    expenditures. Fifteen percent (the equivalent of more than 5,000 US
    museums) confirmed there was a ``significant risk of permanent
    closure'' or they ``didn't know'' if they would survive the next six
    months absent additional financial relief. Nearly half (46 percent) of
    museums surveyed report that their total staff size has decreased by an
    average of 29 percent compared with pre-pandemic levels. Only 44
    percent of all respondents plan to rehire or increase their staff size
    in the coming year. Pre-pandemic museums supported 726,000 jobs. Fifty-
    nine percent of responding museums were forced to cut back on
    education, programming, and other public services due to budget
    shortfalls and/or staff reductions during the pandemic. Thirty-nine
    percent of responding museums require investments in their building,
    HVAC equipment, and other infrastructure to improve energy efficiency
    and reduce the environmental impact of their operations. The average
    anticipated cost of these improvements is $668,000 per museum.
        Despite economic distress, museums have been filling critical gaps
    in our communities. During the pandemic, museum professionals--severely
    impacted by the pandemic themselves-stepped up by serving the needs of
    their communities. They are addressing education gaps and contributing
    to the ongoing education of our country's children by providing free
    lesson plans, online learning opportunities, and drop-off learning kits
    to teachers and families. Museums are using their outdoor spaces to
    grow and donate produce to area food banks and are maintaining these
    spaces for individuals to safely relax, enjoy nature, and recover from
    the mental health impacts of social isolation. They have donated their
    PPE and scientific equipment to fight COVID-19, and provided access to
    child care and meals to families of health care workers and first
    responders. In the midst of financial distress, they are even raising
    funds for community relief and providing reliable information on COVID-
    19 and vaccinations, some even serving as vaccination sites themselves.
    Museums are pivotal to our nation's ability to manage through the
    pandemic and recover from it as our nation opens back up.
        Here are just a few examples of how OMS helps museums better serve
    their communities:
        In 2021, the Suquamish Indian Tribe of the Port Madison Reservation
    in Washington was awarded a $85,400 Native American/Native Hawaiian
    Museum Services grant to update an oral history project conducted from
    1981-83 that has guided the development of the Suquamish Museum for
    over 30 years. The project will engage the 78 Suquamish elders who are
    70 years of age and older to document their biographical, cultural, and
    personal knowledge for use in more contemporary programming and museum
    exhibits. Although the tribe recognized the need to gather oral
    histories during a retreat in 2018, the COVID-19 pandemic not only
    increased the sense of urgency but provided time to consider a plan for
    the project. Collecting oral histories of experiences in the more
    recent past will guide long range planning and help the museum focus
    its collections acquisitions for the next foreseeable decades.
        In 2020, the Seattle Art Museum in Washington was awarded a
    $216,970 Museums for America grant to expand its early learner
    initiative known as Artful Beginnings to create increased opportunities
    for hands-on arts learning and engagement for children ages 2 through
    6, their caregivers, and educators. The focus is on three core Artful
    Beginnings programs: Tiny Tots Workshops and Family Fun Storytime, Art
    Adventures, and an art-based outdoor preschool curriculum with Tiny
    Trees. The museum's three locations--as well as community partner
    facilities in South Seattle and South King County--will host the
    programs. Programming will focus on engaging traditionally underserved
    and lower-income audiences. The project underscores the museum's
    commitment to equity and inclusion and will work to engage all
    audiences more deeply.
        In 2020, Port Townsend Marine Science Society in Washington was
    awarded a $49,613 Program Inspire! Grants for Small Museums grant to
    complete an exhibition master plan as part of a larger facility
    improvement project. The expanded and renovated facility will create an
    accessible, unified, cohesive exhibition experience with strong content
    linkages and seamless indoor-outdoor integration that gives the feeling
    of a journey into the Salish Sea. The process of developing the
    exhibition master plan will involve formative evaluation, including
    site visits, surveys, focus groups, and consultations with
    professionals. Representatives of key stakeholder groups, including
    educators and students, volunteers, marine conservation professionals,
    and other Salish Sea environmental organizations will provide input on
    the plan concept and exhibition content. The center intends to inspire
    responsible stewardship of global oceans through the development of
    immersive, informative content.
        In 2020, the Walt Disney Hometown Museum in Marceline, Missouri,
    was awarded a $38,240 Program Inspire! Grants for Small Museums grant
    to expand its education and professional development programs for rural
    educators. The initiative is the result of a collaborative partnership
    that includes museum staff, K-16 educators, and others from the local
    community. Educators will have the opportunity to participate in an
    immersive learning workshop program where they will experience and
    explore place-based learning opportunities alongside guided
    instructional planning. The initiative will solidify bonds between the
    museum and the community, as educators and museum personnel collaborate
    to strengthen their understanding of how local culture connects to
    learning.
        In 2020, the Missouri Botanical Garden in Saint Louis, Missouri,
    was awarded a $202,220 Museums for America grant to create a Butterfly
    House Entomology Lab to serve as a functional space for staff and
    volunteers to properly care for their invertebrate animal collection
    while providing guests an interactive experience. This exhibition will
    promote learning experiences focused on the butterfly life cycle,
    invertebrate animal conservation, and the field of entomology. The
    project also will include the addition of digital components such as
    monitors that highlight the characteristics of each display species and
    their region of origin. The addition of technology also will allow
    virtual field trips to the Butterfly House Entomology Lab.
        In closing, I highlight recent national public opinion polling that
    shows that 95% of voters would approve of lawmakers who acted to
    support museums and 96% want federal funding for museums to be
    maintained or increased. Museums have a profound positive impact on
    society.
        If I can provide any additional information, I would be delighted
    to do so. Thank you again for the opportunity to submit this testimony.

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

       Prepared Statement of the American Association for Cancer Research
        Chair Murray, Ranking Member Blunt, and members of the subcommittee
    and staff, thank you for the opportunity to submit testimony. I am Dr.
    David Tuveson, Director of the Cold Spring Harbor Laboratory Cancer
    Center and Chief Scientist for the Lustgarten Foundation, the largest
    pancreatic cancer research philanthropic organization. I am submitting
    testimony as President of the American Association for Cancer Research
    (AACR). On behalf of the AACR's 48,000 members, I ask for your support
    for at least $46.1 billion in FY 2022 funding for the National
    Institutes of Health (NIH), and $7.6 billion for the National Cancer
    Institute (NCI).
        We are in an era of unprecedented progress against cancer,
    including advances in immunotherapies and targeted anti-cancer
    therapies that led to spectacular decreases in cancer mortality. Thanks
    to investments at the NCI, we have new tools at our disposal that could
    only be dreamed of decades ago to maximize advances in early diagnosis
    of many types of cancer and offer highly effective treatments that
    improve health outcomes and reduce health disparities. Additionally,
    the funding that NCI provides to the NCI-designated cancer centers that
    are located all throughout the country is supporting pioneering new
    research, serving patients in their communities, and training the next
    generation of cancer scientists.
        There are so many breakthroughs within our grasp, but to achieve
    them, we need federal investments to keep up with demand on basic
    research for cancer.
        Since FY 2015, thanks to your leadership, NIH funding has increased
    by nearly 42%. But due to other funding needs at NIH, including worthy
    initiatives that take away from the top line, and a nearly 50% increase
    in applications at NCI since 2013, the funding increases have not kept
    up with demand.
        Even with the significant funding you have provided, the percent of
    NCI grant applications that are funded, referred to as the success
    rate, is among the lowest of all institutes at NIH. In FY 2020, the
    NIH-wide success rate for competing research project grants, or RPGs,
    was nearly 21%. For NCI, it was only 12.8%, and that's the highest
    NCI's success rate has been in six years.
        NCI has been stretching dollars to fund more grants. NCI Director,
    Dr. Sharpless, released his 15-by-25 milestone, an effort to increase
    the number of R01 grants funded until it reaches the 15th percentile in
    2025. The AACR strongly supports this important mission, but to achieve
    the goal of funding more meritorious research, more funding will be
    needed.
        While the success rate of an RPG at NHLBI is 22.2%, and NIDDK is
    23%, NIAID is 23.9%, and the National Institute on Aging is 25.8%,
    NCI's rate of 12.8% is not sustainable to meet our pledge to apply new
    cancer science and medicine towards improving patient outcomes. With
    the low success rate, I worry the best and the brightest, in particular
    early-stage researchers, will choose other career paths. The United
    States cannot lead the world in cancer discoveries if the NCI success
    rate is so low that researchers choose another field.
        Thanks to your leadership, language was included in the last two
    explanatory statements to prioritize competing grants and sustain
    commitments to continuing grants. I humbly ask you to continue these
    efforts in FY 2022 and provide funding to meet Dr. Sharpless' goal so
    the cancer research community can accelerate the path to discoveries
    and save lives.
        I know cancer is personal for you, as it is for me. Thank you for
    this opportunity and for your commitment to bringing us closer to our
    mutual goal of conquering cancer.

        [This statement was submitted by David A. Tuveson, MD, PhD, FAACR,
    President, American Association for Cancer Research.]
                                     ______

     Prepared Statement of the American Association for Clinical Chemistry
        The American Association for Clinical Chemistry (AACC) welcomes the
    opportunity to provide testimony to the Senate Appropriations
    Subcommittee on Labor, Health & Human Services, and Education regarding
    our nation's fiscal year (FY) 2022 budget priorities. AACC and its
    partners are urging the subcommittee to support two initiatives vital
    to improving the quality and efficacy of healthcare in the United
    States:
      --Improving Pediatric Reference Intervals--$10 million for the
            Centers for Disease Control and Prevention, Division of
            Laboratory Services, Environmental Health Laboratory to improve
            the quality of pediatric reference intervals used by health
            practitioners to diagnose, monitor, and treat children.
      --Harmonizing Clinical Laboratory Test Results--an additional $7.2
            million ($9.2 million in total) for the Centers for Disease
            Control and Prevention, Division of Laboratory Services,
            Environmental Health Laboratory to continue its ongoing efforts
            to harmonize the reporting of clinical laboratory test results,
            which is the vital to providing better, more consistent
            healthcare in the United States.
                    improving pediatric reference intervals
        AACC, the American Academy of Pediatrics, the Children's Hospitals
    Association, and 30 other organizations have written to the
    subcommittee urging additional funding for the Centers for Disease
    Control and Prevention (CDC) to improve the quality of pediatric
    reference intervals (PRIs)--the range of numeric values expected in a
    healthy child--available to health practitioners to care for their
    young patients.
        When making a diagnosis, the healthcare professional considers a
    laboratory test value within the context of a reference interval. If
    the test result falls outside of the defined reference interval for a
    healthy child--either higher or lower--the practitioner may order a
    medical intervention to address a health condition or change an ongoing
    treatment protocol. If the diagnosis or treatment change is incorrect
    for any reason, including an inaccurate reference interval, it could
    result in patient harm. Therefore, it is critical that the range of
    values used by practitioners to interpret test results are accurate.
        Whereas the reference intervals for adults are generally reliable,
    there is considerable inconsistency and large gaps in the ranges
    available for children. Healthcare practitioners need reference
    intervals reflective of healthy children at each unique stage of
    physical development from birth through adolescence to adulthood. In
    addition, the intervals must also take into consideration any
    variations due to biological factors, such as ethnicity and gender.
        Accurate and actionable PRIs are particularly important for our
    youngest patients, who are often unable to verbally communicate their
    symptoms. Unfortunately, most laboratories are unable to obtain enough
    samples from a diverse, healthy population of children to develop their
    own reference intervals.
        Congress recognized the importance of this issue when in the
    accompanying report language to the Further Consolidated Appropriations
    Act of 2020 it requested CDC to develop and submit a plan for improving
    PRIs. The agency outlined its plan in the Department of Health and
    Human Services fiscal year 2021 congressional justification to
    Congress. The plan calls for the CDC to employ its existing
    infrastructure to initiate and advance this vital work. According to
    CDC, it can:
      --collect clinical samples through its National Health and Nutrition
            Examination Survey (NHANES), which has the organization and
            expertise to collect specimens from healthy children; and
      --utilize its Environmental Health Laboratory (EHL) to generate the
            reference intervals for children and disseminate the
            information to clinical laboratories. EHL has developed
            reference intervals in the past.
        AACC and its partners support providing CDC with an additional $10
    million to improve the quality of PRIs critical to caring for our
    nation's children.
                  harmonizing clinical laboratory test results
        Another issue that AACC and its allies request your assistance with
    is the harmonization of clinical laboratory test results. Laboratory
    test methods provide accurate test results, but different methods
    generate different numeric values. With different methods in use across
    the healthcare system, lack of harmonization makes it difficult to
    develop widely applicable clinical guidelines or performance measures.
    It also complicates data aggregation, which limits the development of
    tools to better inform health decision-making.
        Tests that are harmonized (or standardized) provide the same
    numeric value for a condition regardless of the method or instrument
    used or the setting where the tests are performed. An early example of
    harmonization is cholesterol, which is widely utilized by the medical
    community to diagnose heart disease. A 2011 study published in
    Preventing Chronic Disease reports that early drug intervention based
    on cholesterol levels saved the health system $338 million to $7.6
    billion annually between 1980--2000.\1\ Harmonization can improve
    patient care while also saving money.
    ---------------------------------------------------------------------------
        \1\ Hoerger TJ, Wittenborn JS, Young W. A cost-benefit analysis of
    lipid standardization in the United States. Preventing Chronic Disease
    2011; 8: A136.
    ---------------------------------------------------------------------------
        In recent years, Congress has supported the expansion of CDC's
    harmonization efforts, resulting in new activities to improve the
    detection and management of hormone disorders, kidney disease, cancer,
    and heart disease. With additional funding, the agency will be able to
    expand its harmonization activities to develop materials for non-
    traditional biomarkers, such as apolipoproteins, and the assessment of
    point of care testing devices that are increasingly being used by
    healthcare providers and patients.
        AACC and its partners respectfully request that the subcommittee
    provide an additional $7.2 million ($9.2 million in total) for the CDC
    to continue and advance its harmonization activities. Congress has
    provided $2 million annually for this program since FY18.
        AACC is a global scientific and medical professional organization
    dedicated to clinical laboratory science and its application to
    healthcare. We look forward to working with the subcommittee on these
    most important issues as it goes through the FY22 budget process. If
    you have any questions, please email Vince Stine, PhD, AACC's Senior
    Director of Government and Global Affairs, at vstine@aacc.org.

        [This statement was submitted by David Grenache, PhD, D(ABCC),
    President, American Association for Clinical Chemistry.]
                                     ______

       Prepared Statement of the American Association for Dental Research
        On behalf of the American Association for Dental Research (AADR), I
    am pleased to submit testimony describing AADR's funding requests for
    fiscal year (FY) 2022. I currently serve as the chair of the Board of
    Directors and president of the Association. I am a professor in the
    Department of Diagnostic and Biological Sciences at the University of
    Minnesota School of Dentistry, where I also serve as the director
    emeritus of the Minnesota Craniofacial Research Training Program
    (MinnCResT).
        For FY 2022, the American Association for Dental Research--along
    with our colleagues in the oral health community--is seeking at least
    $520 million for the National Institute of Dental and Craniofacial
    Research (NIDCR) and at least $46.111 billion for all of the Institutes
    and Centers at the National Institutes of Health (NIH). Funding at
    these recommended levels will allow for the entities' base budgets to
    keep pace with the biomedical research and development price index
    (BRDPI) and provide meaningful growth of 5%.
        As our nation continues to respond to the global COVID-19 pandemic,
    we are reminded of the importance of the federal investment in science,
    and in particular, biomedical research. AADR is grateful to Congress
    for consistently prioritizing this research at NIH by providing steady
    and meaningful funding increases, which will be more important than
    ever to carry forward in the wake of the pandemic. While we recognize
    there will be funding challenges in FY 2022 given the tremendous
    resources allocated to COVID-19 relief, we cannot afford to underfund
    our nation's research agencies now. Underfunding will leave us ill-
    equipped to complete our exit from the current pandemic, deal with
    future pandemics, and risk losing the progress that has been made by
    congressional investment in biomedical research.
        The requested 5% growth above BRDPI would provide critical support
    for these research agencies, which have been among the many enterprises
    negatively impacted by this public health crisis. The ongoing pandemic
    caused closures of university campuses and forced laboratories to scale
    back or halt research projects. It also required research agencies to
    shift existing resources and funding to coronavirus-related research at
    the expense of other important scientific inquiries about health and
    disease.
        NIDCR--the largest institution dedicated exclusively to research to
    improve dental, oral and craniofacial (skull and face) health--is one
    the NIH Institutes and Centers that has prioritized COVID-19 research.
    To date, NIDCR has funded approximately $3.9 million of immediate and
    high impact research to protect and ensure the safety of personnel and
    patients in dental practices during the COVID-19 pandemic. The
    Institute will soon release a second round of funding related to COVID-
    19.\1\ Funding for NIDCR COVID-19 research is critical to the nation's
    public health, supporting work that includes the use of personal
    protective equipment (PPE) in dental settings, aerosol and droplet
    transmission in dental settings, the infection of salivary glands and
    oral tissues by SARS-CoV-,\2\ and the use of biosensors to detect SARS-
    CoV-2 in saliva.
        This important research agenda with broad public health impact
    notwithstanding, NIDCR was not included among the NIH Institutes and
    Centers to receive targeted supplemental funding in COVID-19 relief
    legislation--nor has the annual investment in NIDCR kept pace with the
    overall funding increases provided to NIH over the past several years.
    Funding of at least $520 million in FY 2022 would help bring NIDCR
    funding into alignment with the overall NIH request and allow NIDCR to
    build on its myriad successes in its mission to improve dental, oral
    and craniofacial health.
        Oral health--too often considered in isolation--is integral to
    overall health. The research being conducted at, and supported by,
    NIDCR impacts the lives of millions of Americans. Oral health can
    affect activities that may be taken for granted: the ability to eat,
    drink, swallow, smile, speak, and maintain proper nutrition. The oral
    cavity also serves as a window into potential health issues, including
    but not limited to systemic diseases, such as diabetes, HIV/AIDS and
    Sjogren's, an autoimmune disease that causes one's immune system to
    attack parts of its own body.
        Coronavirus research shows that the virus can infect more than the
    upper airways and lungs, but also cells in other parts of the body. In
    fact, recent NIDCR-supported research has also shown that the novel
    coronavirus can infect cells in the mouth. As the study's authors
    explain.\2\ :
        ``The potential of the virus to infect multiple areas of the body
    might help explain the wide-ranging symptoms experienced by COVID-19
    patients, including oral symptoms such as taste loss, dry mouth and
    blistering. Moreover, the findings point to the possibility that the
    mouth plays a role in transmitting SARS-CoV-2 to the lungs or digestive
    system via saliva laden with virus from infected oral cells.''
        According to NIDCR's press release on the study, this research is
    contributing to our understanding of COVID-19, including oral
    transmission, and could inform interventions to help combat the virus
    and alleviate the associated oral symptoms. Indeed, this seminal
    research may have important implications to explain why super-spreader
    events occur in places where people sing, speak loudly, or party.
        Dental, oral and craniofacial research presents vast research
    opportunities, and we know NIDCR will continue to be the key player in
    advancing our understanding of the role of the mouth and oral tissues
    in many scientific frontiers going forward. One path to highlighting
    the Institute's work and the future of this research in the United
    States is through the U.S. Surgeon General's Report on Oral Health, a
    critical update to the seminal ``Oral Health in America'' report from
    July 2000. The report--originally set to be released in the fall of
    2020--will document the progress in the improvement of oral health
    since 2000, provide insight into issues currently affecting oral
    health, and identify opportunities and challenges that have emerged
    over the past 20 years. The 2000 report shifted perspectives among the
    public and policymakers by showing that oral health goes beyond healthy
    teeth and gums and that it is essential to our general health and well-
    being. We believe the 2020 report will also have a significant impact,
    and we have encouraged the administration to swiftly review and release
    the report. The long-awaited report is a critical public health
    document and is essential to moving our nation's health forward.
        In addition to the important work of NIDCR, AADR recognizes that
    federal research and public health efforts work in concert and that
    success in one area can benefit another. Therefore, we encourage
    Congress--in addition to supporting NIH and NIDCR in FY 2022, to
    support the full breadth of federal agencies supporting oral health.
    Complementing our NIDCR and NIH requests, we urge you to provide $30
    million for the CDC's Division of Oral Health, $46 million for the
    Title VII Health Resources and Services Administration (HRSA) programs
    that train the dental health workforce, at least $500 million for the
    Agency for Healthcare Research and Quality (AHRQ), and at least $200
    million for the National Center for Health Statistics (NCHS).
        The COVID-19 crisis shook our nation and reminded us of the
    critical role biomedical and public health research play in our
    society. Over the course of 2020 and 2021, we saw how the research
    enterprise can safeguard public health, national security and economic
    growth. We urge Congress to continue to prioritize biomedical research,
    including dental, oral and craniofacial research in FY 2022 so our
    nation's citizens can continue to enjoy the benefits of state-of-the-
    art, world-leading health care.
        We appreciate the opportunity to submit this testimony and thank
    the Subcommittee for considering our request of at least $520 million
    in funding for NICDR and at least $46.111 billion for the Institutes
    and Centers at NIH. AADR stands ready to assist the Congress in any way
    we can and to answer any questions you may have.
    ---------------------------------------------------------------------------
        \1\ National Advisory Dental and Craniofacial Research Council--
    January 2021. National Institutes of Health, 2021. https://
    videocast.nih.gov/watch=38984.
        \2\ Scientists Find Evidence that Novel Coronavirus Infects the
    Mouth's Cells. Press Release, NIDCR. https://www.nidcr.nih.gov/news-
    events/nidcr-news/2021/scientists-find-evidence-novel-coronavirus-
    infects-mouths-cells; Huang, N., Perez, P., Kato, T. et al. SARS-CoV-2
    infection of the oral cavity and saliva. Nat Med 27, 892-903 (2021).
    https://doi.org/10.1038/s41591-021-01296-8.

        [This statement was submitted by Mark C. Herzberg, D.D.S., Ph.D.,
    President, American Association for Dental Research.]
                                     ______

     Prepared Statement of the American Association of Colleges of Nursing
             strengthening the current and future nursing workforce
        On behalf of the American Association of Colleges of Nursing
    (AACN), we want to thank the Subcommittee for its leadership and
    continued support of nursing education, the nursing profession, and
    nursing research, especially during this unprecedented time. As the
    national voice for academic nursing, AACN represents nearly 840 schools
    of nursing at private and public universities, who educate more than
    580,000 students and employ more than 52,000 faculty.\1\ Collectively,
    these institutions play a critical role in protecting the health of our
    nation by graduating registered nurses (RN), advanced practice
    registered nurses (APRN), educators, researchers, and other frontline
    providers. As we work to combat current public health challenges, such
    as COVID-19, and prepare for the future, ensuring a robust supply of
    nursing professionals requires a strong and sustained federal
    investment. For Fiscal Year (FY) 2022, AACN respectfully requests that
    you provide bold support of at least $530 million for the Nursing
    Workforce Development Programs (Title VIII of the Public Health Service
    Act [42 U.S.C. 296 et seq.] administered by HRSA and at least $199.755
    million for the National Institute of Nursing Research (NINR), which
    was included in the President's FY 2022 Budget.
    ---------------------------------------------------------------------------
        \1\ American Association of Colleges of Nursing. (2021) Who We Are.
    Retrieved from: https://www.aacnnursing.org/About-AACN/Who-We-Are.
    ---------------------------------------------------------------------------
                      the growing nursing workforce demand
        Nurses comprise the largest sector of the healthcare workforce with
    more than four million RNs and APRNs, which include Nurse Practitioners
    (NPs), Certified Registered Nurse Anesthetists (CRNAs), Certified
    Nurse-Midwives (CNMs), and Clinical Nurse Specialists (CNSs).\2\ Nurse
    educators, students, and practitioners are leaders within their
    institutions and communities; many of whom are also serving on the
    frontlines of the COVID-19 public health emergency. Even prior to
    COVID-19, our nation was in need of additional nurses. This demand is
    only expected to grow as we continue to combat the pandemic and address
    the healthcare needs of all patients, including those in rural and
    underserved areas. In fact, the Bureau of Labor Statistics' outlook for
    RN workforce demand projected an increase of 7% by 2029, representing
    the need for an additional 221,900 jobs.\3\ Additionally, the need for
    most APRNs is expected to grow by 45%.\4\ This increasing demand in the
    nursing workforce can be attributed to several factors such as an aging
    population, nursing retirements, and an increase in workplace
    stress.\5\ Bold investments in Title VIII Nursing Workforce Development
    Programs and NINR would help prepare a highly educated nursing
    workforce and strengthen the foundation of nursing science, not only as
    we confront existing health challenges, but as we provide tomorrow's
    equitable and innovative healthcare solutions.
    ---------------------------------------------------------------------------
        \2\ National Council of State Boards of Nursing. (2021). Active RN
    Licenses: A profile of nursing licensure in the U.S. as of April 23,
    2021. Retrieved from: https://www.ncsbn.org/6161.htm.
        \3\ U.S. Bureau of Labor Statistics. (2021). Occupational Outlook
    Handbook-Registered Nurses. Retrieved from: https://www.bls.gov/ooh/
    healthcare/registered-nurses.htm.
        \4\ U.S. Bureau of Labor Statistics. (2021). Occupational Outlook
    Handbook-Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners.
    Retrieved from: https://www.bls.gov/ooh/healthcare/nurse-anesthetists-
    nurse-midwives-and-nurse-practitioners.htm.
        \5\ American Association of Colleges of Nursing. (2020) Fact Sheet:
    Nursing Shortage. Retrieved from: https://www.aacnnursing.org/Portals/
    42/News/Factsheets/Nursing-Shortage-Factsheet.pdf.
    ---------------------------------------------------------------------------
    nursing workforce investments: sustaining education to secure a strong
                               nursing workforce
        Our ongoing efforts to combat COVID-19 have made it abundantly
    clear that a well-educated nursing workforce is essential. For over
    fifty years, Title VIII Nursing Workforce Development Programs have
    been a catalyst for strengthening nursing education at all levels, from
    entry-level preparation through graduate study. Through grants,
    scholarships, and loan repayment programs, Title VIII federal
    investments positively impact the profession's ability to serve
    America's patients in all areas, bolster diversity within the
    workforce, and increase the number of nurses, including those at the
    forefront of public health emergencies and caring for our aging
    population.
        Each Title VIII Nursing Workforce Development Program provides a
    unique and crucial mission to support nursing education and the
    profession. For example, the Advanced Nursing Education (ANE) programs
    help increase the number of APRNs in the primary care workforce and
    supported more than 8,200 students in Academic Year 2019-2020 alone.\6\
    In addition, the Nurse Faculty Loan Program (NFLP) awarded 45 grants to
    schools that supported 2,270 graduate nursing students in Academic Year
    2019-2020.\7\ According to AACN's Annual Survey, student enrollment in
    entry-level baccalaureate nursing programs increased by 5.6% in
    2020.\8\ While this heightened interest in nursing education is
    promising news, we need to ensure these students have ample nursing
    faculty to guide them through their clinical and didactic education and
    prepare them to respond to our nation's ever-changing healthcare
    environment.
    ---------------------------------------------------------------------------
        \6\ Department of Health and Human Services Fiscal Year 2022 Health
    Resources and Services Administration Justification of Estimates for
    Appropriations Committees. Pages 153-155. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2022.pdf.
        \7\ Department of Health and Human Services Fiscal Year 2022 Health
    Resources and Services Administration Justification of Estimates for
    Appropriations Committees. Page 167. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2022.pdf.
        \8\ American Association of Colleges of Nursing. (2021). Student
    Enrollment Surged in U.S. Schools of Nursing in 2020 Despite Challenges
    Presented by the Pandemic. Retrieved from https://www.aacnnursing.org/
    News-Information/Press-Releases/View/ArticleId/24802/2020-survey-data-
    student-enrollment%20%20%20%20%20.
    ---------------------------------------------------------------------------
        As we address social determinants of health and work to build an
    equitable healthcare system for all patients, it is imperative that we
    recruit individuals from diverse backgrounds to the nursing profession.
    Increasing diversity in the profession will not only create lifelong
    career pathways, but will also improve care quality and access to
    population-centered care. The Nursing Workforce Diversity (NWD) program
    serves as a glowing example of a successful Title VIII initiative that
    accomplishes this goal. In fact, in Academic Year 2019-2020, the NWD
    program awarded grants supporting 11,620 nursing students from
    disadvantaged backgrounds.\9\ The recruitment of underrepresented
    racial and ethnic individuals and those from economically diverse
    backgrounds to nursing positively impacts the classroom, professional
    practice environments, and ultimately patients.
    ---------------------------------------------------------------------------
        \9\ Department of Health and Human Services Fiscal Year 2022 Health
    Resources and Services Administration Justification of Estimates for
    Appropriations Committees. Page 159. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2022.pdf.
    ---------------------------------------------------------------------------
        As such, to ensure the stability of our nursing workforce now and
    in the future, we request at least $530 million for Title VIII Nursing
    Workforce Programs.
      from research to reality: nursing science protects americans' health
        AACN recognizes how scientific research and discovery is the
    foundation on which nursing practice is built and is essential to
    advancing evidence-based interventions, informing policy, and
    sustaining the health of the nation. As one of the 27 Institutes and
    Centers at NIH, NINR plays a fundamental role in improving care and is
    on the cutting edge of new innovations impacting how nurses are
    educated and how they practice. In fact, 80% of research-focused
    educational training grants at nursing schools are funded by NINR.\10\
    Through these grants and others, nurse scientists, often working
    collaboratively with other health professionals, are generating and
    translating impactful new research in areas such as big data and data
    science, precision health, and genomics.\11\ Despite the critical
    research these grants support, NINR was only able to fund 8.9% of grant
    applications in 2017, due to insufficient funding.\12\ This is the
    lowest research project grant (RPG) success rate among all NIH
    institutes and centers, and is significantly lower than the overall NIH
    RPG success rate of 18.7%.\13\ To further this vital work, we are
    requesting a total of at least $199.755 million for the National
    Institute of Nursing Research.
    ---------------------------------------------------------------------------
        \10\ Schnall, R. (2020) National Institute of Health (NIH) funding
    patterns in Schools of Nursing: Who is funding nursing science research
    and who is conducting research at Schools of Nursing? Journal of
    Professional Nursing, 36(1), 34-41. Retrieved from https://
    www.sciencedirect.com/science/article/pii/S8755722319301164?via=ihub#.
        \11\ National Institutes of Health, National Institute of Nursing
    Research. The NINR Strategic Plan: Advancing Science, Improving Lives.
    Retrieved from: https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/
    NINR_StratPlan2016_reduced.pdf.
        \12\ Federal Funding of Nursing Research by the National Institutes
    of Health (NIH): 1993-2017 Kiely, Daniel P. et al. (2019) Page 9.
    Retrieved from: https://www.nursingoutlook.org/article/S0029-
    6554(19)30315-X/addons.
        \13\ Ibid.
    ---------------------------------------------------------------------------
        From the classroom to the frontlines, nurses and nursing students
    are integral members of the healthcare team. Strong investments in
    Title VIII Nursing Workforce Development Programs and NINR have a
    direct impact on sustaining pathways into nursing and patient access to
    high-quality, evidence-based care in all communities across the nation.
    During these unprecedented times, AACN respectfully requests bold
    support in FY 2022 of at least $530 million for the Title VIII Nursing
    Workforce Development Programs and at least $199.755 million for the
    National Institute of Nursing Research. Together, we can ensure that
    such investments promote innovation and improve health and healthcare
    in America.

        [This statement was submitted by Susan Bakewell-Sachs, PhD, RN,
    FAAN, Board Chair, American Association of Colleges of Nursing.]
                                     ______

         Prepared Statement of the American Association of Colleges of
                              Osteopathic Medicine
        The American Association of Colleges of Osteopathic Medicine
    (AACOM) strongly supports fiscal year (FY) 2022 funding for the
    following programs important to the osteopathic medical education (OME)
    community:
      --$46.1 billion for the National Institutes of Health (NIH)
      --$6.1 billion for the Teaching Health Centers Graduate Medical
            Education (THCGME) Program
      --$9.2 billion for discretionary Health Resources and Services
            Administration (HRSA)
      --$980 million for the Title VII health professions workforce
            development programs under the Public Health Service Act
      --Permanent funding for the Rural Residency Planning and Development
            (RRPD) Program
      --$130 million for discretionary National Health Service Corps (NHSC)
            Scholarship and Loan Repayment programs
      --$67 million for the Area Health Education Center (AHEC) Program
      --$125 million for the Primary Care Training and Enhancement (PCTE)
            Program
      --$500 million for the Agency for Healthcare Research and Quality
            (AHRQ)
      --$10 billion for the Centers for Disease Control and Prevention
            (CDC)
        AACOM leads and advocates for the full continuum of OME to improve
    the health of the public. Founded in 1898 to support and assist the
    nation's osteopathic medical schools, AACOM represents all 37
    accredited colleges of osteopathic medicine--educating nearly 31,000
    future physicians, 25 percent of all U.S. medical students--at 58
    teaching locations in 33 U.S. states, as well as osteopathic graduate
    medical education professionals and trainees at U.S. medical centers,
    hospitals, clinics, and health systems.
        Osteopathic medicine plays an essential role in our nation's
    healthcare delivery system and is a growing field. According to recent
    data, AACOM received more than 28,000 applicants to osteopathic medical
    school for the 2020-2021 application cycle, representing a 19.26
    percent increase over the previous year. Osteopathic physicians focus
    on treating the whole person, and over half practice in the primary
    care specialties of family medicine, internal medicine, and pediatrics.
    Importantly, osteopathic medical students receive 200 hours of
    additional training in osteopathic manipulative treatment, a hands-on
    treatment used to diagnose and treat illness and injury, giving us a
    unique voice and perspective in the medical community. However, the
    clinician workforce and scientists at osteopathic medical schools are
    underutilized in NIH funding opportunities and underrepresented on NIH
    Advisory Councils and standing study sections.
        AACOM urges Congress to overcome the historic bias against
    osteopathic medical research by expanding representation on NIH
    Councils and study sections and increasing NIH funding. Expanding
    engagement by osteopathic medical schools and professionals will result
    in innovative healthcare delivery solutions, expanded evidence-based
    research, and broader community-focused treatment models. OME
    investment will advance research in primary care, prevention, and
    treatment and employ an already diverse physician population that is
    enriched in socioeconomically disadvantaged rural communities. AACOM's
    request of $46.1 billion for NIH will support scientific advancements
    that incorporate the osteopathic philosophy and strengthen the United
    States position as the world's research and development leader.
        OME has a proven history of establishing educational programs for
    medical students and residents that target the healthcare needs of
    rural and underserved populations. With health disparities on the rise,
    and worsening because of the COVID-19 pandemic, we are proud to help
    make healthcare access more equitable for all our country's patients
    and communities. In fact, recent AACOM data show that 40 percent of
    graduating 2019-2020 osteopathic medical students plan to practice in a
    medically underserved or health shortage area; of those, 45 percent
    plan to practice in a rural community.
        AACOM expresses its strong support for $6.1 billion for the THCGME
    Program and our desire for permanent, mandatory funding for this
    critical program. According to HRSA, physicians who train in Teaching
    Health Centers (THCs) are three times more likely to work in such
    centers and more than twice as likely to work in underserved areas. The
    continuation of this program is critical to addressing primary care
    physician workforce shortages and delivering health care services to
    underserved communities. AACOM is pleased that Congress supported this
    highly successful bipartisan program through the Consolidated
    Appropriations Act, 2021 and American Rescue Plan Act of 2021, which
    extended the THCGME Program through fiscal year 2023 and provided
    additional funding. However, new funding is needed to extend the THCGME
    Program to meet economic challenges caused by the COVID-19 pandemic and
    support additional expansion to underserved areas that face existing
    shortages of primary care physicians.
        AACOM appreciates the opportunity to submit its views and looks
    forward to continuing to work with the Subcommittee on these important
    matters.

        [This statement was submitted by Robert A. Cain, DO, FACOI, FAODME,

    President and Chief Executive Officer, American Association of Colleges
    of
    Osteopathic Medicine.]
                                     ______

        Prepared Statement of the American Association of Immunologists
        The American Association of Immunologists (AAI), the nation's
    largest professional association of research scientists and physicians
    who are dedicated to understanding the immune system through basic,
    translational, and clinical research, respectfully submits this
    testimony regarding fiscal year (FY) 2022 appropriations for the
    National Institutes of Health (NIH). AAI recommends an appropriation of
    $52 billion for NIH for FY 2022, including at least $46.1 billion for
    the regular NIH budget, to enable the agency to fund needed research to
    prevent dangerous infectious diseases and treat debilitating chronic
    illnesses, support meritorious scientists at all career stages, and
    ensure a robust research enterprise that maintains U.S. preeminence in
    biomedical science and innovation. Because the COVID-19 pandemic has
    posed difficult challenges, including lab closures and other
    interruptions, to many biomedical (particularly early career)
    scientists, NIH needs, and AAI strongly supports, an infusion of
    additional funding that would likely be considered outside of the
    annual appropriations process.
        AAI also supports the appropriation of substantial funding to
    launch the newly proposed Advanced Research Projects Agency for Health
    (ARPA-H). While AAI is enthusiastic about ARPA-H's potential, we
    believe that any funding provided must supplement, and not supplant,
    the NIH regular budget, and that this new agency must enhance, and not
    interfere with, NIH's historic commitment to funding basic research.
    AAI also urges that NIH solicit stakeholder input to help answer many
    outstanding questions, including whether existing programs--and which
    research areas--will be integrated into ARPA-H. Finally, AAI believes
    that funding for ARPA-H projects should be provided for longer than
    three years to ensure sufficient time for the kind of innovative,
    collaborative, and transformative research that is contemplated.
     illustrating the importance of understanding the immune system: covid-
                                       19
        The COVID-19 pandemic has highlighted both the importance, and high
    stakes, of biomedical research. Our lives, health, security, and
    prosperity depend on scientific understanding and advances. What felt
    remote to many people--scientists toiling away unseen in their
    laboratories--has become urgent, everyday news. The surge of interest
    in immunology--and scientists' ability to meet this historic moment--
    have been bright spots in an otherwise tragic, painful, and
    unprecedented year, and rapidly developed vaccines to prevent COVID-19
    infection have been a historic success story.
        But SARS-CoV-2, the virus that causes COVID-19, continues to
    mutate, giving rise to new variants. We know that this is what viruses
    do, and we know that this is what our immune systems must be primed to
    fight. Despite excellent news on the vaccine front, the regular
    appearance of new variants, our paucity of therapeutics for those who
    contract COVID-19, and our lack of understanding of, and treatments
    for, Post-Acute Sequelae of SARS-CoV-2 infection (PASC, or ``long
    COVID'') all render as premature any declaration of victory. We must
    continue to invest robustly not only in a deeper understanding of how
    the immune system responds to this virus and these vaccines, but also
    in research devoted to the basic understanding of the immune system.
    Such research will help us both emerge from this pandemic and prevent--
    and more rapidly extinguish--any future ones.
        But the study of immunology is about much more than infectious
    diseases. Research on the immune system has taught us how to harness it
    to kill malignant tumors and treat other chronic diseases
    (immunotherapy); how it prevents or exacerbates chronic conditions such
    as Alzheimer's, multiple sclerosis, and cardio-vascular disease; how it
    enables--or prevents--the successful transplantation of a lifesaving
    organ; and how it can protect its host from (natural or man-made)
    agents of bioterrorism.
      how basic immunology research led to rapid approval of vaccines and
                            treatments for covid-19
        In this pandemic era, there is no better way to illustrate the
    importance of a long-term commitment to biomedical research, and
    specifically to immunological research, than to describe how science
    achieved the near-impossible: the successful testing, manufacture, and
    distribution of multiple, highly effective, and safe vaccines against
    COVID-19 in less than a year after the identification of the causative
    agent. The development of both treatments and vaccines for SARS-CoV-2
    infection and COVID-19 was a result of decades of basic research, much
    of which was funded by, or performed at, NIH. This work includes
    understanding the virus, identifying good antigens for a vaccine, and
    defining immune system responses to infection.
        SARS-CoV-2 is a member of the beta-coronavirus family responsible
    for two other recent outbreaks, SARS-CoV-1 (2003) and MERS (2012) and
    is related to the coronaviruses that cause 15-30% of common colds. More
    than 50 years of research on this virus family has allowed us to
    understand key portions of the viral genome and viral life cycle, as
    well as the importance of the spike protein for infection. While work
    at NIH's National Institute of Allergy and Infectious Diseases' Vaccine
    Research Center identified how to manipulate the spike protein so it
    could be used in a vaccine, work on other infectious diseases and some
    cancers facilitated the implementation of the mRNA platform into a
    ready-to-use state. After developing mRNA vaccines for 10-15 years,
    scientists launched some of the first clinical trials using the mRNA
    platform against Zika virus and influenza. As a result, the platform
    was ready to be quickly adapted to target the SARS-CoV-2 spike protein.
        In other work, scientists rapidly characterized immune responses in
    people who experienced SARS-CoV-2 infection. Patients with poor
    outcomes had over exuberant immune responses; blocking these responses
    with steroids improved survival. Immunologists also identified several
    immune molecules that are at too high levels (e.g., IL-6) or too low
    levels (e.g., interferon). Work is ongoing to understand what
    protective immunity looks like, including the types of antibodies and
    cellular immunity that prevent reinfection and characterize immunity
    after vaccination. These studies will support the generation of booster
    vaccines and give us insight into how well current vaccines protect
    against new viral variants.
        Finally, because of this longstanding research into coronaviruses,
    scientists can reasonably infer how long protective immunity will last
    following infection with, or vaccination against, SARS-CoV-2, giving
    the public confidence to resume their daily activities while providing
    the scientific community with a needed window in which to develop
    booster vaccines that will protect against circulating viral variants.
     vaccines against other infectious diseases and newly emerging threats
        Vaccines remain the most effective method of disease prevention.
    Vaccination against more than two dozen viral, bacterial, and fungal
    diseases prevents about 2.5 million deaths globally and reduces the
    severity of illness for millions of people annually.\1\ As the world's
    population grows and as travel enables people to become even more
    interconnected, we will continue to experience the very real threat of
    new emerging pathogens causing a deadly pandemic. Lessons we learn from
    developing and administering vaccines against SARS-CoV-2 will be
    essential to protecting against other infectious diseases and a future
    pandemic.
    ---------------------------------------------------------------------------
        \1\ https://www.who.int/immunization/global_vaccine_action_plan/
    GVAP_doc_2011_2020/en/.
    ---------------------------------------------------------------------------
        Last year, I testified that there was no approved vaccine against
    SARS-CoV-2, but that NIH-funded research conducted on other causative
    pathogens in recent epidemics, including SARS and MERS, had made
    possible the rapid development of vaccine candidates against SARS-CoV-
    2.\2\ Since then, three vaccine candidates have received an Emergency
    Use Authorization (EUA) from the Food and Drug Administration (FDA),
    and two will be considered soon for licensure.\3\ AAI is confident that
    previously conducted research, together with new research now being
    urgently pursued, will result in additional vaccines and treatments to
    prevent and/or reduce both the lethality of, and long-term symptoms
    caused by, COVID-19.
    ---------------------------------------------------------------------------
        \2\ https://www.niaid.nih.gov/diseases-conditions/coronaviruses.
        \3\ https://www.fda.gov/emergency-preparedness-and-response/
    coronavirus-disease-2019-covid-19/covid-19-vaccines; https://
    www.pfizer.com/news/press-release/press-release-detail/pfizer-and-
    biontech-initiate-rolling-submission-biologics; https://
    investors.modernatx.com/news-releases/news-release-details/moderna-
    announces-initiation-rolling-submission-biologics.
    ---------------------------------------------------------------------------
      nih: the essential role of the nation's leading biomedical research
                                     agency
        As the nation's major funding agency for biomedical research, NIH
    is an indispensable scientific leader both in the U.S. and around the
    world. The steward of nearly $43 billion in federal funds, NIH
    distributes more than 80% of its budget via a competitive peer review
    process to more than 300,000 researchers at 2,500 universities,
    medical schools, and other research institutions across the nation and
    internationally.\4\ About 10% of its budget supports 6,000 additional
    researchers and clinicians who work at NIH facilities around the
    country.\5\ By funding these researchers and laboratories, NIH not only
    advances scientific achievement, it also helps strengthen state and
    local economies; in 2020, NIH funding supported more than 536,000 jobs
    and accounted for $91 billion in economic activity across the U.S.\6\
    The basic research that NIH funds is an essential and irreplaceable
    part of the biomedical research pipeline; data show that it contributed
    to all 210 of the new drugs approved by the FDA from 2010-2016.\7\
    ---------------------------------------------------------------------------
        \4\ https://www.nih.gov/about-nih/what-we-do/budget; https://
    report.nih.gov/award/index.cfm.
        \5\ https://irp.nih.gov/about-us/research-campus-locations.
        \6\ https://www.unitedformedicalresearch.org/wp-content/uploads/
    2021/03/NIHs-Role-in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
        \7\ https://directorsblog.nih.gov/2018/02/27/basic-research-
    building-a-firm-foundation-for-biomedicine/.
    ---------------------------------------------------------------------------
        NIH plays an essential role in responding to emerging health
    threats; throughout the coronavirus pandemic, NIH leaders and
    researchers have provided critically needed scientific advice to the
    President, Congress, and the American public while also utilizing their
    expertise to help develop a vaccine and treatments. NIH also regularly
    apprises our nation's leaders about other scientific advancements and
    research priorities, and its unparalleled peer review process fosters
    the wise distribution of taxpayer dollars.
      continued funding increases needed to rebuild and grow nih capacity
        Leadership by this subcommittee has helped Congress provide
    generous increases to the NIH budget over the last six years. Although
    these increases have helped restore much of the purchasing power that
    NIH lost after years of inadequate budgets and erosion from biomedical
    research inflation, NIH's purchasing power remains below its 2003 peak
    funding level. Meaningful budget growth will help close this gap and
    allow NIH to invest not just in important research priorities across
    its Institutes and Centers, but also in the research workforce. While
    NIH should continue to support meritorious senior scientists, it is
    urgent to ensure that we will have sufficient mid- and early career
    scientists ready to take on increasingly complex scientific challenges.
    We must provide NIH with the resources needed to provide a dynamic
    research environment that allows for the training, development, and
    support of our next generation of researchers, doctors, professors, and
    inventors--and give them the confidence to pursue these careers.
                                   conclusion
        AAI greatly appreciates the subcommittee's strong support for NIH
    and urges a budget for NIH of $52 billion for FY 2022. Within that, AAI
    recommends an appropriation of at least $46.1 billion for the regular
    NIH budget to help the agency grow its ability to invest in critically
    important research, including vital immunologic research, support
    meritorious scientists at all career stages, and help scientists
    discover new ways to prevent, treat, and cure deadly and debilitating
    diseases that afflict people in the U.S. and throughout the world. AAI
    also urges a substantial appropriation to launch the new ARPA-H, which
    could greatly advance human immunology at a time in our history when
    pressing public health needs, and unprecedented scientific
    opportunities, have converged.

        [This statement was submitted by Ross M. Kedl, Ph.D., Chair of the
    Committee on Public Affairs, American Association of Immunologists.]
                                     ______

       Prepared Statement of the American Association of Neuromuscular &
                           Electrodiagnostic Medicine
                        fiscal year 2022 recommendations
    _______________________________________________________________________

      --Please continue to provide meaningful, annual funding increases for
            healthcare fraud and abuse programs at the Centers for Medicare
            and Medicaid Services (CMS) while allowing for flexibility and
            innovation to address emerging challenges.
      --Please continue to include timely recommendations in the Committee
            Report accompanying the annual Labor-Health and Human Services-
            Education (LHHS) Appropriations Bill encouraging CMS to take
            substantive action to systematically address fraud, abuse, and
            the quality of patient care in electrodiagnostic (EDX)
            medicine.
      --Please provide the National Institutes of Health (NIH) with $46.1
            billion in discretionary funding, an increase of $3.2 billion
            over FY 2021. Please also provide proportional increases for
            various NIH Institutes and Centers, including the National
            Institute of Arthritis and Musculoskeletal and Skin Diseases
            (NIAMS), the National Institute of Allergy and Infectious
            Diseases (NIAID), and the National Institute of Neurological
            Disorders and Stroke (NINDS).
      --Please support adequate funding to establish the new Advanced
            Research Projects Agency for Health (ARPA-H) at NIH to
            facilitate robust and swift scientific progress on a variety of
            neuromuscular conditions.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished Members
    of the Subcommittee, thank you for the opportunity to present the views
    of the American Association of Neuromuscular & Electrodiagnostic
    Medicine (AANEM) during the consideration of FY 2022 L-HHS
    appropriations. First and foremost, thank you for the ongoing
    investment in medical research and patient care programs. Please
    continue this investment in FY 2022.
        In regards to fraud and abuse, the challenges and opportunities
    that I will review today are not unique to AANEM, but impact a variety
    of medical professional societies and patient communities who rely on
    proper EDX testing. My comments are provided in the interest of
    spotlighting serious issues that continue to undermine patient care and
    waste federal healthcare resources, while advancing policy tools to
    efficiently and effectively address these issues. In this regard,
    please consider the AANEM a resource moving forward. Thank you again
    for this important opportunity.
                                  about aanem
        AANEM is a nonprofit membership association dedicated to the
    advancement of neuromuscular, musculoskeletal, and EDX medicine. Our
    members--primarily neurologists and physical medicine and
    rehabilitation (PMR) physicians--are joined by allied health
    professionals and PhD researchers working to improve the quality of
    medical care provided to patients with muscle and nerve disorders.
    Founded in 1953, AANEM currently has over 5,400 members across the
    country. Our mission is to improve quality of patient care and advance
    the science of neuromuscular (NM) diseases and EDX medicine by serving
    physicians and allied health professionals who care for those with
    muscle and nerve disorders. Our members are dedicated to diagnosing and
    managing a variety of nerve and muscle disorders including, but not
    limited to, amyotrophic lateral sclerosis, muscular dystrophies, and
    neuropathies, as well as more common conditions, such as pinched nerves
    and carpal tunnel syndrome.
                               about edx medicine
        When functioning properly, nerves send electrical impulses to the
    muscles to activate them. A nerve disorder means that signals are not
    getting through like they should. A muscle disorder means that muscles
    aren't responding to the signals correctly. To determine whether your
    nerves and muscles are working properly, your doctor may recommend you
    have EDX testing, which generally includes both a nerve conduction
    study (NCS) and needle electromyography (EMG) testing. Other tests may
    include imaging, genetic testing, biopsies, biochemical tests, and
    strength testing. The results of these tests help your doctor diagnose
    your condition and determine the best treatment.
        NCS.--These studies evaluate how quickly and efficiently electrical
    impulse move through the nervous system. While it may sound straight-
    forward, proper testing requires sophisticated equipment, an
    understanding of the patient's health history, and, most importantly,
    the ability to design/perform the study and interpret the results.
        EMG.--These tests evaluate muscles and nerves through the use of
    electrodes under the skin. Since the procedure is invasive and highly
    technical, it is considered to be the practice of medicine by the
    American Medical Association, requiring training, study, and experience
    to ensure patient safety and testing efficacy.
                           about edx fraud and abuse
        In 2014, the HHS OIG published a report entitled, Questionable
    Billing for Medicare Electrodiagnostic Tests, which found roughly $140
    million in suspicious activity annually. But experience tells us that
    this is just the tip of the iceberg. And the toll of patient suffering
    and hardship as the result of fraudulent EDX testing is incalculable.
    Unfortunately, since this report was released, the situation has
    deteriorated rather than improved. Our members have anecdotally noted
    an increase in fraud activity (both through solicitations and by re-
    testing patients that were victims of improperly performed tests),
    which appears to be supported by CMS utilization data. CMS revised the
    EDX codes in 2013 which has actually made it harder to identify
    systematic fraud and abuse in this area. Bad actors are aware of the
    gaps in the current CMS regulatory and enforcement framework that
    create unique blind spots for EDX testing, and this deficiency
    continues to be exploited with many criminal endeavors operating in the
    open for years as sham professional service providers (the small number
    that are caught and convicted annually has not served as a deterrent).
    To be clear, the victims continue to be the patients that are
    improperly tested, subjected to a battery of studies, and over-billed,
    with no intention of receiving an accurate diagnosis or who were never
    in need of testing in the first place.
                             current opportunities
        CMS, the FBI, and the HHS OIG have been doing tremendous work to
    root out fraud and abuse in EDX medicine, but these dedicated public
    servants are limited by the constraints of the current pay-and-chase
    model. Additional resources for ongoing CMS efforts to address
    healthcare fraud and abuse will facilitate incremental improvements and
    further protect patients, but modernization is needed as well. Over
    recent appropriations cycles, Congress has called on CMS to work with
    the EDX community on innovative solutions that could better identify
    bad actors conducting EDX testing or simply prevent payments for
    improper studies before they are made. Please continue to work with CMS
    through the FY 2022 appropriations process to recommend greater
    community collaboration and to encourage meaningful and timely progress
    in the area of EDX fraud and abuse.
                statement of aanem member dr. vince tranchitella
        New NCS codes became effective on January 1, 2013. The new codes
    were developed as a direct response to fraudulent activity that
    resulted in the exponentially increased billing for NCSs.
    Unfortunately, the new NCS codes failed to have the desired effect. My
    most recent case involved 56 EDX studies, all of which were performed
    AFTER the NCS codes were changed in 2013, and every single one of the
    reports were deemed so far below the standard of care that none of them
    could be considered a reliable representation of the true medical
    status of the patients who received those tests. Therefore, none of
    those tests should have been billed or reimbursed.
                      recent examples from dr. peter grant
        EDX fraud not only wastes healthcare dollars, but, more
    importantly, the quality of patient care suffers severely. As an
    example, a recent case in which I testified in Houston working for the
    FBI and the US Attorney's Office, many patients' insurance companies
    were being billed more than $30,000 for a study that should cost $800
    to $1200. Of note, when a detailed review was performed, more than 85%
    of the diagnoses arrived at with these fraudulent studies were
    incorrect and unreliable. These inappropriate and inaccurate studies
    did not help these patients in finding appropriate treatments or
    solutions to their medical problems. In fact, they often sent the
    patients down costly and ineffective paths of treatment. In this case
    alone the perpetrators were convicted of EDX fraud totaling nearly $5
    million.
        As is invariably the case with mobile EDX laboratories, quality of
    care suffers while costs skyrocket and the real losers are,
    unfortunately, the patients. In a case I had in California, a 47 year
    old man had a mobile EDX study done that cost him (and his insurance
    company) more than $7,500 and told him his symptoms were from a
    ``pinched nerve in his leg''. When I performed the correct study
    (charging about $750) I found his true diagnosis to be ALS (or Lou
    Gehrig's disease).

        [This statement was submitted by Peter A. Grant, MD, EDX, Fraud and
    Abuse Consultant for FBI/OIG, American Association of Neuromuscular &
    Electrodiagnostic Medicine.]
                                     ______

    Prepared Statement of the American Association of University Professors
        Dear esteemed Members of Congress:
        The American Association of University Professors (AAUP) is the
    oldest organization of its kind, representing faculty and graduate
    employees in institutions of higher education. Since its founding in
    1915, the AAUP has been an active and influential voice in higher
    education. The AAUP defines and develops fundamental professional
    values, standards, and procedures for higher education; advances the
    rights of academics, particularly as those rights pertain to academic
    freedom and shared governance; and promotes the interests of higher
    education teaching and research.
        On behalf of all faculty, and our chapters across hundreds of
    institutions, we write to thank you for your historic investments in
    higher education over the course of the past year. Across the country,
    funding provided by the CARES Act and subsequent COVID-19 relief bills
    have stopped the worst financial impacts from hitting our campus
    communities. However, as appreciated as the unprecedented $135 billion
    has been, faculty and staff have not shared in all the benefits, to the
    detriment of the student experience. According to a survey we recently
    ran of faculty senate chairs, 10 percent of institutions had laid off
    tenured faculty and 28 percent had laid off contingent faculty in the
    past year,\1\ despite the influx of federal funds that explicitly said
    that they could be used to meet payroll budget gaps. Faculty working
    conditions are student learning conditions. To us, it is clear that our
    institutions need sustained, increased funding to invest more in the
    people and infrastructure that make them run.
    ---------------------------------------------------------------------------
        \1\ https://www.aaup.org/report/survey-data-impact-pandemic-shared-
    governance.
    ---------------------------------------------------------------------------
        We are pleased to see the historic levels of funding proposed in
    the American Families Plan and the President's FY22 budget. This
    funding makes meaningful progress towards our call for a New Deal for
    higher education,\2\ which calls for free college, faculty and staff
    job security, and student debt cancellation. These planks of our New
    Deal platform will provide institutions the resources they need to
    better foster innovation and ensure high quality instruction. Beyond
    that, in a time of political division and heightened social tension,
    open access to a college education might also help us strengthen civic
    engagement and advance racial and economic justice. However, as
    ambitious and appreciated as the President's proposals have been, in
    some ways they fall short of what students need--and don't go far
    enough to equitably fund our institutions.
    ---------------------------------------------------------------------------
        \2\ https://newdealforhighered.org/.
    ---------------------------------------------------------------------------
        The AAUP recommends that the Appropriations Committee prioritize
    the following to better meet the needs of faculty and students:
          1. Double the Pell Grant, the purchasing power of which has
            fallen to less than a third of the annual cost of tuition at
            the average public institution. More than a thousand
            organizations have called on Congress to increase Pell Grant
            funding dramatically, and that call seems more urgent than ever
            given increased student need during the pandemic. Furthermore,
            we strongly encourage you to maintain the Pell Grant reserve,
            and not rescind it to fund other programs within the Labor-HHS-
            Education budget.
          2. Increase funding for programs that support students of color,
            non-traditional students, and low-income students, such as but
            not limited to Title III funds to minority serving
            institutions, TRIO, SEOG, work study, and CCAMPIS. These
            programs ought to see more generous funding to help close
            equity gaps between non-traditional students and their peers,
            and to begin to address historic underfunding that minority-
            serving institutions have faced.
          3. Increase funding to scientific research programs, which are a
            significant source of funding to support graduate students in
            their pursuit of knowledge and a degree. The cutting-edge
            academic and scientific discoveries made by researchers at
            American institutions makes our higher education system one of
            the most respected in the world. Many of these discoveries lead
            to robust partnerships with private industry that result in job
            creation and economic growth. And, the scientific breakthroughs
            of the past year make a clear case for increased funding for
            broad and exploratory research.
          4. Create a federal-state partnership to make college free, so
            that any qualified student might pursue an associate's or
            bachelor's degree at the institution of their choice. Congress
            should also consider how to increase funding to private
            institutions so that they too can offer reduced costs, such as
            Title III programs and noting in report language that states
            may use these funds for student grant aid to subsidize the cost
            of attendance at private institutions in their home state.
          5. As a condition of this new funding, it ought to protect
            faculty and staff job security by setting a baseline of support
            for workers. Gig work and the exploitation of contingent
            faculty erodes the foundations of what makes American higher
            education so respected internationally. Beyond supporting an
            increase in the share of faculty on the tenure track, where
            applicable, positions on college campuses should provide a
            guarantee of good pay, continuity of employment, and parity in
            wages and benefits between full and part time positions.
            Institutions should work as much as possible to convert
            existing short-term contracts with employees to longer-term or
            tenure-track appointments.
          6. Promote shared governance, by making clear in bill and report
            language that federal funding to institutions and states in the
            aftermath of the COVID-19 pandemic ought to maintain
            instructional spending levels and faculty jobs, ahead of
            administrative costs or debt financing. Furthermore, faculty
            and staff must have meaningful input when administration seek
            to cut costs in moments of financial uncertainty.
        We would again like to thank you for your generous and historic
    funding to meet the needs of students and institutions of higher
    education during the pandemic. We look forward to working with you to
    help our country recover from the pandemic, strengthen our communities
    and civil society, and create thousands more good-paying jobs on campus
    in the process.

        [This statement was submitted by Kaitlyn Vitez, Government
    Relations Officer, and John McNay, Government Relations Committee
    Chair, American Association of University Professors.]
                                     ______

            Prepared Statement of the American College of Cardiology
        The American College of Cardiology (ACC) commends Congress for
    boosting funding for the National Institutes of Health (NIH) and
    Centers for Disease Control and Prevention (CDC) in FY21. To continue
    this important progress in FY22 and beyond, and to adequately fund
    public health and research infrastructure in response to the COVID-19
    pandemic, ACC urges members of Congress to appropriate the following
    funds toward agencies doing vital work in cardiovascular disease (CVD)
    treatment and prevention: $3.963 billion for the National Heart Lung &
    Blood Institute (NHLBI) to increase the NIH's purchasing power and
    preserve U.S. leadership in research; $160 million toward the CDC's
    Division for Heart Disease and Stroke Prevention to strengthen heart
    disease prevention efforts at state and local levels, $10 million
    toward CDC's Million Hearts to prevent 1 million heart attacks and
    strokes, $46.7 million toward CDC's WISEWOMAN to help uninsured or
    under-insured women prevent or control heart disease, $10 million
    toward CDC congenital heart research to study its effects over the
    patient's lifespan, and $310 million toward CDC's Office on Smoking and
    Health to maintain the program's cost-effective tobacco control
    efforts. ACC asks for the inclusion of report language promoting
    valvular heart disease research at the NHLBI since clinical predictors
    of patients at higher risk of sudden cardiac death are still lacking.
        ACC envisions a world where innovation and knowledge optimize
    cardiovascular care and outcomes. As the professional home for the
    entire cardiovascular team, the mission of the College and its more
    than 52,000 members is to transform cardiovascular care and improve
    heart health. The ACC bestows credentials upon cardiovascular
    professionals who meet stringent qualifications and leads in the
    formation of health policy, standards and guidelines. The College also
    provides professional medical education, disseminates cardiovascular
    research through its world-renowned JACC Journals, operates national
    registries to measure and improve care, and offers cardiovascular
    accreditation to hospitals and institutions.
        CVD, a class of diseases that includes diseased blood vessels,
    structural problems, and blood clots, continues to be the leading cause
    of death among men and women in the United States and is responsible
    for 1 in every 4 deaths.\1\ More than 92 million Americans currently
    suffer from some form of CVD--nearly one-third of the population--but
    it remains one of the most underfunded deadly diseases, as the NIH only
    invests 4 percent of its research dollars on heart research.\2\ The
    heart disease death rate has continued to drop since the 1970s \3\ due
    to scientific advances and improved heart medications and procedures--
    but to meet the challenges of an aging population, rising obesity rates
    and the long-term complications of COVID-19 and patients with heart
    disease, the NIH must maintain its place at the forefront of medical
    innovation for years to come. The NHLBI, the third-largest institute at
    the NIH, conducts research related to heart, blood vessel, lung, and
    blood diseases, generating drugs for lowering cholesterol, controlling
    blood pressure, and dissolving blood clots. These biomedical
    advancements have contributed to a 71 percent \4\ decrease in death
    rates due to cardiovascular disease.
    ---------------------------------------------------------------------------
        \1\ Heart Disease Facts; Centers for Disease Control and
    Prevention. https://www.cdc.gov/heartdisease/facts.htm.
        \2\ National Coalition for Heart and Stroke Research; American
    Heart Association. http://www.heart.org/HEARTORG/Advocate/
    IssuesandCampaigns/Research/National-Coalition-for-Heart-and-Stroke-
    Research_UCM_428347_Article.jsp#.Wt4h-m4vypo.
        \3\ Decline in Cardiovascular Mortality; National Library of
    Medicine. https://www.ncbi.nlm.
    nih.gov/pmc/articles/PMC5268076/.
        \4\ HHS/NIH/NHLBI FY2017 Congressional Justification Report;
    https://www.nhlbi.nih.gov/sites/default/files/media/docs/
    Final%20NHLBI%202017%20CJ_R508_v1_0.pdf.
    ---------------------------------------------------------------------------
        Preventing and treating CVD applies to long-term COVID-19 patients.
    Recent studies have shown that cardiovascular consequences of COVID-19
    extend beyond initial infection, and many COVID-19 survivors experience
    some type of heart damage, even if they did not have underlying heart
    disease and were never hospitalized. Imaging tests taken months after
    recovery from COVID-19 have shown lasting damage to the heart muscle in
    people who experienced only mild symptoms, which may increase the risk
    of heart failure or other heart complications in the future.\5\ As CVD
    continues to be the country's leading cause of death while COVID-19
    infections also present risks to cardiovascular health, we recommend
    the NHLBI be funded at $3.965 billion to support research on COVID-19
    by leveraging existing NIH-funded studies and infrastructure, and to
    maintain current activities and investment toward new research and
    emerging technologies related to heart disease.
    ---------------------------------------------------------------------------
        \5\ https://www.mayoclinic.org/diseases-conditions/coronavirus/in-
    depth/coronavirus-long-term-effects/art-20490351.
    ---------------------------------------------------------------------------
        More than 11 million Americans have heart valve disease (HVD) which
    involves damage to one or more of the heart's valves and leads to
    disrupted blood flow by not opening or closing properly.\6\ HVD can
    lead to major complications and some people with HVD do not always have
    symptoms, even if their disease is severe. ACC recommends that the
    NHLBI address gaps in understanding heart valve disease to better
    recognize indicators of patients at higher risk of sudden cardiac
    death. We propose report language to better understand and develop
    guidelines for treatment of high-risk patients: The committee
    recognizes that heart valve disease involves damage to one or more of
    the heart's valves, and symptoms can be difficult to detect and lead to
    major complications. The committee encourages the NHLBI to expand
    research on valvular disease to better understand and develop
    guidelines for treatment of high-risk patients by using precision
    medicine and advanced technological imaging to generate data,
    identifying and developing a cohort of individuals with valvular heart
    disease and available data, and corroborating data generated through
    clinical trials to develop a prediction model to identify patients at
    high risk for sudden cardiac arrest or sudden cardiac death from
    valvular disease.
    ---------------------------------------------------------------------------
        \6\ Heart Valve Disease Awareness Day; https://
    www.valvediseaseday.org/the-issue/.
    ---------------------------------------------------------------------------
        The CDC plays a vital role in protecting public health through
    healthy lifestyle promotion and educational activities designed to curb
    non-infectious diseases such as obesity, diabetes, stroke, and heart
    disease. The CDC Division for Heart Disease and Stroke Prevention
    supports efforts to improve cardiovascular health by promoting healthy
    lifestyles and behaviors, healthy environments, and access to early
    detection and affordable treatment. The division engages with local and
    state health departments, and a variety of other partners, to provide
    funding and resources, conduct research, track risk factors, and
    evaluate current programs and policies relating to heart disease. We
    recommend that the CDC Division for Heart Disease and Stroke Prevention
    be funded at $160 million to explore the intersections between COVID-19
    and cardiovascular disease; build or enhance critical data
    infrastructure; and expand current work in priority areas through new
    partnerships, programs, and projects, all focused on eliminating
    disparities in health outcomes.
        Launched in 2012 and co-led by the CDC and the Centers for Medicare
    and Medicaid Services, the Million Hearts program coordinates and
    enhances CVD prevention activities with the objective of preventing 1
    million heart attacks and strokes in 5 years. The initiative aims to
    achieve this goal by encouraging the public to lead a healthy and
    active lifestyle, as well as improving medication adherence for aspirin
    and other medications to manage blood pressure, cholesterol, and
    smoking cessation. New funding would frontload the success of Million
    Hearts by facilitating extensive partner input into the design of the
    next five-year phase; integration of insights gleaned from the
    pandemic, including and especially the inequities further exposed by
    COVID-19; and analysis of the individual, community, and healthcare
    actions with the greatest impact on cardiovascular health for all. We
    recommend that Million Hearts be funded at $10 million to enhance
    efforts preventing heart attacks and strokes.
        CDC's WISEWOMAN initiative provides more than 165,000 under-
    insured, low-income women ages 40-64 with services to help reduce heart
    disease and stroke risk factors. Heart disease ranks as the leading
    cause of death for women. Only 1 in 5 \7\ women believes heart disease
    is her greatest health threat, and 11 percent \8\ of women remain
    uninsured. We recommend that $46.7 million be allocated for WISEWOMAN
    to provide preventive health services, referrals to local health care
    providers, lifestyle programs, and counseling in all 50 states.
    ---------------------------------------------------------------------------
        \7\ WISEWOMAN; Centers for Disease Control and Prevention. https://
    www.cdc.gov/
    wisewoman/.
        \8\ Women's Health Insurance Coverage; The Henry J. Kaiser Family
    Foundation. http://kff.org/womens-health-policy/fact-sheet/womens-
    health-insurance-coverage-fact-sheet/.
    ---------------------------------------------------------------------------
        Congenital heart disease (CHD), a life-long consequence of a
    structural abnormality of the heart present at birth, is the number one
    birth defect in the U.S. While the diagnosis and treatment of CHD has
    greatly improved over the years, most patients with complex heart
    defects need special care throughout their lives, and only by expanding
    research opportunities can we fully understand the effects of CHD
    across the lifespan. As authorized by the Congenital Heart Futures
    Reauthorization Act of 2017, we recommend that the CDC National Center
    for Birth Defects and Developmental Disabilities be funded at $10
    million for enhanced CHD surveillance and public health research.
        Programs within CDC's Office on Smoking and Health (OSH) work to
    prevent smoking among young adults and eliminate tobacco-related health
    disparities in different population groups. From 2012-2018, the CDC
    estimates that more than 16.4 million people who smoke have attempted
    to quit and about 1 million have successfully quit because of the OSH
    Tips from Former Smokers campaign.\9\ While these programs have proven
    effective in tobacco cessation and prevention, more than 480,000 people
    still die every year from causes attributable to smoking, and 33
    percent of those deaths stem from heart disease\10\ We recommend that
    OSH be funded at $310 million to continue leading the nation's efforts
    in preventing chronic diseases caused by tobacco use.
    ---------------------------------------------------------------------------
        \9\ CDC Office on Smoking and Health; https://www.cdc.gov/
    chronicdisease/pdf/aag/osh-H.pdf.
        \10\ FDA Tobacco Products Public Health Information; https://
    www.fda.gov/tobacco-products/public-health-education/health-
    information.
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        On behalf of our members who work to prevent and treat CVD, ACC
    would like to thank members of Congress for supporting medical
    innovation as we continue the fight against heart disease and
    understand the cardiovascular consequences of COVID-19. Stable funding
    for medical research and healthy lifestyle promotion will save lives
    and health care costs in the long term by creating jobs and new
    technologies, which will produce billions of dollars in Medicare and
    Medicaid savings over the next decade. Please help us secure robust
    funding for NIH and CDC funding to protect the health of future
    generations.

        [This statement was submitted by Dipti Itchhaporia, MD, FACC,
    President,
    American College of Cardiology.]
                                     ______

        Prepared Statement of the American College of Obstetricians and
                                 Gynecologists
        The American College of Obstetricians and Gynecologists (ACOG),
    representing more than 60,000 physicians and partners dedicated to
    advancing women's health, is pleased to offer this statement to the
    Senate Committee on Appropriations, Subcommittee on Labor, Health and
    Human Services, Education, and Related Agencies. We thank Chairwoman
    Murray, Ranking Member Blunt, and the entire Subcommittee for this
    opportunity to provide comments on some of the most important programs
    to support and advance women's health in FY22. ACOG commends Congress
    for making great strides to support research and data collection that
    advance the health of women and families. Looking ahead, we urge you to
    appropriate:
      --Centers for Disease Control & Prevention (CDC): At least $10
            billion for the CDC, including $102.5 million for the Safe
            Motherhood Initiative, including $30 million for maternal
            mortality review committees and $30 million for perinatal
            quality collaboratives; and $250 million for public health
            surveillance;
      --National Institutes of Health (NIH): $46.1 billion for the NIH,
            including at least $1.7 billion for Eunice Kennedy Shriver
            National Institute of Child Health and Human Development
            (NICHD), and $50 million shared evenly between CDC and NIH, for
            research into firearm morbidity and mortality prevention;
      --Health Resources & Services Administration (HRSA): $750 million for
            the Title V Maternal and Child Health Block Grant, including
            $15 million for the Alliance for Innovation on Maternal Health
            (AIM) within the Special Projects of Regional and National
            Significance (SPRANS); $10 million to expand depression
            screening and treatment for pregnant and postpartum women; and
            $5 million to establish, identify, and distribute clinicians in
            maternity care health professional target areas;
      --Office of Population Affairs (OPA): $737 million for the Title X
            Family Planning Program; and
      --$500 million for the Agency for Healthcare Research and Quality
            (AHRQ).
        Safe Motherhood Initiative at CDC: The United States has the
    highest rate of maternal mortality and severe morbidity of any
    industrialized country. The Safe Motherhood Initiative at CDC works
    with state health departments to collect information on pregnancy-
    related deaths, supports maternal mortality review committees (MMRCs),
    tracks preterm births, and improves maternal outcomes through perinatal
    quality collaboratives. Important strides have been made as nearly
    every state either currently has, is in the process of implementing, or
    is making plans to develop a state MMRC. In addition, the CDC currently
    supports 13 perinatal quality collaboratives (PQCs), often considered
    the implementation arm of MMRCs. We must continue to build on this
    progress and improve maternal health outcomes. ACOG requests that you
    fund the Safe Motherhood Initiative at $102.5 million, including $30
    million to help states expand or establish maternal mortality review
    committees, and $30 million to support state-based perinatal quality
    collaboratives in every state.
        Women's Health Research at NIH: Women represent half of the US
    population. As such, conditions and diseases that are specific to
    women's health, or those that present differently in women than men,
    must be a priority for federally funded research. Women's health
    research is a central part of the research mission and portfolio of
    NICHD, and the Institute has achieved great success in advancing
    research on women's health throughout the life cycle; maternal, child,
    and family health; fetal development; reproductive biology; population
    health; and medical rehabilitation. With sufficient resources, NICHD
    can build upon existing initiatives to produce new insights and
    solutions to benefit women and families. ACOG supports an appropriation
    of $46.1 billion for the NIH in FY22, including at least $1.7 billion
    for NICHD.
        Maternal Therapeutics at NIH: In the United States each year, more
    than 4 million women give birth and more than 3 million breastfeed.
    However, little is known about the effects of most drugs on the woman
    and her child. In 2015 as part of the 21st Century Cures Act (Sec. 2041
    of P.L. 114-255), Congress created the Task Force on Research Specific
    to Pregnant Women and Lactating Women (PRGLAC) to advise the Secretary
    of HHS on gaps in knowledge and research on safe and effective
    therapies for pregnant and breastfeeding women. In August 2020, PRGLAC
    produced an implementation plan for each of the 15 recommendations made
    in 2018 to facilitate the inclusion of this population in clinical
    research. ACOG supports the implementation of these recommendations
    under the oversight of NICHD, working with other relevant NIH
    Institutes, the CDC, and the Food and Drug Administration, and urges
    Congress to express its continued support.
        Title X Family Planning Program at OPA: Title X is the only federal
    program dedicated to providing family planning services for people with
    low incomes. For many individuals, particularly those who are low-
    income, uninsured, or adolescents, Title X is essential to their
    ability to affordably and confidentially obtain birth control, cancer
    screenings, STI tests and other basic care. Title X has been cut or
    flat-funded every year for the past decade. A significant investment is
    needed to support robust restoration of the program and ensure demand
    for services is met. ACOG requests $737 million for Title X in FY22 to
    ensure individuals in need have access to evidence-based care. ACOG is
    pleased that the Biden administration has proposed to eliminate the
    2019 Title X regulations that decreased access to health care services
    and disproportionately imposed barriers to care for Black, Latinx, and
    Indigenous communities. ACOG urges Congress to show its strong support
    for transparent, respectful, evidence-based, and comprehensive
    reproductive health care by funding this critical program.
        Title V Maternal and Child Health Block Grant at HRSA: The Title V
    Maternal and Child Health (MCH) Block Grant at HRSA is the only federal
    program that exclusively focuses on improving the health of mothers and
    children. The Block Grant is a cost-effective, accountable, and
    flexible funding source used to address critical, pressing, and unique
    needs of maternal and child health populations in each state, territory
    and jurisdiction. Notably, through the SPRANS discretionary grant, the
    Block Grant supports the Alliance for Innovation on Maternal Health
    (AIM) program--a program that works with states and hospital systems to
    implement evidence-based best practices to improve maternal health
    outcomes and reduce rates of maternal mortality and severe maternal
    morbidity. For FY22, ACOG requests at least $750 million to respond to
    the increased demands placed on the Block Grant, including $15 million
    within SPRANS to support continued implementation of AIM.
        Investing in Data and Quality at AHRQ: AHRQ is the federal agency
    with the sole purpose of improving health care quality. AHRQ produces
    data with the mission of making health care safer, higher quality, more
    accessible, equitable, and affordable. AHRQ works with HHS and other
    partners to ensure that the evidence improves patient safety. ACOG
    supports $500 million for AHRQ in FY22, which reflects the FY10 funding
    level for the agency adjusted for inflation and additional funding to
    respond to the pandemic.
        Public Health Surveillance at CDC: Uniform, accurate, and
    comprehensive data is essential for addressing the rising rates of
    maternal mortality and severe maternal morbidity in the US.
    Unfortunately, the nation's public health data systems are antiquated,
    lack interoperability and data and reporting standards, and are in dire
    need of security updates. ACOG urges Congress to include a robust
    investment in public health surveillance, and requests funding to be
    used to modernize these systems to improve health. ACOG requests $250
    million in FY22 for public health surveillance at CDC to implement
    advanced technologies and train the next generation of data scientists.
        Firearm Morbidity and Mortality Prevention (CDC and NIH): In 2017,
    there were more than 39,000 U.S. firearm-related fatalities. Federally
    funded public health research has a proven track record of reducing
    public health-related deaths, whether from motor vehicle crashes,
    smoking, or Sudden Infant Death Syndrome. This same approach should be
    applied to increasing gun safety and reducing firearm-related injuries
    and deaths, and CDC research will be as critical to that effort as it
    was to these previous public health achievements. The foundation of a
    public health approach is rigorous research that can accurately
    quantify and describe the facets of an issue and identify opportunities
    for reducing its related morbidity and mortality. For FY22, ACOG
    requests $50 million, shared evenly between CDC and NIH, to conduct
    public health research into firearm morbidity and mortality prevention.
        Diagnosing and Treating Maternal Depression (HRSA): About 1 in 5
    women experience maternal depression, and ACOG recommends that all
    women be screened, yet barriers to accessing treatment remain. ACOG
    commends Congress for funding Sec. 10005 of P.L. 114-255 to support the
    establishment of a program at HRSA to expand depression screening and
    treatment for pregnant and postpartum individuals. ACOG urges you to
    fund the program at $10 million for FY22, a $5 million increase over
    FY21, and increase support for the maternal mental health hotline to $5
    million.
        Maternity Care Target Areas (HRSA): Major pockets of the U.S. do
    not have adequate access to needed maternity care, due to both a
    workforce shortage and maldistribution of clinicians. This
    disproportionately impacts access to obstetric care in rural
    communities. Maternity care shortages threaten the ability of pregnant
    individuals to receive timely prenatal and labor/delivery services.
    According to the latest available data, more than half of pregnant
    people living in rural areas reside more than 30-minutes by car from
    the nearest hospital offering perinatal services. Further, a 2019 study
    that analyzed severe maternal morbidity and mortality during childbirth
    hospitalizations among rural and urban residents found that when
    controlling for sociodemographic factors and clinical conditions, rural
    residents had a 9 percent greater probability of severe maternal
    morbidity and mortality, compared with urban residents.
        The Improving Access to Maternity Care Act of 2018 (P.L. 115-320)
    requires HRSA to identify maternity care health professional target
    areas that are suffering from a shortage of maternity care clinicians,
    including obstetrician-gynecologists and certified nurse-midwives, so
    that those participating in the National Health Service Corps can be
    placed in the communities most in need of their services. ACOG urges
    you to fulfill the President's request for $5 million in FY22 to
    implement the Improving Access to Maternity Care Act. Funding would be
    used to establish criteria for and identify maternity care health
    professional target areas, distribute maternity care health
    professionals to those areas, and collect and publish data on the
    availability and need for maternity care services within primary care
    health professional shortage areas.
        Thank you again for the opportunity to submit our recommendations
    to the
    subcommittee, and for your commitment to improving women's health.
                                     ______

            Prepared Statement of the American College of Physicians
        The American College of Physicians (ACP) is pleased to submit the
    following statement for the record on its priorities, as funded under
    the U.S. Department of Health & Human Services, for Fiscal Year (FY)
    2022. ACP is the largest medical specialty organization and the second-
    largest physician group in the United States. ACP members include
    163,000 internal medicine physicians (internists), related
    subspecialists, and medical students. Internal medicine physicians are
    specialists who apply scientific knowledge and clinical expertise to
    the diagnosis, treatment, and compassionate care of adults across the
    spectrum from health to complex illness. As the Subcommittee begins
    deliberations on appropriations for FY2022, ACP is urging funding for
    the following proven programs to receive appropriations from the
    Subcommittee:
      --Health Resources Services Administration (HRSA), $9.2 billion;
      --Title VII, Section 747, Primary Care Training and Enhancement
            (PCTE), Health Resources and Services Administration (HRSA),
            $71 million;
      --National Health Service Corps (NHSC), $860 million in total program
            funding;
      --Agency for Healthcare Research and Quality (AHRQ), $500 million;
      --Centers for Medicare and Medicaid Services (CMS), Program
            Operations for Federal Exchanges, $296.5 million;
      --Centers for Disease Control and Prevention (CDC), $10 billion,
            Injury Prevention and Control, Firearm Injury and Mortality
            Prevention Research, $50 million; National Center for Chronic
            Disease Prevention and Health Promotion (NCCDPHP), Social
            Determinants of Health program, $153 million;
      --National Institutes of Health (NIH), $46.1 billion.
        The United States is facing a shortage of physicians in key
    specialties, notably in general internal medicine and family medicine-
    the specialties that provide primary care to most adult and adolescent
    patients. Current projections indicate there will be a shortage of
    21,400 to 55,200 primary care physicians by 2033. Without critical
    funding for vital workforce programs, this physician shortage will only
    grow worse. HRSA is responsible for improving access to health-care
    services for people who are uninsured, isolated or medically
    vulnerable. Without critical funding for vital workforce programs, this
    physician shortage will only grow worse. A strong primary care
    infrastructure is an essential part of any high-functioning healthcare
    system. A recent report by the National Academy of Sciences, calls on
    policymakers to increase our investment in primary care as evidence
    shows that it is critical for achieving health care's quadruple aim
    (enhancing patient experience, improving population, reducing costs,
    and improving the health care team experience. Therefore, we urge the
    Subcommittee to provide $9.2 billion for HRSA programs for FY2022 to
    improve the care of medically underserved Americans by strengthening
    the health workforce.
        The health professions' education programs, authorized under Title
    VII of the Public Health Service Act and administered through HRSA,
    support the training and education of health care providers to enhance
    the supply, diversity, and distribution of the health care workforce.
    Within the Title VII program, we urge the Subcommittee to fund the
    Section 747 PCTE program at $71 million, in order to maintain and
    expand the pipeline for individuals training in primary care. While the
    College appreciates the $10 million increase to the program in FY2018,
    ACP urges more funding because the Section 747 PCTE program is the only
    source of federal training dollars available for general internal
    medicine, general pediatrics, and family medicine. For example, general
    internists, who have long been at the frontline of patient care, have
    benefitted from PCTE grants for primary care training in rural and
    underserved areas that have helped prepare physicians for a career in
    primary care.
        The College urges at least $860 million in total program funding
    for the NHSC in FY2022. In FY2021, the NHSC received $120 million in
    discretionary funding to expand and improve access to quality opioid
    and substance use disorder treatment in underserved areas, in addition
    to $310 million in mandatory funds which have been extended through
    FY2023. The NHSC awards scholarships and loan repayment to health care
    professionals to help expand the country's primary care workforce and
    meet the health care needs of underserved communities across the
    country. In FY2020, with a projected field strength of over 14,000
    primary care clinicians, NHSC members are providing culturally
    competent care to a target of almost 15 million patients at a targeted
    18,000 NHSC-approved health care sites in urban, rural, and frontier
    areas. These funds would help maintain NHSC's field strength helping to
    address the health professionals' workforce shortage and growing
    maldistribution. There is overwhelming interest and demand for NHSC
    programs, and with more funding, the NHSC could fill more primary care
    clinician needs. In FY2016, there were 2,275 applications for the
    scholarship program, yet only 205 new awards were made. There were only
    150 scholarship awards in FY2020. There were 7,203 applications for
    loan repayment and only 3,079 new awards in FY2016. Accordingly, ACP
    urges the subcommittee to double the NHSC's overall program funding to
    $860 million to meet this need and to sustain the American Rescue Plan
    Act's $800 million for the NHSC for when the pandemic subsides.
        AHRQ is the leading public health service agency focused on health
    care quality. AHRQ's research provides the evidence-based information
    needed by consumers, clinicians, health plans, purchasers, and
    policymakers to make informed health care decisions. The College is
    dedicated to ensuring AHRQ's vital role in improving the quality of our
    nation's health and recommends a budget of $500 million, restoring the
    agency to its FY2010 enacted level adjusted for inflation. This amount
    will allow AHRQ to help providers help patients by making evidence-
    informed decisions, to fund research that serves as the evidence engine
    for much of the private sector's work to keep patients safe, and to
    make the healthcare more efficient by providing quality measures to
    health professionals.
        ACP supports at least $296.5 million in discretionary funding for
    federal exchanges within CMS' Program Operations, which has been funded
    at $2.8 billion in FY2020. This funding would allow the federal
    government to continue administering the insurance marketplaces, as
    authorized by the Affordable Care Act, if a state has declined to
    establish an exchange that meets federal requirements. CMS now manages
    and operates some or all marketplace activities in over 30 states.
    Without these funds it will be much more difficult for the federal
    government to operate and manage a federally-facilitated exchange in
    those states, raising questions about where and how their residents
    would obtain and maintain coverage, especially with increased need for
    health coverage due to the COVID-19 pandemic.
        The Center for Disease Control and Prevention's mission is to
    collaborate to create the expertise, information, and tools needed to
    protect their health-through health promotion, prevention of disease,
    injury, and disability, and preparedness for new health threats. ACP
    supports $10 billion overall for this mission, especially in light of
    the ongoing COVID-19 public health emergency (PHE). The College also
    supports $50 million for the CDC's Injury and Prevention Control to
    fund research on firearm Injury and mortality prevention research and
    support 10 to 20 multi-year studies to continue to continue to rebuild
    lost research capacity in this area. ACP greatly appreciates funding
    for this research in FY2020 and FY2021 after many years of no federal
    resources for researching the prevention of firearms-related injuries
    and deaths. The College also supports the administration's budget
    request of $153 million for the NCCDPHP to fund its Social Determinants
    of Health program. The PHE caused by the COVID-19 has highlighted the
    urgent need to collect racial, ethnic, and language preference
    demographic data on testing, infection, hospitalization, and mortality
    during a pandemic. These data should be shared with local, state,
    territorial, and tribal governments. Frequent, granular, and high-
    quality disaggregated demographic data are needed to fully understand
    the impact on racial and ethnic minority communities and better offer
    targeted care not only for COVID-19, but for health care overall.
        Lastly, the College strongly supports $46.1 billion for NIH in
    FY2022 so the nation's medical research agency continues making
    important discoveries that treat and cure disease to improve health and
    save lives and that maintain the United States' standing as the world
    leader in medical and biomedical research.
        The College greatly appreciates the support of the Subcommittee on
    these issues and looks forward to working with Congress on the FY2022
    appropriations process.

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

             Prepared Statement of the American College of Surgeons
        Chairwoman Murray, Ranking Member Blunt, and Members of the
    Subcommittee, on behalf of the more than 82,000 members of the American
    College of Surgeons (ACS), thank you for the opportunity to submit
    written testimony addressing fiscal year (FY) 2022 appropriations. The
    ACS is a scientific and educational organization of surgeons that was
    founded in 1913 to raise the standards of surgical practice and improve
    the quality of care for all surgical patients. ACS is dedicated to the
    ethical and competent practice of surgery. Its achievements have
    significantly influenced the course of scientific surgery in America
    and have established it as an important advocate for all surgical
    patients.
        The ACS respectfully requests your consideration of the following
    priorities as the Subcommittee works through the annual appropriations
    process for FY 2022:
    Military and Civilian Partnership for the Trauma Readiness Grant
            Program (MISSION ZERO)
        In 2016, the National Academies of Science, Engineering, and
    Medicine (NASEM) released a report titled, ``A National Trauma Care
    System: Integrating Military and Civilian Trauma Systems to Achieve
    Zero Preventable Deaths After Injury.'' This report suggests that one
    in four military trauma deaths and one in five civilian trauma deaths
    could be prevented if advances in trauma care reach all injured
    patients. The report concludes that military and civilian integration
    is critical to saving lives both on the battlefield and at home,
    maintaining the nation's readiness and homeland security.
        The MISSION ZERO Act was signed into law on June 24th, 2019 as part
    of S. 1279, the Pandemic and All Hazards Preparedness and Advancing
    Innovation (PAHPAI) Act (Public Law No:116-22). MISSION ZERO takes the
    recommendations of the NASEM report to create a grant program, within
    the U.S. Department of Health and Human Services (HHS), to cover the
    administrative costs of embedding military trauma professionals in
    civilian trauma centers. These military-civilian trauma care
    partnerships will allow military trauma care teams and providers to
    gain exposure to treating critically injured patients and increase
    readiness for when these units are deployed, further advancing trauma
    care and providing greater patient access.
        By facilitating the implementation of military-civilian trauma
    partnerships, this program will preserve lessons learned from the
    battlefield, translate those lessons to civilian care, and ensure that
    service members maintain their readiness to deploy in the future. The
    ACS strongly supports the funding of MISSION ZERO at the authorized
    amount of $11.5 million for FY 2022.
    Funding for Cancer Research and Prevention
        The ACS Cancer Programs, including the Commission on Cancer (CoC),
    is dedicated to improving survival and quality of life for cancer
    patients through advocacy on issues pertaining to prevention and
    research. To continue the progress that has led to medical
    breakthroughs for treatment therapies for millions of cancer patients,
    the ACS supports the following funding increases for FY 2022.
        To ensure a robust, long-term commitment to cancer research and
    prevention, Congress should increase the overall budget of the National
    Institutes of Health (NIH) to at least $46.111 billion including $7.609
    billion for the National Cancer Institute (NCI). The ACS also urges the
    inclusion of $559 million for cancer programs at the Centers for
    Disease Control and Prevention (CDC), including $50 million for the
    National Comprehensive Cancer Control Program, and $70 million for the
    National Program of Cancer Registries (NPCR).
    Firearm Morbidity and Mortality Prevention Research
        According to the Centers for Disease Control and Prevention (CDC),
    there were more than 39,000 firearm-related fatalities in 2019, a
    measured increase over previous years. ACS believes this number can be
    reduced through federally funded firearms research. As with other
    injury prevention related efforts, public health research can play a
    role in reducing the number of firearm-related injuries and deaths.
        Federally funded research from the perspective of public health has
    contributed to reductions in motor vehicle crashes, smoking, and Sudden
    Infant Death Syndrome (SIDS). ACS believes that a similar approach can
    provide necessary data to inform efforts to reduce firearm-related
    injuries and deaths. The ACS supports $50 million specifically for
    public health research into firearm morbidity and mortality prevention
    through the CDC for FY 2022.
    Removal of Language in Section 510
        Serious patient safety concerns arise if a patient's health record
    is mismatched or includes inaccurate or incomplete information,
    potentially resulting in missed allergies, medication interactions, or
    duplicate tests ordered. Unfortunately, there is no accurate or
    consistent way for surgeons to link patients to their health
    information across the continuum of care, due to long-standing federal
    statutory language. The language, located in Section 510 of the LHHS
    Appropriations bill, has prohibited HHS from spending any federal
    dollars to promulgate or adopt a Unique Patient Identifier, thereby
    hampering public-private sector collaborative efforts to advance a
    nationwide patient identification strategy that is cost-effective,
    scalable, secure, and prioritizes patient privacy.
        Removing the language in Section 510 will provide HHS with the
    ability to evaluate a range of patient identification solutions and
    enable the agency to work with the private sector to explore potential
    challenges. ACS supports removal of Section 510 from the Labor-HHS
    appropriations bill that prohibits HHS from spending any federal
    dollars to promulgate or adopt patient identification strategies.
        Thank you for your consideration of our requests. Please contact
    Amelia Suermann, ACS Congressional Lobbyist, at asuermann@facs.org if
    you have any questions or would like additional information.
                                     ______

      Prepared Statement of the American Educational Research Association
        Chair Murray, Ranking Member Blunt, and Members of the
    Subcommittee, thank you for the opportunity to submit written testimony
    on behalf of the American Educational Research Association (AERA). AERA
    recommends that the Institute of Education Sciences (IES) within the
    Department of Education receive $737.47 million for FY 2022, aligned
    with the top line included in the president's budget request. This
    recommendation is also consistent with the request from the Friends of
    IES coalition, for which we are a leading member. In addition, AERA
    recommends the base funding level of $46.1 billion for the National
    Institutes of Health (NIH) in fiscal year 2022, in support of important
    research in the Eunice Kennedy Shriver National Institute of Child
    Health and Human Development (NICHD) and the Office of Behavioral and
    Social Science Research (OBSSR).
        AERA is the major national scientific association of 25,000
    faculty, researchers, graduate students, and other distinguished
    professionals dedicated to advancing knowledge about education,
    encouraging scholarly inquiry related to education, and promoting the
    use of research to improve education and serve the public good. Our
    members, as well as state and federal policymakers and practitioners,
    rely on IES to provide and support reliable education statistics, data,
    research, and evaluations.
        IES is the independent and nonpartisan statistics, research, and
    evaluation arm of the U.S. Department of Education charged with
    supporting and disseminating rigorous scientific evidence on which to
    ground education policy and practice. Located within the Department of
    Education to provide essential education data, statistics, and science
    to the Department, the federal government, and the nation, the mission
    of IES is analogous to other prominent federal research agencies such
    as the National Science Foundation and the National Institutes of
    Health.
        We appreciate the increase to IES appropriations over the past few
    fiscal years and the funding provided in the American Rescue Plan Act,
    the latter of which will go toward needed resources in data and special
    education research to understand how schools will work to address
    learning gaps due to lost instructional time. Throughout the pandemic,
    IES has served as an important resource in providing information about
    distance learning; pursuing interventions to address socioemotional
    needs; and collecting salient data on schools offering remote, hybrid,
    and in-person learning. The increased demand for evidence-based
    programs since the onset of COVID-19 and the need to address potential
    learning recovery only further speaks to the priority importance of
    support for education research and statistics at IES to inform policy
    and practice.
        We see numerous examples of bipartisan support for scientific
    research and evidence-based decision making. The Department of
    Education is implementing the provisions of the bipartisan Foundations
    of Evidence-Based Policymaking Act, which directs federal agencies to
    leverage data and evaluations to inform policy decisions. A bipartisan
    bill that has been introduced to inform the forthcoming reauthorization
    of the Workforce Investment and Opportunity Act (WIOA) would call for
    investment in research in adult education. The data and research
    infrastructure to build evidence for improving educational outcomes
    require additional funding necessitating action by your committee.
        Since IES was created in 2002, it has made visible scientifically-
    based contributions to the progress of education that are used in
    classrooms across the country. For example, IES has funded research on
    multi-tiered systems of support, including positive behavior
    interventions and supports, that have been highlighted in the
    Department of Education's COVID-19 handbook to guide school reopening.
    Several webinars and resources produced by the Regional Educational
    Laboratories highlighting evidence-based practices for educators,
    school support staff, and school leaders are incorporated in the Safer
    Schools and Campuses Best Practices Clearinghouse. As the nation
    continues to emerge from the pandemic, this is a critical time to
    invest in education research to produce essential knowledge about
    teaching and learning across all levels of education as well as to
    identify lessons learned that can foster educational innovations.
        States are increasingly seeking ways to determine the long-term
    impact of state policies, including in education, and they turn to
    information in their Statewide Longitudinal Data Systems (SLDS).
    Initially developed to help states measure accountability, data has
    transformed from a hammer to a flashlight, increasing understanding
    about student performance and teacher effectiveness. To date, IES has
    been unable to meet the state demand for SLDS grants. For the FY 2019
    competition, 28 of 44 states that submitted applications received
    grants, although the average amount of grants was reduced by half
    compared with those awarded in FY 2015. Growing interest in using data
    from these systems, including an IES research competition encouraging
    the research use of these data for examining longitudinal impacts of
    state policies, show the importance of continuing investment in these
    data systems.
        AERA also is concerned with the reduced staff capacity at IES, and
    I would like to draw particular attention to the decades-long staff
    attrition at the National Center for Education Statistics (NCES). As
    the second-oldest principal federal statistical agency in the United
    States, NCES provides objective, nonbiased data on a wide range of
    education indicators, including information on teacher salaries, the
    amount of loans taken out by undergraduate students, and the
    participation of students in English language learner programs. NCES
    staff are also responsible for the development and administration of
    the National Assessment of Educational Progress, detailing longitudinal
    trends in student achievement. In recognizing the need for NCES to
    produce accurate, reliable, and trustworthy data, we encourage the
    subcommittee to ensure that NCES and IES have the appropriate level of
    staff in order to effectively carry out their missions in the Program
    Management line.
        In addition to IES, AERA recommends $46.1 billion for the National
    Institutes of Health (NIH) in fiscal year 2022 with proportional
    increases for the Eunice Kennedy Shriver National Institute of Child
    Health and Human Development (NICHD) and the Office of Behavioral and
    Social Science Research (OBSSR). NICHD supports research at the
    intersection of health and education, including ways to foster health
    literacy, potential influencers of family environments on child well-
    being and cognitive development, and interventions for students with
    learning disabilities who struggle with reading. Investment in NICHD
    will allow the institute to continue research to both increase
    understanding how best to support executive functioning, and to bolster
    the professional development of early career researchers. OBSSR plays
    an important role in coordinating and co-funding behavioral and social
    science research across NIH that contribute to the understanding of
    influences on health and interventions to improve health outcomes.
    OBSSR has long recognized the interdependence of education and health
    and in terms of prevention, intervention, and the health-risk
    consequences of a lack of or limited educational exposure.
        Thank you for the opportunity to submit written testimony in
    support of $737 million for IES and $46.1 billion in base level funding
    for NIH in fiscal year 2022. AERA welcomes working with you and your
    subcommittee on strengthening investments in essential research, data,
    and statistics related to education and learning.

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

      Prepared Statement of the American Foundation for Suicide Prevention
        The American Foundation for Suicide Prevention (AFSP), the nation's
    largest non-profit dedicated to saving lives and bringing hope to those
    effected by suicide is submitting testimony on behalf of our over 30
    thousand volunteer Field Advocates nationwide. AFSP has Chapters in all
    50 states and sponsors a variety of community-based programming across
    the country each year.
        The following testimony outlines suicide in the United States and
    AFSP's recommendations to the Subcommittee for Fiscal Year 2022.
                    suicide: a national public health crisis
        Suicide is the second leading cause of death for ages 10-34 in the
    United States and in 2019 was the 10th leading cause of death.\1\
    Provisional 2020 suicide death data from the CDC show that deaths by
    suicide in the U.S. declined from 47,511 to 44,834 (5.6%) between 2019
    and 2020.\2\ Suicide reportedly moved from the tenth to the eleventh
    leading cause of death as COVID-19 became the third leading cause of
    death in 2020.\3\ While the decreases in suicide deaths are promising
    and the curve may be beginning to shift downward, efforts must continue
    to be expanded and built upon to ensure there are mental health
    resources as the pandemic continues to shift and impact different
    populations disproportionately. Historically, suicide rates have
    initially gone down during some periods of wartime and other disasters
    and have shown mixed results during or after previous epidemics.
    Provisional 2020 data appear consistent with this trend. It is
    possible, though not pre-determined, that we could experience an
    increase in suicide risk as the immediate COVID-19 threat lessens and
    in the aftermath period if community cohesion diminishes and if less
    attention is paid to intentional social connections, proactive
    resilience and mental health self-care, and the importance at key times
    of engaging in mental health treatment and crisis care. Helping those
    who are struggling with basic needs can also mitigate suicide risk.
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/injury/wisqars/index.html.
        \2\ https://jamanetwork.com/journals/jama/fullarticle/
    2778234?utm_source=newsletter&utm_
    medium=email&utm_campaign=newsletter_axiosvitals&stream=top.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        While provisional 2020 mortality data show a declining rate of
    suicide for the overall U.S. population, we do not yet have the full
    picture as to how this translates to geographic areas within states or
    specific populations. The pandemic has had a disproportionate impact on
    certain populations; there are concerning signals of increasing suicide
    rates in some non-White populations during the pandemic, e.g., in
    Maryland and Connecticut.\4\ It may be a year or longer until data and
    research are available to understand the entire impact of COVID-19 on
    suicide.
    ---------------------------------------------------------------------------
        \4\ https://jamanetwork.com/journals/jamapsychiatry/fullarticle/
    2774107.
    ---------------------------------------------------------------------------
        Furthermore, during the COVID-19 pandemic, data show 50-70% of the
    population report elevations in experiences of depression, anxiety,
    loneliness, trauma, loss, grief and increased substance use.\5\
    Numerous studies have kept abreast of the nation's mental health
    experiences and suffering during the pandemic through various
    mechanisms such as the CDC Household Pulse Survey during COVID which
    has been surveying 60-90,000 Americans adults every 3-5 weeks during
    the pandemic. The portion of the American public experiencing anxiety,
    isolation, symptoms of depression, insomnia and increased substance use
    has been rising.
    ---------------------------------------------------------------------------
        \5\ https://www.cdc.gov/nchs/covid19/pulse/mental-health-care.htm.
    ---------------------------------------------------------------------------
        As the pandemic progressed during 2020, the proportion of
    respondents who reported detrimental effects on their mental health
    continued to rise--39% in May 2020 and 53% in July 2020. It was only
    until just recently, in March 2021, that we are seeing the first
    decreases in distress--8-10 percentage points--for depression and
    anxiety across age and demographic groups.\6\ However, the CDC reported
    on June 18, 2021 there was a 51 percent rise in suspected suicide
    attempts among girls ages 12-17 from February 2021 to March 2021
    compared to the same time period in 2019, prior to the pandemic.\7\
    While this does not mean that there was necessarily an uptick in
    suicide deaths, the statistic is certainly alarming, and we do not yet
    have race and ethnicity data for when this study was conducted.
    ---------------------------------------------------------------------------
        \6\ https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm.
        \7\ https://www.cdc.gov/mmwr/volumes/70/wr/
    mm7024e1.htm?s_cid=mm7024e1_w.
    ---------------------------------------------------------------------------
                                recommendations
        As instances of suicidal ideation and attempts increase, funding
    and resources must meet the needs of those most at risk. Therefore,
    AFSP is advocating for Fiscal Year 2022 funding increases to ensure
    that communities are adequately prepared to respond to crisis,
    implement community-based programming for those most at risk, collect
    data to improve prevention, and to invest in research to meet patients
    where they are, in healthcare settings. We thank Chairwoman Murray and
    Ranking Member Blunt for the opportunity to share our below priorities.
    Substance Abuse and Mental Health Services Administration (SAMHSA)
        The National Suicide Prevention Lifeline coordinates a network of
    over 180 crisis centers across the United States by providing 24/7 free
    and confidential suicide prevention and crisis intervention services
    for people in distress, their loved ones, and best practices for
    professionals. The Lifeline routes calls from anywhere in the country
    to a network of certified local crisis centers that can then link
    callers to local emergency, mental health, and social services
    resources. Last year, over 2.5 million calls were made to the Lifeline,
    resulting in longer wait times and a strain on local crisis centers.
    Additional funding is needed to ensure that the Lifeline is adequately
    equipped to handle increasing call and outreach volume.
        We request at least $102 million for the National Suicide
    Prevention Lifeline, as included in the President's Fiscal Year 2022
    Budget Request. Following passage of the National Suicide Hotline
    Designation Act in September 2020, the easily accessible 9-8-8 dialing
    code was designated to replace the Lifeline's current 1-800 number. 9-
    8-8 will be the new easy to remember and universal phone number for
    suicide prevention and mental health crisis by July 2022. This presents
    an urgent need to ensure that local crisis call centers and the
    national infrastructure for the Lifeline are prepared for the
    anticipated increase in calls and strain on an already overburdened
    system. Additional funding to the Lifeline would facilitate the
    development of a unified call center platform and data analytics,
    telecom costs for each contact and routing to local crisis centers,
    provision of specialized services at national back up centers for
    calls, chat, and text, targeted funding for call centers and national
    backup centers, multi-lingual assistance, quality assurance and
    training standards, and supporting partnership outreach. Based on an
    initial analysis from Vibrant Emotional Health, the current
    administrator of the Lifeline, year one implementation estimates for
    988 could grow to as much as $240 million. It is expected that SAMHSA
    and the Department of Veterans Affairs (VA) will jointly release a
    final cost estimate report to Congress regarding Lifeline funding needs
    later in the summer of 2021 which will help better inform the critical
    resource needs that are urgently needed. We hope the Appropriations
    Committee will work with us to adequately address this critical
    resource, in Fiscal Year 2022 and beyond.
    The Centers for Disease Control (CDC)
        As the nation's leading health protection agency, it is a natural
    fit that the CDC expand their suicide prevention efforts. Through
    investing further in the CDC's new suicide prevention line, there is a
    more holistic approach to suicide prevention programming beyond the
    work that SAMHSA and the National Institutes of Health (NIH) are
    implementing, evaluating, and researching. There is a need to make
    strategic investments that will help save lives and reduce the suicide
    rate. Therefore, AFSP advocates for $36 million for Suicide Prevention
    initiatives at CDC's Center for Injury Prevention and Control. Created
    in Fiscal Year 2020, the Congress has generously provided $22 million
    for the program over the last two fiscal years. Enhanced funding in
    Fiscal Year 2022 will help expand these community-based grants into
    approximately 25 states. The grants are used to implement and evaluate
    a comprehensive public health approach to suicide prevention, with
    attention to vulnerable populations, such as Veterans, tribal and rural
    communities, LGBTQ, or homeless citizens. These groups account for a
    significant proportion of the suicide burden and have suicide rates
    greater than the general population. A key outcome of this funding is a
    10% reduction in suicide and suicide attempts among vulnerable
    populations. Through these cooperative agreements, CDC aims to build a
    national program that will help reverse increasing suicide trends
    across our nation and contribute to the national goal of reducing
    suicide by 20% by 2025.
        Data collection as it relates to suicide deaths is an important
    piece of preventing future deaths and implementing prevention
    strategies within our communities. AFSP advocates for a $10 million
    increase for the National Violent Death Reporting System (NVDRS) as
    included in the President's Fiscal Year 2022 Budget Request. NVDRS is
    the most comprehensive database on circumstances surrounding violent
    deaths in the U.S., including suicide. Since the program's inception in
    2002, NVDRS has grown to a nationwide program with funding to support
    implementation in all 50 states and select territories. Yet, the
    current funding is not sufficient for long-term program success. States
    are clamoring for additional resources to address various
    implementation challenges and support investments in program
    infrastructure, as well as program growth and innovation. NVDRS
    stakeholder organizations support a funding level of $50 million by FY
    2027 to strengthen the program.
    National Institute of Mental Health
        As the largest private funder of suicide prevention research in the
    US, AFSP continues to advocate for increased federal funding and
    prioritization of suicide prevention research. The National Institutes
    for Health and more specifically the National Institute of Mental
    Health (NIMH) play a key role in advancing the Nation's suicide
    prevention research priorities. AFSP encourages the continued
    implementation of the Prioritized Research Agenda for Suicide
    Prevention released by the National Action Alliance for Suicide
    Prevention, that is meant to advance the National Strategy for Suicide
    Prevention. To note, more recently, in January 2021, there was a
    Surgeon Generals Call to Action to Implement the National Strategy for
    Suicide Prevention, which further outlines the six actions and
    associated strategies that will move the U.S. further towards
    implementation of the National Strategy. Overall imparting the need for
    increased federal investment in suicide prevention research and
    programmatic needs.
        As the COVID-19 pandemic shifts, there is a need to ensure that
    when individuals are visiting the Emergency Department or their primary
    care physician that screening tools and resources meet them, so if they
    are in need of mental health and crisis services, they are able to
    receive comprehensive care. This is an especially prominent area for
    necessary research as, up to 45 percent of people who die by suicide
    visit their primary care physician in the month prior to their
    death.\8\ AFSP recommends the following report language for Fiscal Year
    2022, to place a special emphasis on the primary care setting, given
    the great number of Americans seeking mental health care from their
    primary care physician.
    ---------------------------------------------------------------------------
        \8\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146379/
    #::text=A%20review%20of%20
    studies%20analyzing,the%20month%20before%20their%20death.&text=Only%2020
    %25%20 saw%20a%20mental,10%20in%20the%20preceding%20month.
    ---------------------------------------------------------------------------
         proposed fiscal year 2022 report language: suicide prevention
        The Committee is encouraged that 2019 was the first year in two
    decades in which the suicide rate decreased. But death by suicide
    remains the tenth leading cause of death in the United States, and the
    Committee remains committed to providing the resources necessary to
    address this alarming crisis. The Committee commends NIMH for
    consistently expanding resources for suicide screening and prevention
    research over the last four fiscal years and strongly encourages the
    Institute to provide additional increases for this purpose in fiscal
    year 2022, with special emphasis on producing models that are
    interpretable, scalable, and practical for clinical implementation,
    including utilization of healthcare, education and criminal justice
    systems that serve populations at risk. In addition, the Committee
    encourages NIMH to prioritize research efforts related to primary care
    settings to evaluate suicide prevention interventions, strategies, and
    programs, including assessments of the effects of the COVID-19
    epidemic. The Committee requests that NIMH provide an update on these
    efforts in the fiscal year 2023 Congressional Justification.
        The American Foundation for Suicide Prevention is grateful for the
    Subcommittee's continued support of suicide prevention efforts and
    looks forward to additional conversations about the vital resources
    needed to help save lives and prevent suicide. Please do not hesitate
    to contact Natalie Tietjen, Manager of Federal Policy
    (ntietjen@afsp.org) on my staff with additional questions or
    clarifications.

        [This statement was submitted by Laurel Stine, JD, MA, Senior Vice
    President, Public Policy, American Foundation for Suicide Prevention.]
                                     ______

       Prepared Statement of the American Gastroenterological Association
                           national cancer institute
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee, I would like to start by thanking you for the opportunity
    to submit testimony on the U.S. Department of Health and Human Services
    (HHS) fiscal year (FY) 2022 appropriations bill. I am Dr. Fola May, and
    I am an associate professor of medicine at the University of
    California, Los Angeles, and researcher at the UCLA Center for Cancer
    Prevention Control Research (CPCR) and UCLA Kaiser Permanente Center
    for Health Equity. I am submitting testimony on behalf of the American
    Gastroenterological Association (AGA). The AGA was founded in 1897, and
    today, it has expanded its membership to include more than 16,000
    professionals who are dedicated to the advancement of science,
    practice, and research in the field of gastroenterology. We want to
    first thank you for your ongoing bipartisan investment in the National
    Institutes of Health (NIH). We respectfully request the subcommittee to
    support our FY 2022 NIH funding recommendation of at least $46.111
    billion, a $3.177 billion increase over the comparable FY 2021 funding
    level for the NIH, which would allow for the NIH's base budget to keep
    pace with the biomedical research and development price index of 2.3 %
    and allow meaningful growth of 5%. Additionally, we request report
    language to support research to better understand the impact of COVID-
    19 on colorectal cancer disparities.
    Colorectal Cancer Incidence
        Colorectal cancer (CRC) remains the second leading cause of cancer
    deaths in the United States. The American Cancer Society (ACS) \1\
    estimates 149,500 new cases of CRC and 52,980 CRC-related deaths in the
    U.S. in 2021. The ACS 2021 cancer report also shows an emerging trend
    of CRC in a younger demographic; The data shows a 2% increase in CRC in
    individuals under 50 years.
    ---------------------------------------------------------------------------
        \1\ American Cancer Society. Cancer Facts & Figures 2021. Atlanta:
    American Cancer Society; 2021. https://www.cancer.org/content/dam/
    cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-
    and-figures/2021/cancer-facts-and-figures-2021.pdf.
    ---------------------------------------------------------------------------
        CRC has a higher impact on communities of color. Specifically,
    Black, and Native American individuals have the highest incidence of
    CRC; Black Americans have the highest rate of CRC-related death, and
    Latinos have CRC screening rates far below White and Black
    Americans.\2\
    ---------------------------------------------------------------------------
        \2\ Balzora, S., Issaka, R. B., Anyane-Yeboa, A., Gray, D. M., 2nd,
    & May, F. P. (2020). Impact of COVID-19 on colorectal cancer
    disparities and the way forward. Gastrointestinal endoscopy, 92(4),
    946-950. https://doi.org/10.1016/j.gie.2020.06.042.
    ---------------------------------------------------------------------------
    COVID-19's Impact on CRC Screenings
        Screening can prevent colorectal cancer deaths by detecting
    precancerous polyps early, allowing for early treatment and full
    recovery. Unfortunately, as with other health care services, the COVID-
    19 pandemic significantly reduced the volume of preventive screenings.
    According to a report,\3\ CRC screenings were estimated to have dropped
    by 86% in the first few months of the pandemic and have not yet fully
    recovered.
    ---------------------------------------------------------------------------
        \3\ EPIC Health Research Network. Delayed Cancer Screenings-A
    Second Look. Available at: https://ehrn.org/articles/delayed-cancer-
    screenings-a-second-look/. pdf. Accessed May 17, 2021.
    ---------------------------------------------------------------------------
        With the drop in screenings, delay in diagnosis, lack of access to
    care, abandonment of care, interruption or alteration in treatment and
    job loss resulting in lapsed health insurance coverage etc., cancer
    mortality rates across numerous cancers have increased. The National
    Cancer Institute (NCI) estimates a 1% increase in deaths from breast
    and colon cancer over the next 10 years, which equates to an additional
    10,000 deaths due to the pandemic's impact on screening and
    treatment.\4\
    ---------------------------------------------------------------------------
        \4\ Sharpless, N. E. (2020). COVID-19 and cancer. https://tcjl.com/
    wp-content/uploads/2020/06/Science-COVID-19-and-Cancer-editorial-
    copy.pdf.
    ---------------------------------------------------------------------------
        As communities across the U.S. fight the pandemic locally,
    community-based health care facilities that typically would offer
    cancer screenings and other preventative health services have
    reallocated their limited resources and shifted workforce deployment to
    address the pandemic. This reduction in cancer screening resources has
    heightened the ongoing health care access issues that impact vulnerable
    populations, and their worsening clinical outcomes. Specifically,
    racial, and ethnic minority communities, who, including before the
    pandemic, have lower rates of CRC screening and higher rates of
    incidence and mortality from CRC.
    Health disparities and CRC
        Colorectal cancer (CRC) during the pandemic places a spotlight on
    the health disparities and inequities stemming from social determinants
    of health that continue to plague medically underserved populations.
    COVID-19 cases, hospitalizations and deaths were highest among
    communities of color, especially those with comorbidities like obesity,
    diabetes, and asthma. Although screening rates are resuming, the rates
    in minority communities likely still lag due to access, financial,
    transportation and other socioeconomic factors exacerbated by the
    pandemic.
        The NIH resources spent on COVID-19 and health disparities have
    been essential to better understand the long-term impact of the
    pandemic on the medically underserved population in the U.S. To improve
    CRC screening, prevention and treatment, AGA recognizes the continued
    need to collect systemic data on the short and long-term outcomes of
    COVID-19 and CRC disparities. Therefore, AGA urges the subcommittee to
    include the following report language that would allow NIH to continue
    its support of studies focused on CRC disparities heightened by the
    COVID-19 pandemic.
        COVID-19 Pandemic Impact on Colorectal Cancer Disparities.--Given
    the impact that screening can have on reducing mortality and morbidity
    in colorectal cancer (CRC), the Committee encourages the NIH to study
    the impact of the COVID-19 pandemic on the incidence of CRC in minority
    communities. The committee is hopeful that such information will
    provide policymakers with a better understanding of the effects on
    minority communities and help develop strategies to address barriers to
    screening and reduce health inequities and cancer deaths.
        On behalf of AGA, its members, and the GI community, I would like
    to thank you for your consideration of this request. If you have any
    questions, please contact Kathleen Teixeira, Vice President of
    Government Affairs, at kteixeira@gastro.org.

        [This statement was submitted by Dr. Fola May, MD, PhD, MPhil,
    Associate
    Professor of Medicine, University of California, Los Angeles.]
                                     ______

              Prepared Statement of the American Geophysical Union
        The American Geophysical Union (AGU), a non-profit, non-partisan
    scientific society, appreciates the opportunity to submit testimony
    regarding the fiscal year (FY) 2022 appropriation for the National
    Institute of Environmental Health Sciences (NIEHS). AGU, on behalf of
    its community of 130,000 Earth and space scientists, respectfully
    requests that the 117th Congress appropriate $875 million for the
    NIEHS. AGU's appropriations request takes into consideration any
    previous budget cuts is driven by the need for significant investment
    in federal research and development to ensure that the U.S. remains at
    the forefront of research and innovation.\1\
    ---------------------------------------------------------------------------
        \1\ This amount of growth is recommended by the Innovation: An
    American Imperative statement, which was authored by nine large U.S.
    corporations and endorsed by over 500 leading industry, higher
    education, science, and engineering organizations from across the 50
    states. https://innovation-imperative.herokuapp.com/index.html.
    ---------------------------------------------------------------------------
        Under the umbrella of the National Institutes of Health (NIH), the
    NIEHS conducts essential, innovative research that advances our
    understanding of the effects of environmental changes or exposures on
    human health and disease in the U.S. and across the globe. Through
    NIEHS research, policymakers have access to vital, unbiased science
    that is necessary for making informed decisions when addressing public
    health issues. A few examples of the NIEHS's invaluable work are
    provided below.
    Improving Disaster Response, Reducing Health Impacts, & Preventing
            Future Harm
        The NIH Disaster Research Response program, launched by the NIEHS
    and the National Library of Medicine, helps to address the ongoing need
    for time-sensitive research in the aftermath of disasters, such as
    hurricanes, wildfires, oil spills, and public health crises. Such
    research helps scientists, government agencies, and communities better
    understand immediate environmental exposures and injury risks,
    potential short-term and long-term health impacts, the effectiveness of
    health response efforts and environmental cleanup efforts, as well as
    factors affecting post-disaster recovery and resiliency to future
    events. To support timely gathering of the environmental and toxicology
    data needed, the program has readily available research protocols, data
    collections tools, and training resources.\2\
    ---------------------------------------------------------------------------
        \2\ See, NIH Disaster Research Response Program (DR2), https://
    dr2.nlm.nih.gov/.
    ---------------------------------------------------------------------------
    Increasing Knowledge of Health Effects Related to PFAS Exposure
        The NIEHS continues to be at the forefront of research on
    perfluoroalkyl and polyfluoroalkyl substances (PFAS). A couple of years
    ago, at least 610 locations in 43 states were known to be affected by
    PFAS contamination, which included drinking water systems serving an
    estimated 19 million people.\3\ Research into the possible health
    impacts of PFAS chemicals exposure has already unmasked many links to
    adverse health outcomes. For example, research has revealed that PFAS
    exposure may increase a woman's risk of pregnancy complications.\4\
    However, there is still much to understand regarding the effects of
    PFAS exposure, which is why the NIEHS continues to conduct research and
    award grants to external organizations across the nation.
    ---------------------------------------------------------------------------
        \3\ Based on data analysis by the Environmental Working Group and
    Northeastern University. Walker, B., (6 May 2019). Mapping the PFAS
    contamination crisis: New data show 610 sites in 43 states, EWG News
    and Analysis, https://www.ewg.org/news-and-analysis/2019/04/mapping-
    pfas-contamination-crisis-new-data-show-610-sites-43-states.
        \4\ Broadfoot, M., (February 2020). Replacement chemicals may put
    pregnancies at risk. Environmental Factor, NIEHS Newsletter, https://
    factor.niehs.nih.gov/2020/2/science-highlights/replacement/index.htm.
    ---------------------------------------------------------------------------
    Growing the Environmental Health Science Workforce
        To further expand the world's understanding of environmental
    impacts on human health and disease and support interdisciplinary
    scientific research, the NIEHS provides training and educational
    opportunities for students of all ages-from the high school and
    undergraduate levels to graduate students and faculty. For example, the
    NIEHS Medical Student Research Fellowship program provides medical
    students an opportunity to train in environmental health-related
    research for a year at the NIEHS.\5\ The NIEHS also awards NIH Summer
    Research Experience Program (R25) grants that give high school and
    college students and science teachers an opportunity to gain valuable
    research experience at a higher education institution during the
    summer.\6\
    ---------------------------------------------------------------------------
        \5\ See, NIEHS Medical Student Research Fellowships, https://
    www.niehs.nih.gov/careers/research/med-students/index.cfm.
        \6\ See, the NIH Summer Research Experience Programs (R25), https:/
    /www.niehs.nih.gov/research/supported/irt/summer_research/index.cfm.
    ---------------------------------------------------------------------------
                                   conclusion
        At a time when our nation is recovering and has many pressing
    priorities that need to be addressed, the future of the U.S. will be
    strengthened by strong and sustained investments in the full scope of
    our research enterprise-including new, innovative research regarding
    the impact of environmental factors on human health generated by the
    NIEHS. AGU appreciates the Subcommittee's leadership in this area, as
    well as the opportunity to submit this testimony. Thank you for your
    thoughtful consideration of our request.

        [This statement was submitted by Michael Villafranca, Senior
    Specialist, Science Policy & Government Relations.]
                                     ______

             Prepared Statement of the American Geriatrics Society
        The American Geriatrics Society (AGS) greatly appreciates the
    opportunity to submit this testimony. The AGS is a national non-profit
    organization of nearly 6,000 geriatrics healthcare professionals and
    basic and clinical researchers dedicated to improving the health,
    independence, and quality of life of all older Americans. As the
    Subcommittee works on its fiscal year (FY) 2021 Labor, Health and Human
    Services, and Related Agencies Appropriations Bill, we ask that you
    prioritize funding for the geriatrics education and training programs
    under Title VII of the Public Health Service (PHS) Act, and for aging
    research within the National Institutes of Health (NIH) and National
    Institute on Aging (NIA).
        We are appreciative of your ongoing support of the Title VII
    Geriatrics Health Professions Programs at the Health Resources and
    Services Agency (HRSA), which includes the Geriatrics Workforce
    Enhancement Program (GWEP) and Geriatrics Academic Career Award (GACA)
    program. However, the AGS believes it is urgent that we increase the
    educational and training opportunities in geriatrics and gerontology
    and ensure that HRSA receives the funding expansion necessary for these
    critically important programs for the care and health of older adults.
        We ask that the Subcommittee consider the following funding levels
    for these programs in FY 2022:
      --At least $105.7 million to support the GWEP and GACA program (PHS
            Act Title VII, Sections 750 and 753(a))
      --An increase of no less than $3.3 billion over the enacted FY 2021
            level in the FY 2022 budget for total spending at NIH for
            current institutes and operations; a minimum increase of $500
            million to invest in biomedical, behavioral, and social
            sciences aging research efforts across NIH; and a minimum
            increase of $289 million for research on Alzheimer's disease
            and related dementias over the enacted FY 2021 level in the FY
            2022 budget
        Sustained and enhanced federal investment in these initiatives is
    essential to delivering high-quality, better coordinated, efficient,
    and cost-effective care to our older Americans whose numbers are
    projected to increase dramatically in the coming years. According to
    the U.S. Census Bureau, the number of people age 65 and older is
    projected to more than double from 54.1 million today \1\ to more than
    94 million by 2060,\2\ while those 85 and older is projected to more
    than triple from 6.4 million today to 19 million by 2060.\3\ As our
    aging population increases, so too will the prevalence of diseases
    disproportionately affecting older people--most notably Alzheimer's
    disease and related dementias (including vascular, Lewy body, and
    frontotemporal dementia)--and the economic burden associated with these
    diseases.
    ---------------------------------------------------------------------------
        \1\ U.S. Census Bureau. 2019 American Community Survey 1-Year
    Estimates Subject Tables. Available at https://data.census.gov/cedsci/
    table?q=S0101&tid=ACSST1Y2019.S0101&hide
    Preview=false.
        \2\ U.S. Census Bureau. An Aging Nation: Projected Number of
    Children and Older Adults. Available at https://www.census.gov/library/
    visualizations/2018/comm/historic-first.html. Published March 13, 2018.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        To ensure that our nation is prepared to meet the unique healthcare
    needs of this rapidly growing population, we request that Congress
    provide additional investments necessary to expand and enhance the
    geriatrics workforce, which is an integral component of the primary
    care workforce, and to foster groundbreaking medical research.
             programs to train geriatrics healthcare professionals
    Geriatrics Workforce Enhancement Program and Geriatrics Academic Career
            Award Program (at least $105.7 million)
        Our healthcare workforce receives little, if any, training in
    geriatric principles,\4\ which leaves us ill-prepared to care for older
    Americans as health needs evolve, especially during the current COVID-
    19 public health emergency. With our nation continuing to face a severe
    shortage of geriatrics healthcare providers and academics with the
    expertise to train these providers, the AGS believes it is urgent that
    we increase the number of educational and training opportunities in
    geriatrics and gerontology. The requested increase in funding over FY
    2021 levels would help ensure that HRSA receives the funding necessary
    to expand these critically important programs commensurate with the
    increasing need.
    ---------------------------------------------------------------------------
        \4\ Only 3 percent of medical students take even one class in
    geriatric medicine and fewer than 1 percent of RNs, pharmacists,
    physician assistances and physical therapists are certified in
    geriatrics or gerontology. Yet estimates are that by 2030, 3.5 million
    additional health care professionals and direct-care workers will be
    needed to care for older adults. 2018 Issue Brief, Eldercare Workforce
    Alliance, Available at https://eldercareworkforce.org/wp-content/
    uploads/2018/03/GWEP_OnePager_v2.pdf.
    ---------------------------------------------------------------------------
        The GWEP is currently the only federal program designed to increase
    the number of providers, in a variety of disciplines, with the skills
    and training to care for older adults. The GWEP awardees educate and
    engage the broader frontline workforce, including family caregivers,
    and focus on opportunities to improve the quality of care delivered to
    older adults, particularly in underserved and rural areas. Due to
    GWEPs' partnerships with primary care and community-based
    organizations, GWEPs are uniquely positioned to rapidly address the
    needs of older adults and their caregivers. The GWEP was launched in
    2015 by HRSA with 44 three-year grants provided to awardees in 29
    states. In 2019, HRSA funded a second cohort of 48 GWEPs across 35
    states and two territories (Guam and Puerto Rico) and provided
    extension grants to 15 former GWEP awardees.
        The GACA program is an essential complement to the GWEP. GACAs
    ensure we can equip early-career clinician educators to become leaders
    in geriatrics education and research. It is the only federal program
    designed to increase the number of faculty with geriatrics expertise in
    a variety of disciplines. The program was eliminated in 2015 through a
    consolidation of several training programs. However, the program was
    reestablished in November 2018 when HRSA released a funding opportunity
    indicating their intention to fund 26 GACAs for four years starting
    September 1, 2019. Since 1998, original GACA recipients have trained as
    many as 65,000 colleagues in geriatrics expertise and have contributed
    to geriatrics education, research, and leadership across the U.S.
        Most recently, the GWEPs and GACAs have been an asset for states as
    many states and localities grapple with the rollout of the COVID-19
    vaccine and address vaccine hesitancy. GWEPs have been staffing call
    lines to assist older adults to register for the vaccine, advising
    local authorities on making the sign-up websites age-friendly, and
    working with health systems to participate in the rollout and outreach
    to vulnerable and hard-to-reach populations, preventing widening the
    health disparity gap exacerbated by the pandemic. Looking forward,
    these programs will be critical in providing assistance for proactive
    public health planning with their geriatrics expertise and knowledge of
    long-term care and can help ensure states and local governments have
    improved plans for older adults in disaster preparedness for future
    pandemics and natural disasters. Furthermore, as the U.S. population
    rapidly ages, access to a well-trained workforce and appropriate care
    for medically complex older adults is imperative to maintaining the
    health and quality of life for this growing segment of the nation's
    population.
        To address this issue, we ask the Subcommittee to provide a FY 2022
    appropriation of at least $105.7 million for the GWEP and GACA program.
    This increase in funding over FY 2021 levels would help ensure that
    HRSA receives the funding necessary to carry these critically important
    programs forward. Additional funding will also allow HRSA to expand the
    number of GWEPs and GACAs and move towards closing the current
    geographic and demographic gaps in geriatrics workforce training. As
    laid out in President Biden's American Jobs Plan, the infrastructure of
    care in the U.S. needs substantial investments so that access to long-
    term services and supports is expanded while the healthcare workforce
    is adequately supported and prepared to care for us all as we age.
                          research funding initiatives
    National Institutes of Health/National Institute on Aging (additional
            $500 million for aging research efforts and a minimum increase
            of $289 million for Alzheimer's disease and related dementias
            research)
        The institutes that make up the NIH, and specifically the NIA, lead
    the national scientific effort to understand the nature of aging and to
    extend the healthy, active years of life. As a member of the Friends of
    the NIA (FoNIA), a broad-based coalition of aging, disease, research,
    and patient groups committed to the advancement of medical research
    that affects millions of older Americans--the AGS urges you to include
    an increase of at least $500 million in the FY 2022 budget for
    biomedical, behavioral, and social sciences aging research efforts
    across NIH and a minimum increase of $289 million for research on
    Alzheimer's disease and related dementias over the enacted FY 2021
    level.
        The federal government spends a significant and increasing amount
    of funds on healthcare costs associated with age-related diseases. By
    2050, for example, the number of people age 65 and older affected by
    dementia is estimated to reach 12.7 million cases--nearly double the
    number in 2021--and is projected to cost $355 billion which does not
    include the $256.7 billion in unpaid caregiving by family and
    friends.\5\ Further, chronic diseases related to aging, such as
    diabetes, heart disease, and cancer continue to afflict 80 percent of
    people age 65 and older \6\ and account for more than 75 percent of
    Medicare and other federal health expenditures.\7\ Continued and
    increased federal investments in scientific research will ensure that
    the NIH and NIA have the resources to conduct groundbreaking research
    related to the aging process, foster the development of research and
    clinical scientists in aging, provide research resources, and
    communicate information about aging and advances in research on aging.
    ---------------------------------------------------------------------------
        \5\ Alzheimer's Association. 2021 Alzheimer's Disease Facts and
    Figures. Alzheimers Dement. 2021; 17(3):327-406. https://doi.org/
    10.1002/alz.12328.
        \6\ National Prevention Council. Healthy Aging in Action: Advancing
    the National Prevention Strategy. Available at https://www.cdc.gov/
    aging/pdf/healthy-aging-in-action508.pdf. Published November 2016.
        \7\ Erdem, E, Prada, SI, Haffer, SC. Medicare Payments: How Much Do
    Chronic Conditions Matter?. Medicare & Medicaid Research Review.
    2013;3(2). http://dx.doi.org/10.5600/mmrr.
    003.02.b02.
    ---------------------------------------------------------------------------
        Additionally, the AGS supports no less than a $3.3 billion increase
    over the enacted FY 2021 level in the FY 2022 budget for total spending
    at NIH for current institutes and operations. We believe that a
    meaningful increase in NIH-wide funding, in combination with aging and
    increase in prevalence of diseases, will be essential to sustain the
    research needed to make progress in addressing chronic disease,
    Alzheimer's disease, and related dementias that disproportionately
    affect older people.
        Strong support such as yours will help ensure that every older
    American is able to receive high-quality care. We greatly appreciate
    the Subcommittee for the opportunity to submit this testimony.
                                     ______

              Prepared Statement of the American Heart Association
        Chair Murray, Ranking Member Blunt, and members of the
    subcommittee, thank you for the opportunity to testify today. My name
    is Dr. Keith Churchwell, and I am President of Yale New Haven Hospital
    and a volunteer for the American Heart Association where I Chair the
    National Advocacy Committee. As a cardiologist for over 25 years, a
    hospital administrator who has worked in a number of roles across the
    country to improve and expand care for our patients, along with more
    than 20 years as a volunteer with the American Heart Association, I
    understand firsthand the burden of heart disease as the world's leading
    killer, and the importance of research and prevention.
        I'm pleased to testify today on two specific opportunities to
    improve Americans' health in the fiscal year (FY) 2022 Labor, Health
    and Human Services, Education and Related Agencies appropriations bill.
    I respectfully request you work over the next three years to triple the
    budget of the Centers for Disease Control and Prevention (CDC) National
    Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to
    $3.75 billion. I also respectfully request that, within this increase,
    you provide $20 million in new funding to expand an existing COVID-19
    Cardiovascular Disease (CVD) registry in partnership with NCCDPHP.
      funding for the national center for chronic disease prevention and
                                health promotion
        Chronic diseases represent 7 of the 10 leading causes of death,\1\
    and account for 90% of the nation's $3.8 trillion in annual health care
    costs.\2\ Heart disease remains the number one cause of death in the
    United States, with approximately 655,000 individuals in America dying
    from heart disease each year. In 2018, stroke accounted for about 1 of
    every 19 deaths in the United States.\3\ Chronic diseases are best
    managed by consistent access to health care services and treatments,
    for example, a 10% increase in hypertension treatment could prevent
    14,000 deaths each year.\4\
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention. Leading causes of
    death. Morality in the United States, 2019. Accessed online February
    17, 2021.
        \2\ Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in
    the United States. Santa Monica, CA: Rand Corp.; 2017 and Martin AB,
    Hartman M, Lassman D, Catlin A. National Health Care Spending In 2019:
    Steady Growth for The Fourth Consecutive Year. Health Aff.
    2020;40(1):1-11.
        \3\ Heart Disease and Stroke Statistics-2021 Update: A Report From
    the American Heart Association https://www.ahajournals.org/doi/10.1161/
    CIR.0000000000000950.
        \4\ Call to Action: Urgent Challenges in Cardiovascular Disease: A
    Presidential Advisory From the American Heart Association, Mark
    McClellan, MD, PhD, Nancy Brown, BS, Robert M. Califf, MD, MACC, John
    J. Warner, MD, FAHA (2019) https://www.ahajournals.org/doi/10.1161/
    CIR.0000000000000652.
    ---------------------------------------------------------------------------
        My positions at Yale New Haven Hospital and the American Heart
    Association have provided me a unique perspective on what individuals
    and families need to prevent disease, cure illness, and manage chronic
    health conditions, and I can personally attest to the importance of
    cardiovascular disease prevention programs specifically supported by
    the CDC. The burden of chronic disease is growing faster than our
    ability to ameliorate the growth, putting an increasing strain on the
    health care system, health care costs, our productivity, educational
    outcomes, military readiness and well-being.\5\ Current funding for CDC
    NCCDPHP falls far short of what is needed to prevent chronic disease,
    slow its spread, and protect patients. The COVID-19 pandemic has only
    exacerbated these challenges, and the underfunding of NCCDPHP has made
    the nation more vulnerable to the pandemic. For example:
    ---------------------------------------------------------------------------
        \5\ Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the
    future of cardiovascular disease in the United States: a policy
    statement from the American Heart Association. Circulation.
    2011;123:933-944.
    ---------------------------------------------------------------------------
      --COVID-19 poses elevated health risks for people with chronic
            conditions-including severe illness and death-and may lead to
            heart failure, stroke, kidney failure, chronic lung disease,
            blood pressure abnormalities, neurological conditions, and
            other long-term health complications in people who have
            survived the virus.
      --Deaths from ischemic heart disease and hypertensive diseases in the
            United States increased during the COVID-19 pandemic, while
            globally, COVID-19 was associated with significant disruptions
            in cardiovascular disease testing, diagnosis and timely
            treatment.\6\
    ---------------------------------------------------------------------------
        \6\ COVID-19 Pandemic Indirectly Disrupted Health Disease Care.
    American College of Cardiology. January 11, 2021. Accessed online
    February 17, 2021.
    ---------------------------------------------------------------------------
        After more than a decade of stagnant funding, a congressional
    commitment to triple CDC NCCDPHP's budget over the next three fiscal
    years is long overdue to respond to the increasing threat chronic
    diseases pose to Americans. A robust investment, appropriate to the
    magnitude of the problem, will allow CDC NCCDPHP to fulfill its mission
    by expanding the current patchwork of existing programs nationwide and
    by implementing new programs to address emerging health challenges,
    including the emerging chronic disease cohort of COVID-19 ``long-
    haulers.''
                    covid-19 cardiovascular disease registry
        Since the start of the pandemic, researchers have made great
    advances in our knowledge of the disease characteristics, associated
    health risks, and appropriate mitigation and treatment of COVID-19. We
    have learned that COVID-19 has a disproportionate impact on patients
    who face endemic inequities, such as lower paying and hourly wage jobs
    deemed ``essential.'' Unstable or unsafe housing and decreased
    availability of health care and insurance coverage also add to that
    impact. COVID-19 has laid bare the health inequities that have long
    affected communities of color in the United States as the burden of
    COVID-19 remains higher among African Americans, American Indians/
    Alaska Natives, Hispanics/Latinos, and Asian Americans and Pacific
    Islanders, compared with whites.\7\
    ---------------------------------------------------------------------------
        \7\ Lopez L, Hart LH, Katz MH. Racial and Ethnic Health Disparities
    Related to COVID-19. JAMA. 2021;325(8):719-720. https://
    jamanetwork.com/journals/jama/fullarticle/2775687.
    ---------------------------------------------------------------------------
        In April 2020, the American Heart Association launched the COVID-19
    Cardiovascular Disease (CVD) Registry, which captures data on
    hospitalized COVID-19 patients' clinical characteristics, medications,
    treatments, biomarkers and outcomes, and focuses on real-time, granular
    data from acute care hospitals to better help clinicians and
    researchers understand and provide feedback on how to best treat COVID-
    19 patients. To date, the COVID-19 CVD Registry includes nearly 170
    hospitals and health systems across 35 states, reporting more than
    40,000 adult COVID-19 patient records. Approximately 50 percent of the
    registry patients identify as Black or Hispanic, making the registry
    representative of communities disproportionately affected by the
    pandemic.
        According to initial research based on the COVID-19 CVD registry
    data, obese patients experienced some of the worst outcomes of all
    patients hospitalized with COVID-19, including increased risks for
    blood clots, the need for breathing assistance and dialysis, and death.
    Research has already found that patients with COVID-19 who are
    hospitalized with a stroke have worse outcomes than stroke patients
    without COVID-19. We are also now beginning to understand the long-term
    health implications of COVID-19 in the population referred to as
    ``long-haulers.'' These patients have an increased risk of developing
    myocarditis, or inflammation of the heart, that can lead to heart
    failure, thromboembolic disease or blood clots, and other lingering
    health conditions.
        Additional funding is needed to expand the registry infrastructure
    nationally to enhance geographic representation for both urban and
    rural hospitals. A more robust, representative registry will provide
    clinicians and researchers with the tools to advance our understanding
    of post-COVID syndromes and provide much needed insights into this new
    chronic disease cohort. Once expanded, this registry also will provide
    an at-the-ready, adaptable infrastructure to respond to new and
    emerging public health threats. Therefore, within the new funding
    provided to the CDC NCCDPHP, the American Heart Association
    respectfully requests that the Committee provide $20 million to expand
    the COVID-19 CVD registry nationwide to include hundreds more
    hospitals-including sole community hospitals, safety net hospitals, and
    disproportionate share hospitals-and support CDC NCCDPHP in collecting,
    curating, analyzing, and publishing the registry data.
        As the pandemic has demonstrated, chronic diseases and infectious
    diseases are inextricably linked. Therefore, any efforts to improve
    pandemic preparedness and prevent the spread of infectious disease must
    also include efforts to prevent chronic disease, address health
    disparities, and ultimately, improve underlying health and wellness for
    all. A significant investment in NCCDPHP is essential to that goal. We
    must make these investments if we are to preserve health, well-being,
    productivity, and longevity for all in America. I thank you for the
    opportunity to offer my perspective today, and for your continued
    leadership.
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        On behalf of the nation's 37 Tribal Colleges and Universities
    (TCUs), which collectively are the American Indian Higher Education
    Consortium (AIHEC), we thank you for the opportunity to share our FY
    2022 funding requests. The following is a list of recommendations
    including Department, program, and funding requests.
    Department of Education--Office of Postsecondary Education
      --Strengthening Institutions HEA Title III--Part A (Sec. 316):
            $53,080,000 (discretionary)
      --Perkins Career and Technical Education Programs (Sec. 117):
            $15,000,000
    Department of Education--Office of Indian Education
      --Indian Education Professional Development Program: $20,000,000
    Department of Health and Human Services
      --Administration for Children and Families/Office of Head Start
        TCU-Head Start Partnership Program: $8,000,000 in existing funds
    Tribal Colleges and Universities: Serving Students Across Indian
            Country and Rural America
        Currently, 37 TCUs operate more than 75 campuses and sites in 16
    states. TCU geographic boundaries encompass 80 percent of American
    Indian reservations and federal Indian trust lands. American Indian and
    Alaska Native (AI/AN) TCU students represent more than 230 federally
    recognized Tribes and hail from more than 30 states. Nearly 80 percent
    of these students receive federal financial aid, and nearly half are
    first generation students. In total, TCUs serve over 160,000 American
    Indians, Alaska Natives, and other rural residents each year through a
    wide variety of academic and community-based programs. Funding cuts of
    any amount to even one TCU program would force TCUs to scale back vital
    programs and services that students rely on to complete degree and
    certificate programs needed to succeed in their chosen career paths.
    Any reduction in funding will threaten TCU accreditation status and
    will further stretch overtaxed faculty and staff or result in cuts to
    faculty and staff. The following are justifications for TCU FY 2022
    funding requests.
                          u.s. department of education
        Strengthening Tribal Colleges (HEA Title III--Part A--Section 316):
    TCUs urge the Subcommittee to provide $53,080,0000 for the
    Strengthening Tribal Colleges program (HEA Title III-Part A). The
    Strengthening Institutions HEA Title III program for TCUs (Section 316)
    is specifically designed to address the critical, unmet needs of AI/AN
    students and their communities. Through this program, TCUs are able to
    provide student support services, Native language preservation, basic
    upkeep of campus buildings and infrastructure, critical campus
    expansion, enterprise management systems, faculty for core courses, and
    other necessary elements for a quality educational experience. The
    Strengthening Institutions program provides formula-based aid to 35
    TCUs through two funding sources: Part A discretionary funding (FY
    2021, $38.08 million) and Part F mandatory funding (FY 2020, $28.2
    million). In 2019, TCUs feared losing nearly half of Title III funding
    with the anticipated expiration of Part F funding. Fortunately, the
    ``Fostering Undergraduate Talent by Unlocking Resources to Education
    Act (P.L. 116-91) was signed into law on December 20, 2019, permanently
    authorizing Part F mandatory funding at $30 million for TCUs. Part A
    and Part F of the Title III program are essential in supporting
    institutional development and student services. AIHEC strongly supports
    the President Budget Request for FY 2022, and we urge the Subcommittee
    to fund these programs at the President's requested levels: HEA Title
    III Part A (discretionary funding) at $53,080,000 and HEA Title III
    Part F (mandatory funding) at $89,000,000.
    Carl D. Perkins Career and Technical Education Programs
        Tribally Controlled Postsecondary Career and Technical
    Institutions: AIHEC requests $15,000,000 to fund grants under Sec. 117
    of the Perkins Act. Carl D. Perkins Career and Technical Education Act
    provides a competitively awarded grant opportunity for Tribally
    chartered career and technical institutions (Sec.117), which provide
    critical workforce development and job creation, education, and
    training programs to AI/ANs from Tribes and communities with some of
    the highest unemployment rates in the nation.
        Native American Career and Technical Education Program (NACTEP):
    NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding to
    support AI/AN career and technical programs. The TCUs strongly urge the
    Subcommittee to continue to support NACTEP, which is vital to the
    continuation of career and technical education programs offered at TCUs
    that provide job training and certifications to remote reservation
    communities.
    Office of Indian Education
        Indian Education Professional Development Program: AIHEC requests
    $20,000,000 for grants to TCUs and other institutions of higher
    education. The Indian Education Professional Development Program,
    administered by the Office of Indian Education at the U.S. Department
    of Education, provides grants to institutions of higher education to
    prepare and train AI/ANs to serve as teachers and school administrators
    at elementary and secondary schools. There is a growing teacher
    shortage across the country, especially in urban and rural communities
    with high AI/AN populations, where teacher recruitment and retention
    pose unique challenges. In communities with teacher shortages, existing
    obstacles to student success such as inadequate facilities and limited
    broadband are further compounded by overcrowded classrooms. Targeted
    resources like the Indian Education Professional Development Program
    help address this shortage and ensure that AI/AN students receive high-
    quality elementary and secondary education.
        Report Language Needed: Funding for two distinct activities is
    provided under the ``Special Programs for Indian Children'' account:
    the Indian Education Professional Develop Program and Native Youth
    Community Projects. Despite increased funding in 2016 to the overall
    account, increases were only provided to Native Youth Community
    Projects; the Indian Education Professional Development Program did not
    receive increased funding. In FY 2020, the Special Programs for Indian
    Children account received $67,993,000, of which $13,668,000 was
    allocated for the Indian Education Professional Development Program.
    AIHEC requests specific report language in order to increase funding
    for the Indian Education Professional Development Program, at a minimum
    of $20,000,000 in FY 2022.
             u.s. department of health and human services programs
        Administration for Children and Families--Office of Head Start:
    Tribal Colleges and Universities Head Start Partnership Program: AIHEC
    requests $8,000,000 for the TCU-Head Start Partnership program. The
    TCU-Head Start Partnership program was re-established with the
    designation of $4,000,000 within the FY 2020 LHHS appropriations bill
    and continued with $4,000,000 within the FY 2021 LHHS appropriations
    bill. TCUs have had marked success in training early childhood
    educators and Head Start teachers who are urgently needed across Indian
    Country. In 2017, 74.5 percent of Head Start teachers nationwide held a
    bachelor's degree as required by federal law; but less than 42 percent
    of Head Start teachers met the requirement in Indian Country (Head
    Start Region 11); only 70 percent of workers in Region 11 met the
    associate-level requirements or were enrolled in associate's degree
    programs, compared to 90 percent nationally. TCUs are the most cost-
    effective way for filling this gap. From 2000 to 2007, the U.S.
    Department of Health and Human Services provided modest funding for the
    TCU-Head Start Program (42 U.S.C. 9843g), which helped TCUs build
    capacity in early childhood education by providing scholarships and
    stipends for Indian Head Start teachers and teacher aides to enroll in
    TCU early childhood/elementary education programs. Before the program
    ended in 2007 (ironically, the same year that Congress specifically
    authorized the program in the reauthorization of the Head Start Act),
    TCUs had trained more than 400 Head Start workers and teachers, many of
    whom have since left for higher paying jobs in elementary schools.
    Today, TCUs such as Salish Kootenai College (Pablo, MT) are providing
    culturally based early childhood education free of charge to local Head
    Start professionals. In Michigan, Bay Mills Community College provides
    online education programming for $50/credit to Head Start staff
    nationwide. However, many Head Start programs in Indian Country are
    paying far more for other sources to provide training. With the
    restoration and continuation of this modestly funded program, TCUs can
    aid in building an early childhood education workforce to better serve
    the education needs of AI/AN children.
    Substance Abuse and Mental Health Services Administration (SAMHSA)
        NEW Tribal College and University Centers for Excellence in
    Behavioral Health/Substance Abuse Prevention: AIHEC requests
    $10,000,000 to establish this program. The goal of the TCU Centers of
    Excellence program, similar to an existing SAMHSA program for HBCUs, is
    to grow a highly skilled and culturally competent AI/AN behavioral
    health workforce by developing an apprenticeship-based network of TCUs
    and partners from the health industry and local, Tribal, state, and
    regional providers. The TCU Centers of Excellence would share best
    practices in curriculum development, program implementation, and
    apprenticeships; recruit students to careers in behavioral health
    fields to address mental and substance use disorders; provide job
    training in behavioral health fields; and prepare students to earn
    credentials in behavioral health fields. The TCU Centers of Excellence
    would emphasize education, awareness, workforce training, and
    preparation for careers in mental and substance use treatment,
    prevention, and research, including addressing opioid abuse prevention,
    opioid use disorder treatment, serious mental illness, and suicide
    prevention.
                                   conclusion
        Tribal Colleges and Universities provide thousands of AI/AN
    students with access to high-quality, culturally appropriate,
    postsecondary education opportunities, including critical early
    childhood education and behavioral health programs. The modest federal
    investment in TCUs has paid great dividends in terms of employment,
    education, and economic development. We ask you to renew your
    commitment to help move our students and communities toward self-
    sufficiency and request your full consideration of our FY 2022
    appropriations requests. Thank you.
                                     ______

              Prepared Statement of the American Liver Foundation
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least $46.1
            billion and provide individual NIH Institutes and Centers, such
            as NIDDK, NIMHD, and NCI with proportional discretionary
            increases.
        --Please support establishment and adequate funding for the new
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH as proposed in the Administration's Budget Request to
                Congress to facilitate robust scientific progress on
                cancers and other conditions.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $10 billion to facilitate timely public health efforts
            along with proportional increases for CDC Centers and
            Divisions, such as NCCDPHP and NCHHSTP.
        --Please provide $134 million for the Division of Viral Hepatitis
                at CDC.
        --Please provide $120 million for the Opioid and Infectious
                Diseases Program at CDC.
        --Please provide $5 million for the new Chronic Disease Education
                and Awareness Program at CDC.
      --Provide the Health Resources and Services Administration (HRSA)
            with a funding level of at least $9.2 billion and ensure that
            the agency has sufficient resources to enhance organ donation
            through awareness activities and partnerships.
      --Please support timely committee recommendations on liver diseases
            and health disparities, NASH/NAFLD, organ donation, and related
            areas.
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of the
    American Liver Foundation (ALF) and the liver disease community.
    Chairwoman Murray, Ranking Member Blunt, and distinguished members of
    the subcommittee, we extend our thanks for the significant investments
    in HHS, particularly NIH, provided over recent years. Please maintain
    this commitment and further enhances support for public health programs
    as you work on appropriations for Fiscal Year (FY) 2022. Thank you
    again.
                              about the foundation
        Founded in 1976, the American Liver Foundation (ALF) is the
    nation's largest patient advocacy organization for people with liver
    disease. ALF reaches more than?4?million individuals each year with
    health information, education and support services via its national
    office and an active online presence. Recognized as a trusted voice for
    liver disease patients, ALF also operates a national toll-free helpline
    (800-GO-LIVER), educates patients, policymakers and the public, and
    provides grants to early-career researchers to help find a cure for all
    liver diseases. ALF is celebrating more than 40 years of turning
    patients into survivors. For more information about ALF, please visit
    liverfoundation.org.
                                  liver facts
        The liver is one of the body's largest organs, performing hundreds
    of functions daily including, removal of harmful substances from the
    blood, digestion of fat, and storing of energy. Non-alcoholic fatty
    liver disease (NAFLD), hepatitis C, and heavy alcohol consumption are
    the most common causes of chronic liver disease or cirrhosis (severe
    liver damage) in the U.S. Approximately 30% of adults and 3-10% of
    children have excessive fat in the liver or NAFLD which can lead to a
    severe liver disease called non-alcoholic steatohepatitis (NASH).
    Approximately 4.4 million Americans are living with Hepatitis B or C
    but most do not know they are infected. More than 2 million Americans
    are living with alcohol related liver disease. Approximately 5.5
    million Americans are living with chronic liver disease or cirrhosis.
    Vaccinations for hepatitis A and B and treatments for hepatitis C are
    helping to change the course of this chronic life altering disease for
    the patient community.
               cdc chronic disease education & awareness program
        Thank you for establishing the CDC Chronic Disease Education &
    Awareness Program in FY 2021 and providing $1.5 million in initial
    support. Many patient organizations seek valuable collaborations with
    CDC that can directly impact patients and improve public health. A few
    contemporary examples include raising awareness of NASH/NAFLD, and
    sharing public health information that can slow or stop the progression
    of various liver conditions into liver cancer. This new program
    provides a competitive mechanism that allows CDC to award meritorious
    cooperative agreements on an annual basis. Since there is tremendous
    demand in this area, and no shortage of quality opportunities for CDC,
    we ask that funding be systematically increased with $5 million
    provided for FY 2022.
                                 organ donation
        Consistently, the number of organs available for transplantation on
    an annual basis amounts to only a fraction of the number of patients on
    the transplant list. Compounding this situation is the fact that fatty
    liver disease affects a large and growing number of individuals and
    makes livers unavailable for transplantation. Another complicating
    factor is the fact that the rationing of cures for hepatitis ensures
    that many patients who could otherwise be healthy end up on the
    transplant list too and arbitrarily deny available organs to other
    patients facing a variety of life-threatening illnesses. Please promote
    organ donation and otherwise work to ensure Medicaid and other patients
    impacted by hepatitis receive curative therapy when medically
    appropriate.
                              the opioid epidemic
        CDC has dubbed opioids and the infectious diseases that arrive in
    the wake of the opioid crisis a ``dual epidemic''. This epidemic has
    been further fueled by the well-documents rise in opioid abuse during
    the COVID-19 pandemic. Due to the ongoing increase in rates of
    injection drug use, CDC recently identified a 400% increase in rates of
    hepatitis C among 20--29 year olds an 300% increase among 30--39 year
    olds. A few years ago, the elimination initiative was established at
    CDC, and the current funding level is $13 million. We ask that this
    allocation be systematically increased along with the annual funding
    for the Division of Viral Hepatitis to ensure CDC has adequate
    resources to make progress.
                          covid-19 and liver diseases
        There is a growing body of work focused on COVID-19's impact on the
    liver and persistent impacts for COVID ``long haulers''. We appreciate
    that a well-resourced NIH and public health response can continue to
    advance research in this critical area. Moreover, in regards to
    vaccination, please note that the American Association for the Study of
    Liver Diseases (AASLD) recommends that providers advocate for
    prioritizing patients with compensated or decompensated cirrhosis or
    liver cancer, patients receiving immunosuppression such as SOT
    recipients, and living liver donors for COVID-19 vaccination based upon
    local health policies, protocols, and vaccine availability.
                              nash bill of rights
        Nonalcoholic steatohepatitis or NASH is liver inflammation and
    damage caused by a buildup of fat in the liver. The prevalence of NASH
    has been rising and innovative treatment options have been coming to
    market along with improved healthcare. To better serve patients, ALF
    crafted a NASH Patient Bill of Rights that provides critical
    information on non-invasive testing options and coordinating
    multidisciplinary healthcare. The Foundation looks forward to working
    with the U.S. Public Health Services to disseminate critical
    information about NASH to patients and providers.
                              patient perspectives
        (Alison).--Alison is now a healthy 25-year-old from Trumbull,
    Connecticut, only five years ago she was near death. Alison had been
    suffering for most of her life with primary sclerosing cholangitis
    (PSC), a condition that left her in need of a live-saving liver
    transplant. On October 19th, 2009, Alison began her new life when her
    transplant was successfully performed at Yale-New Haven Hospital.
    Further complications ensued. Alison needed three additional surgeries
    to ensure her health and that of her new liver. Today, she is healthy.
        (Kevin).--In May 2007, a medical team at New York Columbia
    Presbyterian Hospital conducted its first living donor liver transplant
    surgery on a bile duct cancer patient. The patient was Kevin, my
    younger brother. I was the living donor. The transplant worked, but
    Kevin had to endure multiple follow-up surgeries to address a bile
    leakage that would not stop. But now, over ten years later, he has long
    since healed and doing great. We were lucky. And we know it. Despite
    advances in medical and surgical science, the demand for organs
    continues to vastly exceed the number of donors. Here, in New York,
    only 27% of people age 18 and over have enrolled in the New York State
    Donate Life Registry. But every ten minutes another person is added to
    the national transplant waiting list. We need to encourage more people
    to sign up to donate organs.
        (David).--In October 2014 my mother Geraldine passed away after a
    very brief and completely unexpected battle with late-stage NASH. They
    call NASH the ``silent killer'' and in Mom's case it was certainly
    true; she was never diagnosed with any form of liver disease at all
    before NASH. We had noticed some yellowing of her eyes and convinced
    her to go to the doctor about a month earlier, but it took time to get
    an appointment with a specialist, who checked her into a hospital upon
    the visit. I founded NASHAWARE.com to help raise awareness and educate
    others. If I can help even a few people it will all be worth it. But I
    still want to do much more.

        [This statement was submitted by Lorraine Stiehl, Chief Executive
    Officer,
    American Liver Foundation.]
                                     ______

              Prepared Statement of the American Lung Association
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

    $10 billion for the Centers for Disease Control and Prevention (CDC)
      --National Center for Chronic Disease Prevention & Health Promotion
            (NCCDPHP)
        Provide $3.75 billion for NCCDPHP
          -- Provide $310 million for CDC's Office of Smoking and Health
                (OSH)
          -- Provide $5 million for CDC's Chronic Disease Education and
                Awareness Program

      --National Immunization Program at CDC's National Center for
            Immunization and Respiratory Diseases (NCIRD)
        Provide $1.13 billion for NCIRD

      --National Center for Environmental Health (NCEH)
        Provide $322 million for NCEH
          -- Provide $110 million for CDC's Climate and Health Program
          -- Provide $35 million for CDC's National Asthma Control Program
                (NACP)
    $46.1 billion for the National Institutes of Health (NIH)
      --Provide $3.94 billion for the National Heart, Lung, and Blood
            Institute
      --Support establishment of, and adequate funding for, the new
            Advanced Research Projects Agency for Health (ARPA-H) at NIH
    _______________________________________________________________________

        The American Lung Association is the leading public health
    organization working to save lives by improving lung health and
    preventing lung disease through education, advocacy and research.
    Chairwoman DeLauro, Ranking Member Cole, and distinguished members of
    the subcommittee, we extend our thanks for the significant investments
    in the Department of Health and Human Service (HHS), including the
    robust response to the COVID-19 pandemic. Please maintain this
    commitment and further enhance support for public health programs as
    you work on appropriations for Fiscal Year (FY) 2022. The American Lung
    Association also asks for your leadership in opposing all policy riders
    that would weaken key lung health protections.
        The COVID-19 pandemic has underscored the need for significant and
    sustained investments in our nation's public health infrastructure,
    especially at CDC. For years, the Lung Association has requested for
    robust CDC funding. Unfortunately, funding for CDC has remained
    stagnant, and the failure to adequately invest has become evident
    during the public health emergency that has taken the lives of over a
    half a million people in the US. We ask that CDC funding be increased
    to at least $10 billion for fiscal year 2022. This funding must be in
    addition to, not in lieu of, emergency funds to respond to the current
    pandemic.
        The COVID-19 pandemic has also highlighted the importance of
    preventing and managing chronic lung conditions. Individuals living
    with certain lung diseases and people who smoke are among the most at
    risk for severe illness from COVID-19. Research also shows that long-
    term exposure to air pollution leads to worse COVID-19 outcomes. The
    Lung Association recognizes the tremendous challenges Congress has
    faced in responding to the pandemic and appreciates all that it has
    done thus far. Continued investment in CDC programs that help smokers
    quit; promote asthma control; support prevention and treatment of lung
    and other chronic diseases, including chronic obstructive pulmonary
    disorder (COPD) and lung cancer; and prepare for and respond to the
    health impacts created by a warming climate is vital.
        The American Lung Association strongly supports substantial federal
    investments in key public health and biomedical research activities,
    especially at CDC and NIH, respectively. For FY22, the Lung Association
    encourages Congress to take a balanced approach in its increases for
    these vital agencies and urges Congress to make significant investments
    in public health programs at CDC.
        Provide $10 billion for the Centers for Disease Control and
    Prevention (CDC): The nation is relying on CDC more than ever before.
    CDC is faced with unprecedented challenges and responsibilities,
    especially in the respiratory space. Consequently, the American Lung
    Association strongly supports the CDC Coalition's request of $10
    billion for CDC for FY22 and sustained, robust and predictable funding
    moving forward annually.
        Provide $3.75 billion for National Center for Chronic Disease
    Prevention and Health Promotion (NCCDPHP): In 2019, COPD was one of
    seven chronic diseases included in the top 10 causes of death in the
    United States. Chronic diseases can be prevented and/or managed through
    supportive public health interventions including tobacco prevention and
    cessation; however, they continue to be a major problem in the United
    States. Over 90% of the nation's $3.8 trillion in annual health care
    costs result from chronic diseases. The American Lung Association
    strongly supports tripling the NCCDPHP budget over three years (FY22-
    FY24). Such funding will allow NCCDPHP to fulfill its mission by
    expanding the current patchwork of existing programs to all
    jurisdictions nationwide and by implementing new efforts to address
    health challenges currently without programs, including the chronic
    disease cohort of COVID-19 ``long-haulers.'' It will also enable a
    significant investment in CDC's Social Determinants of Health (SDOH)
    program, which seeks to work with communities to identify and remedy
    SDOH.
        Provide $310 million for CDC's Office of Smoking and Health (OSH):
    One in four high school students continues to use at least one tobacco
    product. OSH is the lead federal agency for tobacco prevention and
    control. The American Lung Association is appreciative of the $7.5
    million increase in funding for OSH in FY21 and asks for an additional
    $72.5 million for FY22. The additional funding will be used to continue
    to address the e-cigarette pandemic, to enhance the ``Tips from Former
    Smokers'' campaign so that it can be run year-round, to invest in youth
    prevention efforts and to work to eliminate health inequities among
    racial, ethnic, sexual, rural and socio-economic groups.
        Provide $5 million for CDC's Chronic Disease Education and
    Awareness Program: Far too many individuals in the United States have
    or are at risk of potentially devastating chronic diseases without
    knowing. COPD is one of the leading causes of death and disability in
    the United States. Approximately 16 million people in the United States
    have COPD, and millions more remain undiagnosed. Given this significant
    gap in knowledge, the Lung Association greatly appreciates the creation
    and funding of the Chronic Disease Education and Awareness competitive
    grant program at CDC in FY21. In FY22, the Lung Association asks for
    this program to be increased to $5 million to continue the momentum and
    allow CDC to expand its work with stakeholders to respond to chronic
    diseases, such as COPD, that do not have standalone programs.
        Provide $110 million for CDC's Climate and Health Program: CDC's
    Climate and Health Program is the only HHS program devoted to
    identifying the risks and developing effective responses to the health
    impacts of climate change (which include worsening air pollution;
    diseases that emerge in new areas; stronger and longer heat waves; and
    more frequent and severe droughts and wildfires) and provides guidance
    to states in adaptation. Currently, projects in 16 states and two city
    health departments develop and implement health adaptation plans and
    address gaps in critical public health functions and services.
    Unfortunately, the level of investment thus far has been insufficient
    for this program to reach its full, possibly lifesaving, potential. The
    President's budget requests $110 million, which would allow CDC to
    implement a 50-state climate and health program.
        Provide $35 million for CDC's National Asthma Control Program
    (NACP): It is estimated that 24.8 million Americans currently have
    asthma, of whom 5.5 million are children. The NACP tracks asthma
    prevalence promotes asthma control and prevention and builds capacity
    in states. This program has been highly effective: asthma mortality
    rates have decreased despite the rate of asthma increasing. Additional
    funding would allow approximately four to five additional states beyond
    the current 25 states and localities to be funded to implement these
    lifesaving programs.
        Provide $1.13 billion for the National Immunization Program at
    CDC's National Center for Immunization and Respiratory Diseases
    (NCIRD): The success of the nation's vaccination programs has enabled
    many individuals to forget about the impact of many vaccine preventable
    diseases, such as polio, that once wreaked havoc. The COVID-19
    pandemic, however, has provided a stark reminder of the need and
    significance of vaccines and a robust national vaccination program. The
    National Immunization Program must receive strong and sustained
    funding. The Lung Association asks for $1.13 billion for NCIRD to
    enhance COVID19 vaccinations, bolster the nation's immunization
    infrastructure and address any gaps in routine immunizations that may
    have emerged as a result of the pandemic.
        Provide $46.1 billion for the National Institutes of Health (NIH):
    The Lung Association supports increased funding for NIH research on the
    prevention, diagnosis, treatment and cures for tobacco use and all lung
    diseases including lung cancer, asthma, COPD, pulmonary fibrosis,
    influenza and tuberculosis. The Lung Association also supports robust
    funding increases for the individual institutes within NIH, recognizing
    the need for research funding increases to ensure the pace of research
    is maintained across NIH. Lastly, the Lung Association urges increased
    funding for lung cancer research in addition to the Cancer Moonshot and
    the All of Us Program.
        Thank you for your consideration of our recommendations. Below
    please find a vignette demonstrating the importance of CDC programs.
            sharon l. from oklahoma: lung cancer & covid-19 survivor

    ``I now live with cancer. I am not a cancer patient; I am a patient who
                                 has cancer.''

        Sharon was diagnosed with Stage 4 lung cancer in October 2015.
    After six rounds of aggressive chemotherapy, followed by another two
    rounds shortly thereafter, Sharon is currently six years out from her
    diagnosis and living without the need for additional treatment. This
    past year, Sharon became one of the over 32 million individuals in the
    United States diagnosed with COVID-19.
        ``I can't emphasize how important funding for the CDC is. Having
    had COVID, it is even more important, but it has always been important
    to me.''

        Sharon and husband tenaciously fought to quit smoking, her husband
    with the help of a CDC-funded quitline, and they were ultimately
    successful in doing so. From her experiences, Sharon believes that
    public health programs are critical to raising awareness about lung
    cancer prevention and increasing tobacco cessation.
        ``What the CDC does with smoking cessation is vitally important, so
    people don't end up like me, thinking they have 14 months to live and
    watching every plan they have for growing old with their husband flash
    before their eyes. It is vitally important. Public health is important
    for everybody. You either pay for it now, or you pay for it at the end.
    And it always costs more at the back end than now.''
            michigan asthma prevention and control program (miapcp)
        Michigan is one of the 23 states that receive funding through the
    National Asthma Control Program (NACP). Through funding from CDC,
    Michigan was able to create the Asthma Initiative of Michigan website,
    www.GetAsthmaHelp.org, which enables access to a plethora of resources
    for those struggling with asthma. The MiAPCP has also worked to
    facilitate and support Managing Asthma Through Case-Management in Homes
    (MATCH) throughout parts of Michigan with the highest burden of asthma.
    Through MATCH programs, individuals can benefit from home visits, an
    environmental assessment, access to a certified asthma educator, and a
    physician care conference. As a result, Michigan saw a 60% decrease in
    asthma-related emergency room visits, 82% decrease in hospitalizations
    and a 58% decrease in the number of children who missed one or more
    school days due to asthma.
        ``Interventions and policy efforts by our program that impact
    asthma care and environments cannot be sustained without CDC's
    support.''
      --John Dowling, Lead Asthma Coordinator of the MiAPCP

        Most recently, MiAPCP launched a cohesive effort to improve asthma
    surveillance and data collection.

        [This statement was submitted by Harold P. Wimmer, National
    President and CEO, American Lung Association.]
                                     ______

         Prepared Statement of the American Massage Therapy Association
        The American Massage Therapy Association (AMTA) appreciates the
    opportunity to submit written testimony for the record to the Senate
    Subcommittee on Labor, Health and Human Services, and Education
    Subcommittee in support of continued robust funding in FY 2022 for the
    National Center for Complementary and Integrative Health (NCCIH) within
    the National Institutes of Health (NIH) as well as for suggested report
    language for both NCCIH as well as the Centers for Disease Control
    (CDC).
        Established in 1943 and numbering over 95,00 members, AMTA works to
    advance the massage therapy profession through the promotion of fair
    and consistent licensing of massage therapists in all states, public
    education on the benefits of massage therapy, and support of research
    to advance knowledge about massage therapy. Massage therapists are
    currently licensed in 46 states and the District of Columbia.
        We appreciate and acknowledge the Committee's ongoing support for
    massage therapy, including past report language urging the adoption of
    recommendations from the groundbreaking and widely supported 2019 HHS
    final report from the Pain Management Best Practices Task Force (Task
    Force). Unfortunately, most recommendations from that task force--
    including those that support inclusion of massage therapy and other
    integrative and complementary health treatments for pain--have still
    not been adopted.
        COVID-19 has exacerbated the already existing public health crisis
    of acute and chronic pain from delayed access to health care, as well
    as a rise in substance abuse and overreliance on opioids. We encourage
    the Committee to include report language in the FY 2022 bill that
    focuses on the need for greater public awareness on treatment options
    for pain that include complementary and integrative approaches such as
    massage therapy. We request the Committee to direct NIH to coordinate
    with the DoD and VA to launch a much-needed public awareness campaign
    about these non-opioid treatment options and to widely disseminate the
    Task Force recommendations to health care providers and public health
    stakeholders. Last, we request the Committee's continued support to
    direct all relevant HHS agencies to update their pain management
    practices to reflect the Task Force recommendations, including those
    that support massage therapy.
        We also support the inclusion of report language accompanying the
    FY 2022 bill that would direct the CDC to collect and publish
    population research data that provides a comprehensive assessment of
    the nature of pain management, who is affected by pain, and direct and
    indirect costs to society related to pain.
        Over recent years, research continues to increase support for
    massage therapy, which has thus increased policymakers' awareness of
    the benefits of massage therapy as a non-pharmacologic alternative to
    opioid use to manage pain. As noted above, massage is specifically
    addressed throughout the 2019 Task Force report and is even included in
    the Task Force ``Pain Management Toolbox'' as an example of a treatment
    modality that should be considered as part of an overall integrative
    and collaborative care model to ensure optimal patient outcomes.
    https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-
    23.pdf. NCCIH notes the value of massage therapy for a wide variety of
    health conditions involving both acute and chronic pain, including low
    back pain, neck and shoulder pain, symptoms and side effects associated
    with certain cancers, fibromyalgia, HIV/AIDS, among others.
        In addition to NIH, massage therapy is supported by the American
    College of Physicians and The Joint Commission. Massage is currently
    utilized in many nationally renowned hospitals and other institutions,
    such as the Mayo Clinic, M.D. Anderson Cancer Center, Duke Integrative
    Medicine, the Cleveland Clinic, and Memorial Sloan Kettering Cancer
    Center. Finally, CMS includes massage therapy provided by a state
    licensed massage therapist as a supplemental benefit for pain
    management in Medicare Advantage plans, and massage is also a covered
    benefit for our nation's veterans and active-duty military personnel.
        Despite the demonstrated value and efficacy of massage therapy
    through research, we know that more needs to be done. As recently as
    last August, a national survey of 1,581 people with pain indicated that
    massage therapy is the most desired treatment for pain (at 48.4%,
    followed by pain physician at 32.9% and acupuncture at 29%), but
    unfortunately a majority of those surveyed indicated that cost
    prevented them accessing massage therapy. This underscores the
    disconnect between the best practices that already exist in pain
    management and those that are realistically available to patients, due
    to cost and lack of 3rd party insurance coverage, as well as
    insufficient provider awareness of the benefits of massage and other
    complementary therapies.
        For over 30 years, the Massage Therapy Foundation (MTF) a 501(c)
    (3) organization, working with AMTA, has provided over $1 million in
    research grants studying the science behind therapeutic massage. This
    seed money has funded needed research on a wide range of topics
    including: the benefits of massage therapy for pediatric populations,
    patients with heart failure, and those with muscle atrophy, among
    others. Many of these efforts have been specifically designed to
    include racially diverse and underserved populations.
        We know that massage therapy can improve health outcomes and is
    also among the most cost-effective therapies that can save health care
    expenditures in the long run. Massage therapy demonstrably reduces or
    mitigates reliance on opioids to address pain. Massage therapy can
    serve as a 'portal' to increase patient involvement in other important
    health activities, e.g. research shows that patients who obtain massage
    are more likely to be able to move better, and thus engage in other
    physician-prescribed activities such as corrective exercise programs.
        We encourage a sustained and robust finding stream for NIH and
    NCCIH that supports the role of integrative therapies to help mitigate
    opioid abuse and misuse, and which will enable continued advancements
    in the use of non-pharmacologic therapies such as massage.
        Thank you for your consideration, and AMTA would be happy to
    provide more information as needed.
        Sincerely,
        James Specker, AMTA Director, Industry and Government Relations at
    jspecker@amtamassage.org.
                                     ______

           Prepared Statement of the American National Red Cross and
                         the United Nations Foundation
        Chairwoman Patty Murray, Ranking Member Roy Blunt, and Members of
    the Subcommittee on Labor, Health and Human Services, Education and
    Related Agencies, the American Red Cross and the United Nations
    Foundation appreciate the opportunity to submit testimony. We are
    writing to request that Congress invest $60 million for CDC's global
    measles and rubella elimination efforts for fiscal year 2022.
        The American Red Cross and United Nations Foundation recognize the
    leadership that Congress has shown in funding CDC in prior years and
    urge Congress to protect the CDC's funding necessary for their global
    measles elimination activities for FY2022 at $60 million, which is part
    of the overall Global Immunization Division line.
                              covid-19 environment
        COVID-19 has had an unprecedented impact on global immunization
    programs. As of June 1st twenty-three measles and rubella vaccination
    campaigns that were scheduled for 2020 continue to be postponed as a
    result of the COVID-19 pandemic, leaving an estimated one hundred and
    thirty-five million children unvaccinated and vulnerable to the
    diseases. This growing immunity gap is creating a looming cliff in
    global public health, as social distancing measures are lowered, the
    measles virus will quickly spread amongst unvaccinated individuals and
    communities. Because the measles virus is one of the most transmissible
    human viruses--with each infectious person capable of infecting as many
    as 18 unvaccinated individuals--a drastic increase in measles outbreaks
    around the world is anticipated. Failing to close these immunity gaps
    will leave millions of children at risk and will compromise U.S. global
    health security by disrupting economies, trade, and country stability,
    and increasing the likelihood of the virus infecting U.S. communities.
    Investments that will quickly close these global immunity gaps will
    help to ensure that gains made in reducing maternal and child mortality
    and morbidity are maintained, and that the global health infrastructure
    established through these investments is preserved and strengthened.
    Among other benefits, this global health architecture is vital to
    protecting global health security. Measles investments have established
    networks of laboratories around the world capable of processing
    diagnostics, and has bolstered the global public health workforce of
    trained professionals and volunteers who are often the first responders
    during health crises. During the pandemic, for instance, these assets
    and infrastructure investments were pivoted to detect and test cases of
    COVID-19, giving vulnerable countries a head start in their pandemic
    response. With this context in mind, we respectfully provide the
    following justification for continued robust investment in CDC's global
    measles and rubella elimination efforts.
                            why measles and rubella?
        U.S. leadership has saved the lives of 25.5 million children
    between 2000 and 2019, with the Measles & Rubella Initiative driving
    measles deaths down by 62%.
        Measles is a highly contagious disease that can cause blindness,
    swelling of the brain, and death. Nine out of ten people who are not
    immune to measles will contract the disease if they come into contact
    with a contagious person, and there are long-term damages to the immune
    system for those who contract the virus. The rubella virus is a leading
    infectious cause of birth defects in the world despite availability of
    an affordable, effective vaccine since 1969. Every day, roughly 567
    children still die of measles-related complications. When rubella
    occurs early in a pregnancy, it can cause miscarriages, stillbirths, or
    a constellation of severe birth defects as part of congenital rubella
    syndrome (CRS) that can impact vision, hearing, heart health, overall
    development. Each year roughly 100,000 babies are born with CRS despite
    the preventable nature of the disease.
        Since 2000, measles vaccines have been the single greatest
    contribution in reducing preventable child deaths globally. We have had
    safe and effective vaccines against both rubella and measles for over
    50 years, but unfortunately vaccination rates globally have stagnated
    for over a decade.
                             domestic implications
        In the U.S., measles control measures have been strengthened, and
    endemic transmission of measles cases has been eliminated since 2000
    and rubella in 2002. However, importations of measles cases into this
    country continue to occur each year. In 2019, for example, the U.S.
    reported 1,282 cases of measles in 32 states, the largest number of
    cases since 1992. Major outbreaks in New York and Washington state have
    been linked to importation of the disease by unvaccinated U.S.
    residents returning from trips to Israel and Ukraine. Controlling
    measles and rubella around the world reduces the likelihood of similar
    disease importations in the future.
        Responding to measles outbreaks is resource intensive and costly
    for health systems, including in the U.S. In a literature review that
    included 10 studies on measles outbreaks from 2001 to 2018 in the U.S.,
    researchers estimated the cost per case to range from about $7,000 to
    $76,000 and the total cost per outbreak ranged from $10,000 to $1
    million. A recent study of a 72-case outbreak in the U.S. cost local
    public health and government authorities an estimated $3.4 million for
    response activities, medical costs, and productivity losses.
                        the measles & rubella initiative
        The Measles & Rubella Initiative (M&RI)--which includes the
    American Red Cross, CDC, UNICEF, the United Nations Foundation, and
    WHO, all working in collaboration with Gavi, the Vaccine Alliance as
    well as the Bill & Melinda Gates Foundation--supports countries to
    prevent, identify, and respond to measles outbreaks through key
    interventions like surveillance, supplementary vaccination campaigns,
    and emergency response.
        M&RI has achieved outstanding results by helping to vaccinate
    nearly 3 billion individuals in over 90 countries since 2001, saving
    the lives of more than 25.5 million children. In part due to M&RI,
    global measles mortality has dropped 62%, from an estimated 545,000
    deaths in 2000 to an approximately 207,000 in 2019 (the latest year for
    which data is available), mostly children under the age of five. During
    this same period, measles deaths in Africa fell by 57%.
        Despite these gains, we continue to see unfortunate and preventable
    deaths and complications due to both measles and rubella. In 2019,
    every day approximately 567 children died of measles-related
    complications. These deaths could have been prevented with a safe,
    effective, and inexpensive vaccine that is typically available for less
    than $2 USD in lower income countries, which protects against both
    measles and rubella.
        Thanks to M&RI leadership, most measles vaccination campaigns have
    been able to reach more than 90% of their target populations. Countries
    recognize the opportunity that measles vaccination campaigns provide in
    reaching mothers and young children and integrating the campaigns with
    other life-saving health interventions. These include administering
    vitamin A, which is crucial for preventing blindness in under nourished
    children; de-worming medicine to reduce malnutrition; doses of oral
    polio vaccines; distributing insecticide treated bed nets to help
    prevent malaria and screening for malnutrition. The provision of
    multiple child health interventions during a single campaign is far
    less expensive than delivering the interventions separately and has a
    far greater impact on a child's health.
        In addition to the lifesaving benefits of the measles-rubella
    vaccine, immunization makes sound economic sense. A 2016 Johns Hopkins
    University study compared the costs for vaccinating against 10 disease
    antigens in 94 low- and middle-income countries between 2011-2020
    versus the costs for estimated treatments of unimmunized individuals
    during the same period. Their findings show, on average, every $1
    invested in these 10 immunizations produces $44 in savings in
    healthcare costs, lost wages, and economic productivity. The return on
    investment for measles immunization was found to be the greatest with
    $58 saved for every $1 invested.
        Securing sufficient funding for measles and rubella-elimination
    activities both globally and nationally is critical. The decrease in
    donor funds available at a global level to support measles and rubella
    elimination activities makes increased political commitment and country
    ownership of the activities critical for achieving and sustaining the
    goal of increasing measles vaccination coverage to 95%. Implementation
    of timely measles and rubella vaccination campaigns is increasingly
    dependent upon countries funding these activities locally, which can be
    challenging under such downward financial pressure.
        If such challenges are not addressed, the remarkable gains made
    since 2000 will be lost and a major resurgence in measles death and
    disability will occur. The combined factors of a highly contagious
    disease, growing immunity gaps exacerbated by COVID-19 disruptions, and
    our highly interconnected world means measles is poised to spread
    quickly, with devastating results that could even threaten countries
    that have already eliminated the disease. The threat of importation of
    measles was one of the reasons that the Global Health Security Agenda
    has selected measles as an important indicator of whether a country's
    routine immunization system is able to effectively reach and vaccinate
    all its children.
             the role of cdc in global measles mortality reduction
        Since FY 2001, Congress has generously provided funding to protect
    children and their families from the threat of measles and rubella in
    developing countries, thereby also protecting the U.S. population from
    the threat of measles importations. Funding for measles and rubella
    globally has remained level since FY 2010 at $50 million dollars. The
    COVID-19 pandemic has gravely disrupted immunization systems around the
    world, leaving millions of children vulnerable to measles and other
    vaccine-preventable diseases. We must quickly ``catch up'' vaccination
    coverage rates to reach unvaccinated populations and prevent
    devastating measles outbreaks. The CDC plays an essential role within
    this space by providing support for vaccination programs and
    surveillance to detect outbreaks early and stop them at their source.
    An increase in resources for these and other critical activities
    provided by the CDC are needed to prevent needless childhood deaths
    around the globe.
        In 2019, thanks in part to U.S. funding, M&RI supported 62
    immunization campaigns in 53 countries, resulting in the vaccination of
    nearly 203 million children. Funding for CDC permitted the provision of
    technical support to Ministries of Health that included: 1) planning,
    monitoring, and evaluating large-scale measles vaccination campaigns;
    2) conducting epidemiological investigations and laboratory
    surveillance of measles outbreaks; 3) CDC's Global Measles Reference
    Laboratory serving as the leading worldwide reference laboratory for
    measles and rubella; and 4) conducting operations research to guide
    cost-effective and high-quality measles and rubella elimination
    programs.
        Since FY10, the CDC's measles and rubella elimination program has
    been funded at approximately $50 million. In FY 2022, the American Red
    Cross and United Nations Foundation respectfully request an increase of
    $10 million to raise funding to $60 million. This investment will allow
    CDC to help countries to close the immunization gap created by COVID-
    19, safeguard the progress made over the last decade and protect
    Americans by preventing measles cases and deaths in the U.S. The CDC
    Global Immunization Division, through which the Measles & Rubella
    Initiative is funded, has been highly effective and we strongly support
    fully funding this work. All the programs funded through the Global
    Immunization Division budget line also help to build stronger health
    systems. We respectfully request $60 million for CDC's measles
    elimination activities, as part of the overall funding for the entire
    Global Immunization Division account in FY2022.
        Thank you for the opportunity to submit testimony, and for your
    continued commitment to ending preventable death and disability from
    measles and rubella.

        [This statement was submitted by Koby J. Langley, Senior Vice
    President,
    International Services and Service to the Armed Forces, American
    National Red Cross and Peter Yeo, Senior Vice President, United Nations
    Foundation.]
                                     ______

             Prepared Statement of the American Nurses Association
        The American Nurses Association (ANA), representing the interests
    of the nation's 4.2 million registered nurses, thanks Chair Murray,
    Ranking Member Blunt, and the U.S. Senate Appropriations Subcommittee
    on Labor, Health and Human Services, Education and Related Agencies for
    the opportunity to provide written testimony for Fiscal Year (FY) 2022.
        ANA is committed to advancing the nursing profession by fostering
    high standards of nursing practice, promoting a safe and ethical work
    environment, bolstering the health and wellness of nurses, and
    advocating on health care issues that affect nurses and the public. ANA
    is at the forefront of improving quality of health for all.
                      nursing workforce and health equity
        Investments in the Title VIII Nursing Workforce Development
    Programs are essential to ensuring nurses and nursing students have the
    resources to tackle our nation's health care needs, remain on the
    frontlines of the COVID-19 pandemic, and be prepared for the public
    health challenges of the future. Funding for Title VIII has become even
    more crucial during the pandemic, as these programs connect patients
    with high-quality nursing care in community health centers, hospitals,
    long-term care facilities, local and state health departments, schools,
    workplaces, and patients' homes.
        ANA believes there are multiple policy levers to eliminate or
    reduce health disparities. Our Principles for Health System
    Transformation \1\ call for expanded access to care through universal
    coverage and other steps to improve the quality and affordability of
    health care. We also believe policymakers must consider and account for
    an adequate health care workforce of the future. The nursing workforce,
    in particular, can play a tremendous role in efforts to create a more
    equitable health care system. Nurses provide the type of care and
    coordination that can help people manage their chronic conditions,
    including links to community resources they need to be healthy.
    Registered nurses and advanced practice registered nurses are often the
    backbone of health care delivery in rural and underserved areas,
    providing access to primary care, maternity care, and prevention. These
    roles should be strengthened through meaningful reforms.
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        \1\ https://www.nursingworld.org/4afd6b/globalassets/
    practiceandpolicy/health-policy/principles-
    healthsystemtransformation.pdf.
    ---------------------------------------------------------------------------
        Expanding the minority health care workforce would be one of the
    most meaningful steps we could take to improve access and health care
    in African American population groups. We know that positive patient
    experience and trust in health care providers can be powerful drivers
    of health outcomes. The National Sample Survey of Registered Nurses
    recently reported an increase in the minority nursing workforce between
    2008 and 2018.\2\ This is encouraging, but there is a long way to go.
    An increased funding in minority nursing education, to develop a
    workforce that is more reflective of the patient population would be a
    first step in the right direction.
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        \2\ https://bhw.hrsa.gov/data-research/access-data-tools/national-
    sample-survey-registered-nurses.
    ---------------------------------------------------------------------------
        ANA is a member of the Nursing Community Coalition which is
    comprised of 63 national nursing organizations who collectively
    represent the cross section of education, research, practice, and
    regulation within the nursing profession. Together, we respectfully
    request supporting at least $530 million for the Nursing Workforce
    Development Programs (authorized under Title VIII of the Public Health
    Service Act [42 U.S.C. 296 et seq.] and administered by HRSA) in FY
    2022.
                          public health infrastructure
        The nation's public health infrastructure and workforce have been
    underfunded for decades, and we have witnessed the highlighted impacts
    of this chronic underfunding throughout the COVID-19 public health
    emergency. Federal funds for state, local, and tribal public health
    preparedness shrunk from $940 million in 2002 to $675 million in
    2019.\3\ During the same time period, hospital emergency preparedness
    was cut by nearly fifty percent, from $515 million in 2004 to $265
    million in 2019. This has resulted in a loss of 55,000 public health
    workers since 2008. The current COVID-19 public health emergency has
    underscored that our nation must be better equipped with preparedness
    and response personnel, measures and processes. A robust public health
    infrastructure and workforce is not only important during the time of
    crisis, but generally to address the overall health and well-being of
    our population.
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        \3\ https://www.tfah.org/wp-content/uploads/2020/04/
    TFAH2020PublicHealthFunding.pdf.
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        The public health nursing workforce touches every aspect of health
    care and community well-being. Unfortunately, we can only imagine how
    different the coronavirus response would have been had greater federal
    public health infrastructure investment afforded availability of
    sufficient numbers of nurses and other public health personnel in areas
    of the greatest need. Nurses could have played an enhanced role in
    encouraging and administering COVID-19 tests in high-risk populations,
    conducting contact tracing at an effective pace, educating the public
    about vaccine safety and all facets of COVID-19 prevention and
    mitigation, informing school opening protocols, and collecting data for
    feedback to pandemic response efforts.
                                 mental health
        Nurses, particularly those early in their career, continue to feel
    exhausted and overwhelmed. According to the findings of an American
    Nurses Foundation survey of nearly 13,000 nurses, 51 percent of nurses
    surveyed continue to feel exhausted and 43 percent report feeling
    overwhelmed. A breakdown of findings demonstrates that the mental
    health of early-career nurses, 34 and under, is impacted most, with 81
    percent reporting they are exhausted, 71 percent saying they are
    overwhelmed, and 65 percent who report being anxious or unable to
    relax. Nurses who are 55 and older reported some strain on their mental
    health, with 47 percent reporting feeling exhausted and 31 percent
    reporting they had a desire to quit.\4\
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        \4\ https://www.nursingworld.org/practice-policy/work-environment/
    health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/
    mental-health-and-wellness-survey-2/.
    ---------------------------------------------------------------------------
        ANA is a member of the Mental Health Liaison Group. We count the
    American Psychiatric Nurses Association as a premier Organizational
    Affiliate and many psychiatric nurses as members. We request that the
    Committee approve the appropriations request put forward by the Mental
    Health Liaison Group for FY 2022 for mental health and addiction
    policies and programs.\5\
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        \5\ https://www.mhlg.org/wordpress/wp-content/uploads/2021/04/MHLG-
    FY2022-Approps-Request-Final-4.7.21.pdf.
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                          minority fellowship program
        ANA supports funding and expanding the Minority Fellowship Program
    (MFP), which is currently administered by the Substance Abuse and
    Mental Health Services Administration (SAMHSA).\6\ The program provides
    scholarships to minority mental health and addiction professionals in
    nursing, but also in the fields of psychiatry, psychology, social work,
    marriage and family therapy, counseling and addictions. The program's
    mission is to increase the number of culturally competent behavioral
    health professionals who provide mental health and substance use
    disorders services to underserved populations.
    ---------------------------------------------------------------------------
        \6\ https://www.samhsa.gov/minority-fellowship-program/about.
    ---------------------------------------------------------------------------
        The MFP was created in 1974 to provide fellowships to minority
    mental health professionals, and, since then, more than 4,400
    fellowships have been issued to nurses, psychiatrists, psychologists,
    social workers, marriage and family therapists, counselors, and
    addiction specialists. According to HHS, minorities are less likely to
    receive diagnosis and treatment for their mental illness, have less
    access to and availability of mental health services, and often receive
    a poorer quality of mental health care. The MFP is the only federal
    program financing culturally competent mental health and substance use
    disorders professionals.
        ANA, along with the MFP Coalition, urges Congress to increase
    funding for the MFP to $20,200,000 in FY 2022 in order to expand access
    to nurses and other mental health professionals who provide culturally
    competent mental health and substance abuse services to ethnic minority
    populations.
        Thank you for the opportunity to provide written testimony as the
    Subcommittee continues its important work. If you have any questions,
    please contact Ingrida Lusis, Vice President of Policy and Government
    Affairs, at Ingrid.Lusis@ana.org.

        [This statement was submitted by Debbie D. Hatmaker, PhD, RN, FAAN,
    Chief Nursing Officer/EVP.]
                                     ______

               Prepared Statement of the American Psychological
                           Association Services, Inc.
        The American Psychological Association (APA) is the largest
    scientific and professional organization representing psychology in the
    United States, with more than 122,000 researchers, educators,
    clinicians, consultants, and students as its members. Our mission is to
    promote the advancement, communication, and application of
    psychological science and knowledge to benefit society and improve
    lives.
        Many programs in the Labor-HHS-Education Appropriations bill are
    critical to strengthening the mental health workforce, supporting
    psychology-based research and education, and improving access to needed
    mental and behavioral health services, particularly for underserved
    communities. As the COVID-19 pandemic continues to present broad
    challenges for our nation in both the short and long term, federal
    investments are needed to bolster research, expand equitable access to
    primary and mental health services, and support data-informed
    approaches to education and public welfare at all levels. To boost
    critical research funding, support the psychology workforce, improve
    access to mental and behavioral health services across the lifespan,
    and address social determinants of health, APA requests the following
    funding levels for FY22 within the U.S. Department of Health and Human
    Services, U.S. Department of Education, and U.S. Department of Labor.
        Boosting Critical Research Funding: APA requests at least $46.111
    billion for NIH in FY22, including $48.9 million for the NIH Office of
    Behavioral and Social Sciences Research (OBSSR). This funding would
    allow OBSSR to continue leading the coordination and support of
    research designed to address the social, behavioral, and economic
    effects of COVID-19 and its associated containment and mitigation
    efforts. Understanding these impacts will help policymakers improve
    their long-term response to the pandemic and prepare more effectively
    and efficiently for the country's next public health emergency. APA
    encourages the Committee to resist calls to limit the availability or
    use of non-human animal models in research, and to ensure this research
    continues to be conducted appropriately and ethically.
        APA recommends at least $700 million for the Institute of Education
    Sciences (IES), which supports and disseminates scientific evidence on
    which to base education policy and practice and funds innovative
    research into many aspects of teaching and learning, including research
    on pandemic-related learning loss. Finally, APA urges the Committee to
    provide $50 million in funding shared evenly between the CDC and NIH to
    conduct public health research into firearm morbidity and mortality
    prevention. This research is fundamental to helping our nation better
    understand and address our gun violence public health crisis.
        Supporting the Psychology Workforce: The nation's mental and
    behavioral health workforce must be expanded to adequately respond to
    the long-term mental health and substance use disorder ramifications of
    the COVID-19 pandemic, particularly the needs of long-underserved
    communities like communities of color and older adults. This includes
    foundational investments in higher education, as well as workforce
    training programs that support the integration of behavioral
    healthcare. To address this, APA supports increased funding for the
    following programs within the Department of Education and HHS' Health
    Resources and Services Administration (HRSA), Substance Abuse and
    Mental Health Services Administration (SAMHSA).
        Given the heavy burden of student loan debt, APA supports added
    investments in grant programs for graduate study within the Department
    of Education, including $35 million for the Graduate Assistance in
    Areas of National Need (GAANN) Program. The most recent funding cycle
    marked the first time in nearly a decade where psychology was among the
    designated areas of national need under this program. As the mental
    health impact of the pandemic continues to unfold, APA requests that
    the committee again direct the Secretary to include academic areas that
    fall under the Classification of Instructional Programs (CIP) 51.15
    Mental Health Services in the next grant competition.
        Within HRSA, APA joins the Mental Health Liaison Group (MHLG) in
    urging the Committee to provide $23 million for the Graduate Psychology
    Education Program; $90 million for the Behavioral Health Workforce
    Education and Training (BHWET) Grant Program; and $37 million for the
    Mental and Substance Use Disorder Workforce Training Demonstration.
    These essential programs increase work to increase our nation's supply
    of health service psychologists trained to provide integrated services
    to high-need, underserved populations in rural and urban communities.
    To expand access to non-pharmacological pain management to improve pain
    care and reduce the incidence of opioid use disorders, APA recommends
    $10 million for a program for education and training in pain care, as
    authorized by the SUPPORT Act under Section 759 of the Public Health
    Service Act (42 U.S.C. 294i).
        Within SAMHSA, APA requests $20.2 million for the Minority
    Fellowship Program (MFP). This increase will support the program's dual
    mission to both increase the diversity of the mental and behavioral
    health workforce while improving access to mental health and substance
    use disorder services in underserved communities.
        Improving Access to Mental and Behavioral Health Care Across the
    Lifespan: Given the rise in COVID-related mental health concerns, APA
    joins MHLG in requesting $833 million for SAMHSA's Community Mental
    Health Block Grant (MHBG) and $1.9 billion for the Substance Abuse
    Prevention and Treatment (SAPT) Block Grant in FY22. To address rising
    suicide rates, we urge the Committee to provide $240 million for the
    National Suicide Prevention Lifeline; $5 million for 988
    implementation, $37 million for the State/Tribal Youth Suicide
    Prevention Program; $6.7 million for the Campus Mental and Behavioral
    Health Program; and $9.3 million for the Suicide Prevention Resource
    Center.
        To ensure that our K-12 students receive a well-rounded education,
    and access to school-based mental health services and programs that
    foster safe and healthy schools, APA requests $2 billion for Title IV-
    A, the Student Support and Academic Enrichment (SSAE) block grant.
    Additionally, to increase the number of mental health providers working
    in school settings, APA requests $606 million for the Safe Schools
    National Activities Program in order to support new competitions for
    the School Based Mental Health Services Professional Demonstration
    Grant and the School-Based Mental Health Services Grant Program. APA
    also urges the Committee to include $15.5 billion for Part B (Grants to
    States) of the Individuals with Disabilities Education Act (IDEA) to
    help provide an equitable education for students with disabilities.
        Given that maternal mental health conditions are the most common
    complication of pregnancy and childbirth, APA joins the Maternal Mental
    Health Leadership Alliance and more than 100 other organizations in
    requesting $5 million for HRSA's Maternal Mental Health Hotline, and
    $10 million for the Screening and Treatment of Maternal Depression and
    Related Behavioral Disorders Program. APA urges to Committee to provide
    $750 million for Title V Maternal and Child Health Services Block Grant
    Program, which supported 92% of all pregnant women in the U.S. in FY19.
        Finally, APA urges the Committee to provide much-needed funding to
    support Mental Health Parity and Addiction Equity Act (MHPAEA)
    enforcement. Within the DOL's Employee Benefits Security
    Administration, APA requests $25 million for MHPAEA enforcement, with
    10% allocated to Office of Solicitor for parity litigation. To support
    MHPAEA enforcement within HHS, APA requests $10 million for CMS' Center
    for Medicaid and CHIP Services (CMCS).
        Addressing Social Determinants of Health & Social Safety Net:
    Within HHS' Administration for Children and Families, APA supports $1.7
    billion for the Social Services Block Grant, which provides vital
    social services, such as protective services agencies and special
    services to people with disabilities. In addition, APA urges the
    Committee to provide $10.7 billion for the Head Start Program, $5.9
    billion for Preschool Development Grants, and $500 million for CAPTA
    Title I to support state child abuse prevention and treatment.
        To expand the reach out various federal HIV programs, APA requests
    $100 million for the CDC Division of Adolescent and School Health
    (DASH), to increase access to health services, implement evidence-based
    sexual health education, and foster supportive environments for young
    people to learn. APA also supports $160 million for the SAMHSA Minority
    AIDS Initiative to expand efforts at preventing domestic HIV
    transmission and to increase treatment options for those living with
    co-morbid conditions. APA urges the Committee to provide $120 million
    for the infectious diseases and opioid program at CDC. Currently funded
    at a level well below its actual need, this program increases
    prevention, testing, and linkages to provide a strong ground-level
    response to the intersecting crises of opioid addiction, HIV, and
    hepatitis. Finally, to strengthen public health surveillance
    activities, APA requests $250 million for the CDC's Data Modernization
    Initiative (DMI).

        [This statement was submitted by Katherine B. McGuire, Chief
    Advocacy Officer, American Psychological Association Services, Inc.]
                                     ______

          Prepared Statement of the American Public Health Association
        APHA is a diverse community of public health professionals that
    champions the health of all people and communities. We are pleased to
    submit our request of at least $10 billion for the Centers for Disease
    Control and Prevention and at least $9.2 billion for the Health
    Resources and Services Administration in FY 2022. Robust funding for
    CDC and HRSA programs that promote public health and prevention,
    support surveillance of infectious disease and bolster America's public
    health workforce will be critical in addressing both the short-term and
    long-term health impacts of COVID-19 and the many other health
    challenges we face as a nation. We are thankful for the emergency
    supplemental funding provided to CDC and HRSA to support the nation's
    response to COVID-19 and we urge the committee to ensure that all CDC
    and HRSA programs are adequately funded in FY 2022.
        Centers for Disease Control and Prevention: CDC provides the
    foundation for our state and local public health departments,
    supporting a trained workforce, laboratory capacity and public health
    education communications systems. It is notable that more than 70% of
    CDC's budget supports public health and prevention activities by state
    and local health organizations and agencies, national public health
    partners and academic institutions. We urge a funding level of at least
    $10 billion in FY 2022. We are grateful for the important increases
    provided for CDC programs in FY 2021 and for the critical emergency
    funding provided to the agency to address COVID-19. We urge Congress to
    build upon these investments to strengthen all of CDC's programs, many
    of which remain woefully underfunded. We also urge your continued
    support for the Prevention and Public Health Fund which currently makes
    up approximately 11% of CDC's budget.
        CDC serves as the command center for the nation's public health
    defense system against emerging and reemerging infectious diseases.
    From aiding in the surveillance, detection and prevention of the
    current COVID-19 outbreak globally and in the U.S. to playing a lead
    role in the control of Ebola in West Africa and the Democratic Republic
    of the Congo, to monitoring and investigating disease outbreaks in the
    U.S., to pandemic flu preparedness to combating antimicrobial
    resistance, CDC is the nation's--and the world's--expert resource and
    response center, coordinating communications and action and serving as
    the laboratory reference center for identifying, testing and
    characterizing potential agents of biological, chemical and
    radiological terrorism, emerging infectious diseases and other public
    health emergencies.
        We strongly support the president's budget request for $400 million
    in new funding to bolster core public health infrastructure and
    capacity at the federal, state, territorial and local levels. This
    flexible funding is critical to addressing the gaps in core public
    health infrastructure and capacity at all levels as well as ensuring
    our nation's health departments are able to attract and retain
    experienced leaders and respond to future public health emergencies and
    disease outbreaks. Sustained, flexible funding is critical to
    rebuilding and strengthening the nation's public health system.
        CDC serves as the lead agency for bioterrorism and other public
    health emergency preparedness and response programs. We urge you to
    provide adequate funding for the Public Health Emergency Preparedness
    grants which provide resources to our state and local health
    departments to help them protect communities during public health
    emergencies. We also urge you to provide adequate funding for CDC's
    infectious disease, laboratory and disease detection capabilities to
    ensure we are prepared to tackle both ongoing COVID-19 pandemic and
    other public health challenges and emergencies that will likely arise
    during the coming fiscal year. Your continued support for CDC's public
    health Data Modernization Initiative is critical to ensuring we have
    both the world-class data workforce and data systems that are ready for
    the next public health emergency.
        We thank Congress for providing CDC with dedicated funding for
    firearm morbidity and mortality prevention research in FY 2020 and FY
    2021 and we strongly urge you to increase this funding in FY 2022 to
    $50 million for CDC and NIH, as requested in President Biden's FY 2022
    discretionary budget proposal. This will allow CDC to conduct research
    into important issues including the best ways to prevent unintended
    firearm injuries and fatalities among women and children; the most
    effective methods to prevent firearm-related suicides; and the measures
    that can best prevent the next shooting at a school or public place.
        CDC's National Center for Environmental Health works to control
    asthma, protect against threats associated with natural disasters and
    climate change, reduce and monitor exposure to lead and other
    environmental health hazards and ensure access to safe and clean water.
    We urge you to provide at least $322 million for NCEH in FY 2022,
    including $110 million for CDC's Climate and Health program, as
    requested in President Biden's FY 2022 discretionary budget request.
    Climate change is threating our health in many ways through the
    increased spread of vector-borne diseases, degraded air quality from
    ozone pollution and wildfire smoke, hotter temperatures and more
    extreme weather events. Increased funding will allow CDC to provide
    funding to all 50 states and to support additional, cities, counties
    and tribes to help them prepare for and respond to the health impacts
    of climate change in their communities.
        Programs under the National Center for Chronic Disease Prevention
    and Health Promotion address heart disease, stroke, cancer, diabetes
    and tobacco use that are the leading causes of death and disability in
    the U.S. and are also among the costliest to our health system. CDC
    provides funding for state programs to prevent disease, conduct
    surveillance to collect data on disease prevalence, monitor
    intervention efforts and translate scientific findings into public
    health practice in our communities. We strongly urge increased
    investments in these critical programs that are essential to reducing
    death, disability and health care costs. In particular, we urge your
    support for the president's request of $153 million for CDC's Social
    Determinants of Health Program. This increased funding would allow CDC
    to provide public health departments, academic institutions and
    nonprofit organizations funding and tools to support cross sector
    efforts to address the impact that social determinants of health such
    as unsafe and unstable housing, income insecurity, lack of
    transportation, and underlying health inequities have on the health of
    their communities.
        Health Resources and Services Administration: HRSA is the primary
    federal agency dedicated to improving health outcomes and achieving
    health equity. HRSA's 90-plus programs and more than 3,000 grantees
    support tens of millions of geographically isolated, economically or
    medically vulnerable people, in every U.S. state and territory, to
    achieve improved health outcomes by increasing access to quality health
    care and services; fostering a health care workforce able to address
    current and emerging needs; enhance population health and address
    health disparities through community partnerships; and promote
    transparency and accountability within the health care system.
        We are grateful for the increases provided for HRSA programs in FY
    2021 and for the emergency supplemental funding to battle the COVID-19
    pandemic, but HRSA's discretionary budget authority is far too low to
    effectively address the nation's current public health and health care
    needs. We recommend Congress build upon the important increases they
    provided HRSA in FY21 and provide at least $9.2 billion for the Health
    Resources and Services Administration in FY 2022
        HRSA programs and grantees are providing innovative and successful
    solutions to some of the nation's greatest health care challenges
    including the rise in maternal mortality, the severe shortage of health
    professionals, the high cost of health care and behavioral health
    issues related to substance use disorders-including opioid misuse.
    Additional funding will allow HRSA build upon these successes and pave
    the way for new achievements by supporting critical HRSA programs,
    including:
        Primary Health Care that supports nearly 13,000 health center sites
    in medically underserved communities across the U.S., providing access
    to high-quality preventive and primary care to nearly 30 million people
    including 1 in 3 people living in poverty.
        Health Workforce supports the health workforce across the training
    continuum and offers scholarship and loan repayment programs to ensure
    a well-prepared, well-distributed and diverse workforce that is ready
    to meet the current and evolving health care needs of the nation.
        Maternal and Child Health supports initiatives that reduce infant
    mortality, minimize disparities, prevent chronic conditions and improve
    access to quality health care for vulnerable women, infants and
    children; and serves 60 million people through the MCH block grant.
        HIV/AIDS programs deliver a comprehensive system of care to more
    than 519,000 individuals impacted by HIV/AIDS, improving health
    outcomes for people with HIV and reducing the chance of others becoming
    infected, and provides training for HIV/AIDS health professionals.
    HRSA's Ryan White HIV/AIDS Program effectively engages clients in
    comprehensive care and treatment, including increasing access to HIV
    medication, which has resulted in 88.1% of clients achieving viral
    suppression, compared to just 64.7% of all people living with HIV
    nationwide.
        Family Planning Title X services ensure access to comprehensive
    family planning and preventive health services for over 3.1 million
    people, reducing unintended pregnancy rates, limiting sexually
    transmitted infection transmission and increasing early detection of
    cancers.
        Rural Health supports community solutions to improve efficiencies
    in delivering rural health services and expand access, including
    supporting activities that aim to increase access to opioid treatment
    in rural areas and promote the use of health information technology and
    telehealth.
        HRSA has also been active in the COVID-19 pandemic response,
    awarding billions of dollars to health centers to administer COVID-19
    tests and reimbursing providers who offer COVID-19 care to uninsured
    individuals.
        In closing, we emphasize that the public health system requires
    stronger financial investments at every stage. It is critical that
    Congress increase its investments in CDC and HRSA programs to enable
    the nation to meet the mounting health challenges we currently face and
    to become a healthier nation.

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

      Prepared Statement of the American Society for Engineering Education
        This written testimony is submitted on behalf of the American
    Society for Engineering Education (ASEE) to the Senate Subcommittee on
    Labor, Health and Human Services, Education, and Related Agencies for
    the official record. ASEE appreciates the Committee's support for the
    Department of Education (ED) in fiscal year (FY) 2021 and asks you to
    robustly fund student aid, teacher preparation, and STEM programs in FY
    2022. Additionally, ASEE requests federal funding to support
    initiatives aimed at increasing the diversity of the STEM pipeline and
    support for Minority-Serving Institutions (MSIs). The strong support of
    the National Institutes of Health (NIH) in FY 2021 was greatly
    appreciated and ASEE requests continued support of NIH.
        The American Society for Engineering Education (ASEE) advances
    innovation, excellence, and access at all levels of education for the
    engineering profession and is the only society representing the
    country's schools and colleges of engineering and engineering
    technology. Membership includes over 12,000 individuals hailing from
    all disciplines of engineering and engineering technology including
    educators, researchers, and students as well as industry and government
    representatives. As the pre-eminent authority on the education of
    engineering professionals, ASEE seeks to advance the development of
    innovative approaches and solutions to engineering education and
    advocates for equal access to engineering educational opportunities for
    all.
    Student Aid
        Student aid programs like Pell Grants, Federal Work-Study (FWS),
    TRIO, and others make higher education accessible and affordable for
    millions of students. We appreciate the commitment the Biden
    Administration has made to affordable education through its preliminary
    Presidential Budget Request and the American Families Plan. ASEE joins
    the higher education community in requesting funding to support
    doubling the maximum Pell Grant award to $12,990. Pell Grants are
    essential to low-income students being able to afford higher education.
    These awards are vital in helping students access the significant life
    and career benefits that higher education provides. These benefits are
    especially prevalent for engineering education, which provides a proven
    pathway to the middle class, especially for students from low-income
    backgrounds. ASEE requests funding for Federal Work Study (FWS) at
    $1.480 billion and $1.061 billion for Supplemental Educational
    Opportunity Grant (SEOG). These programs are need-based, and often this
    aid provides the resources a student needs to complete their education.
    ASEE asks the Committee to consider ways to support work-based
    learning, such as co-operative education and apprenticeships, within
    the FWS program. ASEE firmly believes in ensuring access to engineering
    and engineering technology education for all students, not just those
    who can afford it, which is why ensuring student aid programs for
    graduate students is also very important. ASEE requests funding for the
    Graduate Assistance in Areas of National Need (GAANN) program, which
    provides fellowships, through academic departments and programs of
    institutions of higher education, to assist graduate students with
    excellent records who demonstrate financial need. ASEE requests $35
    million for GAANN.
    Teacher Preparation
        The need for well-prepared and content-confident teachers in early
    childhood, elementary, and secondary education is high, particularly in
    STEM subjects. The lack of teacher training focused on STEM, and
    engineering in particular, is an important issue facing K-12 education.
    Problem-based learning that incorporates engineering design and
    analysis skills are often absent from teacher preparation and
    professional development programs. ASEE supports vigorous funding for
    Title II of the Elementary and Secondary Education Act (ESEA), which
    supports the preparation and professional development of school
    personnel, and Title II of the Higher Education Act, which supports
    teacher preparation programs at institutions of higher education. ASEE
    also supports President Biden's proposal to invest $9 billion in
    training and diversifying the teaching workforce presented in the
    American Families Plan. Efforts to support teaching skills for STEM
    postsecondary faculty should also be considered and could include
    partnerships between STEM disciplines and Schools of Education to
    support STEM faculty and support for teaching and learning centers at
    postsecondary institutions. Support of postsecondary faculty and their
    promotion of STEM learning should utilize research-based methods. Our
    future is dependent on today's students finding solutions to tomorrow's
    problems. This can only be accomplished if those students have teachers
    who are prepared to guide them in developing the knowledge and skills
    needed to solve those problems.
    STEM
        Support for science, technology, engineering, and mathematics
    (STEM) continues to grow and ASEE appreciates the support many STEM
    programs received in FY 2021. ASEE supports funding for Title IV of the
    Elementary and Secondary Education Act (ESEA) at its authorized amount
    of $1.6 billion, which will allow states and school districts
    additional resources to pursue STEM programs. ASEE supports robust
    funding for STEM programs for higher education students including the
    Hispanic-Serving Institutions (HSI) STEM and Minority Science and
    Engineering Improvement (MSEIP) programs. The STEM workforce is a
    driving force behind innovation and our economic development. These and
    other programs targeted towards increasing the representation of
    historically underrepresented populations, including women, will ensure
    a healthy STEM workforce pipeline.
    Career and Technical Education (CTE)
        ASEE knows that high-quality Career and Technical Education (CTE)
    prepares students for careers and further postsecondary education while
    fulfilling employer needs in high-demand sectors of the economy.\1\
    ASEE supports CTE and wants to ensure best practices and high-quality
    programs are embedded in its programs, for example through faculty
    professional development and connections to the National Science
    Foundation -supported Advanced Technological Education (ATE) programs.
    ASEE also wants to strengthen pathways between CTE at the associate
    degree level to 4-year engineering technology and engineering degrees.
    ASEE believes that students should have lifelong options for continuing
    study and career advancement and that CTE programs can help students
    achieve their goals. In order for states and their CTE educators to
    provide high-quality CTE opportunities for students and strengthen
    pathways between two- and four-year institutions of higher education,
    ASEE urges Congress to robustly fund the Perkins Basic State Grant
    funding program in FY 2022 and encourage the program to build
    connections with NSF's ATE program.
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    National Institutes of Health--National Institute of Biomedical Imaging
            and Bioengineering (NIBIB)
        NIBIB is the major NIH Institute focused on engineering
    applications to human health and training the next generation of
    biomedical engineers. ASEE is grateful to the committee for its strong
    bipartisan support of the NIH in FY 2021. NIBIB funding is critical for
    the development of devices and tools that can improve the detection,
    treatment, and prevention of disease, and also plays a critical role in
    assessing the effectiveness of new drugs and treatment procedures.
    NIBIB also supports training programs to enhance and expand education
    and training for the next generation biomedical engineering workforce.
    Through grant programs like the Enhancing Science, Technology, and Math
    Education Diversity Research Education Experiences, and Team-Based
    Design in Biomedical Engineering Education, NIBIB is committed to
    supporting all stages of the biomedical engineering career pathway and
    increasing the participation of traditionally underrepresented groups
    in engineering. ASEE urges the Committee to provide NIH with $46.1
    billion in FY 2022 so that NIBIB can continue to support critical
    biomedical engineering research and training.
                                   conclusion
        Engineering and engineering technology academic programs play
    critical roles in the STEM ecosystem. The requests made here support
    the development of a skilled technical workforce, broadening
    participation, and transdisciplinary study. Thank you for the
    opportunity to submit this testimony.

        [This statement was submitted by Sheryl Sorby, Ph.D., President,
    and Norman Fortenberry, Sc.D., Executive Director, American Society for
    Engineering
    Education.]
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) is the one of the
    largest life science societies, composed of more than 30,000 scientists
    and health professionals. Our mission is to promote and advance the
    microbial sciences. ASM respectfully requests that Congress provide at
    least $46.1 billion for the National Institutes of Health (NIH) and at
    least $10 billion for the Centers for Disease Control and Prevention
    (CDC) in fiscal year (FY) 2022. Within the CDC budget, we request $60
    million for the Advanced Molecular Detection (AMD) program in the
    National Center for Emerging and Zoonotic Infectious Diseases.
    Achieving Remarkable Outcomes Through a Strong Investment in the NIH
        We thank Congress for its longstanding, bipartisan support for the
    NIH and for its commitment to basic, translational, and clinical
    microbial research funded through multiple Institutes and Centers,
    particularly through the National Institute of Allergy and Infectious
    Diseases (NIAID). We especially thank Chairman Leahy, Vice Chairman
    Shelby, Chair Murray and Ranking Member Blunt and members of the Senate
    Appropriations Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies for their unwavering support for the NIH
    and leadership over the past six years, during which they and their
    Senate counterparts have worked in a bipartisan manner to place the NIH
    budget back on the path of meaningful growth above inflation.
        Thanks to a renewed commitment to NIH, researchers were able to
    pivot when SARS-CoV-2 emerged and the race to develop tests, vaccines
    and therapeutics commenced. Researchers built on decades of federally-
    funded basic science and technological advances to develop safe and
    effective vaccines at record speed. This remarkable achievement has
    reenergized existing and aspiring scientists worldwide, allowed our
    country to begin moving past the pandemic, and demonstrated the power
    of public-private partnerships. Continuing to provide robust, sustained
    and predictable funding for the NIH is the only way we will seize the
    unparalleled scientific opportunities in microbial research that lie
    before us, and the only way we will be equipped to address the demands
    that future infectious disease outbreaks will place on our society.
    NIH Funding has Transformed the Microbial Sciences
        Even before the COVID-19 pandemic, investments in microbial
    research at NIH led to great strides in protecting and improving human
    health as illustrated by the following advances:
      --A young person diagnosed with Human Immunodeficiency Virus (HIV)
            today who receives treatment will have a near normal life
            expectancy. The AIDS death rate has dropped 80% from its peak
            in 1995.
      --Routine childhood vaccinations prevent millions of cases of
            illness. For children vaccinated in 2009, an estimated $82
            billion in costs will be saved and 20 million cases, including
            42,000 early deaths, will be prevented.
      --The first preventive vaccine and experimental treatments were
            recently deployed in Africa against the Ebola virus, marking a
            significant public health achievement. The Ebola virus, which
            ravaged West Africa in 2013 and continues to cost lives in the
            Democratic Republic of the Congo, has killed more than 10,000
            people and severely strained regional socioeconomic stability.
      --Since 2007, the NIH has been on the forefront of supporting
            microbiome research with the Common Fund's Human Microbiome
            Project (HMP), which was formed to develop research resources
            to study of microbial communities and how they impact human
            health and disease. Microbiome research has increased over 40
            times since the inception of the HMP, and the work engages over
            20 NIH Institutes and Centers. This important research has had
            implications for our understanding of microbiome interactions
            in pregnancy and preterm birth, inflammatory bowel disease, and
            diabetes, among other topics.
    Continued Progress Requires Sustained Funding and Support for
            Investigators
        Even in the face of the promise and progress highlighted above,
    well known pathogens and pathogen resistance threaten our nation's
    health with serious economic and social ramifications. Seasonal flu
    continues to cost the U.S. billions annually in direct medical costs
    and lost productivity due to illness, and claims the lives of thousands
    of Americans each year. Through sustained funding to NIAID, scientists
    continue the quest for a universal flu vaccine. Antimicrobial
    resistance (AMR) is a daunting public health challenge and considered a
    global crisis by the World Health Organization, the G20 and the United
    Nations. Continued investment in research to better understand how
    microbes become resistant, and develop more precise clinical
    diagnostics, novel therapeutics and vaccines is greatly needed.
        The COVID-19 pandemic has exacted a toll on the broader research
    enterprise, especially early career investigators and those who were
    unable to pivot to work on SARS-CoV-2. Pandemic-related laboratory
    closures disrupted ongoing research, resulted in loss of animal
    colonies and cell lines, and loss of laboratory positions. Experiments
    will need to be restarted, animal colonies repopulated and fieldwork
    rescheduled for an indeterminate later time. While our nation's
    research capacity has demonstrated it can absorb shocks, the scale of
    this one is still growing and unprecedented in duration and impact.
    Congress should consider additional ``research relief'' funding to NIH
    to assist in the recovery of our research workforce and projects
    negatively affected by the pandemic.
    CDC's Indispensable Role in Preventing and Controlling Infectious
            Disease
        The programs and activities supported by CDC are essential to
    protect the health of the American people. ASM appreciates the
    extraordinary emergency funding provided to the agency in FY 2021 to
    meet the needs presented by the pandemic. However, had Congress
    provided necessary support for CDC and public health infrastructure
    over time, our country would have been in a better position to address
    the public health crisis more effectively from the start. With this in
    mind, we urge Congress to build on emergency investments in FY 2022,
    including robust funding for the Data Modernization Initiative and the
    Prevention and Public Health Fund. CDC aids in surveillance, detection
    and prevention of global and domestic outbreaks from novel Coronavirus,
    to Ebola, to the measles, to seasonal flu. CDC is the nation's expert
    resource and response center, coordinating communications and action,
    and serving as the laboratory reference center. As we have seen over
    the course of the pandemic, states, communities, and international
    partners rely on CDC for accurate information, direction, and resources
    to ensure they continue to be prepared in a crisis or outbreak.
        Three areas that ASM would like to highlight under CDC are: (1)
    advanced molecular detection technology; (2) antimicrobial resistance;
    and, (3) laboratory capacity.
      --The Advanced Molecular Detection (AMD) program brings cutting edge
            genomic sequencing technology to the front lines of public
            health by harnessing the power of next-generation sequencing
            and high performance computing with bioinformatics and
            epidemiology expertise to study pathogens. The program has
            played an indispensable role by leading genomic surveillance
            efforts and sequencing of SARS-CoV-2 samples, especially aimed
            at getting in front of emerging variants. We thank Congress for
            providing transformational funding for AMD in the American
            Rescue Plan Act, and with increased base funding, the AMD
            program can continue to promote innovation, expand workforce
            development, and enter into productive partnerships with
            academic research institutions and state/local public health
            agencies. ASM requests $60 million for AMD in FY 2022.
      --Multiple programs support antimicrobial resistance, one of the most
            daunting health challenges we face today. ASM requests funding
            for the Antibiotic Resistance Solutions Initiative at $672
            million, the National Healthcare Safety Network at $100
            million, and the Division of Global Health Protection at $465.4
            million, which will ensure that we have the resources across
            multiple programs to address this urgent public health
            challenge.
      --Support for laboratory capacity is paramount, and the Emerging and
            Zoonotic Infectious Disease labs are the world's reference
            labs. But maintaining labs costs more each year, from quality
            and safety initiatives, to the cost of shipments and supplies,
            to recruiting and retaining specialized and highly trained
            staff. We urge you to consider additional funding for resources
            to this area, particularly as we consider ways to bolster lab
            capacity in times of public health emergency.
        ASM looks forward to working with you to ensure that researchers
    and public health professionals have the resources they need to apply
    fundamental microbial science research to meet 21st Century challenges
    in public health promotion, the prevention, detection and treatment of
    infectious diseases, and the prevention of outbreaks.

        [This statement was submitted by Allen Segal, Public Policy and
    Advocacy
    Director, American Society for Microbiology.]
                                     ______

            Prepared Statement of the American Society for Nutrition
        Dear Chairman Murray and Ranking Member Blunt:
        Thank you for the opportunity to provide testimony regarding Fiscal
    Year (FY) 2022 appropriations. The American Society for Nutrition (ASN)
    respectfully requests at least $46.1 billion dollars for the National
    Institutes of Health (NIH) and $200 million dollars for the Centers for
    Disease Control and Prevention/National Center for Health Statistics
    (CDC/NCHS) in Fiscal Year 2022. ASN is dedicated to bringing together
    the world's top researchers to advance our knowledge and application of
    nutrition, and has more than 8,000 members working throughout academia,
    clinical practice, government, and industry.
    National Institutes of Health (NIH)
        The NIH is the nation's premier sponsor of biomedical research and
    is the agency responsible for conducting and supporting the largest
    percentage of federally funded basic and clinical nutrition research
    with $3.2 billion estimated for nutrition and obesity research in 2020.
    Although nutrition and obesity research make up just five percent of
    the NIH budget, some of the most promising nutrition-related research
    discoveries have been made possible by NIH support. NIH nutrition-
    related discoveries have impacted the way clinicians prevent and treat
    heart disease, cancer, diabetes and other chronic diseases. For
    example, from 1990 to 2019, U.S. diet-related death rates decreased
    from 154 to 101 deaths per 100,000 population, although the proportion
    of deaths attributable to dietary risks was largely stable.\1\ However,
    the burden and risk factors remain high. With additional support for
    NIH, additional breakthroughs and discoveries to improve the health of
    all Americans will be made possible.
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        Investment in biomedical research generates new knowledge, improved
    health, and leads to innovation and long-term economic growth. ASN
    recommends at least $46.1 billion dollars for NIH in Fiscal Year 2022
    to support NIH nutrition-related research that will lead to important
    disease prevention and cures. A budget of $46.1 billion will allow NIH
    to provide support to the new NIH Common Fund's Nutrition for Precision
    Health, powered by the All of Us Research Program, while still
    providing much needed increases to other parts of the portfolio. NIH
    needs sustainable and predictable budget growth to fulfill the full
    potential of biomedical research, including nutrition research, that is
    aimed at improving the health and wellbeing of all Americans, as well
    as global populations.
    Centers for Disease Control and Prevention National Center for Health
            Statistics (CDC NCHS)
        The National Center for Health Statistics, housed within the
    Centers for Disease Control and Prevention, is the nation's principal
    health statistics agency. ASN recommends a Fiscal Year 2022 funding
    level of $200 million dollars for NCHS to help ensure uninterrupted
    collection of vital health and nutrition statistics and help cover the
    costs needed for technology and information security maintenance and
    upgrades that are necessary to replace aging survey infrastructure. The
    U.S. is a leader in this area and a decade of flat funding has taken a
    significant toll on NCHS's ability to keep pace.
        The NCHS provides critical data on all aspects of our health care
    system, and it is responsible for monitoring the nation's health and
    nutrition status through surveys such as the National Health and
    Nutrition Examination Survey (NHANES), that serve as a gold standard
    for data collection around the world. Nutrition and health data,
    largely collected through NHANES, are essential for tracking the
    nutrition, health and well-being of the American population, and are
    especially important for observing nutritional and health trends in our
    nation's children. This is an invaluable source of data that has been
    and can continue to be used to address major health issues as they
    arise.
        Nutrition monitoring conducted by the Department of Health and
    Human Services in partnership with the U.S. Department of Agriculture/
    Agricultural Research Service is a unique and critically important
    surveillance function in which dietary intake, nutritional status, and
    health status are evaluated in a rigorous and standardized manner.
    Nutrition monitoring is an inherently governmental function and
    findings are essential for multiple government agencies, as well as the
    public and private sector. Nutrition monitoring is essential to track
    what Americans are eating, inform nutrition and dietary guidance
    policy, evaluate the effectiveness and efficiency of nutrition
    assistance programs, and study nutrition-related disease outcomes.
    Funds are needed to ensure the continuation of this critical
    surveillance of the nation's nutritional status and the many benefits
    it provides.
        Through learning both what Americans eat and how their diets
    directly affect their health, the NCHS is able to monitor the
    prevalence of obesity and other chronic diseases in the U.S. and track
    the performance of preventive interventions, as well as assess
    'nutrients of concern' such as calcium, iron, folate, iodine, vitamin
    D, and other micronutrients which are consumed in inadequate amounts by
    many subsets of our population. Data such as these are critical to
    guide policy development in health and nutrition, including food
    safety, food labeling, food assistance, military rations and dietary
    guidance. For example, NHANES data are used to determine funding levels
    for programs such as the Supplemental Nutrition Assistance Program
    (SNAP) and the Women, Infants, and Children (WIC) clinics, which
    provide nourishment to low-income women and children. Additional
    support would enable collection of more data on under-represented
    groups, such as pregnant and lactating women, and assessment of
    nutritional status indicators for nutrients on which we have no, or
    inadequate, information.
        Thank you for the opportunity to submit testimony regarding FY 2022
    appropriations for the National Institutes of Health and the CDC/
    National Center for Health Statistics. Please contact John E. Courtney,
    Ph.D., ASN Executive Officer, at 9211 Corporate Boulevard, Suite 300,
    Rockville, Maryland 20850, jcourtney@nutrition.org, if ASN may provide
    further assistance.
        Sincerely.

        [This statement was submitted by Lindsay H. Allen, Ph.D., 2020-2021
    President, American Society for Nutrition.]
                                     ______

            Prepared Statement of the American Society of Hematology
        The American Society of Hematology (ASH) represents more than
    17,000 clinicians and scientists committed to the study and treatment
    of blood and blood-related diseases, including malignant disorders such
    as leukemia, lymphoma, and myeloma; conditions including thrombosis and
    bleeding disorders; and congenital diseases such as sickle cell
    disease, thalassemia, and hemophilia.
    FY 2022 Request: National Institutes of Health (NIH)
        American biomedical research has led to new medical treatments,
    saved innumerable lives, reduced human suffering, and spawned entire
    new industries, none of which would have been possible without support
    from the NIH. Hematology research, funded by many institutes at the
    NIH, including the National Heart, Lung and Blood Institute (NHLBI),
    the National Cancer Institute (NCI), the National Institute of
    Diabetes, Digestive and Kidney Diseases (NIDDK), the National Institute
    on Aging (NIA), and the National Institute of Allergy and Infectious
    Diseases (NIAID), has been an important component of this investment in
    the nation's health.
        NIH-funded research has led to tremendous advances in treatments
    for children and adults with blood cancers and other hematologic
    diseases and disorders. Hematology advances also help patients with
    other types of cancers, heart disease, and stroke. Basic research on
    blood has aided physicians who treat patients with heart disease,
    strokes, end-stage renal disease, cancer, and AIDS. The Society
    recently updated the ASH Agenda for Hematology Research, which serves
    as a roadmap to prioritize research within the hematology field and
    includes recommendations for areas of additional federal investment
    that will equip researchers to make truly practice-changing discoveries
    in hematology and other fields of medicine for years to come.
        Additionally, the extraordinary research that has occurred to
    identify and develop potential COVID-19 vaccines, antivirals, and other
    medical countermeasures is all built on the scientific foundation
    enabled by the federal investment in NIH. In response to the emergence
    of hematologic complications from COVID-19 infection, ASH developed the
    COVID-19 Research Agenda in Hematology, which highlights fundamental
    questions that experts in hematology and blood research deem of
    critical importance to researchers, physicians, and patients.
        ASH thanks Congress for the robust bipartisan support that has
    resulted in several consecutive years of welcome and much needed
    funding increases for NIH. For FY 2022, ASH joins nearly 400
    organizations and institutions across the NIH stakeholder community to
    strongly support the Ad Hoc Group for Medical Research recommendation
    that NIH receive a program level of at least $46.1 billion. This
    funding level would allow for meaningful growth above inflation in the
    base budget that would expand NIH's capacity to support promising
    science in all disciplines.
        While we are grateful for Congress's ongoing commitment to NIH as a
    top national priority through the regular appropriations process, we
    also urge the inclusion of emergency supplemental investments for the
    NIH as Congress considers future legislation to promote the nation's
    physical, health, and economic resilience to the COVID-19 pandemic.
        The pandemic's impact on biomedical research has been serious and
    far-reaching. Researchers in every state were forced to suspend many
    laboratory activities for their own personal safety and to comply with
    physical distancing guidelines. The closure of many research facilities
    impacted trainees, technicians, early-stage investigators, and
    established investigators alike, preventing the research workforce from
    maintaining momentum toward better prevention, treatments, diagnostics,
    and cures for diseases such as blood cancers, sickle cell disease, and
    other hematologic diseases and conditions. While many institutions have
    been implementing plans to ramp this work back up again as safely as
    possible, challenges associated with the disruptions continue to
    linger. For example, certain types of research--such as clinical trials
    and other research projects with human participants--have been slower
    to recover. Additionally, as a result of the lags, we risk undoing
    progress we have made in recent years in strengthening the research
    workforce, including among women, underrepresented minorities, and
    early-career investigators and others at a pivotal point in their
    career trajectories.
        To enable NIH to mitigate the pandemic-related disruptions without
    foregoing promising new science, ASH strongly supports emergency
    funding for federal research agencies as outlined in the bipartisan
    Research Investment to Spark the Economy (RISE) Act (H.R. 869/S. 289),
    including $10 billion for NIH.
    FY 2022 Request: Centers for Disease Control and Prevention (CDC)
        The Society also recognizes the important role of the CDC in
    preventing and controlling clotting, bleeding, and other hematologic
    disorders. This is especially important for improving the care and
    treatment of individuals with sickle cell disease (SCD).
        Sickle cell disease is an inherited, lifelong disorder affecting
    approximately 100,000 Americans. Individuals with the disease produce
    abnormal hemoglobin which results in their red blood cells becoming
    rigid and sickle-shaped, causing them to get stuck in blood vessels and
    block blood and oxygen flow to the body, which can cause severe pain,
    stroke, organ damage, and in some cases premature death. Though new
    approaches to managing SCD have led to improvements in diagnosis and
    supportive care, many people living with the disease are unable to
    access quality care and are limited by a lack of effective treatment
    options.
        The Sickle Cell Disease and Other Heritable Blood Disorders
    Research, Surveillance, Prevention, and Treatment Act of 2018 (P.L.
    115-327) authorized CDC, through its Sickle Cell Data Collection
    program, to award grants to states, academic institutions, and non-
    profit organizations to gather information on the prevalence of SCD and
    health outcomes, complications, and treatment that people with SCD
    experience. Currently eleven states participate in the data collection
    program. Funding through the CDC Foundation has allowed Georgia and
    California to collect data since 2015; seven additional states
    (Alabama, Indiana, Michigan, Minnesota, North Carolina, Tennessee, and
    Wisconsin) were able to begin their programs in FY 2021 with the $2
    million in funding provided by Congress in the FY 2021 Consolidated
    Appropriations Act. In early March 2021, the program expanded to
    Colorado and Virginia with additional funding from the CDC Foundation.
    These eleven states are estimated to include just over 35% of the U.S.
    SCD population.
        ASH thanks Congress for the $2 million provided for the data
    collection program in FY 2021 and for the Administration's request for
    $2 million in funding for the program in FY 2022. The Society strongly
    supports providing CDC with at least $5 million in FY 2022 to continue
    to phase in the data collection program in the currently participating
    states and to allow for an expansion to additional states with the goal
    of covering the majority of the U.S. SCD population over the next five
    years.
    FY 2021 Request: Health Resources and Services Administration (HRSA)
        Finally, ASH supports the Administration's funding requests for the
    SCD programs within HRSA's Maternal and Child Health Bureau, including
    $7.205 million for the SCD Treatment Demonstration Program (SCDTDP) and
    $5 million for the SCD Newborn Screening Program, which is part of
    HRSA's Special Projects of Regional and National Significance (SPRANS)
    program. The grantees funded by these programs work to improve access
    to quality care for individuals living with SCD and sickle cell trait.
    The SCDTDP funds five geographically distributed regional SCD grants
    that support SCD providers to increase access to high quality,
    coordinated, comprehensive care for people with SCD, while the SCD
    Newborn Screening Program provides grants to support the comprehensive
    care for newborns diagnosed with SCD. ASH also supports the inclusion
    of language in the report accompanying the FY 2022 appropriations bill
    asking HRSA to provide Congress with a report detailing how the Sickle
    Cell Disease Treatment Demonstration Program is supporting the growth
    of comprehensive sickle cell disease centers.
        Thank you again for the opportunity to submit testimony. Please
    contact ASH Senior Manager, Legislative Advocacy, Tracy Roades at
    troades@hematology.org, if you have any questions or need further
    information concerning hematology research or ASH's FY 2022 requests.
                                     ______

          Prepared Statement of the American Society of Human Genetics
        The American Society of Human Genetics (ASHG) thanks the
    Subcommittee for its continued strong support and leadership in funding
    the National Institutes of Health (NIH). The $1.25 billion increase
    provided for Fiscal Year (FY) 2021 reinforces our nation's commitment
    to the health and well-being of all Americans--at a time when investing
    in biomedical research and scientific innovation is most needed to
    defeat the COVID-19 pandemic. ASHG urges the Subcommittee to
    appropriate $46.1 billion for NIH in FY 2022.
        ASHG was delighted to see President Biden propose a major increase
    to NIH's budget in FY 2022. We note that President Biden proposes a
    significant investment for the creation of a new Advanced Research
    Projects Agency for Health (ARPA-H). We look forward to learning more
    about ARPA-H and how research on human genetics and genomics might play
    a role in its mission.
         saving lives: genetics research in the fight against covid-19
        Less than a year after the first case of COVID-19 was reported, the
    U.S. Food and Drug Administration (FDA) authorized the use of two
    COVID-19 vaccines.\1\ This record speed in vaccine development was
    built on decades of research and scientific knowledge, including NIH-
    funded basic research and private investments that have led to rapid
    and inexpensive DNA sequencing technologies.\2\ Our ability to quickly
    and inexpensively analyze the genome of the SARS--CoV-2 virus has been
    crucial for developing diagnostics and vaccines, testing, tracking
    variants, and trying to understand the range of responses to infection.
    NIH Director Dr. Francis Collins noted that the ability to rapidly
    sequence the new coronavirus ``...made it possible within 24 hours for
    the first vaccine design to get started!'' \3\
    ---------------------------------------------------------------------------
        \1\ https://covid19.nih.gov/research-highlights/vaccine-
    development.
        \2\ Ibid.
        \3\ https://www.forbes.com/sites/billfrist/2021/01/20/nih-director-
    dr-francis-collins-connecting-the-dots-from-the-human-genome-project-
    to-the-covid-19-vaccine/?sh=36f948a27543.
    ---------------------------------------------------------------------------
        Human geneticists across the world mobilized quickly to try to
    understand why some individuals were asymptomatic while others suffered
    from severe disease, including so-called ``Long COVID.'' Early data
    supports that genetic differences between individuals play a part in
    determining susceptibility to the disease. The COVID-19 Host Genetics
    Initiative and the COVID-19 Human Genetics Effort brought together
    researchers from dozens of countries to share resources and data to
    understand how human genetics affects COVID-19 susceptibility,
    severity, and outcomes.\4,5\
    ---------------------------------------------------------------------------
        \4\ https://www.covid19hg.org/partners/.
        \5\ https://www.covidhge.com/.
    ---------------------------------------------------------------------------
          return on investment: genetics research benefits the economy
        The pandemic has demonstrated that federally funded research is
    critical for us to return to normalcy and recover economically. In
    addition, investments in research and development continue to be a
    strong driver of economic activity overall. A new study commissioned by
    ASHG and conducted by TEConomy Partners highlights the growth of a
    dynamic ecosystem derived from human genetics research, and that the
    development and manufacturing of genomic technologies, diagnostics and
    therapeutics, and the associated healthcare services, ``generate
    substantial U.S. economic activity and support a large volume of jobs
    across the nation.'' \6\ The report estimates that the human genetics
    and genomics sector supports 850,000 jobs and generates $265 billion in
    total economic activity annually,\7\ demonstrating that this sector has
    grown around five-fold in the last decade. Beyond the economic impact,
    the study also catalogues the many ways in which human genetics and
    genomics is being integrated into routine clinical care across a broad
    range of diseases.\8\ Key data from the report are shown below.
    ---------------------------------------------------------------------------
        \6\ Tripp, S., and Grueber, M. 2021. The Economic Impact and
    Functional Applications of Human Genetics and Genomics. https://
    www.ashg.org/wp-content/uploads/2021/05/ASHG-TEConomy-Impact-Report-
    Final.pdf.
        \7\ Ibid.
        \8\ Ibid.
    ---------------------------------------------------------------------------
                    genetics & genomics: striving for equity
        The COVID-19 pandemic has disproportionately affected racial and
    ethnic minorities in the U.S., reinforcing that there are social
    factors in this country that cause major health disparities.\9\ It is
    imperative that the application of genetic science in healthcare does
    not worsen existing health disparities, but instead advances health to
    benefit all Americans. Indeed, NIH-funded research has demonstrated how
    genetics and genomics research can be a tool for health equity through
    deliberate inclusion and participation of individuals from diverse
    groups. As genetics research is foundational to our understanding of
    human biology, gleaning the full scope of genetic variation will
    improve both healthcare and health equity. Inclusion of populations
    from diverse ancestries in studies is revealing novel insights about
    drug responses, diagnostic accuracy, and disease risk, demonstrating
    the need for increased diversity in research studies and clinical
    trials.\10\ In ensuring broad cohort diversity in biomedical research,
    we need to consider all types of diversity, including engagement with
    both urban and rural communities, and taking into account social
    demographics such as gender, age, and economic status.
    ---------------------------------------------------------------------------
        \9\ https://www.cdc.gov/coronavirus/2019-ncov/community/health-
    equity/racial-ethnic-disparities/index.html.
        \10\ Collins, F., Doudna, J.A., Lander, E., and Rotimi, C.N. Human
    Molecular Genetics and Genomics--Important Advances and Exciting
    Possibilities. N.Engl.J.Med 2021. 384:1-4.
    ---------------------------------------------------------------------------
        The Society commends NIH's efforts to advance diversity and equity
    in research, which are made possible by the strong support of this
    Subcommittee in providing robust funding for the NIH. The great strides
    made by the All of Us Research Program in having its research cohort
    reflect the diversity of the United States is one such example.\11\
    Furthermore, UNITE, NIH's new initiative to address ``racial equity in
    the biomedical research workforce'' and ``long-standing health
    disparities and issues related to minority health inequities in the
    United States'' \12\ comes at a crucial time for our nation.
    ---------------------------------------------------------------------------
        \11\ https://allofus.nih.gov/.
        \12\ https://www.nih.gov/ending-structural-racism/unite.
    ---------------------------------------------------------------------------
        America's greatest asset is its people--all of its people. From the
    research workforce to research participants, increasing diversity is
    essential if we are to realize the full promise of genomics research
    and the equitable application of genetic discoveries in healthcare and
    society. Sustained budget increases for NIH are necessary to fund
    programs that emphasize diversity and equity in the workforce and that
    broaden participation by the public in research.
                           nih funding for the future
        The COVID-19 pandemic caused unprecedented disruptions to the
    biomedical research enterprise in 2021. This was especially true in the
    human genetics and genomics community, where researchers either closed
    laboratories or repurposed their genome sequencing machines for
    performing SARS-CoV-2 testing, tracking and tracing. Strong funding is
    needed in FY2022 to help the workforce recover.
        ASHG joins its fellow members of the Federation of American
    Societies for Experimental Biology (FASEB) and the Ad Hoc Group for
    Medical Research in recommending a $46.1 billion base budget for NIH
    for FY 2022. This funding level would allow NIH's base budget to keep
    pace with inflation, specifically the biomedical research and
    development price index, and support crucial research on human genetics
    and genomics across all of the NIH's 27 Institutes and Centers.
        The American Society of Human Genetics (ASHG), founded in 1948, is
    the primary professional membership organization for human genetics
    specialists worldwide. The Society's nearly 8,000 members include
    researchers, clinicians, genetic counselors, nurses and others who have
    a special interest in the field of human genetics.

        [This statement was submitted by Gail Jarvik, MD, PhD, President,
    American
    Society of Human Genetics.]
                                     ______

            Prepared Statement of the American Society of Nephrology
        On behalf of the more than 37 million Americans living with kidney
    diseases, the American Society of Nephrology respectfully requests that
    in the Office of the Secretary of Health and Human Services (IOS),
    General Department Management, $25 million be included for KidneyX, a
    public-private partnership to accelerate innovation in the prevention,
    diagnosis, and treatment of kidney diseases, in the Fiscal Year (FY)
    2022 Labor, Health and Human Services, Education and Related Agencies
    Appropriations bill.
        More than 37 million people in the United States are living with
    kidney diseases, and nearly 800,000 have kidney failure, for which
    there is no cure. This under-recognized epidemic disproportionately
    affects communities of color. For instance, Black Americans comprise 13
    percent of the U.S. population but represent 33 percent of Americans
    receiving dialysis, the most common therapy for kidney failure.
        The COVID-19 pandemic is especially deadly for kidney patients.
    Americans with kidney diseases are among the most at risk among
    Medicare beneficiaries for severe outcomes from COVID-19--including
    hospitalization and death,i,ii,iii,iv and COVID-19 damages the kidneys
    of as many as 40-50% of all hospitalized COVID-19 patients, even those
    without a prior history of kidney diseases.v,vi
        The status quo for treating and managing kidney diseases is far too
    costly to taxpayers to continue without intervention. Before the COVID-
    19 pandemic, Medicare dedicated $130 billion, or 25 percent of all
    traditional Medicare fee-for-service spending, to the care of all
    kidney diseases, including $50 billion, or 7 percent of Medicare fee-
    for-service spending, to manage kidney failure alone. Relative to other
    chronic diseases with comparable federal spending and disease burden,
    people with kidney diseases have had a lack of innovation in the
    prevention, diagnosis, and treatment of kidney diseases, but hope is on
    the horizon: KidneyX is attracting a new generation of innovators and
    investors and transforming kidney care.
        KidneyX is incentivizing innovators to fill unmet patient needs
    through a series of prize competitions, de-risking the
    commercialization process by fostering coordination among federal
    agencies and creating a sense of urgency on behalf of patients and
    families. To date, KidneyX has provided funding to more than 50
    innovators across 4 prize competitions for solutions ranging from
    patient-generated solutions that improve quality of life while living
    with kidney diseases to steps toward paradigm-shifting technologies
    such as a wearable or implantable artificial kidney. In 2020, KidneyX
    awarded the COVID-19 Kidney Care Challenge to identify solutions that
    will reduce the risk of COVID-19 to kidney patients and launched the
    Artificial Kidney Prize to accelerate the development of an artificial
    kidney. Winners of Phase 1 of the Artificial Kidney Prize will be
    announced in September 2021. FY 22 funding will support continued
    development of an artificial kidney through Phase 2 and 3 of the
    Artificial Kidney Prize and other innovations to catalyze further
    private investment in meeting the long unmet needs of this underserved
    population.
        Winning innovations awarded KidneyX prizes have supported
    innovators in 22 states, including those highlighted below:
      --Applying advances in science and technology to improve current
            kidney failure therapies, such as nanomaterials to reduce
            infections in dialysis grafts and an innovative catheter which
            might exponentially reduce infections in the provision of
            dialysis, both seeded through the Redesign Dialysis Phase 1 and
            Redesign Dialysis Phase 2 prize competitions
      --Patient generated solutions to better manage their care, such as
            clothing which provides health care staff easy access to
            dialysis ports without having to remove or scrunch up clothing,
            seeded through the Patient Innovator Challenge
      --Novel methods for maintaining kidney health during the pandemic
            such as a ``Good Humoral Immunity Truck'' to deliver vaccines
            to patients in hard-to-reach communities, and a new reusable N-
            95 respirator to aid in the high-touch care setting of a
            dialysis unit, seeded through the COVID-19 Kidney Care
            Challenge
      --New technologies as innovative treatment options, such as an
            implantable silicon filter cartridge that mitigates the need
            for dialysis needles or a method to grow human kidney cells on
            animal kidney scaffolds that could increase the number of
            transplantable organs, both seeded through the Redesign
            Dialysis Phase 1 and Redesign Dialysis Phase 2 prize
            competitions
        A bipartisan achievement, KidneyX was first unveiled as a concept
    at the 2016 Obama White House Organ Summit and was a central pillar of
    Former President Donald J. Trump's July 2019 Executive Order on
    Advancing American Kidney Health. KidneyX is a true public-private
    partnership: the private sector has already committed $25 million to
    KidneyX and is committed to matching federal funding to achieve a total
    $250 million in the first 5 years. KidneyX has received $10 million
    since FY 20 in enacted appropriations. Since its inception, KidneyX has
    demonstrated the success of its public-private prize funding model,
    delivering on its mission of accelerating innovation in kidney care,
    attracting new innovators and investors to the kidney space, and
    broadening the availability of novel ideas and capital to improve the
    lives of the 37 million Americans with kidney disease.
        In light of this strong track record, we respectfully request that
    the Labor-HHS Subcommittee continue its commitment by appropriating $25
    million in FY 2022 for KidneyX, catalyzing private sector investment in
    kidney health including to develop the world's first artificial kidney.
    In addition, we also ask that you include the following language in the
    report accompanying your Committee's appropriations bill:
        The Committee is aware that more than 37 million people in the
    United States are living with kidney diseases, and for nearly 800,000
    of those individuals, the diseases progress to kidney failure,
    requiring access to dialysis or kidney transplantation to live. The
    Committee notes that kidney failure alone accounted for more than 7% of
    Medicare spending (approximately $50 billion) in CY 2018, yet
    therapeutics for kidney failure remain limited and 50% of patients
    starting dialysis, the most common therapy for kidney failure, will die
    within 5 years.
        Given the high cost of kidney disease in terms of health
    consequences and federal spending, the Committee recommends that a
    total of $25,000,000 be added to the funds for the Office of the
    Secretary in FY 2022 and that those funds be made available to support
    KidneyX. These funds will accelerate the development and adoption of
    the artificial kidney and other novel therapies and technologies that
    improve the diagnosis and treatment of people with kidney diseases.
        Thank you for your consideration of this important request. Should
    you have questions or need additional information, do not hesitate to
    contact Zach Kribs, Senior Government Affairs Specialist of the
    American Society of Nephrology, at (202) 618-6991 or zkribs@asn-
    online.org.
                    about the american society of nephrology
        The American Society of Nephrology is a 501(c)(3) non-profit, tax-
    exempt organization that leads the fight against kidney disease by
    educating the society's more than 21,000 nephrologists, scientists, and
    other healthcare professionals, advancing research and innovation,
    communicating new knowledge, and advocating for the highest quality
    care for patients. For more information, visit www.asn-online.org.
    ---------------------------------------------------------------------------
        \1\ https://www.cms.gov/newsroom/press-releases/cms-proposes-
    medicare-payment-changes-support-innovation-and-increased-access-
    dialysis-home-setting.
        \2\ https://www.cms.gov/files/document/medicare-covid-19-data-
    snapshot-fact-sheet.pdf.
        \3\ Cheng Y, Luo R, Wang K, et al. Kidney disease is associated
    with in-hospital death of patients with COVID-19. Kidney Int.
    2020;97(5):829-838. doi:10.1016/j.kint.2020.03.005.
        \4\ Ng JH, Hirsch JS, Wanchoo R, et al. Outcomes of patients with
    end-stage kidney disease hospitalized with COVID-19. Kidney Int.
    2020;98(6):1530-1539. doi:10.1016/j.kint.2020.07.030.
    ---------------------------------------------------------------------------
        v Birkelo, B C. et al. Comparison of COVID-19 versus influenza on
    the incidence, features, and recovery from acute kidney injury in
    hospitalized United States Veterans. Kidney Int. 2020;0(0). doi.org/
    10.1016/j.kint.2021.05.029
        vi Chan L, et al. AKI in Hospitalized Patients with COVID-19. JASN.
    2021;32(1):151-160. doi: 10.1681/ASN.2020050615

        [This statement was submitted by Zachary Kribs, Senior Government
    Affairs Specialist, American Society of Nephrology.]
                                     ______

    Prepared Statement of the American Society of Nephrology, the American
      Society of Pediatric Nephrology, and the National Kidney Foundation
        On behalf of more than 37 million children, adolescents, and adults
    living with chronic kidney diseases (CKD) in the United States, the
    American Society of Nephrology, the American Society of Pediatric
    Nephrology, and the National Kidney Foundation request $46.11 billion
    for the National Institutes of Health in FY 2022, an increase of 7.3%
    that will provide real growth of 5% after accounting for the biomedical
    research and development price index of 2.3%, and request an increase
    for the National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) that is at least proportional to the increase for NIH.
    Greater investment in kidney research is needed to advance
    understanding of the under-recognized public health epidemic of kidney
    diseases and address the disproportionate impact of COVID-19 and racial
    disparities experienced by Americans living with kidney diseases.
        For nearly 800,000 Americans, kidney diseases progress to kidney
    failure, a life-threatening condition for which there is no cure.
    Kidney failure is most commonly managed by in-center hemodialysis, a
    therapy that has changed little in the 50 years since its development
    with a survival rate worse than most cancers (and comparable with brain
    cancers), or a kidney transplant, the optimal therapy for most patients
    but often inaccessible due to a shortage of organs and inequities in
    our nation's transplant health system. Both therapies involve
    suppression of the immune system and put patients at increased risk of
    communicable diseases--especially COVID-19--and significant racial and
    ethnic disparities exist in terms of therapy access and patient
    outcomes.
        Almost 50 years ago, Congress made a commitment to treat all
    Americans with irreversible kidney failure through the Medicare End-
    Stage Renal Disease (ESRD) Program regardless of age. Medicare spends
    $130 billion on the care of people with kidney diseases, or 22% percent
    of all Medicare fee-for-service spending. Of this amount, $49 billion
    is spent managing the care of people with kidney failure. Individuals
    with kidney failure represent only 1% of Medicare beneficiaries but
    comprise 7.2% of Medicare fee-for-service expenditures. Despite this
    enormous societal cost, kidney disease research supported by NIH is
    equivalent to one-half of one percent of Medicare fee for service
    expenditures for beneficiaries with kidney diseases and kidney failure.
        People with kidney diseases face stark racial and socioeconomic
    disparities in disease burden and access to care. Black Americans (17%)
    and Hispanic Americans (15%) are more likely to have kidney diseases
    than white Americans (14%) and these disparities increase as kidney
    diseases progress to kidney failure: Black Americans are 3.5 times more
    likely than white Americans to have kidney failure and Hispanic
    Americans are 1.5 times more likely to have kidney failure than white
    Americans. Disparities in prevalence and outcomes are due to multiple
    factors including lack of access to care, social determinates of
    health, and systemic racism. Greater investment in research is needed
    to increase understanding about the underlying causes of disparities
    and generate interventions to address them.
        Kidney disease patients also are at an increased risk of severe
    outcomes from COVID-19, such as hospitalization and death, due to their
    vulnerable physical conditions, multiple chronic conditions, weakened
    immune systems, and for those on dialysis, the need to leave home three
    times a week to receive care in a facility with other vulnerable
    patients. Further, COVID-19 has been shown to cause kidney damage in as
    many as 50% of hospitalized COVID-19 patients, even those without a
    previous history of kidney disease, often requiring emergency dialysis.
    While the long-term effects of COVID-19 on kidney health and function
    are under investigation, it is likely that COVID-19 will lead to an
    influx of new patients with kidney diseases, and that some of these
    patients will require ongoing care. Despite the severe impact of COVID-
    19 on people with kidney diseases and kidney health, no dedicated
    COVID-19 funding has been provided to NIDDK to-date, forcing research
    of the impact of COVID-19 on kidney health to come at the expense of
    existing research projects.
        Many kidney disease patients also experience comorbidities such as
    cardiovascular disease (including heart attack and stroke), anemia,
    bone disease, hypertension, and diabetes. Pediatric kidney disease
    patients often have rare medical conditions with different needs
    associated with them than typical adult patients, which must be better
    understood. Greater investment in kidney research should be an urgent
    priority to slow disease progression, improve treatment, reduce
    morbidities, and improve patients' quality of life. NIDDK-funded
    scientists have produced several major breakthroughs in the past
    several years that require further investment to stimulate therapeutic
    advancements. For example, NIDDK launched the Kidney Precision Medicine
    Project that will pinpoint targets for novel therapies-setting the
    stage for personalized medicine in kidney care. However, additional
    funding is needed to accelerate these and other novel opportunities to
    improve the care of patients with kidney disease. Better understanding
    of the natural history of kidney disease and its progression in adults
    and children could lead to earlier detection and better treatments to
    slow disease progression and perhaps prevent irreversible kidney
    failure.
        Thank you again for your leadership, and for your consideration of
    our request. Should you have any questions or wish to discuss kidney
    disease research in more detail, please contact Erika Miller with the
    American Society of Pediatric Nephrology at emiller@dc-crd.com; Rachel
    Meyer with the American Society of Nephrology at rmeyer@asn-online.org;
    or Lauren Drew with the National Kidney Foundation (NKF) at
    lauren.drew@kidney.org.
                    about the american society of nephrology
        The American Society of Nephrology is a 501(c)(3) non-profit, tax-
    exempt organization that leads the fight against kidney disease by
    educating the society's more than 21,000 nephrologists, scientists, and
    other healthcare professionals, advancing research and innovation,
    communicating new knowledge, and advocating for the highest quality
    care for patients. For more information, visit www.asn-online.org.
               about the american society of pediatric nephrology
        Founded in 1969, the American Society of Pediatric Nephrology is a
    professional society composed of pediatric nephrologists whose goal is
    to promote optimal care for children with kidney disease and to
    disseminate advances in the clinical practice and basic science of
    pediatric nephrology. ASPN currently has over 600 members, making it
    the primary representative of the Pediatric Nephrology community in
    North America.
                      about the national kidney foundation
        The National Kidney Foundation is the largest, most comprehensive,
    and longstanding patient-centric organization dedicated to the
    awareness, prevention, and treatment of kidney disease in the U.S. In
    addition, NKF has provided evidence-based clinical practice guidelines
    for all stages of chronic kidney disease (CKD), including
    transplantation since 1997 through the National Kidney Foundation
    Kidney Disease Outcomes Quality Initiative (KDOQI). For more
    information about NKF, visit www.kidney.org

        [This statement was submitted by Sharon Pearce, Senior Vice
    President, Government Relations, National Kidney Foundation, American
    Society of Nephrology, American Society of Pediatric Nephrology, and
    National Kidney Foundation.]
                                     ______

         Prepared Statement of the American Society of Plant Biologists
        On behalf of the American Society of Plant Biologists (ASPB), we
    would like to thank the Subcommittee for its support for the National
    Institutes of Health (NIH). ASPB and its members strongly believe that
    sustained investments in scientific research are a critical component
    of economic growth, job creation, and innovation for our nation. ASPB
    supports continued robust funding for NIH in fiscal year (FY) 2022 and
    asks that the Subcommittee encourage increased support for plant-
    related research with relevance to health within the agency.
        ASPB, founded in 1924 as the American Society of Plant
    Physiologists, was established to promote the growth and development of
    plant biology, to encourage and publish research in plant biology, and
    to promote the interests and professional advancement of plant
    scientists in general. ASPB members educate, mentor, advise, and
    nurture future generations of plant biologists; they work to enhance
    understanding of plant biology and its impacts on public health and
    wellbeing, as well as science in general, in K-16 schools and among the
    general public; they advocate in support of plant biology research;
    work to convey the relevance and importance of plant biology; and they
    provide expertise in policy decisions world-wide. Overall, ASPB
    members, as representatives of the society, work to disseminate
    information and to excite future generations about plant sciences,
    especially through ASPB's advocacy, outreach activities, conferences,
    and publications.
                  plant biology research and america's future
        Among many other functions, plants are the building blocks at the
    base of the food chain upon which all life depends. Importantly, plant
    research is also helping make many fundamental contributions to the
    study of human health, including that of a sustainable supply and
    discovery of plant-derived pharmaceuticals, nutriceuticals, and
    alternative medicines. One example is the antimalarial compound
    artemisinin, purified from sweet wormwood plants, whose biosynthetic
    pathway was defined and transplanted into yeast to create a low-cost
    source of this pharmaceutical for the developing world. Plants are
    potential resources to produce vaccines against infectious diseases
    such as Ebola, hepatitis B, cholera, and coronavirus. At least one
    plant-derived COVID-19 vaccine candidate, developed by GlaxoSmithKline
    and Medicago, is already in phase III clinical trials and could be a
    valuable asset in ending the COVID-19 pandemic.\1\ Nearly 120 pure
    compounds extracted from plants are used globally in medicine, hinting
    at the significant possibilities for future discoveries applicable to
    human health, agriculture, and manufacturing.\2\ Plant research also
    contributes to the continued, sustainable, development of better and
    more nutritious foods and the understanding of basic biological
    principles that underpin improvements in public health and human
    nutrition.
    ---------------------------------------------------------------------------
        \1\ https://www.medicago.com/en/media-room/medicago-and-gsk-start-
    phase-3-trial-of-adjuvanted
    -covid-19-vaccine-candidate/.
        \2\ Page 19, Decadal Vision, https://
    plantsummit.files.wordpress.com/2013/07/plantsciencedeca
    dalvision10-18-13.pdf.
    ---------------------------------------------------------------------------
              plant biology and the national institutes of health
        Plant science and many of our ASPB member research activities have
    enormous positive impacts on the NIH mission to pursue ``fundamental
    knowledge about the nature and behavior of living systems and the
    application of that knowledge to extend healthy life and reduce the
    burdens of illness and disability.'' In general, plant research aims to
    improve the overall human condition-be it food, nutrition, medicine,
    clean air, or agriculture-and the benefits of plant science research
    readily extend across disciplines. In fact, plants are often the ideal
    model systems to advance our ``fundamental knowledge about the nature
    and behavior of living systems'' as they provide complexity of multi-
    cellular organisms including humans while affording ease of genetic
    manipulation, a lesser regulatory burden, and maintenance requirements
    that are less expensive than those required for the use of animal
    systems.
        Fundamental Biological Research.--Many fundamental biological
    components and mechanisms are shared by plants and animals. Examples
    include but are not limited to genetic principles, cell division, host-
    pathogen interactions, organism-environment interactions, polar growth,
    DNA methylation and repair, innate immunity signaling, and circadian
    (biological) rhythms. Fundamental hereditary laws were derived from the
    study of garden peas. The phenomenon of RNA interference, which has
    application in gene therapies for human disease, was first discovered
    in plants. Contributions of plant genetics to advancing human health
    were exemplified when Barbara McClintock, an American scientist and
    cytogeneticist, was awarded the Nobel Prize in Physiology for the
    discovery of ``jumping genes'' or transposable elements in maize, which
    function as mobile DNA sequences within a genome. Similar elements
    constitute 40% or more of the human genome. More recently, plants are
    among organisms that have been used to develop revolutionary
    technologies such as gene editing (CRISPR), capable of precisely
    editing genomes to potentially correct mutations that lead to disease.
    These technologies will benefit plant biology and agriculture to
    produce healthy food and feed the world. Furthermore, many treatments
    and therapies are based on metabolites derived from plants, which
    exemplifies the application of plant biology research to improving
    human health. These important discoveries, among many others in science
    and technology, reflect the fact that some of the most important
    biological discoveries applicable to human physiology and medicine can
    find their origins in plant-related research endeavors.
        Health and Nutrition.--Plant biology research is also central to
    the application of basic knowledge to ``extend healthy life and reduce
    the burdens of illness and disability.'' Without good nutrition, there
    cannot be good health. Indeed, a World Health Organization study on
    childhood nutrition in developing countries concluded that over 50% of
    child deaths under the age of five could be attributed to
    malnutrition's effects on weakening the immune system and exacerbating
    common illnesses such as respiratory infections and diarrhea; \3\ this
    is expected to worsen as global populations increase. One example of
    how advances in plant biology have been applied to tackling nutritional
    deficiencies is golden rice, designed to address vitamin A deficiency
    and reduce blindness risk in vulnerable children. Golden rice was
    engineered to include additional genes that switch on production of
    beta-carotene, and a bowl of this golden rice can provide 60% of a
    child's daily requirement of vitamin A to prevent blindness.
    Significant advances have also been made in the production of value-
    added and resilient crops capable of withstanding drought, natural
    disasters, and extreme temperature shifts. DroughtGard Hybrid corn,
    engineered to maximize water storage, usage, and crop yield in
    unfavorable drought conditions, is just one example of the progress
    being made towards health, nutrient, and food security through
    innovations made in plant science.
    ---------------------------------------------------------------------------
        \3\ https://www.who.int/bulletin/archives/78(10)1207.pdf.
    ---------------------------------------------------------------------------
        Obesity, cardiac disease, and cancer also take a striking toll
    globally. Research to improve and optimize concentrations of plant
    compounds known to have, for example, anti-cancer properties, will help
    in reducing disease incidence rates. Ongoing development of crop
    varieties with value-added nutraceutical content is an important
    contribution that plant biologists are making toward realizing a common
    goal of personalized, preventative medicine.
        Drug Discovery.--Plants are fundamentally important as sources of
    both extant drugs and drug discovery leads. In fact, 60% of anti-cancer
    drugs in use within the last decade are of natural product origin-
    plants being a significant source. An excellent example is the anti-
    cancer drug Taxol, which was discovered as an anti-carcinogenic
    compound from the bark of the Pacific yew tree through collaborative
    work involving scientists at the NIH National Cancer Institute and
    plant natural product chemists. While the pharmaceutical industry has
    invested some efforts on natural products-based drug discovery,
    research support from NIH remains a crucial component of the drug
    development pipeline. Multidisciplinary teams of plant biologists,
    bioinformaticians, and synthetic biologists are being assembled to
    develop new tools and methods for natural products discovery and
    creation of new pharmaceuticals. We appreciate NIH's current investment
    into understanding the biosynthesis of natural products through
    transcriptomics and metabolomics of medicinal plants and support more
    funding opportunities similar to the ``Genomes to Natural Products''
    which will enhance new plant-related medicinal research.
                                   conclusion
        Plants play unique and pivotal roles in nutrient and health,
    agriculture, and food supply, as well as basic science discoveries
    directly or indirectly relevant to public health. Plant biology
    research integrates seamlessly and synergistically with many different
    disciplines and core missions at NIH. As such, ASPB asks the
    Subcommittee to provide continued robust funding for NIH and direct the
    agency to support additional plant research in order to continue to
    pioneer new discoveries and new methods with applicability and
    relevance in biomedical research. Thank you for your consideration of
    ASPB's testimony. For more information about ASPB, please see
    www.aspb.org.

        [This statement was submitted by Crispin Taylor, Ph.D., Chief
    Executive Officer, American Society of Plant Biologists.]
                                     ______

     Prepared Statement of the American Speech-Language-Hearing Association
        Chairwoman Murray and Ranking Member Blunt: The American Speech-
    Language-Hearing Association (ASHA) thanks you for the opportunity to
    submit testimony on the fiscal year (FY) 2022 Labor-HHS-Education
    funding bill. My name is A. Lynn Williams, PhD, CCC-SLP, ASHA's
    President for 2021. As the Subcommittee begins its work on this
    critical legislation, I offer support for the following funding
    requests:
      --$15.5 billion for Individuals with Disabilities Education Act
            (IDEA) Part B State Grants, $598 million for IDEA's Part B
            Section 619 Preschool Grants, and $732 million for IDEA Part C
            Infants and Toddlers with Disabilities within the Department of
            Education.
      --$11,851,488 for the Centers for Disease Control and Prevention
            (CDC) and $19,522,758 for the Health Resources and Services
            Administration (HRSA) for the Early Hearing Detection and
            Intervention programs within the Department of Health and Human
            Services. In addition, ASHA urges the Subcommittee to include
            report language to address hearing health care disparities in
            medically underserved communities.
      --$15.5 million increase in funding for the National Institute on
            Deafness and Other Communications Disorders (NIDCD) at the
            National Institutes of Health (NIH), while ensuring that NIDCD
            receives an equitable funding share from any increases to NIH
            funding in FY 2022.
      --$122,970,000 for the National Institute on Disability, Independent
            Living, and Rehabilitation Research (NIDILRR) at the
            Administration for Community Living (ACL) within the Department
            of Health and Human Services.
                  individuals with disabilities education act
        ASHA thanks members of the Subcommittee for increasing funding for
    the Individuals with Disabilities Education Act (IDEA) last year.
    Children and youth (ages 3-21) receive special education services and
    related services under IDEA Part B, and infants and toddlers (birth-2
    years old) with disabilities and their families receive early
    intervention services under IDEA Part C. Congress must continue to make
    appropriate investments in IDEA to ensure children with disabilities
    receive the free appropriate public education (FAPE), which they are
    entitled to under law. A substantial increase in funding for IDEA is a
    step toward fulfilling the promise that Congress made to fund 40% of
    the average per-pupil expenditure in public elementary and secondary
    schools. This critical program serves more than 6.5 million children in
    our nation's schools, including students with communication
    disorders.\1\ ASHA appreciates the Administration's budget request for
    IDEA, which would provide substantial increases for IDEA Part B State
    Grants, Section 619 Preschool Grants, and Part C Infants and Toddlers
    early intervention services, and that is a significant investment
    toward fully funding this program.
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Education. (n.d.). About IDEA. https://
    sites.ed.gov/idea/about-idea/.
    ---------------------------------------------------------------------------
        These resources are essential to support states and local education
    agencies in providing FAPE to all students with disabilities. However,
    schools and districts continue to grapple with costs associated with
    the Coronavirus Disease 2019 (COVID-19) pandemic and require additional
    resources to address challenges associated with ensuring continued
    education and delivering the services and supports for children with
    disabilities. ASHA supports robust funding for IDEA as identified to
    ensure students with disabilities can continue to access the services
    to which they are entitled.
                early hearing detection and intervention program
        The Early Hearing Detection and Intervention (EHDI) Act is one of
    the nation's most important public health programs, offering early
    hearing screening and intervention to all newborns, infants, and young
    children in every state and territory. EHDI provides state grants to
    develop and support infant hearing screening and intervention programs
    through HRSA and requires the CDC to provide surveillance of
    screenings, referral to treatment and diagnosis, technical assistance,
    and applied research. When the Children's Health Act of 2000 was
    passed-which established the state-based universal newborn hearing
    screening programs-only 46.5% of newborns were screened.\2\ However,
    today approximately 98% of newborns receive an audiologic screening
    totaling 4 million infants and children in 2016 alone.\3\ Funding for
    hearing screenings and early intervention services has proven to be a
    wise investment for the United States' economy and saves the country
    approximately $200 million in education costs each year.\4\
    ---------------------------------------------------------------------------
        \2\ Centers for Disease Control and Prevention (CDC). (2010).
    Summary of infants screened for hearing loss, diagnosed and enrolled in
    early intervention, United States, 1999-2008. Atlanta, GA: U.S.
    Department of Health & Human Services, CDC; 2010. https://www.cdc.gov/
    ncbddd/hearingloss/2008-data/ehdi_1999_2008.pdf.
        \3\ Centers for Disease Control and Prevention (CDC). (2018).
    Summary of 2016 National CDC EHDI Data. https://www.cdc.gov/ncbddd/
    hearingloss/2016-data/01-2016-HSFS-Data-Summary-h.pdf.
        \4\ Gross, S.D. (2007). Education cost savings from early detection
    of hearing loss: New findings. Volta Voices, 14(6),38-40.
    ---------------------------------------------------------------------------
        Fully funding EHDI at its authorized level is critical to ensure
    all newborns are screened for hearing loss and receive follow-up
    services. Hearing loss is a serious health condition that impacts more
    than 34 million Americans, and two to three out of every 1,000 children
    in the United States are born with a detectable level of hearing loss
    in one or both ears.\5\ Underfunding EHDI may leave thousands of
    children with undiagnosed hearing loss and deprive children who are
    deaf or hard of hearing from receiving follow-up services that improve
    language skills and development as many health care appointments and
    treatments have been delayed or canceled due to the COVID-19 pandemic.
    When hearing loss is detected late, the critical time for stimulating
    the auditory pathways to hearing centers of the brain is lost. Late
    hearing loss detection also delays speech and language development
    affecting social and emotional growth, academic achievement, and
    employment options.
    ---------------------------------------------------------------------------
        \5\ National Institute on Deafness and Other Communication
    Disorders (NIDCD). (2017). Researchers help uncover a root cause of
    childhood deafness in the inner ear using animal model. https://
    www.nidcd.nih.gov/news/2017/childhood-deafness-research.
    ---------------------------------------------------------------------------
        Children with hearing loss also face significant barriers in
    accessing hearing health care services. Variables including
    socioeconomic factors, geographic location, medical infrastructure, and
    access to social support contribute to delays in diagnosis and
    treatment of hearing loss. These disparities particularly impact
    members of racial and ethnic minority communities. According to a 2017
    study, African American infants are 92% more likely to experience loss
    to follow-up than infants from other ethnic groups.\6\ Rural Hispanic
    children whose caregivers have low English fluency encounter greater
    difficulty accessing these health care services.\7\ According to CDC
    data, American Indian and Alaskan Native children enroll in early
    intervention services at a rate 26.4% less than their White
    counterparts.\8\ The CDC must expand its work to improve surveillance,
    ensure access to timely identification of congenital and acquired
    hearing loss, and enhance the connection to follow-up services,
    particularly among racial and ethnic minority populations. ASHA
    supports fully funding EHDI at its authorized level and encourages the
    Subcommittee to include the following language in the report on its FY
    2022 bill:
    ---------------------------------------------------------------------------
        \6\ Bush, M. L., Kaufman, M. R., & McNulty, B. N. (2017).
    Disparities in access to pediatric hearing health care. Current opinion
    in otolaryngology & head and neck surgery, 25(5), 359-364. https://
    doi.org/10.1097/MOO.0000000000000388.
        \7\ Ibid.
        \8\ Centers for Disease Control and Prevention (CDC). (2020).
    Hearing Loss in Children. https://www.cdc.gov/ncbddd/hearingloss/2018-
    data/15-screening-demographics.html.
    ---------------------------------------------------------------------------
        The Committee recognizes the importance of access to pediatric
    hearing health care. The Committee is aware of the significant racial
    and ethnic disparities in care facing children with hearing loss, and
    the effect unaddressed congenital hearing loss has on communication
    skills, psychosocial development, educational progress, and language
    development. The Committee encourages the CDC to expand their work to
    improve surveillance of state and territorial-based EHDI systems to
    ensure access to timely identification of congenital and acquired
    hearing loss and develop materials to enhance connection to follow up
    services among racial and ethnic minorities, and other medically
    underserved populations.
    National Institute on Deafness and Other Communication Disorders, and
            the National Institute on Disabilities, Independent Living and
            Rehabilitation Research
        ASHA applauds the Subcommittee's continued efforts to increase
    funding for health care research. ASHA strongly supports continued
    increases in funding for the National Institute on Deafness and Other
    Communications Disorders (NIDCD) at the National Institutes of Health
    (NIH), and the National Institute on Disabilities, Independent Living
    and Rehabilitation Research (NIDILRR) at the Administration for
    Community Living (ACL). NIDCD investments are needed to ensure
    groundbreaking research on communication sciences as rehabilitation
    continues to evolve and expand. Approximately 46 million Americans have
    a communication disorder.\9\ These disorders impact the economy through
    costs related to lost productivity, special education services,
    rehabilitation needs, health care expenditures, and lost revenue.
    Increases in NIDILRR's funding would allow the Institute to support the
    wide range of applied research and expand into new areas of emerging
    science to support individuals with disabilities. ASHA urges the
    Subcommittee to provide necessary funding for NIDCD and NIDILRR to
    ensure this research continues and evolves to address the needs of
    individuals with communication disorders.
    ---------------------------------------------------------------------------
        \9\ National Institute on Deafness and Other Communication
    Disorders (NIDCD). (2019). Mission. https://www.nidcd.nih.gov/about/
    mission.
    ---------------------------------------------------------------------------
                                   conclusion
        Thank you for the opportunity to provide this testimony for the
    record. ASHA appreciates the Subcommittee's past investments in these
    important health and education programs and urges continued support at
    the recommended funding levels. These investments are crucial to
    ensuring audiologists and speech-language pathologists can meet the
    hearing, balance, speech, language, swallowing, and cognition-related
    needs of their patients, clients, and especially students who are
    receiving special education services in schools.
        If you or your staff have any questions, please contact ASHA's
    associate director of federal affairs: Erik Lazdins, elazdins@asha.org,
    444 North Capitol St NE,
    Washington, DC 20001.
                                     ______

              Prepared Statement of the American Thoracic Society
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --ATS urges Congress to provide at least $46.1 billion for the
            National Institutes of Health (NIH) for Fiscal Year (FY) 2022,
            an increase of $3.2 billion over FY2021.
        --$3.94 billion for the National Heart, Lung, and Blood Institute
                (NHLBI) at NIH.
        --$6.52 billion for the National Institute of Allergy & Infectious
                Diseases at NIH.
        --$419.9 million for the National Institute on Minority Health and
                Health Disparities at NIH.
        --$187.9 million for the National Institute of Nursing Research at
                NIH.
        --$875 million for the National Institute of Environmental Health
                Sciences (NIEHS).
      --ATS urges Congress to provide $10 billion in funding for the
            Centers for Disease Control and Prevention (CDC) for FY 2022.
            After decades of under-investment, the COVID-19 pandemic has
            revealed that we must strengthen our national, state and local
            public health systems and reinvest in the CDC.
        --$5 million in funding for the Chronic Disease Education and
                Awareness Program
        --$225 million in FY 2022 for the CDC's domestic Division of TB
                Elimination program and $21 million for the Global TB
                program
        --$35 million in funding for the National Asthma Control Program at
                CDC
        --ATS requests $50 million in FY2022 for CDC's Climate and Health
                Program
        --ATS requests $262.5 million in FY2022 for the Office on Smoking
                and Health
        --$354.8 million in funding for the National Institute of
                Occupational Safety and Health

    _______________________________________________________________________
                      about the american thoracic society
        The ATS is a multi-disciplinary society of 16,000 physicians,
    scientists, respiratory therapists and nurses dedicated to the
    prevention, detection, treatment and cure of pulmonary disease,
    critical illness and sleep disordered breathing. Our members treat a
    wide range of lung disorders and have been on the frontlines of the
    COVID-19 pandemic treating individuals and conducting vital scientific
    research to develop diagnostics, treatments, and prevention
    interventions for COVID, even as we continue our efforts on other
    pulmonary, critical illness and sleep disorders.
    ATS urges Congress to provide at least $46.1 billion for NIH for FY
            2022
        ATS thanks Congress for providing funding for NIH's COVID-19-
    related research which helped develop life-saving vaccines and other
    important advances. But the evolving pandemic requires the continued
    mobilization of research resources to improve our understanding of the
    SARS-CoV2 virus and develop new diagnostics, therapeutics, and updated
    vaccines to combat new virus variants. African Americans, Native
    Americans and other racial and ethnic minorities continue to become
    infected and die from COVID-19 at high rates--we must accelerate
    efforts to address these disparities and develop prevention and
    therapeutic interventions for these and other high-risk populations. In
    addition, thousands of Americans who recovered from COVID-19 are now
    suffering chronic long-term complications. Studies into the causes,
    treatment, and prevention of long-term complications, such as pulmonary
    fibrosis, are urgently needed.
        Respiratory disease in America is on the rise. Even before the
    COVID pandemic, lung disease was the fourth leading cause of death in
    the US, driven primarily by chronic obstructive lung disease (COPD).
    Despite the rising lung disease burden, lung disease research is
    underfunded. Although COPD is the fourth leading cause of death in the
    U.S., research funding for the disease is a small fraction of what is
    invested for the other leading causes of death, such as heart disease,
    cancer, and stroke, as outlined below. Funding for implementation of
    the COPD National Action Plan would address this disparity.
    ATS urges Congress to provide $3.94 billion for NHLBI
        Since 1948, the NHLBI has made important progress in the treatment
    and prevention of cardiovascular disease, respiratory diseases, and
    blood and sleep disorders. Even with this progress, challenges remain
    as these conditions continue to account for more than 1 million
    American deaths each year and cost our nation an estimated $479 billion
    in medical expenses and lost productivity.
        To continue important advances in research, the NHLBI is investing
    in prevention programs and developing novel therapies for lung diseases
    such as chronic obstructive pulmonary disease (COPD), asthma, cystic
    and pulmonary fibrosis and driving precision medicine that is tailored
    to individual patient needs through data science.
    ATS urges Congress to provide $875 million for NIEHS
        NIEHS is the leading institute conducting research to prevent human
    illness and disability by understanding how the environment influences
    the development and progression of human diseases and illnesses such as
    cancer, autism, asthma and autoimmune diseases. Researchers funded by
    NIEHS have highly relevant expertise that will aid our response to
    COVID-19 and future pandemics through study of mechanisms to protect
    health care workers facing occupational exposure to SARS-CoV-2 and
    COVID-19, and how environmental exposures such as air pollution impact
    individual susceptibility to infection and development and severity of
    COVID-19 disease.
    ATS urges Congress to provide $10 billion for CDC for FY 2022
        In order to halt the COVID-19 pandemic and ensure our preparedness
    for future infectious disease outbreaks, it is critical that the CDC
    receives sustained annual funding increases. In FY2022, increased CDC
    funding is needed to ensure resources for COVID-19 vaccine
    distribution, administration and public education, testing, contact
    tracing, disease surveillance and targeted community assistance,
    including to communities that have been disproportionately impacted by
    COVID-19 and remain at high-risk, such as minority populations. More
    than 70 percent of CDC's budget goes directly to state public and local
    health organizations and academic institutions for programs that
    protect public health. CDC programs in chronic disease prevention,
    tuberculosis control, asthma, tobacco control and occupational safety
    and health are essential to protecting the health of millions of
    Americans.
    ATS urges Congress to provide $225 million for the Division of TB
            Elimination and $21 million for CDC's Global TB program through
            the Center for Global Health.
        Prior to the COVID-19 pandemic, TB was the leading global
    infectious disease killer, killing 1.4 million annually. Every state in
    the U.S. reports cases of TB each year. Further, in its 2019 report on
    antibiotic resistance, the CDC identified drug resistant TB as a
    serious health threat to the nation. CDC estimates that up to 13
    million Americans have latent TB infection. These cases, which can be
    preventively treated, are the reservoir of future active TB cases.
    CDC's domestic TB program has been flat funded since FY2014, leaving
    states ill-equipped to manage drug resistant TB and unable to do LTBI
    testing and preventive treatment. In addition, we urge NIH to expand
    research to develop new tools to address TB.
    ATS urges Congress to provide $35 million in funding for the National
            Asthma Control Program
        An estimated 25 million people in the U.S. have asthma, including 6
    million children. Asthma is the most common cause of missed school
    days--about 14 million per year. As recently as 2016, 3,274 Americans
    died of asthma. About 63% of these deaths were among women.
        CDC's asthma program includes the following core functions, 1)
    provides state grants for asthma control activities including asthma
    tracking and public health interventions, 2) Improves asthma education
    and management through coordinated school health programs, and 3)
    Conducts public health research to help target and inform asthma
    control efforts.
    ATS urges Congress to provide $5 million in funding for the Chronic
            Disease Education and Awareness Program
        In response to advocacy by ATS and disease advocates, in FY2021
    Congress created CDC's new Chronic Disease Education and Awareness
    program to address chronic diseases such as COPD and sleep disorders.
    The program will fund competitive grants focused on public health
    initiatives to increase awareness and educate communities on how to
    prevent chronic diseases. Program grants can be used to support
    national and local implementation of the COPD National Action Plan, by
    raising awareness and improving access to COPD care and management and
    prevention. The program is funded at $1.5 million in FY2021, and
    additional resources are needed to support new cooperative agreements
    in meritorious areas. We also urge CDC to include COPD-based questions
    to future CDC health surveys, including the National Health and
    Nutrition Evaluation Survey (NHANES), the Behavioral Risk Factor
    Surveillance System (BRFSS) and the National Health Information Survey
    (NHIS).
                                     sleep
        Research studies demonstrate that sleep-disordered breathing and
    sleep-related illnesses affect an estimated 50-70 million Americans.
    The public health impact of sleep illnesses and sleep disordered
    breathing is known to include increased mortality, traffic accidents,
    cardiovascular disease, and other comorbidities. The ATS recommends a
    funding level of $1 million in FY2022 to support activities related to
    sleep and sleep disorders at the CDC. The ATS also recommends an
    increase in funding for research on sleep disorders at the NHLBI's
    Nation Center for Sleep Disordered Research (NCSDR). Thank you for your
    consideration of these requests.

        [This statement was submitted by Lynn Schnapp, MD, ATSF, President,

    American Thoracic Society.]
                                     ______

           Prepared Statement of the American Urogynecologic Society
        The American Urogynecologic Society (AUGS) thanks the Subcommittee
    for the opportunity to submit comments for the record regarding our
    Fiscal Year 2022 report language recommendations for prioritizing
    research on Overactive Bladder and medications commonly prescribed to
    treat this condition at the NIH National Institute on Aging and the
    National Institute of Diabetes, Digestive and Kidney Diseases. AUGS is
    a national medical society whose mission is to promote the highest
    quality of care in female pelvic medicine and reconstructive surgery
    through excellence in education, research, and advocacy.
        Overactive Bladder is a sudden, intense urgency to urinate often
    followed by an involuntary loss of urine. It can cause the need to
    urinate frequently, and often throughout the night, because of altered
    bladder nerve signaling. Overactive Bladder occurs in the absence of a
    urinary tract infection or other pathology.
        Overactive Bladder affects more than 38 million Americans, and 1 in
    every 3 older adults. It is more common with aging and in women.
    Overactive Bladder has a significant impact on quality of life and on
    the healthcare system. Adults with Overactive Bladder are more likely
    to report anxiety and depression, falls, decreased quality of life, and
    have 20% higher health care utilization than matched counterparts
    without this condition. The Centers for Disease Control and Prevention
    estimated in the U.S., the direct and indirect costs of Overactive
    Bladder would be approximately $76 billion in 2015 and projected these
    costs would account for $82.6 billion of U.S. healthcare costs by 2020.
        Anticholinergic medications are commonly prescribed to treat
    Overactive Bladder. These therapies are the most studied, most
    frequently used, and most often covered by insurance companies as a
    treatment for Overactive Bladder. However, there is increasing clinical
    evidence suggesting an association between long-term use of
    anticholinergic medications and the risk of developing cognitive
    impairment and Alzheimer's disease and related dementias (ADRD) in some
    patients with Overactive Bladder. In fact, the evidence is compelling
    enough that the American Urogynecologic Society's ``Choosing Wisely''
    campaign recommends the avoidance of anticholinergic medications to
    treat Overactive Bladder in women older than 70.
        It is well documented that the prevalence of Overactive Bladder
    increases with age. Therefore, as the American population continues to
    age over the next few decades, the personal and public health burden of
    Overactive Bladder will become more acute. Despite compelling data
    suggesting the negative impact of Overactive Bladder medications on
    cognitive function, more robust evidence is needed to guide evidence-
    based treatment approaches. Thus, current Overactive Bladder
    medications must undergo additional study to definitively determine
    their impact on cognition and Alzheimer's disease and related dementias
    (ADRD) development and to determine if the risks substantially outweigh
    the benefits of these therapies.
        For these reasons, the American Urogynecologic Society urges the
    Subcommittee to adopt the following report language in the report
    accompanying the Fiscal Year 2022 Labor-HHS-Education appropriations
    bill that directs the National Institutes of Health National Institute
    on Aging (NIA) and the National Institute of Diabetes, Digestive and
    Kidney Diseases (NIDDK) to study the association between current
    medications for Overactive Bladder and Alzheimer's disease and related
    dementias (ADRD) in certain patient populations, in order to advance
    research resulting in safe and effective treatment initiatives for all
    patients with Overactive Bladder.
                         national institutes of health
    National Institute on Aging and National Institute of Diabetes,
            Digestive and Kidney Diseases
        Overactive Bladder.--The Committee is concerned that
    anticholinergic medications commonly prescribed to treat Overactive
    Bladder, a condition that affects one in three older Americans, have
    been shown in recent studies to increase the risk of developing
    Alzheimer's disease and related dementias (ADRD). The Committee
    believes that further research of anticholinergic medications as well
    as on alternatives to these treatments is urgently needed to establish
    certainty regarding the safety of these medications as a treatment
    option for Overactive Bladder in older adults. The Committee urges that
    the National Institute on Aging (NIA) and the National Institute of
    Diabetes, Digestive, and Kidney Diseases (NIDDK) prioritize research
    grants and contracts that study the long-term use of anticholinergic
    medications and the risk of cognitive impairment and ADRD. The
    Committee requests an update on this issue and on research activities
    to advance safe and effective alternative treatments for Overactive
    Bladder in the fiscal year 2023 Congressional Budget Justification.
        Thank you in advance for your favorable consideration of this
    report language request and for your support for prioritizing research
    to ensure there are safe and effective treatments for the millions of
    Americans in this country that suffer from Overactive Bladder.
                                     ______

                Prepared Statement of the Anti-Defamation League
        On behalf of the Anti-Defamation League (ADL), I write to urge
    Members of the Subcommittee to adopt legislative and report language
    that condemns proposals that would effectively curtail anti-bias
    programming in public schools. During 2021 sessions, a number of state
    legislatures have considered and adopted proposals that purport to
    block the teaching of material that is vaguely characterized as
    ``divisive concepts,'' or as assigning blame or responsibility or
    creating guilt based on race, ethnicity, or sex. We are deeply
    concerned that these policies would drastically curb the use and
    further development of an essential tool in the effort to eliminate
    hate incidents: lessons and programs that teach young people about the
    history and institutionalization of hateful ideologies, awareness of
    biases, and importance of each person vocally opposing expressions of
    prejudice.
        Founded in 1913 in response to an escalating climate of anti-
    Semitism and bigotry, ADL is a leading anti-hate organization with the
    mission of protecting the Jewish people and securing justice and fair
    treatment for all. Today, we continue to fight all forms of hate with
    the same vigor and passion. A global leader in exposing extremism,
    delivering anti-bias education, and fighting hate online, ADL's
    ultimate goal is a world in which no group or individual suffers from
    bias, discrimination, or hate. To that end, ADL is an advocate for
    Holocaust education. We strongly believe that learning about the
    Holocaust, and the unchecked anti-Semitism and racism that set the
    stage for and sustained it, is one of the best ways to fight prejudice
    and discrimination, and to help ensure that genocide and other
    atrocities never happen again.
        ADL has actively opposed anti-"divisive concepts'' bills and
    policies including Texas HB 3979, Arizona SB 1532, Louisiana HB 564,
    and New Hampshire HB 544; similar proposals that have advanced or been
    enacted in 2021 also include Iowa HF 802, which applies not only to K-
    12 schools but also to government agencies and public universities and
    was enacted by the legislature in early May 2021; West Virginia HB
    2595, which proposes to end state funding for any agencies that promote
    ``divisive'' concepts or acts; and Oklahoma SB 803, which authorizes
    dismissal of teachers for instructing students in disapproved-of ideas
    and beliefs about, for example, the fundamentally racist and sexist
    nature of American society.
        Although these bills vary in their details, their common features
    include vagueness, subjectivity, and the singling out of particular
    ideas for a prohibition on speech, which constitutes unconstitutional
    viewpoint discrimination. In fact, a federal judge has already
    determined that plaintiffs were likely to succeed in a First Amendment-
    based challenge to a similar federal prohibition adopted by a
    subsequently-revoked Executive Order. ADL is acutely dismayed that
    these proposals will have, and already have had, the effect of
    prompting cautious administrators to cancel or postpone critically
    important efforts to expand students' knowledge, experience, and
    sensitivity to systemic biases. The Iowa Department of Education, for
    example, postponed a conference on social justice and equity in
    education originally planned for April 2021, noting publicly that, ``We
    are mindful of pending legislation that may impact the delivery and
    content of certain topics related to diversity, equity and inclusion.''
        Another common feature of recent legislation billed as taking aim
    at the spread of ``divisive concepts'' is language that prohibits
    teaching that makes an individual ``feel discomfort, guilt, anguish or
    any other form of psychological distress because of the individual's
    race, ethnicity or sex.'' We are particularly alarmed that this measure
    would effectively create a ``heckler's veto'' of critical education in
    our public schools. Legitimate Holocaust curricula or educational
    programs must necessarily condemn the antisemitic and racist ideology
    of the Nazis, as well as Holocaust denial. As a leading authority on
    extremism, terrorism, and hate, both foreign and domestic, we also note
    that today's white supremacists and neo-Nazis are virulently
    antisemitic, racist, xenophobic, misogynistic, homophobic, and do not
    consider light-skinned Jews to be ``white people.'' We foresee that
    under the rules set forth in these bills, any student or employee who
    is white and holds these odious beliefs, whether or not affiliated with
    an extremist group, could claim that a Holocaust education program
    impermissibly makes them feel discomfort, guilt, anguish, or other
    psychological distress because of their white race. The same could be
    true for someone holding these beliefs who claims that discussion of
    the Holocaust and historical antisemitism constitutes discrimination
    based on their German ethnicity or national origin. This concern is not
    hypothetical. Only two years ago there was a disturbing issue at a
    South Florida public high school involving parents who did not believe
    the Holocaust occurred, who succeeded in impacting the school's
    delivery of state-mandated Holocaust education.
        At a time of rising hate crimes and anti-Semitic incidents, the
    need to teach young people who are still forming their beliefs and
    principles the universal lessons of the Holocaust, and the devastating
    consequences of all forms of bigotry and hate, is acute and urgent.
    Anti-bias education and the imparting of honest information about the
    historical and social reasons for persistent disparities among people
    of different races, ethnicities, religions, genders, sexual
    orientations, and abilities are essential elements to the
    deconstruction of stratified, discriminatory systems: we simply cannot
    create a more just future without examining and confronting our unjust
    past and its modern-day footprints. Curricula that identify the
    hallmarks of bigotry and bring unconscious prejudices to light not only
    bend the moral arc of the universe toward justice, but also teach youth
    valuable leadership and problem-solving skills, and ensure that
    classroom environments are conducive to every student's progress.
    Positive communities that proactively welcome and celebrate inclusion
    foster academic and life success.
        ADL urges Members of the Subcommittee to protect students' access
    to essential education about discrimination, biases, and the
    consequences of government and institutional embrace of prejudice by
    adopting legislative language that withdraws and withholds federal
    funding for public educational agencies and institutions that implement
    prohibitions on the teaching of so-called ``divisive concepts,'' to
    include histories and present-day indicators of endemic hate and
    discrimination against groups of people based on race, ethnicity,
    national origin, religion, gender, gender identity, sexual orientation,
    and disability. In addition, we urge Members to adopt report language
    that notes the need for and benefits of anti-bias education in schools
    and that condemns attempts to limit or prohibit anti-bias programming
    in schools and other government institutions.
        Thank you for your consideration.

        [This statement was submitted by Erin Hustings, Director of Govt.
    Relations, Civil Rights Anti-Defamation League.]
                                     ______

        Prepared Statement of the Association for Career and Technical
                           Education and Advance CTE
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, on behalf of the Association for Career and
    Technical Education (ACTE), the nation's largest not-for-profit
    association committed to the advancement of education that prepares
    youth and adults for career success, and Advance CTE, the nation's
    longest-standing not-for-profit that represents State Directors and
    leaders responsible for secondary, postsecondary and adult Career
    Technical Education (CTE) across all 50 states and U.S. territories, we
    respectfully request that the subcommittee increase funding for the
    Carl D. Perkins Career and Technical Education Act (Perkins V) Basic
    State Grant program, administered by U.S. Department of Education's
    Office of Career, Technical, and Adult Education, to $2.5 billion in
    the Fiscal Year (FY) 2022 Labor, Health and Human Services, Education,
    and Related Agencies appropriations bill. It is vital that Congress
    continues to build upon the recent increases to Perkins V in order to
    fully support the implementation of the law and the over 11 million
    learners it serves across the nation.\1\
    ---------------------------------------------------------------------------
        \1\ Perkins Collaborative Resource Network, State Profiles.
    Retrieved from https://cte.ed.gov/profiles/national-summary.
    ---------------------------------------------------------------------------
        In the Administration's recent budget proposal, the FY 2022
    discretionary request proposes only a disappointing 1.5%, or $20
    million, increase for the Perkins V Basic State Grant. This is
    inadequate given the growing need for skilled workers facing employers
    and learner demand for CTE. The additional $1 billion annually for
    middle and high school career pathways included in the President's
    budget request but through the American Jobs Plan would actually have a
    greater impact if this increase was authorized and appropriated through
    the Basic State Grant, and thus is included in our request.
        CTE at the secondary and postsecondary levels is an integral part
    of achieving an equitable and efficient economic recovery. COVID-19
    (the coronavirus) has affected the most foundational aspects of our
    society. With millions of Americans unemployed, or underemployed, and
    some industry sectors shuttered or undergoing rapid transformation,
    Black and Latinx workers, workers with a high school education or less
    and female workers have been disproportionately impacted. Now, more
    than ever, CTE is vital to our nation's learners, employers and
    economic recovery. Consider:
      --The unemployment rate reached 14.8 percent in April 2020, the
            highest unemployment rate since data collection started in
            1948. As of May 2021 unemployment remained higher than it had
            been in February 2020, before the pandemic came to the
            forefront (5.8 percent compared to 3.5 percent).\2\
    ---------------------------------------------------------------------------
        \2\ Congressional Research Service, Unemployment Rates During the
    COVID-19 Pandemic, June 2021. Retrieved from https://fas.org/sgp/crs/
    misc/R46554.pdf.
    ---------------------------------------------------------------------------
      --The unemployment rate for teenagers aged 16-19 hit 31.9 percent in
            April 2020, the highest it has even been in over 70 years. The
            only other time the unemployment rate for this population
            reached over 25 percent was during the Great Recession.\3\
    ---------------------------------------------------------------------------
        \3\ U.S. Department of Labor, Bureau of Labor Statistics. Retrieved
    from https://www.bls.gov/opub/ted/2020/unemployment-rate-rises-to-
    record-high-14-point-7-percent-in-april-2020.htm.
    ---------------------------------------------------------------------------
      --As of May 2021, 7.9 million workers reported that they were not
            able to find a job because their original employer either
            closed or was not hiring because of the pandemic.\4\
    ---------------------------------------------------------------------------
        \4\ U.S. Department of Labor, Bureau of Labor Statistics, The
    Employment Situation--May 2021, June 2021. Retrieved from https://
    www.bls.gov/news.release/pdf/empsit.pdf.
    ---------------------------------------------------------------------------
      --The unemployment rates are also much worse for non-White young
            adults--35.5 percent and 31.1 percent for Black and Latino
            teenagers respectively, compared to 29 percent for White
            teenagers.\5\
    ---------------------------------------------------------------------------
        \5\ U.S Department of Labor, Bureau of Labor Statistics, Labor
    Force Statistics from the Current Population Survey. Retrieved from
    https://www.bls.gov/web/empsit/cpsee_e16.htm, based on quarterly
    averages.
    ---------------------------------------------------------------------------
        For those individuals just at the beginning of their careers,
    losing opportunities to gain experience and a foothold in the labor
    market can have major, long-term impacts. For example, the millennial
    generation, who entered the workforce during the height of the Great
    Recession, is estimated to have relatively low levels of home
    ownership, net worth and real income compared to previous
    generations.\6\
    ---------------------------------------------------------------------------
        \6\ Federal Reserve Bank of St. Louis, The Demographics of Wealth,
    How Education, Race and Birth Year Shape Financial Outcomes, 2018.
    Retrieved from https://www.stlouisfed.org//media/files/pdfs/hfs/
    essays/hfs_essay_2_2018.pdf?la=en.
    ---------------------------------------------------------------------------
        Unemployment trends during the pandemic have shown that upskilling
    and reskilling needs have already increased, and we can expect that
    will continue. CTE programs are instrumental in delivering high-quality
    education programs aligned with in-demand careers. It is projected that
    some--but not all--of the jobs lost during the pandemic will come back
    in one form or another. One study estimates approximately 60 percent of
    job loss will be temporary, while other studies predict about a quarter
    of job losses will be permanent. What is not in question is that the
    economy will look different on the other side of the recovery, with
    marginalized communities the most likely to be impacted, given Latinx
    Americans have been the most likely to have hours or shifts reduced and
    Black Americans have been the most likely to have been laid off during
    this crisis.\7\
    ---------------------------------------------------------------------------
        \7\ https://www.stradaeducation.org/wp-content/uploads/2020/04/
    Public-Viewpoint-Report-Week-4.pdf.
    ---------------------------------------------------------------------------
        CTE serves a critical role in supporting learners in their
    reskilling or upskilling as they look to either re-enter the economy or
    grow into new opportunities. Looking at data from the last recession,
    the vast majority of new and replacement jobs went to individuals with
    more than a high school diploma, including 3.1 million jobs that went
    to those with associate degree or postsecondary certificates. There is
    growing data that suggest that those who lost their jobs due to the
    coronavirus will pursue CTE-focused programs and degrees. About a third
    of adults report that, if they lose their jobs, they would need more
    education to replace them. Consider:
      --A third of adults report they would potentially change careers.
      --Two-thirds of adults interested in enrolling in postsecondary
            education and training in the next six months would do so to
            upskill or reskill.
      --A majority of American workers say they prefer non-degree and
            skill-based education and training programs in today's economy.
        This all aligns with outcomes from the last recession, with over 50
    percent of displaced workers changing industries when they re-entered
    the workforce.\8\
    ---------------------------------------------------------------------------
        \8\ The White House, Addressing America's Reskilling Challenge,
    2018. Retrieved from https://www.whitehouse.gov/wp-content/uploads/
    2018/07/Addressing-Americas-Reskilling-Challenge.pdf.
    ---------------------------------------------------------------------------
        Just as all education programs have been hit hard by the pandemic,
    so have CTE programs. This has been exacerbated by the lack of CTE-
    designated funding in stimulus bills. What sets CTE apart from other
    educational pathways is its focus on real-world skills and applied
    learning. High-quality CTE programs provide opportunities for direct
    engagement between industry and learners and instructors, often include
    work-based learning experiences, and enable learners to earn
    credentials of value. Yet what sets CTE apart is also what has
    presented unique challenges during the coronavirus era. CTE programs
    are facing many of the same dire needs as the entire education system,
    particularly those related to broadband and technology access, digital
    curriculum, and teacher professional development. However, many needs
    in CTE are exacerbated by the applied and lab-based nature of many
    courses, the need for learners to meet certification requirements, and
    the benefits of work-based learning and other experiential programs.
    CTE programs stand ready to provide employers a talent pipeline, and
    prepare students for careers in high-skill, high-wage, or in-demand
    industry sectors and occupations, but need additional support. Jobs
    that require more than a high school diploma but less than a
    baccalaureate degree were growing before the pandemic, and will
    continue to do so now. Further, automation coupled with the
    unemployment rate requires nimble, proactive, and responsive CTE and
    workforce programs that provide specific technical as well as
    transferable skills. As jobseekers and employers have looked to recover
    from the economic impacts of the pandemic, additional funding will
    ensure that the CTE system is primed to support their needs.
        Despite this, no stimulus package during the pandemic has included
    CTE-designated funding. Although Perkins V has been named as an
    authorized use of some of the funding under the Education Stabilization
    Fund in each package, there is no guarantee that money will be
    allocated to CTE programs.
        High-quality CTE programs are delivering real results. Across the
    country, CTE programs are preparing learners for promising career paths
    and giving employers and our economy a competitive edge. CTE programs
    provide unique opportunities for learners to engage with employers and
    participate in internships, apprenticeships and other meaningful on-
    the-job experiences. In addition, these programs produce strong
    outcomes for the learners they serve. The average high school
    graduation rate for students concentrating in CTE is 95 percent,
    compared to a national adjusted cohort graduation rate of 85
    percent.\9\ Additionally, students involved in CTE are far less likely
    to drop out of high school than other students, a difference estimated
    to save the economy $168 billion each year.\10\ Furthermore, those
    students are highly likely to continue their education-91 percent of
    high school graduates who earned two to three CTE credits enrolled in
    college.\11\
    ---------------------------------------------------------------------------
        \9\ Perkins Collaborative Resource Network, Perkins Data Explorer,
    customized Consolidated Annual Report data. https://perkins.ed.gov/
    pims/DataExplorer; U.S. Department of Education, Office of Elementary
    Secondary Education, Consolidated State Performance Report, 2010-11
    through 2016-17.
        \10\ Kotamraju, P. Measuring the return on investment for CTE.
    Techniques: 28-31, 2011. Retrieved from https://files.eric.ed.gov/
    fulltext/EJ943149.pdf.
        \11\ U.S. Department of Education, National Center for Education
    Statistics, Data Point: Career and Technical Education Coursetaking and
    Postsecondary Enrollment and Attainment: High School Classes of 1992
    and 2004, 2016. Retrieved from https://nces.ed.gov/pubs2016/
    2016109.pdf.
    ---------------------------------------------------------------------------
        The outcomes for adult learners are also significant: 84 percent of
    adults concentrating in CTE programs either continued their education
    or were employed within six months of completing their program.\12\ In
    fact, 90 percent of Americans agree that apprenticeships and skills
    training programs prepare individuals for a good standard of
    living.\13\
    ---------------------------------------------------------------------------
        \12\ Includes only states that report data on adult CTE learners to
    the U.S. Department of Education. Perkins Collaborative Resource
    Network, Perkins Data Explorer, customized Consolidated Annual Report
    data. Retrieved from https://perkins.ed.gov/pims/DataExplorer/
    Performance.
        \13\ New America, Varying Degrees 2018: Executive Summary.
    Retrieved from https://www.newamerica.org/education-policy/reports/
    varying-degrees-2018/executive-summary/.
    ---------------------------------------------------------------------------
        Expanding funding for CTE programs will create a brighter future
    for communities--leading to more career options for learners, better
    results for employers, and increased growth for our economy. Investing
    in CTE programs provides substantial benefits for not just the students
    enrolled, but for states and communities across the country. Every
    dollar spent on secondary CTE students in Washington state leads to $26
    in lifetime earnings and employee benefits,\14\ while individuals who
    receive a certificate or degree from California Community Colleges
    almost double their earnings within three years.\15\ In Wisconsin,
    taxpayers receive $12.20 in return for every dollar invested in the
    technical college system.\16\ Oklahoma's economy reaps a net benefit of
    $3.5 billion annually from graduates of the CareerTech System.\17\ If
    we are serious about providing learners with the real-world skills,
    hands-on opportunities and real options for college and rewarding
    careers that come with CTE and making progress toward closing the
    skills gap, then there is no better time than now to invest $2.5
    billion in Perkins CTE State Grants.
    ---------------------------------------------------------------------------
        \14\ Workforce Training and Education Coordinating Board, Workforce
    Training Results 2020. Retrieved from https://www.wtb.wa.gov/wp-
    content/uploads/2020/01/2020-Dashboard.pdf.
        \15\ Foundation for California Community Colleges, California
    Community Colleges, n.d. Retrieved from https://foundationccc.org/
    Portals/0/Documents/NewsRoom/FactSheets/ccc-facts-figures.pdf.
        \16\ Wisconsin Technical College System, The Technical College
    Effect, 2016. Retrieved from https://www.wistechcolleges.org/sites/
    default/files/POSTER8.5x11-2016update2_0.pdf.
        \17\ Snead, M. C., The Economic Contribution of CareerTech to the
    Oklahoma Economy: Cost-Benefit Analysis of Career Majors (FY11), 2013.
    Retrieved from https://www.okcareertech.org/about/costbenefit-analysis-
    of-career-majors/cost-benefit-analysis-of-career-majorsfy-11-pdf.
    ---------------------------------------------------------------------------
        CTE programs are also preparing individuals with the skills that
    employers seek. A 2020 survey found that employers believe CTE is good
    for business, the economy, and public education, and the majority of
    those surveyed reported that those from a CTE program are better
    prepared with workplace, technical and real-world skills. Employers who
    recruit from CTE programs are also more likely to report industry
    growth. CTE programs have long provided unique opportunities for
    learners to engage with employers and participate in internships,
    apprenticeships, and other meaningful on-the-job experiences. Now more
    than ever, CTE serves a critical role in supporting learners in their
    reskilling or upskilling as they look to either re-enter the economy or
    grow into new opportunities.
        CTE programs prepare students for careers in in-demand fields and
    provide an affordable pathway to both a family-sustaining career and
    financial independence. Health care occupations, many of which require
    an associate degree or industry credential, are projected to grow 14
    percent by 2028-adding almost 2 million new jobs.\18\ Half of all STEM
    occupations, which offer students high-skilled, high-wage career
    opportunities, require less than a bachelor's degree.\19\ There are
    currently about 30 million ``good jobs''-jobs that pay a median income
    of $55,000 or more and require education below a bachelor's degree.\20\
    ---------------------------------------------------------------------------
        \18\ U.S. Department of Labor, Bureau of Labor Statistics,
    Occupational Outlook Handbook, Healthcare Occupations. Retrieved from
    https://www.bls.gov/ooh/healthcare/home.htm.
        \19\ Rothwell, J. The Hidden STEM Economy, Brookings Institution,
    2013. Retrieved from https://www.brookings.edu/research/the-hidden-
    stem-economy/.
        \20\ Georgetown University Center on Education and the Workforce,
    Good Jobs that Pay Without a BA, 2017. Retrieved from https://
    goodjobsdata.org/wp-content/uploads/Good-Jobs-wo-BA-final.pdf.
    ---------------------------------------------------------------------------
        Additionally, the demand for workforce credentials is growing. The
    number of individuals earning certificates or associate degrees in CTE
    fields, such as manufacturing, health care, and STEM, rose 71 percent
    from 2002 to 2012.\21\ Students can pursue these valuable credentials
    at community and technical colleges for a fraction of the cost of
    tuition at other institutions: $3,730, on average for the 2019-2020
    academic year.\22\ Highly-skilled workers deliver direct benefits to
    American employers through enhanced productivity and innovation;
    however, the increased demands on the workforce pipeline are a
    persistent barrier to economic growth. A projected three million
    workers are needed to fill infrastructure jobs in the next few years,
    including careers in construction, transportation and
    telecommunications.\23\ Meanwhile, 89 percent of executives agree there
    is a talent shortage in the U.S. manufacturing sector, 5 percent higher
    than 2015 results.\24\ These industries still need talent, even in the
    current economic climate.
    ---------------------------------------------------------------------------
        \21\ U.S. Department of Education, Office of Planning, Evaluation
    and Policy Development, Policy and Program Studies Service, National
    Assessment of Career and Technical Education: Final Report to Congress,
    2014. Retrieved from https://www2.ed.gov/rschstat/eval/sectech/nacte/
    career-technical-education/final-report.pdf.
        \22\ College Board, Average published charges, 2018-19 and 2019-20.
    Retrieved from https://research.collegeboard.org/trends/college-
    pricing/figures-tables/average-published-charges-2018-19-and-2019-20.
        \23\ Kane, J. W., and Tomer, A. Infrastructure skills: Knowledge,
    tools, and training to increase opportunity, Brookings Institution,
    2016. Retrieved from https://www.brookings.edu/research/infrastructure-
    skills-knowledge-tools-and-training-to-increase-opportunity/.
        \24\ Deloitte and the Manufacturing Institute, Skills Gap and the
    Future of Work Study, 2018. Retrieved from http://
    www.themanufacturinginstitute.org//media/E323C4D8F75A470E8C96D7
    A07F0A14FB/DI_2018_Deloitte_MFI_skills_gap_FoW_study.pdf; Deloitte and
    the Manufacturing Institute, The skills gap in U.S. manufacturing 2015
    and beyond, 2015. Retrieved from http://
    www.themanufacturinginstitute.org//media/
    827DBC76533942679A15EF7067A704CD.ashx.
    ---------------------------------------------------------------------------
        Funding Perkins V at adequate levels will ensure that educators can
    equip students with the skills they will need for in-demand fields.
    This will become increasingly pressing as the country continues to
    recover from the current health pandemic and economic crisis. Already,
    healthcare jobs are projected to have the largest increase of any
    occupational sector.\25\ Filling these and other positions created, as
    well as ensuring that each individual is able to access the training
    needed for employment, is critical.
    ---------------------------------------------------------------------------
        \25\ U.S. Department of Labor, Bureau of Labor Statistics,
    Occupational Outlook Handbook, Healthcare Occupations. Retrieved from
    https://www.bls.gov/ooh/healthcare/home.htm.
    ---------------------------------------------------------------------------
        CTE programs can serve even more learners and employers--but only
    if they receive more resources. According to The Bureau of Labor
    Statistics Job Openings and Labor Turnover Survey (JOLTS) Highlights
    for May 2021, the ratio of unemployed workers to job openings is 1.2,
    meaning that for 9.8 million unemployed workers there are only 9.1
    million jobs available.\26\ As more jobs lost during the pandemic
    become permanent, CTE remains a critical component to the workforce
    pipeline for key industries that are needed to sustain a long-term
    economic recovery, such as healthcare, STEM, manufacturing,
    construction and transportation distribution and logistics. But,
    learner demand for CTE programs, especially programs in in-demand
    sectors is greater than supply. With current and anticipated demand
    growing, more resources are needed to build, expand and support high-
    quality CTE programs. It is vital that Congress continues to build upon
    the recent increases to Perkins V to ensure we have the talent pipeline
    needed to fully recover from the jobs crisis caused by the pandemic.
    ---------------------------------------------------------------------------
        \26\ U.S. Department of Labor, Bureau of Labor Statistics, Job
    Openings and Labor Turnover Survey (JOLTS) Highlights; January 2020.
    Retrieved from https://www.bls.gov/web/jolts/jlt_labstatgraphs.pdf.
    ---------------------------------------------------------------------------
        And there's widespread support for CTE: 94 percent of parents
    approve of expanding access to CTE.\27\ However, a survey of school
    districts offering CTE found that the top barrier to offering CTE in
    high school was a lack of funding or the high cost of the programs.\28\
    As the chart below demonstrates, between FY2004 and FY2020, funding for
    CTE State Grants declined by over $77 million dollars, the equivalent
    of $427 million inflation-adjusted dollars (i.e., 28 percent in
    inflation-adjusted dollars).
    ---------------------------------------------------------------------------
        \27\ Hart Research Associates, Public School Parents on the Value
    of Public Education: Findings from a National Survey of Public School
    parents conducted for the AFT, September 2017. Retrieved from https://
    www.aft.org/sites/default/files/parentpoll2017_memo.pdf.
        \28\ U.S. Department of Education, National Center for Education
    Statistics, Career and Technical Education Programs in Public School
    Districts: 2016-17. Retrieved from https://nces.ed.gov/pubs2018/
    2018028.pdf.
    ---------------------------------------------------------------------------
        Taking a longer view, before FY18, the investment in CTE State
    Grants had been relatively flat since 1991 without being tied to
    inflation, and the program's buying power had fallen by approximately
    $933 million in inflation-adjusted dollars--a 45 percent reduction over
    a quarter century.\29\ Congress recognized the need to begin to reverse
    this trend and from FY18 to FY21 provided an additional $217 million
    for CTE State Grants, bringing the total investment to $1.342 billion.
    While the past four budgets represented initial down payments to meet
    increased need, a significant, robust investment in CTE programs is
    still imperative to account for persistent underfunding, the lack of
    inflation-adjusted increases, and most importantly, the overwhelming
    growth in demand for these programs from both learners and the American
    economy. Congress should build on the momentum from recent years and
    continue to strengthen the investment in CTE State Grants in FY2022.
    And, Americans agree: 93 percent of voters support increasing the
    investment in skills training.\30\
    ---------------------------------------------------------------------------
        \29\ U.S. Bureau of Labor Statistics, CPI Inflation Calculator.
    Retrieved from https://data.bls.gov/cgi-bin/cpicalc.pl.
        \30\ ALG Research, Poll Finds Overwhelming Support for More Funding
    for Skills Training, 2019. Retrieved from https://
    www.nationalskillscoalition.org/news/press-releases/body/Poll-Finds-
    Overwhelming-Support-for-More-Funding-for-Skills-Training.pdf.
    ---------------------------------------------------------------------------
        Now more than ever, individuals need access to upskilling and
    reskilling opportunities to be part of the evolving workforce, and CTE
    programs will be adapting, as always, to the needs of business and
    industry in the current economy. CTE is both a proactive and responsive
    strategy for attending to the economic downturn--CTE programs prepare
    learners for lifelong success while also offering targeted skilled
    training for others. We applaud the commitment to growing our
    investment in Perkins V, and we urge the subcommittee to make CTE a top
    priority in the FY 2022 Labor, Health and Human Services, Education,
    and Related Agencies appropriations bill. Now is not the time to back
    away from our commitment to advancing high-quality CTE, but rather the
    time to double down and ensure CTE programs are available for every
    learner who seeks to better their own lives and opportunities
        Thank you for your thoughtful consideration of our request. For
    more information or if you wish to discuss our request, please contact
    ACTE's Government Relations Manager Michael Matthews
    (mmatthews@acteonline.org) or Advance CTE's Senior Associate for
    Federal Policy Associate Meredith Hills (mhills@careertech.org).
                                     ______

          Prepared Statement of the Association for Clinical Oncology
        The Association for Clinical Oncology (ASCO), the world's leading
    professional organization representing nearly 45,000 physicians and
    other professionals who treat people with cancer, thanks this
    subcommittee for its long-standing commitment to support federally
    funded research at the National Institute of Health (NIH) and National
    Cancer Institute (NCI). ASCO is extremely grateful for the $1.25
    billion increase for the NIH in fiscal year (FY) 2021. This strong
    commitment to scientific discovery will help the research community
    continue current momentum and sustain our nation's position as the
    world leader in biomedical research. ASCO appreciates this opportunity
    to provide the following recommendations for FY2022 funding to build on
    our nation's investment in biomedical research:
      --National Institutes of Health (NIH): $46.111 billion
        --National Cancer Institute (NCI): $7.609 billion
          -- Beau Biden Cancer Moonshot Initiative: $194 million
      --Centers for Disease Control and Prevention's (CDC) Division of
            Cancer Prevention and Control (DCPC): $559 million
        --Cancer Registries Program: $70 million
                           the nih: a good investment
        In FY2020, the NIH provided over $34 billion in extramural research
    to scientists in all 50 states and the District of Columbia.\1\ NIH
    research funding also supported more than 536,000 jobs and generated
    over $91 billion in economic activity last year.\2\
    ---------------------------------------------------------------------------
        \1\ National Institutes of Health; https://www.nih.gov/about-nih/
    what-we-do/impact-nih-research.
        \2\ United for Medical Research; https://
    www.unitedformedicalresearch.org/wp-content/uploads/2021/03/NIHs-Role-
    in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
    ---------------------------------------------------------------------------
        The importance of federally funded biomedical research has been on
    display over the last year as scientists from all corners of the
    country worked to quickly develop effective COVID-19 vaccines.
    Researchers working towards a vaccine were not starting from scratch;
    years of federally funded research progress led to the discovery and
    identification of practical uses for messenger RNA, or mRNA, as used in
    the Pfizer and Moderna vaccines. Prior to COVID-19 cancer researchers
    were using mRNA to trigger the immune system to target specific cancer
    cells. Building on previous scientific advancements, coupled with
    collaboration across federal agencies, academic institutions, and the
    private sector, unprecedented flexibility, and reduction in regulatory
    red tape, the resulting vaccines came to market at a record pace. This
    remarkable achievement--a result of years of research and scientific
    discovery--is a testament to the need for continued investment.
        Despite recent funding increases, the COVID-19 pandemic has
    resulted in stagnant research progress and low clinical trial accrual
    rates, stifling the progress of our biomedical research enterprise and
    weakening our clinical trials networks. The funding levels we are
    requesting for FY2022 would aid in recovery from these setbacks and
    allow meaningful growth above biomedical inflation for the first time
    in over a decade. They would also allow the extraordinary progress seen
    pre-pandemic to continue. Failure to sustain investment in research
    places health outcomes and the scientific leadership and economic
    growth of the country at risk.
                   the nci: the need for a renewed commitment
        This year marks the 50th anniversary of the passage of the National
    Cancer Act of 1971, which established the NCI in its current form. Over
    the last 30 years alone, the cancer death rate has fallen 31%. This
    includes a 2.4% decline from 2017 to 2018--a record for the largest
    one-year drop in the cancer death rate. However, even during a global
    pandemic, cancer remains the second most common cause of death in the
    United States. In 2021, almost 1.9 million new cancer cases will be
    diagnosed, and more than 600,000 people will die from cancer.\3\
    ---------------------------------------------------------------------------
        \3\ American Cancer Society; https://www.cancer.org/content/dam/
    cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-
    and-figures/2021/cancer-facts-and-figures-2021.pdf.
    ---------------------------------------------------------------------------
        The time is ripe for a renewed commitment for robust NCI funding.
    ASCO is grateful for funding provided to the Beau Biden Cancer Moonshot
    Initiative and its focus on modernizing clinical trials, establishing a
    direct patient engagement network, developing a national cancer data
    ecosystem, continuing advances in precision oncology, and developing
    effective immunotherapies for a broader array of cancers. However,
    funding for the Initiative peaked FY2019, and dropped to $195 million
    in FY2021; FY2023 will mark the last year of authorized Moonshot
    funding. ASCO urges Congress to bolster NCI funding in anticipation of
    the end of the Cancer Moonshot Initiative.
        The NCI is the largest funder of cancer research in the world, with
    most of its funding directly supporting research at NCI and at cancer
    centers, hospitals, community clinics, and universities across the
    country. While the NCI has received modest funding increases over the
    last few years, funding has not kept up with the growth of research
    grant applications as compared to other NIH Institutes or Centers. In
    fact, over the last five years R01 grant applications submitted to the
    NCI rose by 50%, while funding only grew by 20%. This means NCI is
    funding a smaller proportion of grant applications compared to previous
    years. Only 10% of viable applications received funding in 2020
    compared to 28% in 1997. Even after accounting for Cancer Moonshot
    funding, NCI's budget has not kept up with scientific opportunity. ASCO
    supports the NCI's 15 by 25 initiative, in which the Institute aims to
    fund 15% of grant applications by 2025. Unfortunately, the President's
    FY2022 budget proposal of $6.733 billion for the NCI would not allow
    for an increase in funded applications for 2022. ASCO's request of
    $7.609 billion for FY2022 would allow NCI to fund 12% of grants
    submitted, a modest increase, but a step closer to their own goal.\4\
    ---------------------------------------------------------------------------
        \4\ National Cancer Institute; https://www.cancer.gov/research/
    annual-plan/2022-annual-plan-budget-proposal-aag.pdf.
    ---------------------------------------------------------------------------
                      bringing the research to the patient
        NIH-funded translational research and clinical trials have
    significantly improved the standard of care in many diseases. Clinical
    trials and translational research yield insight critical to the
    development of targeted therapies, which identify patients most likely
    to benefit from treatments and help patients who will not benefit avoid
    the cost and pain of treatment unlikely to help them. This is where
    science becomes practice-changing for patients in America.
        ASCO has developed the Targeted Agent and Profiling Utilization
    Registry (TAPUR(tm)) Study, which provides access to targeted therapies
    for patients aged twelve and older and who have been identified as
    candidates for benefitting from those treatments because of a promising
    tumor biomarker target identified in their cancer. TAPUR evaluates use
    of these molecularly targeted anti-cancer drugs and collects data on
    clinical outcomes. As of May 2021, there are over 2,130 participants
    enrolled in the TAPUR Study at 128 sites in 24 states. Without federal
    investment spurring the pipeline of new cancer treatments, studies such
    as TAPUR would not be possible.
        To maintain access to research for cancer patients, ASCO urges a
    substantial increase in funding for the National Clinical Trials
    Network (NCTN) and NCI Community Oncology Research Program (NCORP).
    Just last year, the NCI awarded 53 grants to researchers at 46 NCORP
    sites, which have assembled more than 1,000 affiliates across the
    country to conduct research. The NCORP network now covers 44 states and
    the District of Columbia.\5\ An increase in NCI's budget would enable
    the Institute to maintain or increase the number of accruals to trials
    and cover the cost of conducting research.
    ---------------------------------------------------------------------------
        \5\ National Cancer Institute; https://ncorp.cancer.gov/news/2019-
    08-19.html.
    ---------------------------------------------------------------------------
        cancer registries & clinical trials: harnessing data & reducing
                                  disparities
        We have seen tremendous progress in cancer research. Even so, with
    more targeted and patient-specific therapies in development, certain
    populations are still missing out on potentially life-threatening
    treatment options. ASCO was encouraged to see the CLINICAL TREATMENT
    Act become law at the end of 2020. This legislation will require
    Medicaid to cover routine care costs for clinical trials for patients
    with life-threatening conditions. A step forward, but barriers remain;
    diversity and generalizability of clinical trials is crucial for making
    trial results applicable more broadly and to ensure positive clinical
    outcomes for all patients. We hope to continue our work with Congress,
    NCI, and the Centers for Medicare and Medicaid Services (CMS) to
    improve access to clinical trials for underrepresented patient
    populations.
        As a compliment to inclusive trials, cancer providers and
    researchers also need accessible data to understand cancer at a broader
    level. This data can prove especially crucial for rare and pediatric
    cancers, where trials are limited due to smaller patient populations.
    To that end, ASCO joins the cancer community in requesting $559 million
    for the CDC's Division of Cancer Prevention and Control (DCPC), and $70
    million for the CDC's Cancer Registries Program. Cancer registries are
    a critical tool for providers and researchers, providing cancer
    surveillance, identifying trends amongst different patient cohorts,
    illustrating the impact of early detection, and showing the impact of
    treatment advances on cancer outcomes. Registries allow providers to
    collect data in real time and improve cancer research, public health
    interventions and treatment protocols. While we work towards greater
    trial inclusion, registries help ensure we have data from
    underrepresented patient cohorts such as racial and ethnic minorities,
    women, children, and rural populations.
                     working towards cures: a new approach
        Modern cancer research delivers new treatments to patients faster
    than ever, thanks to continuing innovation in research and regulatory
    infrastructure. The continued investment Congress has made in cancer
    research helps make progress possible. ASCO is committed to partnering
    with Congress and the Administration to spur innovation and expediently
    get treatments to patients.
        As Congress and the Administration evaluate ways to improve our
    national biomedical research enterprise through such efforts as the
    proposed Advanced Research Projects Agency-Health (ARPA-H), we urge
    lawmakers to leverage collaboration between the private market,
    biotech, health care companies, academic institutions, and government
    and regulatory agencies. Fostering public-private partnerships and
    standardization to accelerate discovery to clinically impactful
    products that help patients is vital. Additionally, any efforts to
    establish a new agency or reform the biomedical research enterprise and
    health innovation, should ensure sustained and dedicated funding to
    achieve impactful translational research with demonstration of patient
    benefit. It should not impact the current or future resources of
    existing research enterprises.
        Any new agency should be transparent about its selection criteria
    and decision-making process for its broad strategic goals and selection
    of individual research projects, including clear metrics to ensure the
    funds are being used to advance public health meeting established
    deliverables. Furthermore, innovation should come from peer-reviewed
    science that provides evidence-based decision making for care, and the
    findings should be published in peer-reviewed publications. Finally, as
    previously discussed, all patients should have access to the clinical
    trials and the resulting treatments conducted with investment by the
    agency; insurance coverage and cost should not be a barrier to clinical
    trial participation and equitable care; and should implement strategies
    to encourage decentralization of trials and ensure diversity and equity
    in research.
      mitigating the effects of covid-19 and continuing the work towards
                                     cures
        As with nearly every sector of society, individuals in the research
    community have faced loss of employment, lab closures, and loss of
    momentum in pre-pandemic research. Younger investigators and support
    staff have been especially vulnerable during the last year. Our
    clinical trials network has also been impacted; one study showed that
    clinical trial enrollment in May 2020 was 73% lower than accrual in May
    2019.\6\ Another study found the COVID-19 pandemic was associated with
    a 60% decrease in the number of launches of oncology clinical trials of
    drugs and biologic therapies.\7\ In May 2021, NCI Director Ned
    Sharpless, M.D. speculated that clinical trial accrual was still just
    50% of what it had been pre-pandemic.
    ---------------------------------------------------------------------------
        \6\ U.S. National Institutes of Health's National Library of
    Medicine; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538012/#ref
    \5\.
        \7\ The Journal of the American Medical Association https://
    jamanetwork.com/journals/jamanetworkopen/fullarticle/2775637.
    ---------------------------------------------------------------------------
        To regain the momentum over the last few years, lawmakers and
    researchers will need to work together to mitigate COVID-19 related
    disruptions to research and restore momentum across the nation's
    medical research network. Therefore, I urge you to prioritize the
    important role NIH and NCI play in medical innovation and economic
    growth by protecting and strengthening federally funded research in
    FY2022.
        ASCO again thanks the subcommittee for its continued support of
    cancer patients in the U.S. through funding for the NIH, NCI, and CDC.
    We look forward to working with all members of the subcommittee on an
    FY2022 budget that continues to advance U.S. cancer research. Please
    contact Kristin Stuart at Kristin.Stuart@asco.org with any questions.

        [This statement was submitted by Howard Burris, MD, FASCO, Chair of
    the Board, Association for Clinical Oncology.]
                                     ______

        Prepared Statement of the Association for Psychological Science
            aps recommendations for fiscal year 2021 appropriations
    _______________________________________________________________________

      --APS strongly supports the Administration's request for $51 billion
            for NIH in FY 2022. We are eager to see the details of the
            President's request. We appreciate the Administration's
            commitment to meaningful growth in the base budget and
            expanding NIH's capacity to support promising research in all
            scientific fields that contribute to improved health.
      --APS is pleased that an NIH working group has been established to
            review how to integrate and realize the benefits of overall
            health from behavioral research at NIH, but we request Congress
            include report language urging that this review also address
            the necessary funding, authority, and organizational changes
            needed for the Office of Behavioral and Social Sciences
            Research (OBSSR) to better meet its mission. OBSSR has the
            mission to enhance NIH's behavioral science research enterprise
            across all institutes and centers. Its direct authorities to
            achieve its mission, however, are limited. OBSSR does not
            report directly to the NIH Director and has no grantmaking
            authority. Importantly, with a small budget of less than 1/1000
            of NIH's overall budget, it has limited capacity to leverage
            institutes' research priorities. APS urges that these
            limitations be addressed in the NIH review.
      --Finally, APS asks the Committee to favorably consider the requests
            of the Psychological Clinical Science Accreditation System
            (PCSAS) to urge the modification of HRSA and National Health
            Service Corps regulations to permit the graduates of PCSAS-
            accredited schools to be eligible for employment in these
            programs. APS believes that the strong emphasis on science in
            PCSAS accreditation offers promise of improved prevention and
            treatment interventions which will strengthen HRSA and the
            National Health Service Corps programs.
    _______________________________________________________________________

                      statement of aps executive director
        Chairwoman Murray, Ranking Member Blunt, and Members of the
    Subcommittee, thank you for the opportunity to provide testimony as you
    consider funding priorities for Fiscal Year (FY) 2022. I am Robert
    Gropp, Executive Director of the Association for Psychological Science
    (APS). APS is a nonprofit scientific organization dedicated to
    advancing the science of psychology for the benefit of science and
    society. APS recognizes and appreciates the Subcommittee's efforts to
    strengthen public health research in the United States.
        funding for the national institutes of health and policy issues
        As previously noted, APS recommends an FY 2022 funding level of $51
    billion for NIH, which would enable real growth over health research
    inflation as an important step to ensuring stability in the Nation's
    research capacity over the long term. In addition to funding
    priorities, APS is concerned about several policy issues at HHS.
        1. Inclusion of Psychologists in the Pandemic Response: Nearly
    600,000 Americans have died from COVID-19. This is a tragedy that is
    based in human behavior, both in the human response necessary to stop
    the spread of the disease as well as the disproportionate impact of the
    disease on health disparity and racial and ethnic minority populations.
    Research from psychological science must be one of the inputs informing
    an effective public health emergency response. Psychology research
    teaches us how to encourage individuals to practice safe behaviors and
    receive vaccines, for example. But psychological scientists investigate
    fundamental science questions, too. For instance, improved scientific
    understanding of risk assessment, social motivations, and interpersonal
    relationships can powerfully influence the spread of infectious
    diseases. Psychological science helps us address consequences of social
    distancing such as loneliness and emerging threats to mental health.
    Researchers in our field have proven essential to improving our
    understanding and addressing COVID-19's impact. APS urges that the
    following report language be included in the FY 2022 Labor-HHS Report:
        Behavioral Science and the COVID-19 National Strategy.--The
            Committee applauds the Administration's robust National
            Strategy for the COVID-19 Response and Pandemic Preparedness
            and appreciates that the strategy reflects the best advice of
            scientists and public health experts. However, even with
            effective and safe vaccinations, we must continue and expand
            mask-wearing, testing, and social distancing; all citizens,
            organizations, and communities must rally together in that
            common purpose. As our success in these areas depends on our
            scientific understanding of human behavior, the Committee urges
            that the Department include psychological scientists at every
            level of the Department's response to COVID-19 and future
            public health emergencies to best and most effectively meet
            these common goals.
        2. Behavioral Science at NIH: The NIH mission is to ``seek
    fundamental knowledge about the nature and behavior of living systems
    and the application of that knowledge to enhance health, lengthen life,
    and reduce illness and disability.'' APS is concerned by the continued
    low level of funding support for behavioral science research and
    training at NIH despite the central importance of this research to all
    dimensions of human health. APS is pleased that the NIH Council of
    Councils created a new Behavioral Sciences Working Group on Integration
    and Realization of the Benefits to Health from Behavioral Research at
    NIH to complete an assessment providing recommendations on how NIH-
    funded behavioral research can be better integrated with the NIH
    research programs to improve health. There is concern, however, that
    this working group may not look beyond current structures and
    practices. We request that the following report language be included in
    the FY 2022 Labor-HHS Report to direct NIH to ensure that appropriate
    OBSSR funding levels, authority, and organizational structure be
    included in this review.
        Enhancements for the Office of Behavioral and Social Sciences
            Research.--The Committee notes that the Office of Behavioral
            and Social Sciences Research (OBSSR) has the mission to enhance
            NIH's behavioral science research enterprise across all
            institutes and centers. As multiple Surgeons General and the
            National Academy of Medicine have declared that most health
            problems facing the nation have significant behavioral
            components, the Committee strongly supports the continued
            strengthening of the behavioral science enterprise at NIH and
            urges OBSSR funding and authorities be increased to accomplish
            this mission. In this regard, the Committee is pleased that an
            NIH working group has been established to review how better to
            integrate and realize the benefits of overall health from
            behavioral research at NIH, and directs that appropriate OBSSR
            funding levels, authority, and organizational structure be
            included in this review.
             updating hrsa and national health service regulations
        APS requests the Committee favorably consider the requests of the
    Psychological Clinical Science Accreditation System (PCSAS) to urge the
    modification of HRSA and National Health Service Corps regulations to
    permit the graduates of PCSAS-accredited schools to be eligible for
    employment in these programs. The strong emphasis on science in PCSAS
    accreditation offers promise of improved prevention and treatment
    interventions that will strengthen HRSA and the National Health Service
    Corps.
        PCSAS was recognized by the Council for Higher Education
    Accreditation (CHEA) in 2012 and now accredits 45 of the Nation's
    doctoral clinical science programs. CHEA is the largest higher
    education membership organization in the United States. It is a
    national body formed by 3,000 universities which reviews and screens
    applications from organizations to serve as accrediting bodies for the
    professions. CHEA is widely recognized as a primary national voice for
    accreditation and quality assurance. After a thorough review, CHEA
    approved the Psychological Clinical Science Accreditation System
    (PCSAS) in September 2012 to accredit schools of clinical psychology.
        Prior to 2012, the American Psychological Association (APA) was the
    only accrediting body for clinical psychology programs. Many agency
    regulations are outdated and refer to the need for applicants for
    employment to have graduated from APA accredited programs. This
    historical artifact needs to be updated for HRSA and the National
    Health Service Corps. Doing so will help to ensure the federal
    government is able to recruit and hire top quality psychologists,
    regardless of whether they are from an APA or PCSAS accredited graduate
    program.
        1. Updating Two HRSA Health Professions Programs Regulations is
    Necessary: HRSA's two psychology education training programs, called
    the Behavioral Health Workforce Education and Training Program (BHWET)
    and the Graduate Psychology Education Program (GPE), support programs
    that produce graduates who work in clinical psychology practice upon
    completion of their program. The authorizing statute in the Public
    Health Service Act at 756(a)(2) specifically says the Secretary may
    make grants for the ``...training of psychology graduate students for
    providing behavioral and mental health services...''; however, the
    authorizing legislation limits eligibility to the graduates of APA-
    accredited programs. This excludes the graduates of PCSAS-accredited
    programs. FY 2021 report language is requested to open program
    eligibility to the graduates of PCSAS accredited programs. The language
    follows:
        Health Workforce Eligibility Requirements.--The Committee is
            concerned that HRSA has not complied with the language in the
            Joint Explanatory Statement for Public Law 216-260 which urged
            HRSA to update eligibility requirements for the BHWET program
            and the GPE program to account for accreditation changes that
            have occurred since the eligibility requirements were
            established. The Committee notes the Council for Higher
            Education Accreditation, as well as the Department of Veterans
            Affairs, recognizes the Psychological Clinical Science
            Accreditation System [PCSAS]. HRSA is directed to make the
            necessary administrative updates to ensure that HRSA's health
            workforce programs continue to have access to the best
            qualified applicants, including those who graduate from PCSAS
            programs.
        2. Updating National Health Service Corps Regulations is Necessary:
    The regulations of the National Health Service Corps also need to be
    updated. While this change has been agreed to, it remains pending for
    final approval. The language needed to urge this change follows:
        Public Health Service Corps Eligibility Requirements.--The
            Committee is concerned that the Office of the Surgeon General
            has not complied with the language in the Joint Explanatory
            Statement for Public Law 216-260 which encouraged the Secretary
            to update accreditation and eligibility requirements for the
            Public Health Service Corps to allow access to the best
            qualified applicants, including those who graduate from
            Psychological Clinical Science Accreditation System programs.
            The Committee directs the Department to make these necessary
            the necessary changes to its eligibility requirements.
                             summary and conclusion
        We thank the Subcommittee for its ongoing commitment to supporting
    scientific research that improves the human condition in the United
    States and around the world. Reducing barriers to research and training
    in behavioral science is warranted by the central role of behavior in
    many of our most pressing health problems and by the enormous potential
    of psychological science and other behavioral science disciplines to
    reduce the suffering experienced by the millions of people with
    behavior-based conditions. APS shares your commitment to addressing the
    health needs of the Nation and appreciates the opportunity to provide
    this testimony.

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

         Prepared Statement of the Association for Research in Vision
                               and Ophthalmology
                               executive summary
        The Association for Research in Vision and Ophthalmology (ARVO), on
    behalf of the eye and vision research community, thanks Congress,
    especially the House and Senate LHHS Appropriations Subcommittees, for
    the strong bipartisan support for the National Institutes of Health
    (NIH) funding increases from Fiscal Year (FY) 2016 through FY2021.
        This past investment in NIH has improved our understanding of
    fundamental life and health sciences and prepared the nation to combat
    unprecedented health threats, including COVID-19. To maintain this
    momentum in FY2022, ARVO strongly supports $51.95 billion in NIH
    funding as proposed by President Biden, including no less than $46.1
    billion for NIH's base program level budget (absent proposed funding
    for the Advanced Research Projects Agency--Health [ARPA-H]), an
    increase of at least $3.177 billion or 7.4%, which would allow NIH's
    base budget to keep pace with the Biomedical Research and Development
    Price Index (BRDPI) and allow for 5% growth. This increase will support
    promising science across all Institutes and Centers (ICs), ensure
    continued Innovation Account funding established through the 21st
    Century Cures Act for special initiatives, and support early-stage
    investigators.
        Along with our partners and other scientific societies, ARVO also
    urges one-time emergency funding for federal agency ``research
    recovery'' investment to enable NIH to mitigate pandemic-related
    disruptions without foregoing promising new science. ARVO supports the
    bipartisan Research Investment to Spark the Economy (RISE) Act (H.R.
    869/S. 289) which includes $10 billion for NIH.
        ARVO also urges Congress to fund the NEI at $900 million, a $64.3
    million or 7.7% increase over FY2021 that reflects both biomedical
    inflation and growth, compared to the Administration's suggested $858.4
    million funding level-a $22.83 million or 2.7% increase. Despite NEI's
    total $160 million funding increases in the FY2016-2021 timeframe, its
    enacted FY2021 budget of $835.7 million is just 19% greater than the
    pre-sequester FY2012 funding of $702 million. Averaged over those nine
    fiscal years, the 2.1% annual growth rate is still less than the
    average annual biomedical inflation rate of 2.7%, thereby eroding
    purchasing power. In fact, NEI's FY2021 purchasing power is less than
    that of FY2012.
        The NEI currently faces an increasing burden of vision impairment
    and eye disease due to an aging population, the disproportionate risk/
    incidence of eye disease in minority populations, and the impact on
    vision from numerous chronic diseases, such as diabetes. NEI also faces
    additional challenges with the COVID-19 pandemic, as both the working-
    age population and students have relied almost exclusively on
    electronic devices and e-learning platforms, which research has shown
    correlates to increased rates of myopia, dry eye and eye strain.
        Maintaining the momentum of eye and vision research is vital to
    vision health and to overall health and quality of life and would
    secure the U.S. as the world leader in eye and vision research and
    training the next generation of eye and vision scientists.
              nei-funded research saves sight and restores vision
        Historical federal investment has led to landmark advances in the
    prevention of vision loss as well as the restoration of vision,
    including:
      --Audacious Goals Initiative: The NEI has been at the forefront of
            regenerative medicine with its Audacious Goals Initiative
            (AGI), launched in 2013 with the goal of restoring vision. AGI-
            funded consortia have developed innovative ways to image the
            visual system such that researchers can now look at individual
            nerve cells in the eyes of patients to learn directly whether
            new treatments are successful. Another consortium has
            identified biological factors that allow neurons to regenerate
            in the retina, and current AGI proposals may result in clinical
            trials for therapies within the next decade.
      --Retinal Diseases: The NEI has been at the forefront of research
            into retinal diseases. NEI-funded researchers helped to show
            that the Vascular Endothelial Growth Factor (VEGF) protein
            stimulates abnormal blood vessel growth that occurs in the
            advanced stages of the ``wet'' form of age-related macular
            degeneration (AMD) and diabetic retinopathy. Food and Drug
            Administration (FDA)-approved anti-VEGF drug therapies that
            slow the development of blood vessels in the eye delay vision
            loss and may improve vision for patients. NEI has funded
            comparison trials of anti-VEGF drugs to provide clinicians and
            patients with information they need to choose the best
            treatment options. With respect to the ``dry'' form of AMD,
            also known as geographic atrophy and is the leading cause of
            vision loss among individuals age 65+, since 2019 NEI has been
            performing a first-in-human clinical trial that tests a stem
            cell-based therapy from induced pluripotent stem cells (iPSC)
            to treat geographic atrophy. This trial converts a patient's
            own blood cells to iPS cells which are then programmed to
            become retinal pigment epithelial (RPE) cells, which nurture
            the photoreceptors necessary for vision and which die in
            geographic atrophy. Bolstering remaining photoreceptors, the
            therapy replaces dying RPE with iPSC-derived RPE.
      --Genetics/Genomics: The NEI has been at the forefront of genetics/
            genomics and gene therapy approaches to various eye and vision
            disorders-both common and rare. The causes of AMD and glaucoma
            remain elusive, although most cases are not inherited, genetics
            does play a role. While NEI-funded researchers have identified
            many genetic risk factors for AMD and glaucoma, further study
            of these genes is helping to understand disease biology and the
            promise for improved therapies. NEI-funded research has also
            made discoveries of dozens of rare eye disease genes possible,
            including the discovery of RPE65, which causes congenital
            blindness known as Leber congenital amaurosis (LCA). As of late
            2017, NEI's initial efforts led to a commercialized FDA-
            approved gene therapy for this condition. These gene-based
            discoveries form the basis of new therapies that treat and may
            prevent the disease.
      --Front-of-Eye Research: The NEI has launched an Anterior Segment
            Initiative (ASI) studying clinically significant, front-of-eye
            problems such as ocular pain and Dry Eye Disease (DED),
            especially in terms of pain and discomfort sensations and
            disruptions in the tearing process. Using multi-disciplinary
            approaches, the ASI plans to elucidate relevant anterior
            segment innervation pathways that contribute to normal or
            abnormal functioning of the neural circuits related to the
            ocular surface.
           nei funding demonstrates signifigant return on investment
        Optical coherence tomography (OCT) is a technology developed with
    federal research funding through the NIH, which has led to significant
    cost savings by helping to diagnose conditions that lead to vision loss
    among patients more efficiently. In 2017, ARVO shared the story of OCT,
    including the significant associated cost savings:
      --$9 billion: Medicare savings from clinicians using OCT to optimize
            the injection schedule of anti-VEGF drugs for patients with
            wet-AMD
      --$2.2 billion: Wet-AMD patient savings from reduced spending on drug
            copays
      --$0.4 billion: Total investment over 20 years made by NIH and NSF to
            invent and develop the technology
      --2,100%: Return on taxpayer investment
        [http://www.ajo.com/article/S00029394(17)30419-1/fulltext]
            nei research addresses increasing burden of eye disease
        NEI's FY2021 enacted budget of $835.7 million is less than 0.5% of
    the $177 billion annual cost (inclusive of direct and indirect costs)
    of vision impairment and eye disease, which was projected in a 2014
    Prevent Blindness study to grow to $317 billion--or $717 billion in
    inflation-adjusted dollars--by year 2050. Of the $717 billion annual
    cost of vison impairment by year 2050, 41% will be borne by the federal
    government as the ``Baby Boomer'' generation ages into the Medicare
    program. A 2013 Prevent Blindness study reported that direct medical
    costs associated with vision disorders are the fifth highest--only less
    than heart disease, cancers, emotional disorders, and pulmonary
    conditions. The U.S. is spending only $2.53 per person, per year for
    eye and vision research, while the cost of treating low vision and
    blindness is at least $6,680 per person, per year. [http://
    costofvision.preventblindness.org/]
        Investing in vison health is an investment in overall health. In
    summary, ARVO requests FY2022 NIH funding of at least $51.95 billion,
    but urges the Subcommittee to appropriate no less that $46.1 billion
    for the NIH's base program level. Further, we request NEI funding of
    $900 million. ARVO also supports one-time emergency ``research
    recovery'' investment to mitigate the pandemic-related disruptions
    without foregoing promising new science.
        The Association for Research in Vision and Ophthalmology (ARVO) is
    the largest eye and vision research organization in the world. Members
    include approximately 10,000 eye and vision researchers from over 75
    countries.
                                     ______

      Prepared Statement of the Association of American Cancer Institutes
        The Association of American Cancer Institutes (AACI), representing
    102 premier academic and freestanding cancer centers across the United
    States and Canada, appreciates the opportunity to submit this statement
    for consideration by the subcommittee. AACI submits this request for
    the Department of Health and Human Services budget for the National
    Institutes of Health (NIH) as the subcommittee considers Fiscal Year
    (FY) 2022 funding. AACI requests a $3.177 billion increase for the NIH
    for FY 2022, bringing the recommended funding level for the NIH to
    $46.111 billion. This proposed level of NIH funding would ensure that
    academic cancer centers conducting lifesaving research can continue to
    discover and deliver new therapies for patients with cancer. AACI also
    requests at least $7.609 billion in FY 2022 for the National Cancer
    Institute (NCI).
        Additionally, we look forward to seeing what comes of the $6.5
    billion proposal for an Advanced Research Projects Agency-Health (ARPA-
    H) that was laid out in President Biden's Fiscal Year 2022 (FY22)
    budget. We appreciate the proposal outlining cancer as a primary
    initial focus of ARPA-H. We are pleased with any expenditures that
    include more funding for cancer research; however, our hope is that the
    APRA-H proposal will not be diverting any funding from base funding for
    the NIH or the NCI. As Congress moves into the Fiscal Year 2022 (FY22)
    budget process and consideration of an infrastructure package, we
    wanted to share our priorities related to the budget.
                              aaci cancer centers
        AACI cancer centers are beacons of discovery, largely funded by the
    NIH and NCI. In order to ensure continued progress, these agencies rely
    on stable, predictable federal funding to invest in groundbreaking
    cancer research.
        Cancer centers develop and deliver state-of-the-art therapies and
    provide comprehensive care, from prevention to survivorship, to
    patients. These centers are at the forefront of the national effort to
    eradicate cancer, yet progress in cancer research is complex and time-
    intensive. The pace of discovery and translation of novel basic
    research to new therapies can be accelerated if researchers are able to
    count on an appropriate and predictable investment in federal cancer
    funding.
                              covid-19 challenges
        The COVID-19 pandemic has taken a significant toll on medical
    research, making increased funding more critical than ever. Clinical
    trials were brought to a halt and trial sites experienced challenges
    with safely facilitating care for enrolled patients and freezing the
    process of enrolling new patients.
        As noted in last year's testimony, American Cancer Society data
    show that the mortality rate from cancer in the United States has
    declined 29 percent since its peak in 1991. This translates to more
    than 2.9 million deaths avoided between 1991 and 2016--progress tied to
    the commitment of Congress to fund the NIH and NCI.\1\ Dr. Norman E.
    Sharpless, NCI director, has stated that the COVID-19 pandemic will
    influence cancer mortality for at least the next decade, with an
    estimated 10,000 additional breast and colorectal cancer deaths during
    this time.\2\ Further, the NCI reports that an increase in overall
    cancer mortality rates for the first time in almost 30 years is likely
    due to the impact of COVID-19. But the pandemic has taught us important
    lessons about the benefits of scientific progress to public health.
    ---------------------------------------------------------------------------
        \1\ https://www.cancer.org/latest-news/facts-and-figures-2020.html.
        \2\ https://cancerletter.com/nci-director-report/20200619_1/.
    ---------------------------------------------------------------------------
        The future of cancer research relies on robust funding to the NIH
    and NCI. The broad portfolio of science supported by these agencies is
    essential for improving our basic understanding of cancer and has
    contributed to the health and well-being of Americans. We cannot let
    the challenges of the last year slow this meaningful progress.
                                    payline
        Uncertainty surrounding research project grants (R01s) from year to
    year and a decline in cancer center resources often drives promising
    scientists to explore opportunities abroad or outside of the biomedical
    research community. For most academic cancer centers, the majority of
    NCI grant funds are used to sustain shared core resources that are
    essential to basic, translational, clinical, and population cancer
    research, or to provide matching dollars that allow departments to
    recruit new cancer researchers to a university and support them until
    they receive their first grants. It is imperative that we enable
    America's scientists to master their craft.
        We noted last year that in FY 2020, R01 grants for established and
    new investigators are being funded to the 10th percentile, up from the
    8th percentile in FY 2019. In FY 2021, the grants were funded to the
    11th percentile.\3\ We request that Congress build on progress with a
    FY 2022 funding increase to meet the goal of raising the NCI payline to
    the 15th percentile by FY 2025. AACI supports the NCI Director's
    Professional Judgment Budget Proposal for FY 2022 of $7.609 billion for
    the NCI, which will increase funding to the 12th percentile.\4\
    ---------------------------------------------------------------------------
        \3\ https://www.cancer.gov/grants-training/nci-bottom-line-blog/
    2021/funding-from-congress-allows-nci-to-raise-grants-payline.
        \4\ https://www.cancer.gov/research/annual-plan/budget-proposal.
    ---------------------------------------------------------------------------
                                   conclusion
        Now is the time for Congress to invest in biomedical research--and
    cancer research in particular. According to the American Cancer
    Society, there will be an estimated 1.9 million new cancer cases
    diagnosed in the United States in 2021.\5\ Fortunately, improvements in
    early detection, cancer staging, and surgical techniques, as well as
    the development of innovative therapies, have contributed to better
    outcomes for patients with cancer. We join our colleagues in the
    biomedical research community in recommending that the subcommittee
    recognize the NIH as a national priority by enacting a final FY 2022
    spending package that includes $46.111 billion for the NIH and $7.609
    billion for the NCI.
    ---------------------------------------------------------------------------
        \5\ https://www.cancer.org/research/cancer-facts-statistics/all-
    cancer-facts-figures/cancer-facts-figures-2021.html.
    ---------------------------------------------------------------------------
        A robust federal investment in NCI-Designated Cancer Centers and
    academic cancer centers will allow the cancer research community to
    accelerate progress against cancer, despite challenges such as the
    COVID-19 pandemic.

        [This statement was submitted by Jennifer W. Pegher, Executive
    Director,
    Association of American Cancer Institutes.]
                                     ______

      Prepared Statement of the Association of American Educators Fellows
        My name is Jessica Saum and I am a special education teacher at
    Stagecoach Elementary School in Cabot, Arkansas. I am the current
    Stagecoach Elementary School and Cabot Public School Distict's Teacher
    of the year. I teach a self-contained classroom of students grades
    kindergarten through fourth grade where my students spend less than 40%
    of the school day out of my classroom with their typically developing
    peers. This time includes lunch, recess, activity classes, and for
    certain students instructional times such as phonics, social studies,
    and science.
        Students with diverse needs, especially those in early childhood
    special education, need more time in the general education classroom
    learning prosocial behaviors and having more exposure to grade level
    curriculum. In order to provide this, schools need additional funding
    to ensure staffing of trained paraprofessional support for students
    with moderate to severe learning disabilities as well as to fund
    inclusion co-taught classroom supporting those with specific learning
    disabilities and deficits in specific content areas.
        When learning happens in an inclusive classroom, general education
    teachers and special education teachers work together and are able to
    meet the needs of all students. Carl A. Cohn, EdD, the executive
    director of the California Collaborative for Educational Excellence,
    said, ``It's important ... to realize that special education students
    are first and foremost general education students.'' This is often not
    how students with special needs are treated.
        Inclusive classes look different in how they are arranged and how
    they operate. Some use co-teaching with a collaborative team model
    having is a special education teacher in the room all day. In other
    inclusive classrooms, there is a special education teacher that
    ``pushes in'' to the class during specific times during the day to
    teach. This allows students to minimize transitions that can be very
    overwhelming, and is used in place of pulling kids out of class to a
    separate room. In both of these situations, teachers are available to
    teach and help all students.
        This type of learning is beneficial for all students, not just for
    those who are receiving special education services, having both
    positive short-term and long-term effects. Studies have shown that
    students with special education needs who are in inclusive classes are
    absent less often and develop stronger skills in reading and math.
    Additionally they also more likely to have jobs and pursue education
    after high school. The same research shows that their peers benefit,
    too. The typically developing students are more comfortable with and
    more tolerant of differences. I have seen this in my own children as
    they have formed meaningful relationships with students I teach and are
    advocates even at a young age and friends to exceptional learners.
        Most students than ever with special needs are expected to take the
    same high stakes assessments as students without special needs. Eleven
    of the thirteen students in my special class setting took the same
    district and state assessments as their grade level peers in the 2020-
    2021 school year. They deserve the opportunity to learn alongside
    typical peers, having access to the same curriculum, with the support
    from special educators to navigate appropriate prosocial behaviors and
    receive modifications and accommodations to ensure success.
        What we must directly address is how we can spend this much-needed
    federal money. It is important to determine whom it goes to when
    investing more into this often overlooked population, where the needed
    training comes from, and for whom is it used for. General education
    teachers need additional training provided at the state level through
    professional development at their district or coop, specifically on
    High Leverage Practices for Inclusion to support this data proven
    practice being implement in their classrooms. There needs to be
    increased funding, specifically designated for districts to hire
    additional paraprofessionals and special education teachers to work
    with students in the general education classroom, ensuring students are
    being educated in their least restrictive environment as required
    through the Individuals with Disabilities Act (IDEA). Furthermore,
    there needs to be an increased emphasis nationally at the collegiate
    level in teacher preparation programs on educating diverse learners in
    the general education setting. Teachers are not adequately prepared to
    meet the needs of exceptional learners when they enter the teaching
    profession and the lack of training to ensure this has led to many
    students being educated in settings more restrictive than necessary.
        Teachers can and will do more when supported appropriately and when
    they are properly trained. I have witnessed this first hand as a
    special education teacher. When my students have general education
    teachers trained to support them and confident in their abilities to
    meet their unique needs, they have more growth academically, are more
    socially competent, and lead happier and more successful lives at home
    and in their communities. It is critical to note that lasting effects
    of inclusive practices in schools extend far beyond the school setting
    making children a part of their community, helping them develop a sense
    of belonging and becoming better prepared for life.
        Providing children with the resources to attend schools which are
    committed to and prepared for inclusive practices, demonstrates the
    shared commitment to having all children feel appreciated and accepted
    throughout life. All children deserve to attend age appropriate regular
    classrooms to the maximum extent possible receiving curriculum relevant
    to their needs that will provide for their educational success. All
    children benefit from cooperation, collaboration among home, among
    school, among community.
        Thank you for your time and consideration.

        [This statement was submitted by Jessica Saum, Special Education
    Teacher,
    Association of American Educators Advocacy Fellow.]
                                     ______

       Prepared Statement of the Association of American Medical Colleges
        The Association of American Medical Colleges (AAMC) is a not-for-
    profit association dedicated to transforming health through medical
    education, health care, medical research, and community collaborations.
    Its members are all 155 accredited U.S. and 17 accredited Canadian
    medical schools; more than 400 teaching hospitals and health systems,
    including Department of Veterans Affairs medical centers; and more than
    70 academic societies. Through these institutions and organizations,
    the AAMC?leads and serves America's medical schools and teaching
    hospitals and their more than 179,000 full-time faculty members, 92,000
    medical students, 140,000 resident physicians, and 60,000 graduate
    students and postdoctoral researchers in the biomedical sciences.
        The COVID-19 pandemic has illustrated how sustained support for the
    research, education, and patient care missions of medical schools and
    teaching hospitals, with a strong commitment to community
    collaborations, is essential to ensure a resilient health care
    infrastructure prepared to respond to both novel and existing threats.
    For FY 2022, the AAMC recommends the following for federal priorities
    essential in assisting medical schools and teaching hospitals to
    fulfill their missions that benefit patients, communities and the
    nation: at least $46.1 billion for the National Institutes of Health
    (NIH); $500 million for the Agency for Healthcare Research and Quality
    (AHRQ); $1.51 billion for the Health Resources and Services
    Administration (HRSA) Title VII health professions and Title VIII
    nursing workforce development programs, and $485 million for the
    Children's Hospitals Graduate Medical Education (CHGME) program; and at
    least $10 billion for the Centers for Disease Control and Prevention
    (CDC). The AAMC appreciates the Subcommittee's longstanding, bipartisan
    efforts to strengthen these programs. Additionally, to enable the
    necessary support for the broad range of critical federal priorities,
    the AAMC urges Congress to approve a funding allocation for the Labor-
    HHS subcommittee that enables full investment in the priorities
    outlined below.
        National Institutes of Health. Congress's longstanding bipartisan
    support for medical research has contributed greatly to improving the
    health and well-being of all Americans, highlighted by the central role
    medical research has played in combatting COVID-19. As illustrated over
    the last year, the foundation of scientific knowledge built through
    NIH-funded research drives medical innovation that improves health
    through new and better diagnostics, improved prevention strategies, and
    more effective treatments. Over half of the life-saving research
    supported by the NIH takes place at medical schools and teaching
    hospitals, where scientists, clinicians, fellows, residents, medical
    students, and trainees work together to improve the lives of Americans
    through research. This partnership is a unique and highly productive
    relationship that lays the foundation for improved health and quality
    of life and strengthens the nation's long-term economy.
        The AAMC thanks Congress for the bipartisan support that resulted
    in the inclusion of $42.9 billion for medical research conducted and
    supported by the NIH in the FY 2021 omnibus spending bill.
    Additionally, the AAMC thanks the Subcommittee for recognizing the
    importance of retaining the salary cap at Executive Level II of the
    federal pay scale in FY 2021, and for the emergency resources that have
    advanced COVID-19 research.
        In FY 2022, the AAMC joins nearly 400 partners in supporting the Ad
    Hoc Group for Medical Research recommendation that Congress provide at
    least $46.1 billion in program level funding for the NIH, including
    funds provided through the 21st Century Cures Act for targeted
    initiatives. This funding level for the foundational work at the core
    of NIH's mission would continue the momentum of recent years by
    enabling meaningful growth of 5% in the NIH's base budget over
    biomedical inflation to help ensure stability in the nation's research
    capacity long term. Securing a reliable, robust budget trajectory is
    key in positioning the agency--and the patients who rely on the
    research it funds--to capitalize on the full range of research in the
    biomedical, behavioral, social, and population-based sciences. We must
    continue to strengthen our nation's research capacity, solidify our
    global leadership in medical research, ensure a research workforce that
    reflects the racial and gender diversity of our citizenry, and inspire
    a passion for science in current and future generations of researchers.
        In addition to our strong support for a robust increase in NIH's
    base funding, we look forward to working with lawmakers and the
    administration to fulfill the goals of the proposed Advanced Research
    Projects Agency for Health (ARPA-H) within NIH as part of the
    administration's $52 billion request for the NIH to ``drive
    transformational health research innovation and speed medical
    breakthroughs by tackling ambitious challenges requiring large-scale,
    sustained, and cross-sector coordination.'' The nation's medical
    schools and teaching hospitals are hubs of innovation in research and
    care delivery, and the AAMC looks forward to engaging with lawmakers
    and the administration on opportunities to advance a bold and
    productive medical research agenda in harnessing our shared commitment
    to innovation and scientific discovery.
        We also wish to highlight the challenges that the pandemic has
    imposed on the medical research workforce and the broader research
    enterprise. We continue to be concerned that, without supplemental
    resources, the disruptions imposed by COVID-19 will undermine NIH's
    ability to support previous investments in the existing research
    workforce and new investments in life-saving research. In his recent
    testimony before the subcommittee, NIH Director Francis Collins, MD,
    PhD, cited the $16 billion impact of the coronavirus pandemic on
    medical research progress in all disease areas, and especially on the
    research workforce. We urge support for emergency funding for NIH as
    outlined in the bipartisan Research Investment to Spark the Economy
    (RISE) Act (H.R. 869/S.289).
        Agency for Healthcare Research and Quality. Complementing the
    medical research supported by NIH, AHRQ sponsors health services
    research designed to improve the quality of health care, decrease
    health care costs, and provide access to essential health care services
    by translating research into measurable improvements in the health care
    system. The AAMC joins the Friends of AHRQ in recommending $500 million
    in funding for AHRQ in FY 2022.
        Health Professions Funding. The Health Resources and Services
    Administration (HRSA) Title VII and Title VIII programs have helped the
    country combat COVID-19, despite the challenges the pandemic posed for
    grantees. Many grantees adapted their curricula to educate our health
    workforce during this public health challenge. They also dealt with the
    unexpected costs of providing personal protective equipment for in-
    person clinical training and switching from in-person to virtual
    learning. The pandemic has underscored the need to increase and
    continuously reshape our health workforce. The programs have proven
    successful in recruiting, training, and supporting public health
    practitioners, nurses, geriatricians, mental health providers, and
    other front-line health care workers critical to addressing COVID-19.
    Additionally, in coordination with HRSA, grantees have used innovative
    models of care, such as telehealth, to improve patients' access to care
    during the pandemic.
        The COVID-19 pandemic has also highlighted the pervasive health
    inequities facing minority communities and gaps in care for our most
    vulnerable patients, including an aging population that requires more
    health care services. The HRSA Title VII and Title VIII programs
    educate current and future providers to serve these ever-growing needs,
    while preparing providers for the health care demands of tomorrow. A
    diverse health care workforce improves access to care, patient
    satisfaction, and health professionals' learning environments. Studies
    show that HRSA Title VII and Title VIII programs increase the number of
    underrepresented students enrolled in health professions schools,
    heighten awareness of factors contributing to health disparities, and
    attract health professionals more likely to treat underserved patients.
    The AAMC joins the Health Professions and Nursing Education Coalition
    (HPNEC) in recommending $1.51 million for these critical workforce
    programs in FY 2022.
        In addition to Title VII and Title VIII, HRSA's Bureau of Health
    Workforce also supports the CHGME program, which provides critical
    federal graduate medical education support for children's hospitals to
    train the future primary care and specialty care workforce for our
    nation's children. We support $485 million for the CHGME program in FY
    2022. We also encourage Congress to provide robust funding to HRSA's
    Rural Residency Programs, which provides funding to develop new rural
    residency programs or separately accredited rural training track
    programs, to expand training opportunities in rural areas.
        The AAMC encourages Congress to provide long-term sustained funding
    for the National Health Service Corps (NHSC), through its mandatory and
    discretionary mechanisms. We were appreciative of the $800 million in
    supplemental funding for the NHSC in the American Rescue Plan (H.R.
    117-2), and we support an appropriation for the NHSC that would fulfill
    the needs for current Health Professions Shortage Areas.
        Centers for Disease Control and Prevention. The AAMC joins the CDC
    Coalition in a recommendation of at least $10 billion for the CDC in FY
    2022. In addition to ensuring a strong public health infrastructure and
    protecting Americans from public health threats and emergencies, CDC
    programs are crucial to reducing health care costs and improving
    health. Within the CDC total, the AAMC supports $102.5 million for the
    Racial and Ethnic Approaches to Community Health (REACH) program and
    $25 million to support gun safety research.
        Additional Programs. The AAMC also supports at least $474 million
    for the Hospital Preparedness Program within the Office of the
    Assistant Secretary for Preparedness and Response (ASPR), in addition
    to $40 million to continue the regional preparedness programs created
    to address Ebola and other special pathogens, including funding for
    regional treatment centers, frontline providers, and the National
    Emerging Pathogen Training and Education Center (NETEC).
        Once again, the AAMC appreciates the opportunity to submit this
    statement for the record and looks forward to working with the
    subcommittee as it prepares its FY 2022 spending bill.
                                     ______

        Prepared Statement of the Association of Farmworker Opportunity
                                    Programs
        Chair Murray and Ranking Minority Member Blunt:
        Thank you for the opportunity to present to you and your
    subcommittee the testimony of the Association of Farmworker Opportunity
    Programs (AFOP) in support of the nation's more than 50-year commitment
    to providing eligible agricultural workers the opportunity to achieve
    the American Dream for themselves and their families. As you begin work
    on your fiscal year 2022 Labor-Health and Human Services-Education
    appropriations bill, AFOP encourages you to build on the foundations
    laid by the highly successful programs described below by adequately
    funding them in the coming fiscal year: National Farmworker Jobs
    Program (NFJP), United States Department of Labor (DOL) Employment and
    Training Administration ($98,896,000); and Susan Harwood Training
    Grants, DOL Occupational Safety and Health Administration
    ($10,537,000). Not only do these programs maximize the Federal
    government's investment in them, they also generate for employers the
    qualified and healthy workers essential to their growth. These programs
    also dramatically change peoples' lives for the better, often in rural
    areas, allowing them to enjoy economic success and participate more
    fully in our great nation. Thank you for supporting these very
    effective programs and the excellent results they bring for society's
    most vulnerable.
                        national farmworker jobs program
        NFJP is the bedrock of the nation's commitment to helping
    agricultural workers upgrade their skills in and outside agriculture,
    providing employers with what they increasingly say they need:
    hardworking, well-trained, skilled workers. Administered by DOL, NFJP
    provides funding through a competitive grant process to 54 community-
    based organizations and public agencies nationwide that assist workers
    and their families to attain greater economic stability. One of DOL's
    most successful employment training programs, NFJP helps agricultural
    workers acquire the new skills they need to start careers that offer
    higher wages and a more stable employment outlook. In addition to
    employment and training services, the program provides supportive
    services that help agricultural workers retain and stabilize their
    current agriculture jobs, as well as enable them to participate in up-
    training and enter new careers. NFJP housing assistance helps meet a
    critical need for the availability and quality of agricultural worker
    housing and supports better economic outcomes for workers and their
    families. NFJP also facilitates the coordination of services through
    the American Job Center network for agricultural workers so they may
    access other services of the public workforce system.
        The agricultural workers who come to NFJP seek training to secure
    and excel in the in-demand jobs employers say they find challenging to
    fill. In doing so, the workers establish the financial foundation that
    allows them and their families to escape the chronic unemployment and
    underemployment they face each year. Many NFJP participants enter
    construction, welding, healthcare, and commercial truck-driving. Others
    train for the solar/wind energy sector, culinary arts, and for
    positions such as machinists, electrical linemen, and a variety of
    careers in and outside of agriculture. To be eligible for NFJP, workers
    must be low-income, depend primarily on agricultural employment, and
    provide proof of American citizenship or work authorization.
    Additionally, male applicants must have registered with the Selective
    Service.
        Agricultural workers are some of the hardest working individuals in
    this country, enduring tremendous physical and financial hardships in
    providing produce Americans eat every day. Yet, agricultural workers
    remain among the nation's most vulnerable employees and job seekers,
    facing significant barriers to work advancement, including:
      --The average agricultural worker family of four earns just $20,000
            per year, well below the national poverty line.
      --English-language fluency is a substantial challenge for many.
      --More than half the children of migratory agricultural workers drop
            out of school, and, among all agricultural workers, the median
            highest grade completed is 9th grade (National Agricultural
            Workers Survey).
      --Due to poverty and their rural locations, most agricultural workers
            have extremely limited access to transportation.
        Despite these barriers, NFJP continues to be one of the most
    successful Federal job training programs, exceeding all DOL's goals. In
    2019 alone, NFJP service organizations provided more than 17,300
    agricultural workers with services, according to DOL. These NFJP
    providers have served more than an estimated 170,000 agricultural
    workers and their family members over the last 10 years. Funding
    program this year at $98,896,000 would allow NFJP to train even more
    dependable, capable workers to take on the nation's most challenging
    jobs, such as those needed to rebuild the nation's infrastructure.
    Also, consistent appropriations for youth agricultural workers (ages
    14- to 24-years) will allow this cohort, so often overlooked and
    ignored by anti-poverty programs, to stay in school, and, if not in
    school, to avail themselves of crucial training to get a good job and
    establish themselves as productive and successful members of society.
                      agricultural worker health & safety
        AFOP also supports appropriations for OSHA's Susan Harwood grant
    program, through which AFOP has augmented pesticide safety training
    with curricula to help workers recognize and avoid the dangers of heat
    stress so common in the fields. In supporting this funding, you can arm
    the nation's agricultural workers with the knowledge they need to keep
    themselves safe on the job. The NFJP network of some 220 trainers in 30
    states trains agricultural workers on how to protect against pesticide
    poisoning. Trainers then follow up with agricultural workers to assess
    knowledge gained and retained, and changes in labor practice. Since
    1995, more than 492,000 agricultural workers have become certified as
    trained in safety precautions, and hundreds of thousands of family
    members, children, and community agencies have also received safety
    training. The network collaborates with universities, community
    organizations, local governments, and businesses to maximize its
    unparalleled access to agricultural workers and their families. By
    reaching agricultural workers with pesticide safety training, the
    network's trainers offer access to other services and create a ripple
    effect of positive impact--improving the quality of life for
    agricultural workers and their families--which is what NFJP
    organizations do best.
        Thank you for supporting these worthy programs. AFOP stands ready
    to assist you in any way as you proceed with your very important work.

        [This statement was submitted by Daniel J. Sheehan, Executive
    Director,
    Association of Farmworker Opportunity Programs.]
                                     ______

         Prepared Statement of the Association of Independent Research
                                   Institutes
        The Association of Independent Research Institutes (AIRI) thanks
    the Subcommittee for its long-standing and bipartisan leadership in
    support of the National Institutes of Health (NIH). We continue to
    believe that science and innovation are essential if we are to improve
    our nation's health, sustain our leadership in medical research, and
    remain competitive in today's global information and innovation-based
    economy. AIRI urges the Subcommittee to provide NIH with at least $46.1
    billion in fiscal year (FY) 2022. AIRI also commends Congress for
    continuing to reject harmful policies such as reducing support for
    facilities and administrative (F&A) costs or investigator salary
    support on NIH grants. In addition, AIRI looks forward to working with
    the Subcommittee and the Biden Administration to explore how the
    proposed Advanced Research Project Agency for Health (ARPA-H) can
    support high-risk, high-reward research to quickly develop new cures.
    AIRI urges the Subcommittee to ensure that this proposed effort
    complements, and does not negatively impact, NIH's funding for
    fundamental biomedical research that is critical for understanding and
    addressing the public health challenges facing the United States.
        AIRI is a national organization of more than 90 independent, non-
    profit research institutes that perform basic and clinical research in
    the biological and behavioral sciences. AIRI institutes vary in size,
    with budgets ranging from a few million to hundreds of millions of
    dollars. In addition, each AIRI member institution is governed by its
    own independent Board of Directors, which allows our members to focus
    on discovery-based research while remaining structurally nimble and
    capable of adjusting their research programs to emerging areas of
    inquiry. Investigators at independent research institutes consistently
    exceed the success rates of the overall NIH grantee pool, and they
    receive about ten percent of NIH's peer-reviewed, competitively awarded
    extramural grants.
        AIRI thanks the Subcommittee for providing an increase of $1.25
    billion for NIH in the FY 2021 Consolidated Appropriations Act. The
    Subcommittee's support of NIH is strongly demonstrated by these much-
    needed funds for life-saving biomedical research. However, there is
    still much more to do. NIH is tackling vast, interdisciplinary problems
    such as cancer, Alzheimer's Disease, emerging infectious diseases, and
    the opioid crisis, among others. In addition, NIH's instrumental role
    in developing new vaccines to combat the COVID-19 pandemic reminds us
    that now is not the time to pull back on needed investments in the
    nation's biomedical research ecosystem. Continued budget certainty is
    needed for the agency to predictably fund new and ongoing grants and
    consider new initiatives necessary to improving human health and
    ensuring that we are prepared for the next public health crisis. To
    ensure cutting-edge research at independent research institutes is not
    disrupted, AIRI strongly supports a topline of $46.1 billion for NIH in
    FY 2021.
        AIRI thanks the Subcommittee and Congress for providing critically
    needed supplemental funding in 2020 to combat the COVID-19 pandemic.
    NIH investments were critical in the record-breaking development of
    multiple vaccines and improved treatments and therapeutics for COVID-
    19. Independent research institutions are, by design, structurally
    nimble and responsive to emerging research issues. In part because of
    this, AIRI members have made significant contributions to COVID-19
    research. Selected examples include:
      --The Fred Hutchison Cancer Research Center's and RTI International's
            role in the Accelerating COVID-19 Therapeutic Interventions and
            Vaccines (ACTIV) program essential for the development of
            treatments and vaccines.
      --Fred Hutch's work in modeling the spread and evolution of COVID-19
            and as the coordination center for the NIH-funded COVID-19
            Prevention Network.
      --La Jolla Institute of Immunology's pioneering work to understand T
            cell responses to the infection.
      --Jackson Lab's work in developing a line of ACE2 mice for
            preclinical studies.
        Not only is NIH research essential to advancing health, it also
    plays a key economic role in communities nationwide. In FY 2020, NIH
    invested $34.65 billion, or almost 80 percent of its budget, in the
    biomedical research community. This investment supported more than
    536,338 jobs nationwide and generated nearly $91.35 billion in economic
    activity across the U.S.\1\ AIRI member institutes are particularly
    relevant in this regard, as they are located across the country,
    including in many smaller or less-populated states that do not have
    major academic research institutions. In many of these regions,
    independent research institutes are major employers and local economic
    engines, and they exemplify the positive impact of investing in
    research and science.
    ---------------------------------------------------------------------------
        \1\ NIH's funding information and economic impact data comes from
    United for Medical Research's 2021 State-By-State Update, https://
    www.unitedformedicalresearch.org/wp-content/uploads/2021/03/NIHs-Role-
    in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
    ---------------------------------------------------------------------------
        The NIH model for conducting biomedical research, which involves
    supporting scientists at independent research institutes, medical
    centers, and universities provides an effective approach to making
    fundamental discoveries in the laboratory that can be translated into
    medical advances that save lives. AIRI member institutions are private,
    stand-alone research centers that set their sights on the vast
    frontiers of medical science. However, AIRI member institutes are
    especially vulnerable to reductions in the NIH budget, as they do not
    have other reliable sources of revenue to make up the shortfall.
        AIRI member institutes' flexibility and research-only missions
    provide an environment particularly conducive to creativity and
    innovation. Independent research institutes possess a unique
    versatility and culture that encourages them to share expertise,
    information, and equipment across research institutions, as well as
    neighboring universities. These collaborative activities help minimize
    bureaucracy and increase efficiency, allowing for fruitful partnerships
    in a variety of disciplines and industries. Also, unlike institutes of
    higher education, AIRI member institutes focus primarily on scientific
    inquiry and discovery, allowing them to respond quickly to the research
    needs of the nation.
        AIRI looks forward to working with Congress and the Biden
    Administration to examine how the proposed establishment of an ARPA-H
    can push the research enterprise to take on high-risk, high-reward
    research efforts. If successful, an ARPA-H has the potential to convene
    researchers to take on grand challenges in public health that were
    previously thought to be impossible to solve. However, we still do not
    fully understand many of the basic mechanisms underlying diseases and
    public health challenges facing the nation today, such as cancer,
    Alzheimer's, and addiction, among others. Funding for fundamental
    research is still crucial to address these issues, and AIRI urges the
    Subcommittee to ensure that new proposals do not negatively impact
    these important ongoing efforts.
        The U.S. has the most robust medical research enterprise in the
    world, but our leadership in biomedical research is being challenged by
    the investments being made in the research capacity of other nations,
    such as China. While the most recent funding increases to the NIH
    budget will greatly help sustain biomedical research in the U.S., it is
    important to continue providing stable funding to uphold our biomedical
    excellence.
        AIRI deeply thanks the Subcommittee for its important work
    dedicated to ensuring the health of the nation, and we appreciate this
    opportunity to urge the Subcommittee to continue the success of NIH by
    providing $46.1 billion in FY 2021 and reaffirming support for NIH's
    current F&A and investigator salary policies to strengthen our nation's
    investment in life-saving medical research.
                                     ______

     Prepared Statement of the Association of Minority Health Professions
                                    Schools
                  summary of fiscal year 2022 recommendations
    _______________________________________________________________________

    Health Resources and Services Administration:
      --$1.51 billion for the Health Resources and Services Administration
            (HRSA) Title VII health professions and Title VIII nursing
            workforce development programs.
        --$47.42 million for HRSA's Minority Centers of Excellence
        --$47.95 million for HRSA's Health Careers Opportunity Program.
        --$2 million for HRSA's Minority Faculty Loan Repayment Program.
        --$67 million for HRSA's Scholarships for Disadvantaged Students
                (SDS).
        --$67 million for HRSA's Area Health Education Center (AHEC)
                Program
    Centers for Disease Control and Prevention:
      --$74 million for the Racial and Ethnic Approaches to Community
            Health (REACH) Program
    National Institutes of Health:
      --$46.1 billion for the National Institutes of Health
        --1 billion for the National Institute on Minority Health and
                Health Disparities (NIMHD).
          -- $300 million for the Research Centers at Minority Institutions
                (RCMI)
        --$200 million in new, annual research funding dedicated
                specifically targeted at enabling historically black health
                professions schools to support research that reverses
                health status disparities among minority Americans.
        --$100 million for NIH's Extramural Research Facilities program
        --$100 million to reinvigorate the NIMHD's Research Endowment
                Program (REP)
    Office of the Secretary:
      --$72 million for the Office of Minority Health at the Department of
            Health and Human Services.
      --$5 billion in new funding designated for Historically Black Health
            Professions Institutions for the improvement and development of
            health care infrastructure.
    Department of Education:
      --$100 million for the Strengthening Historically Black Graduate
            Institutions (HBGI) Program.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to submit testimony
    and thank you for your leadership in addressing challenges facing the
    health workforce, health disparities, and medically underserved
    communities. I am Dr. Kathleen Kennedy, Malcolm Ellington Professor of
    Health Disparities Research and Dean, College of Pharmacy Xavier
    University of Louisiana and the Chair of the Association of Minority
    Health Professions Schools (AMHPS), which was established in 1976 to
    promote a national minority health agenda by addressing the needs of
    the health workforce and improving health status in medically-
    underserved communities. Speaking to you today against the backdrop of
    the continued COVID-19 pandemic with hope on the horizon, we have
    learned valuable lessons over the past year and a half, but we know
    that there is more work to be done. The pandemic has pulled back the
    curtain on what many of AMHPS institutions know and work towards
    everyday: the pitfalls and shortcomings of minority health. Given the
    recent deluge of media coverage surrounding this disheartening topic,
    the country is primed and ready to act in a meaningful way. Our funding
    recommendations are robust and we realize ambitious, however there have
    rightfully been discussion concerning the devastating effect of the
    pandemic on people of color and the need to address this effect for any
    future pandemic. To be as clear we can be, there must be more robust
    investment on minority health and disparities. To achieve this we know
    that it will require the steadfast leadership of health equity
    champions. We stand ready to work with you and your colleagues to
    facilitate these efforts.
        AMHPS is comprised of the twelve historically black medical,
    dental, pharmacy, and veterinary schools in the United States. The
    members are two schools of dentistry at Howard University and Meharry
    Medical College; four schools of medicine, at Charles R. Drew
    University, Howard University, Meharry Medical College, and Morehouse
    School of Medicine; five schools of pharmacy, at Florida A&M
    University, Howard University, Texas Southern University, Hampton
    University, and Xavier University; and one school of veterinary
    medicine, at Tuskegee University. Today, the association assists its
    member institutions in the expansion and enhancement of educational
    opportunities in the health professions for minorities and
    disadvantaged students and disadvantaged people. AMHPS continuously
    adheres to is founding call and honors its threefold mission to improve
    the health status of blacks and other minorities; improve the
    representation of blacks and other minorities in the health
    professions; strengthen our institutions and programs and to strengthen
    other programs throughout the nation, which in turn will improve the
    role of minorities in the provision of health care.
        Health disparities across racial and ethnic groups in the U. S.
    have been well documented over the last several decades and have
    remained remarkably persistent in spite of the changes in many facets
    of the society over that period. Moreover, the benefits of increasing
    diversity in the health professions to reduce such disparities have
    been studied at length, are based on empirical data, and are well
    understood by the medical community. Examples of these benefits
    include:
      --Minority physicians are more likely to practice in medically
            underserved areas and care for patients regardless of their
            ability to pay.
      --Minority physicians are more likely to choose primary care
            practices.
      --Evidence suggests that improving cross-cultural communication
            between doctors and patients and providing patients with access
            to a diverse group of doctors improve adherence, satisfaction
            and health outcomes.
      --There is evidence that the intellectual, cultural sensitivity,
            competency, and civic development of students is enhanced by
            learning in a diverse educational environment.
      --A diverse health workforce encourages a greater number of
            minorities to enroll in clinical trials designed to alleviate
            health disparities.
        There is little left to discover or dispute with respect to the
    benefits of achieving greater racial and ethnic diversity of the
    nation's health professionals--the attention has once again shifted to
    identifying the most effective and sustainable methods to do so. While
    there are many national campaigns underway to increase diversity in all
    medical and health professions schools particularly during this period
    of enrollment growth, it is imperative that we further recognize and
    leverage the public value of Historically Black Health Professions
    Schools.
        The daunting news that Blacks Americans in the US are
    disproportionately suffering and dying from the novel coronavirus
    (COVID-19) unfortunately was not a tremendous surprise to those of us
    who regularly monitor and understand health status disparities in this
    nation. There are well-known health status challenges faced daily by
    Black Americans and minority health care providers, it also represents
    a surrogate for the glaring lack of health infrastructure in medically
    under-served communities. At AMHPS institutions, we have long been and
    remain committed to addressing these very same disparities in whatever
    way that we can, with an eye first and foremost towards the communities
    with the greatest need across our country.
        Ironically, as a result of their mission focus the financial models
    of historically black health professions schools are uniquely
    disadvantaged compared to most of their peer institutions. Unlike
    subspecialty-oriented, research-intensive institutions--with higher
    margin clinical services, an integrated hospital system, substantial
    research enterprises, sizeable endowments, and a critical mass of
    wealthy donors--these institutions are faced with an unprecedented set
    of adverse factors that challenge their financial viability.
    Consequently, they are disproportionately dependent on the various
    federal programs that support their core purpose.
        Specifically, these programs include: the Title VII Health
    Professions Training Programs administered by the Health Resources and
    Services Administration (HRSA) of the Department of Health and Human
    Services (HHS); the Research Centers at Minority Institutions (RCMI),
    the Extramural Research Facilities; the Research Endowment; and Centers
    of Excellence programs administered the National Institutes of Health's
    National Institute on Minority Health and Health Disparities; and the
    Historically Black Graduate Institution (HBGI) program administered by
    the Office of Postsecondary Education of the U.S. Department of
    Education (DOE).
        Madam Chair, unfortunately, over the past several years funding for
    diversity-focused programs has deteriorated in varying degrees. Absent
    a monumental overall investment the financial position and academic
    viability of historically black health professions schools will
    deteriorate rapidly. The front loaded investment in health professions
    training programs, graduate programs in biomedical sciences and public,
    and safety net providers is more cost effective than absorbing
    uncompensated care originating from minority and underserved
    communities. Now is the time for targeted investments in historically
    black health professions schools to ensure a steady pipeline of
    minority healthcare providers, biomedical scientists, and other health
    practitioners prepared to support and advance the delivery of high
    quality, culturally appropriate, evidence based health care. Thank you
    all again for the opportunity to share the priorities of the
    Association of Minority Health Professions Schools.

        [This statement was submitted by Kathleen B. Kennedy, Pharm.D.,
    Chair,
    Association of Minority Health Professions Schools, Inc. and Malcolm
    Ellington,
    Professor, Health Disparities Research and Dean, College of Pharmacy
    Xavier
    University of Louisiana.]
                                     ______

              Prepared Statement of the Association of State and
                          Territorial Health Officials
        On behalf of the Association of State and Territorial Health
    Officials (ASTHO), I respectfully submit this testimony on FY22
    appropriations for the U.S. Department of Health and Human Services
    (HHS). ASTHO is requesting $10 billion for the Centers for Disease
    Control and Prevention (CDC), $824 million for the Public Health
    Emergency Preparedness Cooperative Agreement (PHEP), $149 million for
    the CDC Preparedness and Response, All Other CDC Preparedness line,
    $170 million for the Preventive Health and Health Services Block Grant
    (Prevent Block Grant), and $250 million for the data modernization
    effort at the CDC. Under the Assistant Secretary for Preparedness and
    Response (ASPR), ASTHO is requesting $474 million for the Hospital
    Preparedness Program (HPP) and not less than $45.6 million to sustain
    the Regional Treatment Network for Ebola and Other Special Pathogens
    (RTNESP) and the National Ebola Training and Education Center (NETEC).
    Additionally, we are requesting $9.2 billion in discretionary funding
    for the Health Resources and Services Administration (HRSA).
        You are probably wondering, ``Why is governmental public health at
    the table requesting more funding? Didn't Congress just provide
    billions of dollars in emergency funding for you all?'' The answers are
    yes and thank you. We all must recognize the sheer amount of emergency
    funding required to boost our public health system and respond to the
    COVID-19 pandemic. We must also acknowledge that huge sums of this
    emergency funding could have been avoided with ongoing, predictable
    funding that meets the needs of state, territorial, and local public
    health departments. The emergency supplemental funding is narrow,
    specific, and time limited. All too often, after emergency supplemental
    funding expires, health officials are forced to shut down programs,
    allow software licenses to expire, furlough staff, and move on. While
    there are billions of emergency supplemental dollars in the system
    right now--that we are immensely grateful for--we anticipate that,
    without a change of course, there will be an enormous funding cliff in
    two to three years. Meanwhile, we all know that communities of color
    are disproportionately impacted by underinvestment on all public health
    fronts, whether we are discussing maternal morbidity and mortality,
    infant mortality, the prevalence of chronic diseases, substance use and
    misuse, behavioral and mental health, the HIV epidemic, and most
    strikingly, overall life expectancy. We have an opportunity to make
    things better for the American people, especially for those who need it
    most. This committee and Congress can ensure we have sustained,
    predictable, and increased funding for all of public health, which
    translates into better lives for those we serve.
        ASTHO is the national nonprofit organization representing the
    public health agencies of the United States, the U.S. territories and
    freely associated states, and the District of Columbia. ASTHO members,
    the chief health officials of these jurisdictions, are dedicated to
    ensuring excellence in public health practice. The mission of our
    nation's governmental health agencies is to protect and improve the
    health of the population, everywhere, every day. Our members' mission
    is to provide the leadership, expertise, information, and tools to
    assure conditions in which all residents can be healthy. In short:
    Keeping people safe.
        America's state and territorial public health departments work in
    strong partnership with CDC toward this goal. For this essential task,
    we request $10 billion in overall funding for CDC. CDC plays a vital
    role in supporting communities to expand the capacity of our nation's
    front line of public health defense: Our country's state, tribal,
    territorial, and local public health departments. Through this
    partnership with CDC, state and territorial health agencies work across
    the country to prevent avoidable diseases, promote healthy communities,
    protect the public's health, and ensure the vibrance and security of
    our economy. These resources also support disease-neutral
    infrastructure such as data and information technology systems,
    workforce development, community partnership building, and
    administrative preparedness. We continue to learn how far behind we are
    as a country when it comes to our ability to accurately track diseases
    or even transmit data efficiently and accurately to a central location.
    ASTHO is thankful for the current investment in our public health
    systems, but dependable and appropriate financing is essential to keep
    our country ahead of the curve.
        Public health preparedness requires support at the federal level
    and implementation by state, territorial, and local jurisdictions.
    Recognizing this, ASTHO requests $824 million for PHEP at CDC.
    America's public health preparedness outlays have operated in a
    punctuated equilibrium. We make leaps forward after emergencies such as
    September 11, Ebola, Zika, and measles outbreaks, and then are lulled
    into periods of stasis for far too long. PHEP requires ongoing and
    increased funding to ensure that lessons and improvements from the
    COVID-19 response are not lost. In close partnership with the PHEP is
    the Hospital Preparedness Program (HPP) at ASPR, for which ASTHO
    requests $474 million. As the only source of federal funding that
    supports regional healthcare system preparedness, HPP promotes a
    sustained national focus to improve patient outcomes, minimizes the
    need for supplemental state and federal resources during emergencies,
    and enables rapid recovery. Now more than ever, we clearly understand
    the importance of public health and healthcare preparedness programs
    working collaboratively and with proper resources. We are also
    requesting that Congress provide no less than $49.5 million to sustain
    the National Emerging Special Pathogen Training and Education Center
    and the 10 existing regional Ebola and other special pathogen treatment
    centers under ASPR. The investment made in this system over five years
    ago has proven its importance in providing specialty treatment,
    training, and national-level expertise during the COVID-19 response.
    This network is a valuable front-line tool in protecting our country.
        Preventing disease in the first place is the most economical use of
    our public funds when it comes to health spending. ASTHO's members
    strive to implement locally tailored, innovative programs that not only
    prevent disease and disability but support wellness as we work toward
    national health priorities. For this, ASTHO requests $170 million for
    the Prevent Block Grant. Programs funded by the Prevent Block Grant
    cannot be adequately supported or expanded through other funding
    mechanisms. The success of the Prevent Block Grant is achieved by using
    evidence-based methods and interventions, reducing risk factors,
    leveraging other funds, and continuing to monitor and reevaluate funded
    programs.
        ASTHO appreciates this committee's ongoing support of CDC's data
    modernization initiative. Public health is singlehandedly keeping the
    fax industry alive, and we must leap forward. We applaud Congress's
    investment and down payment to date ($600 million through FY21 and FY21
    funding and the CARES Act) and the inclusion of language authorizing
    activities to improve the public health data systems at CDC in the
    Consolidated Appropriations Act for FY21. We respectfully request the
    Subcommittee continue to provide sustained annual funding of at least
    $250 million for the public health Data Modernization Initiative at
    CDC.
        ASTHO is also encouraged by the Administration's plan to end the
    HIV epidemic and address social determinants of health in America.
    State and territorial health officials look forward to working with
    federal and local partners across the country to bring effective
    strategies to scale. State, territorial, local, and tribal
    jurisdictions, community-based organizations, and healthcare partners
    must have the resources necessary to enhance and deliver these
    evidence-based public health interventions.
        While the pandemic is at the forefront of our minds, we have never
    fully addressed the ongoing crisis in our country caused by substance
    misuse, addiction, and drug overdoses. ASTHO is appreciative of
    previous investments in public health to address this crisis. We
    respectfully request Congress to sustain activities and continue the
    response to the opioid epidemic and substance abuse and misuse
    disorders more broadly.
        CDC is not the only federal agency that strives to improve the
    public's health in states and territories. ASTHO is requesting $9.2
    billion for discretionary funding for HRSA. HRSA administers programs
    that focus on improving care for tens of millions of Americans who are
    medically underserved or face barriers to needed care by strengthening
    the health workforce.
        As you look to the FY22 discretionary appropriations bills, we
    strongly urge you to build a base funding for public health--through
    CDC, ASPR, and HRSA--that is sustainable and predictable. Thank you so
    much for your time and consideration of our request. We stand ready to
    continue working toward optimal health for all.

        [This statement was submitted by Michael Fraser, PhD, MS, CAE,
    FCPP, Chief Executive Officer, Association of State and Territorial
    Health Officials.]
                                     ______

        Prepared Statement of the Association of University Programs in
                         Occupational Health and Safety
        On behalf of the Association of University Programs in Occupational
    Health and Safety (AUPOHS), we respectfully request that the Fiscal
    Year 2022 Labor, Health, and Human Services Appropriations bill include
    no less than $375,300,000 for the National Institute for Occupational
    Safety and Health (NIOSH), including no less than $34,000,000 for the
    Education and Research Centers (ERCs), $30,500,000 for the Agriculture,
    Forestry, and Fishing (AgFF) Program, and a $4,000,000 increase over
    the FY21 level for the Total Worker Health(r) (TWH) Program.
        As you have no doubt heard from other testimonies, far too many
    Americans still lose their lives on the job. In 2019, a worker died
    every 99 minutes from injuries they got on the job (BLS 2020). This
    includes our first responders, who can be struck and killed by drivers
    while helping victims of a roadside traffic accident; our construction
    workers, who may fall from an inadequately marked or guarded roof edge;
    and our shop owners and employees who may be asked to work late nights
    without proper security and become victims of violence. Although it is
    harder to measure, we also estimate that an additional 145 people die
    every day in America from work-related disease--developing cancers from
    hazardous chemicals that we encounter at work, or heart disease from
    our chronically stressful work environments. In addition to work-
    related deaths, we also have a high burden of non-fatal workplace
    injury and illness. Leading up to the pandemic, 2.8 million workers
    were seriously injured on the job every year and one-third of those
    injured workers required time off to recover before they could return
    to work. This not only costs the nation's businesses more than $1.1
    billion a week on serious, nonfatal workplace injuries (Liberty Mutual
    2020) but also causes great harm to workers and their families if their
    workers' compensation systems fail to provide adequate care or wage
    replacement.
        The pandemic has amplified all of these issues for the American
    workforce. More than 3,600 of our health care workers died from COVID-
    19 in the first year of the pandemic, and we know that many of these
    deaths are attributable to the extreme shortage of protective gear
    encountered in medical settings (Lost on the Frontline 2021). That is
    to say, these deaths were preventable. In just the first months of the
    pandemic, 16,233 workers in meat and poultry processing facilities were
    infected with COVID-19 (CDC 2020); these were also workers who
    sacrificed their health and wellbeing in order to keep essential goods
    and services moving. We owe an immense debt to all of our essential
    workers, and as such, we have an opportunity to better serve these
    workers moving forward. By designing safer workplaces that reduce the
    risk of exposure to future variants, answering workers' questions about
    vaccines and making them accessible, and by researching, designing, and
    preparing programs to bolster workers' mental health as we come to
    terms with what we have experienced this past year, we can serve our
    essential workers.
        NIOSH is the primary federal agency responsible for conducting
    research that leads to actions and policies that prevent work-related
    illness and injury by promoting safe work practices and work
    environments as well as worker health and well-being. NIOSH is also the
    federal agency charged with certifying and approving Personal
    Protective Equipment (PPE), including the masks that are necessary to
    protect U.S. workers from inhalation exposures to chemical and
    biological agents, including viruses. During this pandemic, NIOSH has
    accelerated the approval process for establishing the safety and
    quality of new masks and other PPE. NIOSH continues to fund and promote
    critical research for a changing workforce and work practices, an
    important service for employers and employees in the face of the
    current pandemic and other disasters. NIOSH has, for example, deployed
    teams across the country in response to industry requests for
    assistance, including more than 15 meatpacking plants that experienced
    outbreaks. NIOSH has contributed key leadership and expertise,
    providing federal guidance and decision tools for industries including
    construction, manufacturing, food and agriculture, mass transit,
    transportation and trucking, restaurants and bars, childcare
    facilities, schools, among others, including recent guidance for
    businesses to safely return to work and/or expand operations.
        The NIOSH-supported extramural Centers, including the Education and
    Research Centers (ERCs), Centers in the Agriculture, Forestry, and
    Fishing (AgFF) Program, and the Total Worker Health(r) (TWH) Centers of
    Excellence, have responded rigorously to the pandemic and supported
    NIOSH to rapidly respond to the needs and safety of the nation's
    workforce. These Centers have been proactive in providing resources,
    employer assistance, over 100,000 hours of outreach training, and
    research that are helping to drive improvements in our rapid response
    to emerging occupational safety and health issues. The work the Centers
    have undertaken during this pandemic underscores the need for increased
    funding for NIOSH and the Centers. As workplaces rapidly evolve,
    changes continue to present new health and safety risks to workers,
    which need to be addressed promptly through occupational health and
    safety research and training.
        The 18 university based ERCs provide local, regional, and national
    resources for all those in need of occupational health and safety
    assistance. Collectively, the ERCs provide graduate- and post-graduate
    level education and research training in the occupational health and
    safety disciplines. The ERCs prepare a workforce of occupational safety
    and health professionals to every Federal Region in the U.S who are
    trained to identify and mitigate vulnerabilities from all sources,
    including increased readiness to respond to chemical, biological,
    radiological, or nuclear attacks. Occupational health and safety
    professionals work with emergency response teams to minimize disaster
    losses, as exemplified by their lead role in minimizing hazards among
    workers involved in clean-up and restoration of the extreme devastation
    caused by Hurricanes Harvey, Irma, and Maria in Texas, Florida, Puerto
    Rico, and the U.S. Virgin Islands. In 2020, the ERCs responded rapidly
    to provide employers across the country with accessible, concise
    information on the workplace implications of COVID-19 and are now
    providing local and national online and telephonic advising programs
    for businesses as they seek to reopen safely.
        NIOSH also focuses research and outreach efforts on the nation's
    most dangerous worksites that often impact lives in more rural parts of
    America. The Centers for AgFF were established by Congress in 1990 (PL
    101-517) in response to evidence that agricultural, forestry, and
    fishing workers suffer substantially higher rates of occupational
    injury and illness than other nation's workers. Agricultural workers
    are more than six times more likely to die on the job than the average
    worker, averaging 540 fatalities per year, and more than 1 in 100
    workers incur nonfatal injuries resulting in lost workdays each year.
    Our food security depends on a healthy and safe agricultural
    workforce--an essential sector that has been hit particularly hard
    during the pandemic. Today, the NIOSH AgFF initiative includes ten
    regional Agricultural Centers and one national Children's Farm Safety
    and Health Center. The AgFF program is the only substantive federal
    effort to ensure safe working conditions in these vital production
    sectors. The program also conducts research and outreach to ensure the
    safety of our nation's 86,000 workers in forestry and logging, an
    industry with a fatality rate more than 30 times higher than that of
    all our nation's workers. The AgFF Centers have had a significant
    impact on protecting safety and health of agricultural workers. For
    example, the developed of rollover protective structures (ROPS or roll
    bars) and seatbelts on tractors were shown to prevent 99% of overturn-
    related deaths. Partnering with fishing communities, the AgFFs
    developed comfortable lifejackets to wear at work, which have increased
    chances of survival in the event of a fall overboard. The lifesaving,
    cost-effective work of the AgFF program is not replicated by any other
    agency. USDA's National Institute of Food and Agriculture interacts
    with experts at NIOSH to learn about cutting-edge research and new
    directions in this area. In addition, state and federal OSHA personnel
    rely on NIOSH research to develop evidence-based standards for
    protecting agricultural workers and would not be able to fulfill their
    mission without the AgFF program.
        NIOSH also supports six TWH Centers of Excellence that conduct
    multidisciplinary research and test practical solutions to emerging
    challenges that impact the safety, health, well-being, and productivity
    of the American workforce. The TWH Centers conduct solutions-focused
    research in partnership with employers and employees and partner with
    government, business, labor, and community to improve the health and
    productivity of the workforce. The TWH Centers' research, education,
    and outreach activities occur in workplaces, such as hospitals,
    factories, offices, construction sites, and small businesses, resulting
    in immediate and measurable improvements in health and safety. These
    Centers have been heavily relied upon by employers and employees to
    address the impact of the current pandemic not only from an infectious
    disease perspective but also to address the impact on mental health,
    stress, burnout, and resiliency of essential workers, workers abruptly
    working remotely, and those furloughed or laid off. The TWH Centers are
    an investment in the American economy, helping valued employees return
    home safe and healthy at the end of a productive workday.
        We urge you to recognize the critical contribution of NIOSH,
    including the ERCs, the AgFF Program, and the TWH Program to the health
    and productivity of our nation's workforce. Thank you for the
    opportunity to submit testimony.

                                     ______

             Prepared Statement of Bennett Katherine, MD FACP deg.
                Prepared Statement of Katherine Bennett, MD FACP
        As the Assistant Director for Education of the Northwest Geriatrics
    Workforce Enhancement Center (NW GWEC) at the University of Washington
    (UW), immediate past president of the National Association for
    Geriatric Education (NAGE), and a current Geriatrics Academic Career
    Award recipient, I am pleased to submit this statement for the record
    on behalf of myself, the NW GWEC, and NAGE recommending appropriations
    of at least $105.7 million in Fiscal Year 2022 to support geriatrics
    workforce training under the Geriatrics Workforce Enhancement Program
    (GWEP) and the Geriatrics Academic Career Award (GACA) program.
    Administered by the Health Resources and Services Administration
    (HRSA), both programs reach rural and underserved populations and
    address health inequities. We thank you for your past extensive support
    of these programs. An appropriation at this level will build upon these
    programs that are vital to the health and well-being of our nation's
    older adults and those who provide care for them.
        We all know that there are many older people in our homes,
    communities, and states who need the care of well-trained health
    professionals. It turns out that we have much of the know-how,
    expertise, curricula, and teachers to offer this training! What we need
    from you is the funding to support the dissemination of this expertise
    to more health care providers and systems who treat older patients. The
    GWEP and the GACA programs are the only federally funded programs
    designed to increase the number of health professionals with the skills
    and training to provide high quality, patient-centered, equitable,
    cost-saving care for older adults. This training is critical to
    addressing the suboptimal care that is so frequent and widespread, and
    something I see the devastating impacts of each day--older adults who
    are prescribed dozens of medications that are contributing to falls and
    cognitive impairment; advanced dementia that has gone undiagnosed for
    years; and life-altering injuries from falls that could have been
    prevented.
        Suboptimal healthcare occurs not because primary care teams do not
    care but because most providers in practice have received insufficient
    and more often no training whatsoever in the core principles of high-
    quality care for older adults. In a just society, we aspire to provide
    adequate health care at every age and stage of life. The care of older
    adults is a unique skill set, largely due to age-related changes to the
    entire body, the simultaneous presence of multiple chronic diseases,
    and conditions that are unique to older adults--this care really cannot
    be done well without specific training. The GWEP and the GACA programs
    seek to change the present reality through quality improvement and
    education initiatives conducted in partnership with primary care
    practices and community agencies, and by training future leaders in
    geriatrics care transformation.
        There are currently 48 GWEPs, located in 35 states and 2
    territories, that are working to rapidly transform and expand the
    health care of older adults. The current appropriation level makes it
    impossible to have at least one GWEP in every state or for current
    GWEPs to have adequate funds to do an expanding body of work. This
    increased funding is urgently needed so that these vital programs can
    equitably reach all areas of the country and effectively respond to the
    rapid growth in number and increasing health complexity of older
    adults. These programs are integral to the training, support, and
    expansion of the eldercare workforce and long-term services and
    supports infrastructure.
        The 48 current GWEPs have tremendous impact on their regions.
    During 2019-2020, 56,603 health professions trainees participated in
    GWEP-led education activities, and 290,161 faculty and providers
    attended 2,069 different continuing education events, which included
    906 events focused on Alzheimer's disease and other dementias. GWEPs
    partner with health systems (including federally qualified health
    centers and Veteran's Affairs Medical Centers) and community-based
    organizations to have the greatest impact and optimize the community/
    health care linkages that are essential to older adults and their
    caregivers. Every GWEP is focused on meeting the needs of rural and/or
    underserved populations, and GWEPs play an integral role in reducing
    health inequities. For example, a GWEP based on the South Side of
    Chicago addressed health disparities for African Americans with
    dementia by partnering with faith-based community leaders, and another
    GWEP partnered with FQHCs to create and distribute multilingual COVID-
    19 education materials and increase behavioral health capacity.
        Over the past two years, GWEPs have joined forces with the
    Institute for Healthcare Improvement and The John A. Hartford
    Foundation to drive spread of the Age-Friendly Health System
    initiative. This initiative aims to align healthcare with an older
    adult's goals by eliciting what matters most to them, ensuring that
    medications regimens minimize the risk of harm, optimizing mood and
    cognition, and guiding them to move safely and prevent falls. This type
    of evidence-based care not only improves outcomes but reduces
    healthcare costs. To date, GWEPs are partnering on this initiative with
    302 health care delivery sites, 42% of which are in medically
    underserved communities and 45% designated as primary care. Nearly
    6,000 different activities focused on Age-Friendly Health System
    transformation have reached 205,322 individuals.
        The COVID-19 pandemic highlighted the fragility of the network of
    supports that help keep older adults healthy and thriving in the
    community. The GWEPs quickly pivoted to redirect the training of the
    healthcare workforce in the face of the obstacles resulting from the
    pandemic while continuing to meet the needs of older adults and their
    caregivers. For example, our GWEP partnered with Area Agencies on Aging
    to provide electronic tablets (along with training and support) and
    telehealth stations to keep older adults connected online to essential
    primary care services. We also quickly shifted our training to an
    entirely virtual format and focused on what interprofessional teams
    need to optimally care for older adults during the pandemic. Training
    sessions covered COVID-19 in older adults, assessing cognition via
    telehealth, addressing goals of care during the pandemic, and screening
    for falls via telehealth.
        Around the country, GWEPs have done nothing short of amazing work
    during COVID-19 by partnering with primary care and community agencies
    to meet the medical, behavioral health, social, and basic needs of
    older adults and their caregivers. GWEPs addressed social isolation via
    virtual connection and phone outreach, trained teams of healthcare
    providers in age-friendly telehealth, provided virtual trainings on key
    care principles for older adults, delivered virtual caregiver support,
    and partnered on rapid vaccine rollout to the most vulnerable in the
    community, to name just a few examples. Taken together, the GWEPs
    delivered 400 unique training sessions that addressed COVID-19 related
    issues and reached over 54,000 individuals. The pandemic demonstrated
    the tremendous ability of GWEPs to adapt to unforeseen circumstances
    and remain focused on transforming the care of older adults to be age-
    friendly and preparing the healthcare workforce to meet the most
    pressing needs of older adults and their caregivers.
        The Northwest Geriatrics Workforce Enhancement Center (NW GWEC),
    UW's GWEP, was established in 2015 and provides training and programs
    that enhance the lives of older adults and their caregivers in
    Washington and throughout the region. Our programs include Project
    ECHO-Geriatrics, a Primary Care Liaison Program based at the Area
    Agencies on Aging (AAA), a AAA Practicum for health professions
    trainees, and the Geriatrics Healthcare Lecture Series. Here are some
    examples of our reach.
      --Project ECHO-Geriatrics: NW GWEC's Project ECHO--Geriatrics, or the
            Extension for Community Healthcare Outcomes, which is based on
            the evidence-based ECHO model that trains and mentors current
            and future primary care providers to provide specialty care to
            their own patients and reduce health disparities. Sessions
            involve virtual mentoring sessions with teaching and
            consultations with an interprofessional geriatrics specialist
            panel. Since 2016, we have held over 60 monthly sessions with
            over 1,000 unique participants. Sessions focus on key primary
            care topics such as dementia, fall prevention, and depression.
            Dr. Braun, a faculty member at the Providence St. Peter Family
            Medicine Residency Program with sites in Olympia and Chehalis,
            WA said, ``The program not only helps achieve our hours of
            required geriatrics training but has transformed the care I see
            provided by our residents in clinic and across healthcare
            settings.''
      --Primary Care Liaison Program: Our GWEP partnered with several Area
            Agencies on Aging in WA to create a Primary Care Liaison (PCL)
            program to connect primary care clinics to AAAs through
            outreach, engagement, and education as well as facilitating
            referrals. This program has increased primary care referrals to
            participating AAAs by over 4-fold.
        The GACA program aims to train the next generation of leaders in
    geriatrics. There are currently 26 GACA awardees across 16 states
    representing a range of health professions disciplines (e.g.,
    physicians, social workers, dentists, physical therapists). GACA awards
    support career development of future educators, leaders, and innovators
    in geriatrics and awardees also train interprofessional teams to
    provide age-friendly care. For example, as a current GACA awardee, I
    partnered with my local Area Agency on Aging (AAA) to create a new
    Project ECHO specifically to train AAA case managers in age-friendly
    care. The curriculum covers dementia, fall prevention, depression, and
    medication safety, and each ECHO session includes consultation on
    complex patients. GACA awardees throughout the country are reshaping
    the care of older adults through innovative projects such as
    redesigning airports to be age-friendly, reducing unsafe opioid
    prescribing in nursing homes, and integrating (oft neglected) oral
    health into routine primary care.
        Although GWEPs are preparing the healthcare workforce to meet the
    needs of older adults and their caregivers, not all states are
    benefiting: Only 35 states and two territories have a GWEP, and only 16
    states have a GACA recipient. Moreover, since renewal of the GWEP
    program in 2019, annual funding per GWEP has been reduced by $100,000
    compared to the initial award period (2015-2019). An increase in
    appropriation is essential to ensure that every state has at least one
    GWEP and that GWEP sites can expand their work. Additionally, increased
    appropriations can ensure that there are more GACA awardees to meet the
    nation's current and future needs for transformative leaders in
    geriatric medicine.
        In summary, GWEPs and GACAs are essential to ensure that the
    healthcare workforce in this country can meet the needs of older
    adults. Through our GWEPs, we have developed the knowledge and
    expertise to train interprofessional health care teams. Through our
    many partnerships and training activities, we have proved integral to
    the training and care delivery of the healthcare workforce including
    those in the long-term services and supports infrastructure as well as
    eldercare workforce infrastructure. I thank you for your consideration
    of this request for appropriations and am deeply grateful for your past
    support of these programs that are revolutionizing healthcare of older
    adults and their caregivers to be age-friendly, high-quality,
    equitable, cost-saving, and aligned with their personal goals and
    preferences.
                                     ______

                Prepared Statement of the Beyond AIDS Foundation
        Dear Committee Members,
        I am writing in support of a FY 2022 budget request for Department
    of Health and Human Services (DHHS) to develop a national strategy and
    implementation plan for the prevention, control and treatment of Herpes
    Simplex Virus, Types 1 and 2 infections.
        It is critical for public health and disease control to address
    Herpes Simplex Virus (HSV), a lifetime infection that impacts nearly
    half of Black women in our country, disproportionately impacts LGBTQ
    populations, and is an important driver of the HIV epidemic.
    Approximately 40% of new cases of HIV infection have been attributed to
    chronic HSV infection. HSV also kills approximately 1,000 infants
    annually as a result of neonatal herpes and injures thousands more.
    Despite this largely preventable mortality and morbidity, neonatal
    herpes is currently not even a national reportable condition.
    Additionally, there is a growing body of research indicating that HSV
    may be a contributing factor to Alzheimer's Disease, Encephalitis,
    Bell's palsy, among other neurodegenerative diseases.
        There is currently no organized national strategy to address HSV.
    It is often not tracked nor routinely tested for during clinical and
    screening visits. And the majority of spread is via asymptomatic
    carriers who are in most cases unaware of their infection status. It is
    estimated that over 60 million Americans have genital infections with
    either HSV-2 or HSV-1, making it among the most prevalent STIs in the
    US. We can and should be doing more to stop the spread and provide
    better treatment to the nearly 1 in 3 Americans with this chronic
    condition.
        For the past two decades, I have served as the volunteer Medical
    Advisor for the largest in-person herpes support (HELP) groups in the
    country (Los Angeles and Orange Counties, San Diego), and since the
    COVID-19 pandemic, the online SoCal HELP group. I have been privy to
    observe the negative outcome of having non-existent federal HSV
    policies and programs. They include severe genital pain syndromes as
    well as bouts of depression, anxiety, shame, and loss of self esteem
    accompanying these infections. As the former Director of the largest
    domestic STD Program (Los Angeles County) in the US for over a decade,
    I was and am currently acutely aware of the shortcomings of our HSV
    policies, planning and services, and the great need to change our
    approach and address this problem.
        If we prioritize women's and maternal health, the health of Black,
    Hispanic, LGBTQ, indigenous and other at-risk communities, we must
    prioritize Herpes Simplex Virus treatment and prevention. If we
    prioritize mental health, biomedical research for incurable diseases
    such as Alzheimer's or HIV, and dismantling systemic racism in
    healthcare, we must also prioritize Herpes Simplex Virus control.
    Addressing HSV addresses all of these national priorities and can
    improve the health and quality of life, and reduce the economic burden
    for millions of Americans.
        Sincerely.

        [This statement was submitted by Gary A. Richwald, MD, MPH,
    President,
    Beyond AIDS Foundation.]
                                     ______

             Prepared Statement of the Big Cities Health Coalition
        On behalf of the Big Cities Health Coalition (BCHC), we
    respectfully request that the Subcommittee provide the highest possible
    funding for the U.S. Centers for Disease Control and Prevention (CDC),
    central to protecting the public's health, for Fiscal Year 2022. Key
    CDC programmatic priorities of the Coalition and our member health
    departments include violence prevention, immunization, public health
    preparedness, epidemiology and laboratory capacity, opioid overdose
    prevention, and the public health data modernization initiative.
        BCHC is comprised of health officials leading 30 of the nation's
    largest metropolitan health departments, who together serve nearly 62
    million--or one in five--Americans. Our members work every day to keep
    their communities as healthy and safe as possible. We thank you for
    your continued leadership and support for our nation's public health
    workforce and systems during the ongoing COVID-19 pandemic.
        As the Subcommittee members recognize, federal funding for CDC and
    the programs that support local and state public health departments
    have remained largely stagnant. Additional investments through
    sustained annual funding is necessary to build public health capacity
    for the next pandemic, as well as the everyday population health
    programs.
           national center for immunization and respiratory diseases
    National Immunization Program
        We respectfully request $1.1 billion in FY2022 for the National
    Immunization Program. The CDC Immunization Program funds 50 states, six
    large, BCHC member cities (Chicago, Houston, New York City,
    Philadelphia, San Antonio, and Washington, D.C.), and eight territories
    for vaccine purchase and immunization program operations. In addition
    to the challenges of the COVID-19 pandemic and continuing disease
    outbreaks, recent growth of electronic health records and compliance
    with associated regulations, new vaccines and school requirements have
    increased the complexity of vaccine management. Additional base funding
    is needed for each grantee to sustain improvements supported by
    emergency funding and maintain sound and efficient immunization
    infrastructure. We also ask that the Committee encourage CDC to be as
    flexible as possible in coordinating funding and guidance across
    immunization program streams as we do COVID vaccinations while still
    also carrying out routine immunizations.
          national center for emerging and zoonotic infectious disease
    Epidemiology and Lab Capacity
        We respectfully request $500 million in FY2022 for the Epidemiology
    and Lab Capacity (ELC) program, which is a single vehicle for multiple
    programmatic initiatives that go to 50 state health departments, six
    large, BCHC member cities (Chicago, Houston, Los Angeles County, New
    York City, Philadelphia, and Washington, D.C.), Puerto Rico, and the
    Republic of Palau. ELC grants strengthen local and state capacity to
    contain infectious disease threats by detecting, tracking and
    responding in a timely manner, as well as maintaining core capacity as
    the nation's public health eyes and ears on the ground. Increased
    funding will help build the epidemiology workforce, allowing state and
    local health departments to begin to move towards establishing a
    minimum epidemiology workforce; to promote and offer training for state
    and local epidemiologists; and to monitor needs in state- and/or local-
    based epidemiology capacity. ELC dollars sent to the states should be
    tracked through existing CDC reporting structures and shared publicly
    to ensure funds are also supporting big city epidemiology activities.
                       public health scientific services
    Public Health Data Modernization Initiative (DMI)
        We respectfully request $250 million in FY2022 for the DMI that is
    working to create modern, interoperable, and real-time public health
    data and surveillance systems at the state, local, Tribal, and
    territorial levels. These efforts will ensure our public health
    officials on the ground are prepared to address any emerging threat to
    public health-whether it be COVID-19, measles, a foodborne outbreak
    like E. coli, or another crisis. COVID-19 exposed the gaps in our
    public health data systems and since then Congress has provided funding
    for DMI through the CARES Act and American Rescue Plan Act. These
    investments have been critical, but the public health surveillance
    systems must live beyond COVID-19 and be ready for any and all future
    threats. This requires long-term, sustained investment that is not just
    to build capacity at the federal and state level, but also at health
    departments in cities and counties across the country.
                            public health workforce
        We respectfully request $160 million in FY2022 for the public
    health workforce and career development programs as proposed in the
    President's budget. The public health workforce is the backbone of our
    nation's governmental public health system at the county, city, state,
    and tribal levels. Investments must be made to build back the public
    health workforce, as well as attract and retain diverse candidates with
    diverse skill sets. These funds support CDC's fellowship and training
    programs including the Public Health Associate Program and the Epidemic
    Intelligence Service that extend the capacity of health departments and
    key partners at all levels of government.
                  cross-cutting activities and program support
    Public Health Infrastructure and Capacity
        We respectfully request $400 million in FY2022 for a new Public
    Health Infrastructure and Capacity investment as proposed in the
    President's budget request. The pandemic exposed the deadly
    consequences of chronic underfunding of basic public health capacity.
    Because public health is largely funded by disease or condition, there
    has been little investment in cross-cutting capabilities that are
    critical for effective public health. These capabilities include:
    public health assessment; preparedness and response; policy development
    and support; communications; community partnership development;
    organizational competencies; accountability; and equity. Governmental
    public health infrastructure requires sustained investments over time
    and we believe this is an important start. This investment is critical
    to ensuring that our governmental public health system is prepared for
    the next pandemic as well as to strengthen the health of our
    communities every day.
               national center for injury prevention and control
    Opioid Overdose Prevention and Surveillance
        We respectfully request $713 million in FY2022 for Opioid Overdose
    Prevention and Surveillance in line with the President's request. Many
    health departments were forced to curtail opioid and other substance
    use disorder services during the pandemic. Unfortunately, overdose
    numbers are increasing in many communities, erasing progress of recent
    years. Previously, programs that connected with people in hospital
    emergency departments after an overdose had seen successful outcomes in
    steering people toward syringe services programs and treatment
    programs. However, these programs rely on in person interactions that
    have been scaled back during the pandemic. Funding is needed in local
    communities to ensure that substance use disorder prevention continues
    to stem the tide of overdose and death. We also encourage the Committee
    to include directive language to insure these dollars reach the local
    level in those communities that are not directly funded, as well as
    have CDC and the Office of the Assistant Secretary of Health at the
    Department of Health and Human Services better track and share publicly
    state expenditures.
    Gun Violence Prevention Research
        We respectfully request $25 million in FY2022 for Gun Violence
    Prevention Research and the same as the President's budget request.
    Firearm violence is a serious public health problem in the United
    States that impacts the health and safety of all Americans. Despite
    initial funding in FY 2021 to research key issues around firearm
    violence, significant gaps remain in our knowledge about the problem
    and ways to prevent it; we need to continue and expand the research.
    Addressing these gaps is an important step toward keeping individuals,
    families, schools, and communities safe from firearm violence and its
    consequences. The public health approach to violence prevention
    includes working to define the problem, identifying risk and protective
    factors, developing and testing prevention strategies, and then,
    assuring widespread adoption of effective, targeted programs.
    Additional funds would be used to provide grants to conduct research
    into the root causes and prevention of gun violence focusing on those
    questions with the greatest potential for public health impact. The
    goal of this research is to stem the continued rise of firearm violence
    across the country to make our communities safer.
    Community Based Violence Intervention Initiative
        We respectfully request $100 million in FY2022 for a new Community
    Violence Intervention initiative as proposed in the President's budget
    request to implement evidence-based community violence interventions
    locally. BCHC whole-heartedly supports such an investment. Violence,
    like many public health challenges, is preventable. Yet, the majority
    of public investments are used to address the aftermath of violence,
    too often through systems that can cause further harm. Communities can
    be made safer when we understand the events that have led to present
    conditions and act on this knowledge by implementing policies and
    practices that address the root causes of violence. By making
    investments in public health strategies within communities that are
    most impacted by violence, cities can work across sectors to shift from
    an overreliance on the criminal justice system and move from
    reimagining to realizing community safety.
                      center for preparedness and response
    Public Health Emergency Preparedness Cooperative Agreements
        We respectfully request $1 billion in FY2022 for the public health
    emergency preparedness (PHEP) grant program. PHEP provides funding to
    strengthen local and state public health departments' capacity and
    capability to effectively respond to public health emergencies,
    including terrorist threats, infectious disease outbreaks, natural
    disasters, and biological, chemical, nuclear, and radiological
    emergencies. PHEP funding has been cut by over 30% in the last decade.
    Recent events, such as the response to the COVID-19 pandemic,
    demonstrate the need to invest in these programs to rebuild and bolster
    our country's public health preparedness and response capabilities.
    America's public health preparedness systems are stretched to the brink
    and will need increased and stable base funding for years to rebuild
    and improve. We also encourage the committee to include directive
    language to insure these dollars reach the local level in those
    communities that are not directly funded, as well as have CDC and the
    Office of the Assistant Secretary of Health at the Department of Health
    and Human Services better track and share publicly state expenditures.
      national center for chronic disease prevention and health promotion
    Social Determinants of Health
        We respectfully request $153 million in FY2022 for the Social
    Determinants of Health (SDOH) program in line with the President's
    request. CDC's SDOH program was initially funded in FY2021 to
    coordinate CDC's activities and to begin to provide tools and resources
    to public health departments, academic institutions, and nonprofit
    organizations to address the social determinants of health in their
    communities. Local and state health and community agencies lack funding
    and tools to support these cross-sector efforts and are limited in
    doing so by disease-specific federal funding. Given appropriate funding
    and technical assistance, more communities could engage in
    opportunities to address social determinants of health that contribute
    to high health care costs and preventable inequities in health
    outcomes.
    Office of Smoking and Health (OSH)
        We respectfully request $310 million in FY2022 for the Office of
    Smoking and Health (OSH). Tobacco use has long been the leading
    preventable cause of death in the United States. Each year, it kills
    more than 480,000 Americans and is responsible for approximately $170
    billion in health care costs. OSH has a vital role to play in
    addressing this serious public health problem. It provides grants to
    states and territories to support tobacco prevention and cessation,
    runs a highly successful national media campaign, conducts research and
    surveillance on tobacco use, and develops best practices for reducing
    it. Additional resources will allow OSH to address the alarmingly high
    rates of youth e-cigarette in addition to other forms of tobacco.
                                     ______

            Prepared Statement of the Campaign for Tobacco-Free Kids
        I am Matthew Myers, President of the Campaign for Tobacco-Free
    Kids. I am submitting this written testimony for the record to urge the
    subcommittee to increase funding by $72.5 million for the Office on
    Smoking and Health (OSH) at the Centers for Disease Control and
    Prevention (CDC). By providing OSH with a fiscal year 2022 funding
    level of $310 million, CDC will be able to more effectively address
    high levels of youth e-cigarette use, expand its highly effective Tips
    from Former Smokers public education campaign, and aggressively address
    the role that tobacco use plays in health disparities by increasing its
    efforts to assist populations and regions of the country with
    disproportionately high rates of tobacco use and tobacco-related
    disease and premature death. Helping tobacco users to quit is of
    particular importance at this time given that cigarette smoking
    increases the risk of severe illness from COVID-19.\1\
    ---------------------------------------------------------------------------
        \1\ CDC, ``People with Certain Medical Conditions,'' accessed April
    28, 2021, https://www.cdc.gov/coronavirus/2019-ncov/need-extra-
    precautions/people-with-medical-conditions.html.
    ---------------------------------------------------------------------------
        Tobacco use remains the leading cause of preventable disease and
    death in the United States. More than 480,000 Americans die from
    tobacco use each year, and over 16 million Americans are currently
    living with a tobacco-caused disease.\2\ Thirty-two percent of heart
    disease deaths, 30 percent of all cancer deaths, 87 percent of lung
    cancer deaths, and nearly 80 percent of all chronic obstructive
    pulmonary disease (COPD) deaths stem from tobacco use.\3\ Smoking
    shortens the life of a smoker by more than a decade.\4\
    ---------------------------------------------------------------------------
        \2\ U.S. Department of Health and Human Services (HHS), The Health
    Consequences of Smoking--50 Years of Progress: A Report of the Surgeon
    General, 2014, http://www.surgeongeneral.gov/library/reports/50-years-
    ofprogress/.
        \3\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014; ``Centers for Disease Control
    and Prevention (CDC) Vital Signs, Cancer and Tobacco Use, Tobacco Use
    Causes Many Cancers,'' November 2016. https://www.cdc.gov/vitalsigns/
    pdf/2016-11-vitalsigns.pdf.
        \4\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
    ---------------------------------------------------------------------------
        Funding for CDC's Office on Smoking and Health remains modest when
    compared to the estimated $226 billion in annual health care costs
    attributable to tobacco use.\5\ Even with the funding increases it has
    received over the past two years, the Office on Smoking and Health's
    resources remain stretched too thin. OSH needs additional resources to
    address an epidemic in youth use of e-cigarettes while continuing to
    reduce other forms of tobacco use, especially among populations
    disproportionately harmed by tobacco products.
    ---------------------------------------------------------------------------
        \5\ Xu, X et al., ``Annual Healthcare Spending Attributable to
    Cigarette Smoking in 2014,'' American Journal of Preventive Medicine,
    2021.
    ---------------------------------------------------------------------------
        High levels of youth e-cigarette use is threatening to undermine
    decades of progress in reducing youth tobacco use. E-cigarettes have
    been the most popular tobacco product used by kids since 2014.\6\ These
    products come in a wide array of flavors that attract youth and often
    deliver high levels of nicotine.\7\ In 2020, 3.6 million youth were
    current users of e-cigarettes, including nearly 1 in 5 high school
    students.\8\ Alarmingly, 38.9 percent of all high school e-cigarette
    users used e-cigarettes for 20 days or more a month, an indicator of
    addiction.\9\ In addition to exposing users to nicotine and other
    harmful and potentially harmful substances, research shows that e-
    cigarette use increases the risk of smoking cigarettes.\10\
    ---------------------------------------------------------------------------
        \6\ Wang, TW, et al., ``E-cigarette Use Among Middle and High
    School Students--United States, 2020,'' MMWR, Volume 69, September 9,
    2020, https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937e1-H.pdf;
    Gentzke, A., et al., ``Vital Signs: Tobacco Product Use Among Middle
    and High School Students--United States, 2011-2018, MMWR, Vol. 68, No.
    6, February 2019. https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6806e1-
    H.pdf.
        \7\ Office of the Surgeon General, ``Surgeon General's Advisory on
    E-Cigarette Use Among Youth,'' December 18, 2018, https://e-
    cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-
    cigarette-use-among-youth-2018.pdf.
        \8\ Wang, TW, et al., ``E-cigarette Use Among Middle and High
    School Students--United States, 2020,'' MMWR, Volume 69, September 9,
    2020, https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937e1-H.pdf.
        \9\ Wang, TW, et al., ``E-cigarette Use Among Middle and High
    School Students--United States, 2020,'' MMWR, Volume 69, September 9,
    2020, https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937e1-H.pdf.
        \10\ HHS, E-Cigarette Use Among Youth and Young Adults. A Report of
    the Surgeon General. Atlanta, GA: U.S. Department of Health and Human
    Services, Centers for Disease Control and Prevention, National Center
    for Chronic Disease Prevention and Health Promotion, Office on Smoking
    and Health, 2016; Barrington-Trimis, JL, et al., ``E-Cigarettes and
    Future Cigarette Use,'' Pediatrics, 138(1), published online July 2016;
    National Academies of Sciences, Engineering, and Medicine. 2018. Public
    health consequences of e-cigarettes. Washington, DC: The National
    Academies Press. http://nationalacademies.org/hmd/Reports/2018/public-
    health-consequences-of-e-cigarettes.aspx. Berry, KM, et al.,
    ``Association of Electronic Cigarette Use with Subsequent Initiation of
    Tobacco Cigarettes in US Youths,'' JAMA Network Open, 2(2), published
    online February 1, 2019;.
    ---------------------------------------------------------------------------
        The CDC's Office on Smoking and Health has a critical role to play
    in addressing the youth e-cigarette epidemic. The agency has extensive
    experience working with state and local health departments and the
    capacity to identify and implement effective prevention strategies
    designed specifically towards youth. An increase in funds would allow
    CDC to provide more resources to state and local health departments;
    educate students, parents and their communities about the risks of
    youth e-cigarette use; and develop and implement other strategies to
    protect kids.
        In addition to the youth e-cigarette epidemic, there remains a
    great need to help adult tobacco users who want to quit. The vast
    majority of adult smokers started as youth, want to quit and wish they
    had never started.\11\ The CDC's national media campaign, Tips from
    Former Smokers (Tips), has proven to be highly successful at helping
    smokers quit. The campaign features former smokers discussing the harsh
    realities of living with a disease caused by smoking and how current
    smokers can access evidence-based resources to assist them in quitting.
    Between 2012 and 2018, the campaign motivated over 16.4 million smokers
    to make a quit attempt and helped over one million smokers to
    successfully quit for good.\12\ A recent cost-effectiveness analysis
    found that over the same timeframe, Tips helped prevent 129,100
    smoking-related deaths and saved an estimated $7.3 billion in smoking-
    related health care costs.\13\
    ---------------------------------------------------------------------------
        \11\ U.S. Department of Health and Human Services (HHS), The Health
    Consequences of Smoking--50 Years of Progress: A Report of the Surgeon
    General, 2014; Babb, S., et al., ``Quitting Smoking Among Adults--
    United States, 2000-2015,'' MMWR 65(52), January 6, 2017;Nayak, P., et
    al., ``Regretting Ever Starting to Smoke: Results from a 2014 National
    Survey,'' International Journal of Environmental Research and Public
    Health, 2017; O'Connor, Richard J., et al., ``Exploring relationships
    among experience of regret, delay discounting, and worries about future
    effects of smoking among current smokers.'' Substance Use & Misuse 51,
    no. 9 (2016).
        \12\ Murphy-Hoefer R, Davis KC, King BA, Beistle D, Rodes R,
    Graffunder C. Association between the Tips From Former Smokers Campaign
    and Smoking Cessation Among Adults, United States, 2012-2018.
    Preventing Chronic Disease, 2020.
        \13\ Shrestha SS, est al., ``Cost Effectiveness of the Tips From
    Former Smokers Campaign--US, 2012-2018. American Journal of Preventive
    Medicine, December 2020.
    ---------------------------------------------------------------------------
        The Tips campaign has been enormously successful despite being on
    air for only part of the year. In 2020, the campaign ran for 28 weeks.
    The 2014 Surgeon General's Report, The Health Consequences of Smoking-
    50 Years of Progress, said that media campaigns like Tips would ideally
    run 12 months a year.\14\ With additional funding, the CDC could extend
    the number of weeks the campaign is on the air as well as the frequency
    with which the ads are run. Research has demonstrated that increased
    exposure to Tips ads leads to increases in intentions to quit and quit
    attempts.\15\
    ---------------------------------------------------------------------------
        \14\ U.S. Department of Health and Human Services (HHS), The Health
    Consequences of Smoking--50 Years of Progress: A Report of the Surgeon
    General, 2014, http://www.surgeongeneral.gov/library/reports/50-years-
    ofprogress/.
        \15\ Davis, Kevin C., et al. ``Association Between Media Doses of
    the Tips From Former Smokers Campaign and Cessation Behaviors and
    Intentions to Quit Among Cigarette Smokers, 2012-2015.'' Health
    Education & Behavior (2017).
    ---------------------------------------------------------------------------
        Tobacco use plays a significant role in health disparities. Despite
    the progress that has been made in reducing tobacco use, certain
    populations and regions of the country face disproportionately high
    rates of tobacco use and tobacco-related disease and premature death.
    For example, Americans with lower levels of education and income,
    American Indians and Alaska Natives, lesbian, gay and bisexual adults,
    and adults with a mental illness all smoke at significantly higher
    rates than other Americans.\16\ Despite initiating smoking later in
    life than whites, Black Americans suffer from significantly higher
    rates of diseases and death caused by smoking.\17\
    ---------------------------------------------------------------------------
        \16\ Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco
    Product Use Among Adults--United States, 2019. MMWR Morb Mortal Wkly
    Rep 2020;69:1736-1742. DOI: http://dx.doi.org/10.15585/mmwr.mm6946a4;
    Substance Abuse and Mental Health Services Administration (SAMHSA),
    HHS, Results from the 2019 National Survey on Drug Use and Health,
    NSDUH: Detailed Tables, 2019, https://www.samhsa.gov/data/report/2019-
    nsduh-detailed-tables.
        \17\ Roberts, ME, et al., ``Understanding tobacco use onset among
    African Americans,'' Nicotine & Tobacco Research, 18(S1): S49-S56,
    2016; Alexander, LA, et al., ``Why we must continue to investigate
    menthol's role in the African American smoking paradox,'' Nicotine &
    Tobacco Research, 18(S1): S91-S101, 2016; CDC, ``Quitting Smoking Among
    Adults-United States, 2000-2015,'' MMWR, 65(52): 1457-1464, January 6,
    2017, https://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6552a1.pdf; HHS,
    ``Tobacco Use Among US Racial/Ethnic Minority Groups-African Americans,
    American Indians and Alaskan Natives, Asian Americans and Pacific
    Islanders, and Hispanics: A Report of the Surgeon General,'' 1998,
    http://www.cdc.gov/tobacco/data_statistics/sgr/1998/complete_report/
    pdfs/complete_report.pdf.
    ---------------------------------------------------------------------------
        With additional funding, CDC could provide targeted assistance to
    groups disproportionately harmed by tobacco use. By collaborating with
    state and local health departments and community organizations, CDC
    could implement prevention and cessation programs tailored to resonate
    with and serve specific groups.
        We urge the subcommittee to increase funding for CDC's Office on
    Smoking and Health from the $237.5 million it received in fiscal year
    2021 to $310 million in fiscal year 2022. An additional $72.5 million
    would provide CDC with the resources it needs to increase funding to
    states and take other steps to address the epidemic of youth e-
    cigarette use, expand the highly successful Tips from Former Smokers
    media campaign, and provide targeted assistance to groups
    disproportionately harmed by tobacco use.
        We appreciate the opportunity to highlight the important work of
    CDC's Office on Smoking and Health and the need to increase its funding
    to $310 million in fiscal year 2022.

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

               Prepared Statement of the Caregiver Action Network
        On behalf of Caregiver Action Network (CAN), I am testifying in
    support of the Care Corps program funded through HHS' Administration
    for Community Living (ACL). We request doubling the appropriation for
    Care Corps from $4 million in FY 2021 to $8 million in FY 2022.
        Care Corps is an innovative Federally funded grant program that was
    created in FY 2019 with a $5 million appropriation, subsequently
    receiving $4 million in FY 2021. In August 2019, the U.S.
    Administration for Community Living (ACL) awarded a five-year
    cooperative agreement to implement the new Care Corps program to a team
    of four organizations comprised of Oasis Institute, Caregiver Action
    Network, the National Association for Area Agencies on Aging, and
    Altarum. The four organizations named the new program the Community
    Care Corps.
        Community Care Corps fosters innovative local models to provide
    volunteer non-medical assistance to family caregivers, older adults,
    and adults with disabilities. Community Care Corps is an opportunity
    for community organizations to use volunteers to address some of the
    gaps in existing basic supports for family caregivers, older adults,
    and people with disabilities. The program, intended as a demonstration
    program over 5 years, will also evaluate the effectiveness of local
    models in different communities nationally.
        For tens of millions of Americans who are older, frail, or
    functionally disabled, timely access to reliable assistance with simple
    household tasks and meaningful companionship can make an enormous
    difference in the quality of their lives and their ability to sustain
    meaningful, ongoing connections to the community in which they live.
        Today, 80% of the care for those over age 65 is provided by family
    caregivers. Yet in the future there will be fewer caregivers. According
    to AARP, in 2010, there were more than 7 potential caregivers for every
    person over age 80. By 2030, the caregiver ratio will drop to 4 to 1;
    and by 2050, the ratio drops to less than 3 to 1. During this same
    period, the number of individuals over the age of 84 is set to rise by
    350%.
        Given the rapidly shrinking ratio of family caregivers to the
    number of older Americans who need assistance, volunteers aged 18 and
    older can help ameliorate the coming ``caregiving cliff'' brought on by
    the nation's demographic changes. In support of the Care Corps program,
    the Report accompanying the House Labor-HHS Appropriations bill last
    year ``recognize[d] the growing demand for services and supports to
    help seniors and individuals with disabilities live independently in
    their homes, and the need to support family caregivers who facilitate
    that independence.''
        Interest in the new Community Care Corps program across the country
    has been tremendous. Community Care Corps issued its first RFP in 2020
    and received 183 applications from 45 states plus DC and Puerto Rico.
    The application process was very competitive, with the 183 applications
    totaling $23 million in funding requests. Clearly, not all applications
    received funding (we were only able to fund 10% of the grant requests);
    and those that did, did not receive the full amount requested.
        We selected 23 grantees from 20 states from this competitive pool
    of applications. The award amounts range in size from $30,000--
    $250,000. The 23 grantees' local model volunteer programs are
    community-based and provide a wide range of non-medical volunteer
    services. Community Care Corps volunteer programs do not replace the
    important services that the home care workforce and other paid
    professionals provide to help individuals live independently in the
    community.
        Our 2020 grantees represent a diverse cross section of the nation,
    representing urban, rural, Frontier and Tribal communities. The
    grantees comprise numerous types of organizations including community-
    based organizations, university-based clinics, area agencies on aging,
    neighborhood villages, government agencies, coalitions, hospitals, and
    social service organizations. The size of the organizations also varies
    considerably--from very large such as Maryland's St. Agnes Hospital, a
    member of Ascension Health, the largest non-profit health care
    organization in the nation, to North Carolina's Carova Beach Volunteer
    Fire and Rescue Auxiliary with a volunteer staff of one serving a small
    ocean front community that can only be accessed by four-wheel-drive.
    Grantees provide services to individuals of a variety of races and
    ethnicities including Hispanic, Native American, White, Black, Asian,
    and Native Alaskan. Two grantees specifically serve new Americans.
        We particularly search for local grantees with innovative ways to
    use volunteers to provide non-medical assistance in their community.
    For example, in Alaska volunteers assisted the target population with
    fishing and hunting to supplement food sources. The grantee in Michigan
    leveraged face-to-face video calls to participants even prior to the
    COVID crisis. In Connecticut, the grantee exercised flexibility by
    using their Trusted Ride Transportation program to pivot and provide
    COVID vaccine appointments and transportation for older adults in need
    of the vaccine.
        In the first six months--even with time needed to adapt their
    original plans to the then-emerging Covid pandemic that required
    changes in how they deliver volunteer services--the grantees have
    already served 2,744 people. That included:
      --2,273 older adults
      --162 adults with disabilities
      --309 family caregivers
        Also, during the first six months, more than a thousand volunteers
    provided non-medical services and 191 training sessions were held for
    these volunteers.
        Over the five years of the Community Care Corps program, local
    models with the most promising results, most effective and efficient
    outputs and outcomes, and greatest positive ROI will be assessed as
    ideal candidates for broader dissemination. Several outcomes and
    outputs are measured on a quarterly basis.
        We are now about to begin the second grant cycle. The Senate
    Appropriations Labor/HHS Subcommittee included $4 million for Community
    Care Corps in FY 2021 and that was the level that was enacted for FY
    2021. With the $4 million appropriated, we are able to fund additional
    grants and look forward to getting applications for innovative
    volunteer models from local communities across the country. The RFP for
    new applications has just been released and applications will be
    accepted through July 9. In addition, current grantees can apply for
    second-year funds. One of the key enhancements to our 2021 RFP is an
    intensified focus on diversity of volunteers, communities served, and
    caregivers in both the application and review process.
        Caregiver Action Network (CAN) is the nation's leading non-profit
    family caregiver organization providing education, peer support, and
    resources to family caregivers across the country free of charge. One
    of the many things CAN does for Community Care Corps is to provide a
    wide range of communication and outreach support. CAN works with the
    grantees to capture videos of the experiences of care recipients,
    family caregivers, and volunteers to amplify their collective voices
    through stories. These videos provide a true and authentic voice that
    increases awareness about the impact of grantee local models on their
    communities. As of this reporting period, grantees have generated more
    than 30 videos of volunteers, care recipients, family caregivers, and
    staff that have been shared on social media, with local media outlets,
    and with elected officials.
        The first grant cycle of the Community Care Corps has been
    extremely successful. With the tremendous interest in the program and
    the large number of worthy applications from communities across the
    country, we request doubling the appropriation for Care Corps to $8
    million in FY 2022 from the $4 million level in FY 2021 (and the $5
    million level in FY 2019). This will allow the program to fund more
    local volunteer services and make up for the gap in funding that
    occurred in FY 2020. Thank you.

        [This statement was submitted by John Schall, Chief Executive
    Officer, Caregiver Action Network.]
                                     ______

                    Prepared Statement of the CDC Coalition
        The CDC Coalition is a nonpartisan coalition of organizations
    committed to strengthening our nation's prevention programs. We
    represent millions of public health workers, clinicians, researchers,
    educators and citizens served by CDC programs. We believe Congress
    should support CDC as an agency, not just its individual programs. We
    urge a funding level of at least $10 billion for CDC's programs in FY
    2022 to help ensure the agency has adequate resources for its many
    important programs to improve the public's health. We appreciate the
    increases provided for CDC in FY 2021 and we are grateful for the
    emergency supplemental funding provided for CDC to address COVID-19. We
    urge Congress to continue efforts to build upon these investments to
    strengthen all of CDC's programs. We strongly support the increases for
    important CDC programs outlined in President Biden's FY 2022 budget
    request and urge the committee to support these and other needed
    funding increases for CDC programs.
        CDC serves as the command center for the nation's public health
    defense system against emerging and reemerging infectious diseases.
    From aiding in the surveillance, detection and prevention of the
    current COVID-19 outbreak globally and in the U.S. to playing a lead
    role in the control of Ebola in West Africa and the Democratic Republic
    of the Congo, to monitoring and investigating disease outbreaks in the
    U.S., to pandemic flu preparedness to combating antimicrobial
    resistance, CDC is the nation's--and the world's--expert resource and
    response center, coordinating communications and action and serving as
    the laboratory reference center for identifying, testing and
    characterizing potential agents of biological, chemical and
    radiological terrorism, emerging infectious diseases and other public
    health emergencies.
        CDC serves as the lead agency for bioterrorism and public health
    emergency preparedness and response programs and must receive sustained
    support for these critical programs. We urge you to provide adequate
    funding for the Public Health Emergency Preparedness grants which
    provide resources to our state and local health departments to help
    them protect communities in the face of public health emergencies. We
    also urge you to provide adequate funding for CDC's infectious disease,
    laboratory and disease detection capabilities to ensure we are prepared
    to tackle both ongoing COVID-19 pandemic and other public health
    challenges and emergencies that will likely arise during the coming
    fiscal year. Additionally, your continued support for CDC's public
    health Data Modernization Initiative is critical to ensuring we have
    both the world-class data workforce and data systems that are ready for
    the next public health emergency.
        We strongly support the president's budget request for $400 million
    in new funding to bolster core public health infrastructure and
    capacity at the federal, state, territorial and local levels. This
    flexible funding is critical to addressing the gaps in core public
    health infrastructure and capacity at all levels as well as ensuring
    our nation's health departments are able to attract and retain
    experienced leaders and respond to future public health emergencies and
    disease outbreaks. Sustained, flexible funding is critical to
    rebuilding and strengthening the nation's public health system.
        Injuries are the leading causes of death for people ages 1-44.
    Unintentional and violence-related injuries, such as older adult falls,
    firearm injury, child maltreatment and sexual violence, account for
    nearly 27 million emergency department visits each year. In 2013,
    injury and violence cost the U.S. $671 billion in direct and indirect
    medical costs. In 2019, opioids killed nearly 50,000 individuals
    nationwide. CDC provides states with resources for opioid overdose
    prevention programs and to ensure that health providers to have
    information to improve opioid prescribing and prevent addiction and
    abuse. In 2019, there were over 39,707 U.S. firearm-related fatalities.
    We thank Congress for providing CDC with dedicated funding for firearm
    morbidity and mortality prevention research and we strongly urge you to
    support the president's request to double this funding in FY 2022. All
    programs within the National Center for Injury Prevention and Control
    must be adequately funded to conduct research, prevent injuries, and
    help save lives.
        In 2019, 659,041 people in the U.S. died from heart disease, the
    nation's number one cause of death, accounting for about 23% of all
    U.S. deaths. More males than females died of heart disease in 2019,
    while more females than males died of stroke that year. Stroke is the
    fifth leading cause of death and is a leading cause of disability. In
    2019, 150,005 people died of stroke, accounting for about one of every
    19 deaths. Annually, heart disease and stroke cost the U.S. an
    estimated $363.4 billion in health care and lost productivity. CDC's
    Heart Disease and Stroke Prevention Program; WISEWOMAN; and Million
    Hearts improve cardiovascular health and we urge you to provide
    adequate funding for these important lifesaving programs.
        More than 1.9 million new cancer cases and over 600,000 deaths from
    cancer are expected in 2021. The amount spent on cancer related
    healthcare is expected to grow from $183 billion in 2015 to $246
    billion in 2030--an increase of 34%. The National Breast and Cervical
    Cancer Early Detection Program helps millions of low-income, uninsured
    and medically underserved women gain access to lifesaving breast and
    cervical cancer screenings and provides a gateway to treatment upon
    diagnosis. The Colorectal Cancer Control Program improves screening
    rates among targeted, low-income populations aged 50-75 years in
    targeted states and territories through evidence-based interventions.
    CDC funds all 50 states, DC, 7 tribes and tribal organizations and 7
    U.S. territories and Pacific Island jurisdictions to develop
    comprehensive cancer control plans to address each state's particular
    needs. We urge Congress to adequately support these critical programs.
        Cigarette smoking causes more than 480,000 deaths each year. CDC's
    Office of Smoking and Health funds important programs and education
    campaigns such as the Tips From Former Smokers campaign which has
    already helped more nearly one million individuals quit smoking and
    millions more to make a serious quit attempt. Congress must continue to
    support these and other programs to reduce the enormous health and
    economic costs of tobacco use in the U.S.
        Of the more than 34 million Americans living with diabetes, more
    than 7 million cases are undiagnosed. Diabetes is the leading cause of
    kidney failure, nontraumatic lower-limb amputations, and new cases of
    blindness among adults in the U.S. and the total direct and indirect
    costs associated with diabetes were $327 billion in 2017. We urge you
    to provide adequate resources for CDC's Division of Diabetes
    Translation and the National Diabetes Prevention Program which fund
    critical diabetes prevention, surveillance and control programs.
        Obesity prevalence in the U.S. remains high. More than 42% of
    adults are obese and 19.3% of children ages of 2 to 19 are obese.
    Obesity, diet and inactivity are cross-cutting risk factors that
    contribute significantly to heart disease, cancer, stroke and diabetes.
    The Division of Nutrition, Physical Activity and Obesity funds programs
    to encourage the consumption of fruits and vegetables, encourage
    sufficient exercise and develop other habits of healthy nutrition and
    physical activity and must be adequately funded.
        CDC provides national leadership in helping control the HIV
    epidemic by working with community, state, national, and international
    partners in surveillance, research, prevention and evaluation
    activities. CDC estimates that about 1.2 million Americans are living
    with HIV with 14% undiagnosed. Prevention of HIV transmission is the
    best defense against the AIDS epidemic. Sexually transmitted diseases
    continue to be a significant public health problem in the U.S. Nearly
    26 million new infections occurred in 2018. STDs, including HIV, cost
    the U.S. healthcare system almost $16 billion annually in direct
    lifetime medical costs.
        The National Center for Health Statistics collects data on chronic
    disease prevalence, health disparities, emergency room use, teen
    pregnancy, infant mortality and causes of death. The health data
    collected through the Behavioral Risk Factor Surveillance System, Youth
    Risk Behavior Survey, Youth Tobacco Survey, National Vital Statistics
    System, and National Health and Nutrition Examination Survey must be
    adequately funded.
        CDC's REACH program helps communities address serious disparities
    in infant mortality, breast and cervical cancer, cardiovascular
    disease, diabetes, HIV/AIDS and immunizations by supporting community-
    based interventions and we urge the committee to provide continued
    funding for these important activities.
        We thank the committee for its initial investment in CDC's Social
    Determinants of Health program and urge you to build upon this
    investment by increasing funding for the program to ensure that public
    health departments, academic institutions and nonprofit organizations
    are supported to address the social determinants of health in their
    communities that contribute to high health care costs and preventable
    inequities in health outcomes. We urge you to support the president's
    request of $153 million for this important program.
        CDC oversees immunization programs for children, adolescents and
    adults, and is a global partner in the ongoing effort to eradicate
    polio worldwide. Childhood immunizations provide one of the best
    returns on investment of any public health program. For every dollar
    spent on childhood vaccines to prevent thirteen diseases, more than $10
    is saved in direct and indirect costs. Over the past 20 years, CDC
    estimates childhood immunizations have prevented 732,000 deaths and 322
    million illnesses. We urge you to provide adequate funding for the
    Section 317 Immunization program and other efforts to prevent vaccine-
    preventable disease.
        Birth defects affect one in 33 babies and are a leading cause of
    infant death in the U.S. Children with birth defects that survive often
    experience lifelong physical and mental disabilities. Approximately one
    in six U.S. children is living with at least one developmental
    disability and one in four adults live with a disability. The National
    Center on Birth Defects and Developmental Disabilities conducts
    programs to prevent birth defects and developmental disabilities and
    promote the health of people living with disabilities and blood
    disorders.
        CDC's National Center for Environmental Health funds programs to
    control asthma, protect from threats associated with natural disasters
    and climate change and reduce, monitor and track exposure to lead and
    other environmental health hazards. Increased funding for all NCEH
    programs is critical to protecting the public from environmental health
    hazards and reducing illness, disease, injury and even death.
        To meet the many ongoing public health challenges facing the
    nation, including those outlined above, we urge you to provide at least
    $10 billion for CDC's programs in FY 2022.

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

      Prepared Statement of the Centers for Disease Control and Prevention
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Committee, it is an honor to appear before you today to discuss
    how investments in the Centers for Disease Control and Prevention (CDC)
    are protecting American's health, now and in the future. I am grateful
    for this opportunity to address this committee, as well as for your
    long-standing and consistent leadership on issues of critical
    importance to the health of Americans, and the world.
        It is my privilege to represent CDC at this hearing. CDC is
    America's health protection agency. For 75 years, CDC has been trusted
    to carry out its mission to protect America's safety, health, and
    security. Even during the unprecedented circumstances of the past year,
    CDC's scientific expertise, determination, selflessness, and innovation
    has helped the agency continue to advance its mission. We work 24/7 to
    prevent illness, save lives, and protect America from threats to our
    health, safety, and security. Addressing infectious diseases and
    pandemics, like COVID-19, is central to our mission. CDC's expertise
    lies in our ability to study emerging pathogens like SARS-CoV-2, to
    understand how they are transmitted, and to translate that knowledge
    into timely action to protect the public's health. CDC identifies and
    mitigates other causes of morbidity and mortality beyond infectious
    diseases, such as environmental and workplace hazards and intentional
    and unintentional injuries (such as those from falls, violence, or
    overdose). CDC promotes healthy behaviors, such as exercise and
    nutrition, to prevent chronic diseases such as diabetes and heart
    disease, and to prevent outcomes such as stroke. We promote healthy
    communities by increasing access to nutritious food and safe walking
    and green space. By deploying experts on the ground to support our
    state, Tribal, local, territorial and global partners, we translate
    science into implementing guidance that protects individuals,
    communities, and populations. In our work with other Federal agencies
    we ensure the safe and appropriate use of medical countermeasures,
    including vaccines, and collaborate with the academic and private
    sector to further our understanding of new diseases and problems that
    affect health.
        The COVID-19 pandemic threw the United States and the world into a
    health, economic, and humanitarian crisis. As the crisis unfolded, it
    put a spotlight on pre-existing weaknesses and gaps that threaten the
    health of Americans. It brought into stark light the great disparities
    in health outcomes by race and ethnicity. We must acknowledge the long-
    standing and too often unstated impact that racism has on public
    health. The pandemic has also highlighted our frail public health
    infrastructure, and the way that frailty impacted our ability to
    respond at the necessary scale and speed.
        Experts had warned for years that a pandemic of this scale was
    coming. Today, we know to expect additional novel and currently rare
    diseases to emerge and gain footing as a result of our changing
    climate, closer interaction with animals, and globalization. Over the
    last 12 years, the United States has faced four significant emerging
    infectious disease threats--the H1N1 influenza pandemic, Ebola, Zika,
    and COVID-19. These experiences show that public health emergencies
    and, specifically, infectious disease threats, are here to stay. While
    urgency demanded rapid and unique responses to each of these threats,
    none resulted in the sustained improvements needed in our nation's
    public health infrastructure. This lack of robust public health
    infrastructure continues to present significant challenges in our
    ongoing fight against COVID-19. In fact, emergencies have resulted in
    the rapid build-up of infrastructure needed to address the emergency,
    then dissolution of that infrastructure, often leaving no sustainable
    infrastructure in place to address the next threat. This lack of robust
    public health infrastructure continues to present significant
    challenges in our ongoing fight to tackle COVID-19.
        World-wide, billions of people do not and will not have immediate
    access to COVID-19 vaccines. Cases will continue to increase, and
    variant COVID-19 strains are likely to emerge, persist, and cause
    outbreaks. As this becomes more common, our public health system at
    home and abroad must be ready with highly sophisticated detection and
    sequencing, combined with a rapid response at the source. The
    unprecedented investments provided to CDC through COVID-19 supplemental
    appropriations have helped our efforts to control COVID-19, and will
    also go a long way toward addressing deficits in the core components of
    the public health infrastructure that has long been ignored. Our
    ability to respond to the next public health crisis will depend on
    whether we invest in a public health system that is highly functional
    on a day-to-day basis and pivots to meet new threats, rather than
    continue our partial defense, which ramps up in response to an urgent
    and often short-term event.
        A resilient public health system can be realized with careful
    planning that builds on the gains made with COVID-19 emergency
    supplementals and incorporates lessons learned as a result of this
    crisis, including reliable, flexible funding. The FY 2022 Discretionary
    Budget Request for CDC and ATSDR includes a total funding request of
    $8.7 billion, an increase of $1.6 billion over FY 2021 Enacted. This is
    the largest increase in budget authority for CDC in nearly two decades
    and defends Americans' health in four ways: (1) building public health
    infrastructure, (2) reducing health disparities, (3) using public
    health approaches to reduce violence, and (4) defeating other diseases
    and epidemics.
        First, building the public health infrastructure. CDC's FY 2022
    request prioritizes foundational funding to rebuild the public health
    infrastructure needed to safeguard the Nation's health and economic
    security. Drawing on lessons learned, as well as the latest information
    and technologies, CDC will begin to address long-standing
    vulnerabilities in the U.S. public health network by training a larger
    cadre of experts who can deploy and support public health efforts, and
    building capacity to detect and respond to emerging global biological
    threats.
        Public health action is driven by data. Earlier improvements in our
    systems for collecting information after other public health
    emergencies, including Ebola and EVALI, facilitated exchange of health
    information, linking local, state, and federal public health systems
    with healthcare systems and the public. With investments in public
    health data modernization in the FYs 2020 and 2021 appropriations and
    the COVID-19 supplementals, CDC increased the scale and speed of these
    systems during the COVID-19 response to protect people who are at risk
    for severe illness (such as older Americans), those with chronic
    medical conditions, and those from racial and ethnic minorities. These
    advancements must be applied across the public health system and at all
    levels of government. The funds requested in FY 2022 will be used to
    continue building a modern disease surveillance system at CDC, which
    will catalyze a multi-sectoral, comprehensive, and cohesive approach to
    documenting evidence, using state-of-the-art technology and analytical
    tools. CDC will continue working diligently to ensure its research and
    data are of the highest quality and are disseminated nationally to
    inform decision-making throughout the public health system, while
    supporting advances in data systems at all levels.
        The COVID-19 pandemic made clear the role that CDC labs and public
    health labs across the nation play in conducting critical surveillance
    and responding to outbreaks and emerging threats. CDC and state
    laboratories were required to flex and surge during peak periods of
    illness, far beyond routine clinical testing. In FY 2019, CDC was only
    able to meet 50% of state and local health departments' stated needs
    for epidemiology and laboratory capacity funding, with personnel
    support being the biggest unfunded need, followed by equipment and
    supplies. The FY 2022 request will foster innovation, collaboration
    with the clinical system, and a commitment to quality. Improving
    technologies at the state and local levels would enable public health
    labs to quickly utilize and scale up essential laboratory analyses. In
    a post-COVID-19 world, investments to maintain and improve laboratories
    will help prevent the failures we experienced while trying to address
    COVID-19.
        The U.S. needs a workforce of qualified public health professionals
    who will prepare for, respond to, and prevent public health crises.
    Physicians working for states often earn less than $150,000 per year.
    This is after having taken on medical school debt of $200,000 on
    average. The FY 2022 request includes an increase to build a diverse
    and culturally competent workforce who can rapidly develop innovative
    approaches in surveillance and detection, risk communications,
    laboratory science, data systems, and disease containment. With this
    funding, CDC will support critical training programs for public health
    professionals that develop strategic and systems thinking, data
    science, communication, and policy evaluation. Existing cooperative
    agreement mechanisms will be leveraged to support public health jobs
    that meet current needs and attract new personnel to work in
    underserved and rural areas.
        Addressing gaps in capacity across levels of government to detect
    and respond to outbreaks while maintaining and surging in other problem
    areas requires investments to be disease-agnostic and flexible. With FY
    2022 funding, CDC will provide support to health departments to meet
    national quality standards, conduct performance improvement activities,
    increase communication and collaboration across the public health
    system, and reshape health departments to meet changing conditions and
    needs. Funding will help health departments strengthen their abilities
    to effectively respond to a range of public health threats, such as
    COVID-19, and build capacities that do not currently exist.
        COVID-19 is a sobering reminder that a disease threat anywhere is a
    disease threat everywhere. Or as stated by WHO: no one is safe unless
    everyone is safe. We cannot adequately protect American lives and the
    U.S. economy without addressing global disease threats wherever they
    may arise. CDC's strategic investments in global health security are
    critical to U.S. health security by building sustainable global
    capacity to prevent, detect, and respond to emerging infectious disease
    threats. CDC works in more than 60 countries on more than 150 projects
    and is a key implementing agency for the U.S. Government's leadership
    role in the Global Health Security Agenda. With additional resources
    requested in FY 2022, CDC will build on existing partnerships with
    Ministries of Health, public health agencies, infectious disease
    research institutions, and international organizations to strengthen
    global laboratory capacity for early disease detection, enhance disease
    surveillance for accurate data to drive decision making, and foster
    effective regional and global coordination.
        Next, I'd like to talk about reducing health disparities. The
    disparities seen over the past year among communities of color were not
    a result of COVID-19. In fact, the pandemic illuminated inequities that
    have existed for generations and revealed a known, unaddressed, and
    serious public health threat: racism. The well-being of our entire
    nation will be compromised as long as we fail to address this.
        Racism is not just discrimination against one group based on the
    color of their skin or their race or ethnicity, but the structural
    barriers that impact racial and ethnic groups differently to influence
    where a person lives, where they work, where their children play, and
    where they worship and gather in community. The social determinants of
    health (SDOH)-such as high-quality education, stable and fulfilling
    employment opportunities, safe and affordable housing, access to
    healthful foods, commercial tobacco-free policies, and safe green
    spaces for physical activity-are critical drivers of health inequities
    in this country. CDC is building the evidence-base for collaborative
    approaches to SDOH through community accelerator planning and expanding
    a network of community health workers to develop a sustainable
    infrastructure to improve health equity. CDC's FY 2022 budget request
    includes an increase of $150 million to use a social determinants of
    health approach to improve health equity and health disparities in
    racial and ethnic minority communities and other disproportionately
    affected communities around the country.
        This budget directly responds to health disparities recorded in our
    public health data. For example, about 700 women die each year in the
    U.S. as a result of pregnancy or delivery complications, and American
    Indian, Alaska Native, and Black women are two to three times more
    likely to die than White women. Data show that about 2/3 of these
    deaths may be preventable. Children from lower-income and racial and
    ethnic minority households experience a disparate, increased risk for
    lead exposure.
        Achieving health equity is central to addressing the HIV epidemic.
    The U.S. Government spends $20 billion per year in direct health
    expenditures for HIV care and treatment. An estimated 1.2 million
    persons have HIV and approximately 15% are unaware they have it. With
    recent advancements in antiretroviral therapy and biomedical
    advancements in HIV prevention, such as pre-exposure prophylaxis
    (PrEP), along with effective care and treatment, we have the tools to
    end the HIV epidemic. An increased investment requested in FY 2022 for
    the Ending the HIV Epidemic (EHE) initiative will enable CDC to advance
    the four key strategies needed to end the epidemic in the 57 EHE focus
    jurisdictions. In addition, CDC will address health equity in the
    entire HIV prevention portfolio, test innovation in service delivery
    models to increase access to prevention services, use syndemic
    approaches to broaden reach to key populations and create efficiencies,
    and strengthen engagement of grassroots community-based organizations
    in implementing EHE initiative.
        Third, the budget request also addresses the public health epidemic
    of violence. We know too well how this epidemic permanently alters the
    lives of its victims and their families and puts enormous strain on our
    communities and local economies. Increases in CDC's FY 2022 budget
    request will help address violence through public health approaches,
    which include improving reporting systems that provide the data needed
    to understand and address violent deaths and injuries in the United
    States.
        And fourth, we must defeat other diseases and epidemics. Just as
    racism underlies a number of public health issues, climate issues
    underlie a number of infectious diseases and have significant health
    impacts. Climate changes are associated with changes in the
    geographical range of mosquitos, ticks, and other disease vectors.
    Climate-related events impact a wide range of health outcomes. Some of
    the most significant climate-related events-such as heat waves, floods,
    droughts, and extreme storms-affect everyone. These climate events
    compromise our access to clean air, clean water, and a reliable food
    supply. In addition, climate events can impact the presence of
    allergens and vectors, like ticks and mosquitoes, and the subsequent
    health outcomes that can result from these changes in exposures. We
    know that a changing climate can intensify existing public health
    threats, and that new health threats will emerge: unequally distributed
    risks (age, economic resources, location), increased respiratory and
    cardiovascular disease, injuries and premature deaths related to
    extreme weather events, changing prevalence and geography of foodborne
    and waterborne illnesses and other infectious diseases, and threats to
    mental health as people feel less safe.
        CDC works with states, cities, and tribes to apply the best climate
    science available, predicting health impacts, and preparing public
    health programs to protect their communities. To do this, CDC developed
    the Building Resilience Against Climate Effects (BRACE) framework to
    help communities prepare for the health effects of climate change by
    anticipating climate impacts, assessing vulnerabilities, projecting
    disease burden, assessing public health interventions, developing
    adaptation plans, and evaluating the impact and quality of activities.
    With the requested increase in FY 2022, we can further expand the
    Climate and Health Program by providing a larger number of health
    departments with technical assistance and funding and finding
    innovative ways to protect health via climate adaptations. As with
    every other public health threat, we will inform our effort by building
    and examining systems that collect data on conditions related to
    climate, including asthma and vector-borne diseases, and coordinate
    programs and communication that improve health outcomes.
        The opioid epidemic has shattered families, claimed lives, and
    ravaged communities across the Nation-and the COVID-19 pandemic has
    only deepened this crisis. Addressing the current overdose epidemic
    remains a priority for CDC. The Administration's strategy brings
    together surveillance, prevention, treatment, recovery, law
    enforcement, interdiction, and source-country efforts to address the
    continuum of challenges facing this country due to drug use. CDC's role
    is to prevent drug-related harms and overdose deaths.
        The additional funding requested in FY 2022 to address the opioid
    epidemic will enable CDC to provide more funding to all States,
    Territories, and select cities/counties. CDC will prioritize support to
    collect and report real-time, robust overdose mortality data and to
    move from data to action, building upon the work of the Overdose Data
    to Action (OD2A) program. To do so, CDC will partner with funded
    jurisdictions to implement surveillance strategies that include
    contextual information alongside data, as well as increase surveillance
    capabilities for polysubstance use and emerging substance threats such
    as stimulants. The additional resources requested will enable CDC to
    support investments in prevention efforts for people put at highest
    risk, for example, supporting risk reduction and access to medications
    for opioid use disorder for people transitioning from alternate
    residence (jail/prison, treatment facility, homeless shelter). CDC will
    also address infectious disease consequences, such as viral hepatitis,
    of the opioid epidemic.
        I look forward to working together to address both the immediate
    challenges ahead in our fight against COVID-19, as well as the
    weaknesses in the public health infrastructure that left our country
    vulnerable to this pandemic. We at CDC are grateful for your support.
    We will continue to work tirelessly to ensure the health of this nation
    and the world. Together, we can build a sustainable and resilient
    public health system that can respond effectively to emerging threats
    and also to ongoing public health needs of every American.

        [This statement was submitted by Rochelle P. Walensky, M.D.,
    M.P.H., Director, and Anne Schuchat, M.D.,Principal Deputy Director,
    Centers for Disease Control and Prevention.]
                                     ______

         Prepared Statement of the Christopher & Dana Reeve Foundation
        Thank you for this opportunity to submit testimony in support of an
    appropriation of $9,700,000 for the Paralysis Resource Center (PRC)
    within the Administration for Community Living (ACL) at the Department
    of Health and Human Services (HHS).
        I am proud to speak on behalf of the 1 in 50 individuals living
    with paralysis in the United States, who rely on programs like the
    Paralysis Resource Center to live independent and empowered lives. The
    Reeve Foundation has operated the Paralysis Resource Center for 19
    years, competing in a rigorous, competitive bidding process every three
    years for renewal of this grant. For fiscal year 2022, we request
    funding of $9.7 million for the Paralysis Resource Center. Of this
    total, we request that the Committee direct no less than $8.7 million
    to the National Paralysis Resource Center. These requests are in line
    with the final appropriation for FY21. The Reeve Foundation was also
    pleased to see that the President's Budget for FY22 requests a 5%
    increase for the Paralysis Resource Center.
        When Christopher Reeve was paralyzed from the neck down due to a
    spinal cord injury in 1995, his family found themselves in total
    darkness as to what to do next. There was no phone number to call for
    guidance or help. There were no experts reaching out to connect them to
    the right rehabilitation facilities, or to discuss how they could
    support his return home and ongoing well-being. There was certainly no
    promise that an individual living with that level of spinal cord injury
    could lead a full and active life as a father and husband. Yet, instead
    of accepting that life with paralysis would be full of limitations, he
    dreamed of a brighter future.
        That was the genesis of the Christopher & Dana Reeve Foundation:
    Christopher's dream to elevate the needs and rights of the 5.4 million
    Americans living with paralysis. But he was far from alone. The real
    drive behind the Paralysis Resource Center came from his wife, Dana. As
    a caregiver herself, she knew that paralyzed individuals and caregivers
    around the country needed a centralized place to call for resources and
    expertise.
        Since the PRC opened its doors in 2002, it has served as a free,
    comprehensive, national source of informational support for people
    living with paralysis and their caregivers. Our work is deeply aligned
    with ACL's mission to empower people living with disabilities and older
    adults to live independently and participate in their communities
    throughout their lives. The PRC is the only program of its kind that
    directly serves individuals living with spinal cord injury, MS, ALS,
    stroke, spina bifida, cerebral palsy and other forms of paralysis. The
    services and programs described below would not be possible without the
    ongoing support of this Subcommittee.
    A. The PRC's Core Programs
        (1) Information Specialists. One of the PRC's most essential
    functions is the team of certified, trained Information Specialists
    (IS) who provide personalized support to individuals, families, and
    caregivers on how to navigate the challenges of life with paralysis.
    This team of experts, many living with paralysis themselves, are often
    the first port of call for individuals who are newly injured or
    diagnosed. Just twenty-four hours after my daughter, Ellie, sustained a
    spinal cord injury, I contacted the Paralysis Resource Center. The same
    day I was told my daughter would probably never walk again; I was
    offered a lifeline. I believe that call turned the nose of the Titanic
    away from the iceberg before it hit us. It altered the course of
    desperation and isolation of what we were dealing with and gave us real
    hope. I was assured that Ellie would drive again, work again, and enjoy
    her life--and that the Foundation and the PRC team would hold my hand
    the entire way. It is also important to note how critically their
    services have been educating and supporting the paralysis community
    during the pandemic.
        To date, the PRC Information Specialists have provided direct
    counseling to over 106,000 people. We have distributed 220,000 copies
    of our Paralysis Resource Guide, which is a staple in hospitals and
    rehabilitation facilities across the country.
        (2) Peer & Family Support Program. A second pillar of the PRC is
    our Peer & Family Support Program. This program is born of the idea
    that the best source of knowledge is experience: and that peer-to-peer
    connections empower not only the newly paralyzed individual, but also
    the mentor. Through the PRC, more than 450 peer mentors have been
    trained and certified in 43 states and Washington, DC. These
    individuals have mentored over 17,000 peers.
        (3) Quality of Life Grants Program. Our third pillar, the Quality
    of Life Grants Program, operates at the community level to fund
    nonprofit initiatives in all 50 states, the District of Columbia and
    the U.S. territories. Since 1999, the Quality-of-Life Grants Program
    has directed over $33 million dollars to assist over 3,300 projects.
    This program has increased employment trainings and accessible
    transportation; established adaptive sports programs and camps for
    children; improved access to buildings, playgrounds, and universities;
    helped individuals learn how to manage their financial well-being and
    provided support services for veterans. In 2020, the PRC created a new
    Quality of Life (QOL) grants program specifically aimed at addressing
    social isolation during the COVID-19 pandemic, with the goal of
    enhancing connectedness of people living with paralysis and their
    caregivers to their communities and preventing adverse health outcomes.
        (4) Military & Veterans Program; Multicultural Outreach Program.
    The PRC has a comprehensive Military and Veterans Program, which
    provides dedicated resources to help individuals navigate military and
    civilian benefits and programs as they reintegrate into their
    communities. The PRC also facilitates a Multicultural Outreach Program
    that is designed to engage and support underserved populations like
    racial and ethnic minorities, older adults, low-income earners, and
    LGBTQ individuals.
        (5) ChristopherReeve.org. One of the most challenging aspects about
    living with paralysis is combating feelings of isolation and exclusion,
    especially for those who are unable to leave their homes due to
    physical and societal barriers. The Reeve Foundation's website,
    ChristopherReeve.org, provides a vibrant online community and resource
    hub as part of the PRC, which attracts close to three million visitors
    per year, and Reeve Connect, our online forum, has allowed over 8,000
    individuals to connect with experts, chat with one another and share
    the experiences that matter to them in a secure, private space.
    B. The Importance of Federal Funding.
        I would like to close my remarks by emphasizing why federal funding
    for this program is so important. Simply put neither the Reeve
    Foundation, nor any organization competing to run the PRC, could
    provide this type of centralized resource alone. Because many
    individuals, including my daughter, are required to attend
    rehabilitation clinics and/or draw on other resources from out of
    state, nationwide expertise is required. To get the benefit of
    investing in a centralized hub of information, we need to promote and
    deliver these services at scale. Federal funds are essential for this
    valuable, life-changing resource to work.
        Christopher Reeve once said, ``Hope is like a lighthouse,'' helping
    individuals who are lost in the darkness find their way. But like a
    lighthouse, hope must be built on solid foundations. The resources,
    support and community created by the PRC are the foundation for hope
    for millions of individuals affected by paralysis around the country. I
    thank you for your ongoing support and urge you to protect the
    Paralysis Resource Center so that individuals nationwide can achieve
    greater quality of life, health, and independence. Thank you.
                                     ______

             Prepared Statement of the Coalition for Clinical and
                             Translational Science
                fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --CCTS joins the broader medical research community in asking
            Congress to provide the National Institutes of Health (NIH)
            with at least a $3.2 billion funding increase for FY22, to
            bring total agency funding up to a minimum of $46.1billion
            annually.
        --Please provide the Clinical and Translational Science Awards
                (CTSA) program at the National Center for Advancing
                Translational Sciences (NCATS) with at least a $32 million
                increase in dedicated line-item funding for FY22 to bring
                annual support for the program up to a minimum of $620
                million.
        --Please provide the Cures Acceleration Network (CAN) at NCATS with
                $100 million in dedicated funding for FY22.
        --Please provide the Institutional Development Awards (IDeA)
                program and the Research Centers in Minority Institutions
                (RCMI) program at NIH with meaningful proportional funding
                increases for FY22.
      --CCTS joins the broader public health community in requesting $500
            million for the Agency for Healthcare Research and Quality
            (AHRQ).
      --CCTS joins the broader public health community in requesting $10
            billion for the Centers for Disease Control and Prevention
            (CDC).
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Subcommittee, thank you for considering the views of the
    clinical and translational research community as work on FY 2022
    appropriations. The community deeply appreciates the ongoing investment
    in medical research, including FY21 NIH funding and overall support for
    the COVID-19 response. Moreover, CCTS commends you for continuing to
    protect line-item funding for the CTSA program, which provides critical
    research infrastructure support to meritorious institutions across the
    country and serves as a major catalyst for advancing the full spectrum
    of medical research at NIH. The value, importance, and impact of the
    CTSA program as well as full-spectrum research at NIH was best
    highlighted by our ability to quickly develop treatments, vaccines,
    diagnostic tools, and health information to quickly respond to the
    ongoing COVID-19 pandemic. As you consider FY 2022 funding, CCTS and
    the broader community would like to highlight recent progress, emerging
    opportunities, and the importance of sustained investment.
           about the coalition for clinical and translational science
        The Association for Clinical and Translational Science, Clinical
    Research Forum, the CTSA PIs, and the related stakeholder community
    work together through the Coalition for Clinical and Translational
    Science (CCTS) to speak out with a unified voice on behalf of the
    clinical and translational research community. CCTS is a nationwide,
    grassroots network of dedicated individuals who seek to educate
    Congress and the administration about the value and importance of
    clinical and translational research, and research training and career
    development activities. Our goals are to ensure that the full spectrum
    of medical research is adequately funded, the next generation of
    researchers is well-prepared, and the regulatory and public policy
    environment facilitates ongoing expansion and advancement of the field
    of clinical and translational science.
        about the ctsa program and the full spectrum of medical research
        The CTSA Program was established to disseminate medical and
    population health interventions to patients and populations more
    quickly, and to enable research teams, including scientists, patient
    advocacy organizations and community members, to tackle system-wide
    scientific and operational problems in clinical and translational
    research that no one team can overcome in isolation. The CTSA program
    honors the promise of the Cures Act by improving research
    infrastructure and accelerating the rate at which breakthroughs in
    basic science are translated to innovations with a tangible benefit to
    patients.
        The goals of the CTSA program include; (1) train and cultivate the
    translational science workforce, (2) engage patients and communities in
    every phase of the translational process, (3) promote the integration
    of special and underserved populations in translational research across
    the human lifespan, (4) innovate processes to increase the quality and
    efficiency of translational research, particularly of multisite trials,
    (5) advance the use of cutting-edge informatics.
        The CTSA Program supports a national network of ``hubs'' at
    academic research centers across the country that work collaboratively
    to improve the translational research process to get more treatments to
    more patients more quickly. The hubs collaborate locally and regionally
    to catalyze innovation in research training, tools, and processes.
    Approximately 60 medical research institutions across the nation
    currently receive CTSA program funding, and these hubs work together to
    speed the translation of research discovery into improved patient care
    and public health. Resources appropriated to these hubs allow the
    network to expand to include additional sites, advance science, and
    directly invest in the health workforce of the communities where they
    are located.
        The full spectrum of translational science takes the fruits of
    basic and pre-clinical research and translates them into effective
    clinical care and public health measures, with a focus on having impact
    on health. In order to maximize efficiency and patient-centeredness,
    this research must be done collaboratively and in a systematic way.
    This team-science approach focuses on outcomes and patient/health
    system benefits, rather than the advancement of science for the sake of
    science.
        Most crucially, the appropriations committees have included
    detailed committee recommendations in the past that have facilitated
    meaningful advancements for the full spectrum of medical research, the
    CTSA program, and career development for early stage investigators and
    we hope similar recommendations advancing full spectrum research and
    team science as well as maintaining the integrity of the CTSA line-item
    will be provided for FY 2022.
                              recent ctsa activity
    Yale Center for Clinical Investigation (YCCI)
        YCCI initiated double-blind randomized outpatient covid treatment
    trials involving the experimental drug apilimod dimesylate (LAM-002A),
    a first in class, highly selective PIKfyve kinase inhibitor from
    Connecticut Biotech firm AI therapeutics, which prevents SARS-CoV-2
    viral entry into cells. Similarly, a randomized, double blind
    outpatient repurposing trial of camostat mesylate, which inhibits SARS-
    CoV-2 infection by blocking the virus-activating host cell protease
    TMPRSS2, was simultaneously initiated. YCCI also supported
    participation in multi-institutional randomized placebo controlled
    trials including Pfizer-sponsored vaccine trials and a randomized,
    placebo controlled cooperative inpatient trial of convalescent plasma
    by a consortium of CTSA institutions. Innovative pandemic monitoring
    approaches were developed including the measuring of SARS-CoV-2 RNA
    concentrations in primary municipal sewage sludgeas a leading indicator
    of COVID-19 outbreak dynamics.
        The YCCI's Cultural Ambassador program, initiated eleven years ago,
    has been a critical component in the response to the pandemic. This bi-
    directional partnership influences Yale research priorities and drives
    research that meets the needs of the surrounding community. The
    Cultural Ambassadors, appointed by the community, collaborate with Yale
    researchers on trial design, recruitment, and reducing access barriers
    for the community and engage in advocacy and education efforts in the
    community, driving awareness of the importance of clinical research.
    The program builds trust-based relationships, increases health system
    engagement and contributes to improved overall health. This has been
    the lynchpin for community-based clinical trials that has resulted in
    participation in clinical trials by underrepresented minorities of 31%
    in the last academic year.
    University of Washington
        Limiting Opioid Abuse.--Over the last several years, our CTSA has
    organized dozens of rural clinics into a network. This network
    initiated an observational study of best practices in the management of
    patients who are on long-term opioid therapy for chronic pain, which
    evolved into a prescribing program. Rigorous testing of the developed
    intervention at 20 rural practice sites demonstrated a 19% reduction in
    high dose opioid prescribing.
        COVID Clinical Trials in Rural Communities.--The UW CTSA, through
    the development of the rural clinic network, was able to push clinical
    trials from the UW to rural Washington rapidly. Providence Health in
    Spokane, WA, one of our Network partners, was 1 of the first 10 US
    sites to open the ACTIV-1 trial and enrolled their first participant 5
    days after receiving the protocol. Inclusion of rural serving clinical
    sites was critical to our regional communities as COVID-19 infections
    were increasing dramatically in migrant farm worker populations.
    Vanderbilt
        The Vanderbilt Institute for Clinical and Translational research
    was well positioned to respond to the pandemic in large part because of
    the CTSA-supported infrastructure. First, the local ecosystem was
    mobilized to organize and coordinate the local response. From this, we
    identified the need to harmonize various trial activities across the
    country, and NCATS supported initiatives for harmonizing COVID-19 trial
    oversight and data pooling. At the same time, we were positioned to
    conduct clinical trials with efficient contracting and regulatory
    approvals, launching PassItOn--a trial of convalescent plasma--with
    seed funding from Dolly Parton. NCATS supported the rest of the trial,
    which has almost reached its enrollment target of 1000 patients. We
    were also identified as the science unit for NHLBI's network of
    networks, providing guidance to the agent selection, design, and
    analysis of trials of the host-tissue response to SARS-CoV-2 infection,
    building on the success of our drug repurposing program and
    biostatistics programs. Continuing to springboard of these foundations,
    we are now leading ACTIV4D-RAAS and serving as the DCC for ACTIV6, this
    latter with funding through NCATS. Lastly, our CTSA-supported learning
    health system has completed the only known large, randomized controlled
    of prone positioning in moderately sick inpatients, with results in the
    process of being disseminated.
    University of Texas Health Science Center at San Antonio
        Resources, facilities, and personnel from the Institute for
    Integration of Medicine & Science, home to the UTHSCSA CTSA grant,
    enabled a rapid, collaborative, and comprehensive response to the
    COVID-19 crisis. Within weeks of the pandemic onset, UTHSCA established
    a unique virtual clinic for newly diagnosed patients. Research teams
    are characterizing health disparities and COVID-19 symptoms in this
    majority (84%) Hispanic population. As part of the NIH Community
    Engagement Alliance Against COVID-19 Disparities, CTSA specialists
    partner with regional health professionals and local organizations in
    underserved regions across South Texas to provide expert community
    engagement, community based-participatory research, and dissemination
    of best practices for COVID-19 care. As a result of the extensive
    preparation of CTSA hub and network research infrastructure, UTHSCA was
    among the top enrolling sites for major national studies including the
    NIH Accelerating COVID-19 Therapeutic Interventions and Vaccines
    (ACTIV) trials. CTSA support was also instrumental in launching a
    pioneering study of immunological resilience in 522 Veterans with
    COVID-19, which has yielded new biomarkers and new insights into the
    relative vulnerability of males to serious illness.

        [This statement was submitted by Harry P. Selker, MD, MSPH,
    Chairman,
    Clinical Research Forum.]
                                     ______

             Prepared Statement of the Coalition for Health Funding
        The Coalition for Health Funding--an alliance of 81 national health
    organizations representing more than 100 million patients and
    consumers, health providers, professionals and researchers--appreciates
    the opportunity to submit testimony for the record about the importance
    of health funding. Together, our members speak with one voice in
    support of federally funded health programs with a shared goal of
    improved health and well-being for all. While each member organization
    has its own funding priorities within the Department of Health and
    Human Services (HHS), our coalition is united in support of increased
    and sustained funding for all federal agencies and programs across the
    public health continuum--from bench to bedside--to ensure that all
    Americans lead long, healthy, productive lives.
        Today, we have an unprecedented opportunity to shape the future of
    this country's public health infrastructure. The COVID-19 pandemic
    critically strained health, social, and economic systems around the
    world, and highlighted the importance of sustained and predictable
    health funding. Supplemental funding to address the urgent needs of the
    pandemic was, and continues to be, essential, but it alone is not the
    solution to respond to future pandemics. For too long, Congress
    neglected critical pieces of our public health infrastructure and
    health research pipeline, which hindered our ability to respond quickly
    and effectively when disaster struck. Now is the time to take
    corrective action and make sustained investment in public health. We
    learned many lessons during the pandemic, including that biomedical
    research and a robust public health workforce are indispensable and
    require sustained investment. A significant fiscal year (FY) 2022
    allocation for public health funding will allow our health systems to
    emerge stronger and better equipped to improve health outcomes.
        The Coalition urges Congress to seize the opportunity FY 2022
    presents as the first appropriations cycle in a decade not governed by
    the spending caps of the Budget Control Act of 2011 (BCA). Without the
    BCA imposed budget caps, Congress should provide funding increases
    across the HHS accounts commensurate with the need for non-defense
    discretionary programs that support public health, medical and
    scientific research, infrastructure, education, public safety, and
    more. Congress should follow the increase set forth in President
    Biden's FY 2022 Discretionary Budget request and increase the HHS
    budget by at least 23.5 percent or $25 billion above FY 2021 levels.
    Increased funding will not only support future economic growth, but
    will strengthen the health, safety, and security of all Americans.
        HHS agencies play a key role in addressing our nation's public
    health needs and work in partnership with state and local governments
    to protect and promote health in our communities. While each agency
    within HHS has a unique mission to respond to our nation's health
    demands, they are all interconnected. For example, the COVID-19
    pandemic has shown that investment in medical research at the National
    Institutes of Health (NIH) is important, but on its own will not
    improve health. You need the Food and Drug Administration to approve
    new treatments. You need the Centers for Disease Control and
    Prevention, Health Resources and Services Administration, Substance
    Abuse and Mental Health Services Administration, and Indian Health
    Service to ensure we have qualified health professionals who can
    translate research into health care and public health delivery, support
    Americans while they're awaiting new cures, and prevent them from
    getting sick in the first place. You also need the Agency for
    Healthcare Research and Quality to provide clinical evidence on what
    treatments work best, for whom, and in what circumstances. And you need
    the Administration for Community Living to support those who are aging
    and those who have disabilities--as well as their caregivers--so that
    they can live their best life, every day. Without robust funding for
    all agencies and programs of the interdependent public health
    continuum, we're falling short on the promise to protect and improve
    the health and well-being of all Americans. Shortchanging public health
    and health research programs--or cutting health programs--leaves
    Americans vulnerable to health threats and will not prevent public
    health crises from arising in the first place as we witnessed over the
    last year.
        As COVID-19 cases begin to decline and life starts to look more
    like it did before the pandemic, it is important to recognize that the
    pandemic's effects go far beyond the virus itself and will have long-
    lasting impacts on Americans. Research is just one of the many areas
    impacted by the pandemic that requires additional investment to get
    back on track. Every agency within HHS conducts research that is
    important to strengthening our public health system. Congress has a
    responsibility to ensure that all agencies within HHS receive equitable
    funding for efforts to regain some of the ground that has been lost due
    to necessary pauses in and increased costs of research as well as
    ensure the pandemic does not wipe out a whole generation of
    investigators who were forced to choose other career paths because of
    the disruption.
        Another well-established impact of the pandemic has been the toll
    it has taken on mental health and substance abuse. Four in ten adults
    report symptoms of anxiety or a depressive disorder, up from one in ten
    adults in June 2019. Substance abuse and misuse, including alcohol, has
    increased by 12 percent.\1\ Gains made in the fight against the opioid
    epidemic-another dire public health crisis-were diminished as an
    estimated 87,000 Americans lost their lives due to overdose from
    September 2019 to September 2020, a 29 percent increase over the
    previous year.\2\ Adequate funding for preventive, supportive, and
    rehabilitative services will be critical to address and reduce these
    concerning trends.
    ---------------------------------------------------------------------------
        \1\ Nirmita Panchal, R. K., & 2021, F. (2021, April 14). The
    Implications of COVID-19 for Mental Health and Substance Use. KFF.
    https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-
    of-covid-19-for-mental-health-and-substance-use/.
        \2\ Centers for Disease Control and Prevention. (2021, May 12).
    Products--Vital Statistics Rapid Release--Provisional Drug Overdose
    Data. Centers for Disease Control and Prevention. https://www.cdc.gov/
    nchs/nvss/vsrr/drug-overdose-data.htm.
    ---------------------------------------------------------------------------
        The detection and management of chronic diseases is another area of
    public health that was set back as a result of the pandemic. An
    estimated six in ten American adults have a chronic disease, with four
    in ten having two or more.\3\ Restrictions on elective procedures and
    non-urgent health care visits, coupled with concerns about the virus
    and obstacles to connecting virtually with providers during the
    pandemic caused many Americans to postpone routine care and skip
    necessary screenings, which in some cases has negatively impacted
    patients' ability to manage their disease.\4\ Additionally, the
    millions of Americans now living with post-acute sequelae of COVID-19-
    often referred to as ``long-haulers'' because they experience lingering
    symptoms that last from weeks to months-could further increase the
    number of people in the U.S. living with a chronic disease, like
    diabetes or heart disease, and adds new complexities to our chronic
    disease management efforts. As a result, there is a significant need
    for increased funding for public health programs that reduce barriers
    to care and help patients detect and manage their conditions.
    ---------------------------------------------------------------------------
        \3\ Centers for Disease Control and Prevention. (2021, January 12).
    Chronic Diseases in America. Centers for Disease Control and
    Prevention. https://www.cdc.gov/chronicdisease/resources/infographic/
    chronic-diseases.htm.
        \4\ Kendzerska, T., Zhu, D. T., Gershon, A. S., Edwards, J. D.,
    Peixoto, C., Robillard, R., & Kendall, C. E. (2021, February 15). The
    Effects of the Health System Response to the COVID-19 Pandemic on
    Chronic Disease Management: A Narrative Review. Risk management and
    healthcare policy. https://www.ncbi.nlm.nih.gov/pmc/articles/
    PMC7894869/#::text=Obese%
    20patients%20with%20chronic%20diseases,during%20in%2Dperson%20medical%20
    visits.
    ---------------------------------------------------------------------------
        Research, mental health, substance use disorders, and chronic
    disease are just some of the areas of public health that have been
    impacted by the pandemic and require increased investments. Despite the
    funding included in the emergency appropriations packages, we have seen
    setbacks in most, if not all, areas of public health. The only way to
    remedy this situation is through robust and sustained funding. As the
    country continues to work to build back, Congress has a responsibility
    to make robust, sustained, investments in our public health system.
    Health security is national security; Congress would not hesitate,
    rightfully so, to make increased investments in defense or national
    security after a crisis. Now is our chance to act boldly and make
    investments in public health that will benefit all Americans. The goal
    for our nation's public health system should not be to return to
    normal, but rather to build a paradigm that makes the U.S. a healthier
    country by addressing health disparities and ensures that when the next
    public health crisis comes, we are prepared.
        The Coalition for Health Funding strongly supports at least a 23.5
    percent increase for the Department of Health and Human Services above
    FY 2021 levels. We look forward to working with Congress to support the
    health of all Americans and we hope that you will view us and our
    member organizations as a resource.

        [This statement was submitted by Erin Morton, MA, Executive
    Director, Coalition for Health Funding.]
                                     ______

            Prepared Statement of the Coalition for Service Learning
        On behalf of the Coalition for Service Learning and the 160+
    organizations we represent, we respectfully request that you include a
    $250 million annual appropriation for the Learn and Serve America
    program and related National Service Trust payments authorized by
    Subtitle B of the Edward M. Kennedy Serve America Act in the FY22
    Labor, Health and Human Services, Education and Related Agencies
    Appropriations bill for the Corporation for National and Community
    Service (CNCS) dba AmeriCorps.
        Additionally, we request that accompanying report language include
    the following:
        ``Within the total, the Committee provides funds for Summer of
    Service programs, Semester of Service programs, and Innovative and
    Community-Based Service-Learning programs in public schools and
    institutions of higher education. Additionally, fifty-percent of the
    funds are to be directed to economically disadvantaged communities and
    at least five-percent to be set aside for payments to Indian tribes and
    territories. Grants to disadvantaged communities are exempt from match
    requirements. There shall be a two-percent set-aside of the total
    appropriation for training and technical assistance contracts and
    program evaluation.''
        Lastly, since the AmeriCorps agency will need to increase their
    capacity in order to administer these new programs, we request that
    such sums as may be necessary shall be appropriated for agency salaries
    and expenses under Subtitle K of the Serve America Act and such sums as
    may be necessary for education awards for Summer of Service
    participants in the National Service Trust.
        The COVID-19 pandemic has amplified existing inequities in
    education, isolated individuals, and put students' educational outcomes
    at risk. Students are struggling academically but also socially and
    emotionally, especially those in underserved areas. Engaging students
    through service-learning is a proven way to instill a sense of
    community, belonging, and responsibility and is a proven strategy to
    help address the academic and emotional learning loss that has
    occurred.
        The congressionally-appointed bipartisan National Commission on
    Military, National, and Public Service completed a report in March of
    2020 in which it set a goal of all K-12 students receiving service-
    learning experiences by 2031. It highlighted the opportunity to give
    young people the problem-solving and academic achievement skills they
    will need to be successful in school, work, and life. In the
    Commission's vision, every American would be exposed to service
    opportunities throughout their lifetime, beginning with young people
    experiencing robust civic education and service-learning during
    elementary, middle, and high school.
        In order to achieve this vision, the Commission recommended that
    Congress provide a $250 million annual appropriation to CNCS to award
    competitive grants to SEAs, LEAs, IHEs, State Service Commissions, and
    nonprofits to develop and implement service-learning programs for K-12
    and postsecondary students across the country, including:
      --$100 million for Summer of Service programs for students who will
            be enrolled in grades 6-12 at the end of the summer;
      --$100 million for Semester of Service programs for students in
            grades 9-12; and
      --$50 million for service-learning programs in public schools and
            institutions of higher education.
        Dedicated resources for educators and districts are essential for
    the success of service-learning programs. Funding would enable school
    districts to provide teachers with the training and support needed to
    develop their service-learning skills and to build service-learning
    activities into their curricula. Funding for Learn and Serve America
    would help lower financial barriers and incentivize schools and
    educators to actively promote and incorporate service-learning into
    classrooms across the nation.
        Service-learning is a critical program strategy at the intersection
    of education, national service, and civic health, with positive impacts
    on increasing academic engagement and 21st Century skill development,
    meeting community needs while building a recruitment pipeline for
    AmeriCorps programs, and improving civic education and participation.
        We are hopeful that Congress recognizes the importance of
    reestablishing a program that will help address academic and emotional
    learning loss, re-engage students through service-learning activities,
    and instill a sense of community. We urge Congress to provide $250
    million for Learn and Serve America and are grateful for your
    consideration of this request.
        Best regards,
      Amy Cohen, Executive Director, The George Washington University
    Honey W. Nashman Center for Civic Engagement and Public Service, and
    Former Director of Learn and Serve America
      Susan Stroud, Senior Fellow, The George Washington University Honey
    W. Nashman Center for Civic Engagement and Public Service, and Founding
    Director of Learn and Serve America
      Emily Samose, Founder, ECS Consulting, and Former Staff, Learn and
    Serve America
      Brad Lewis, Former Staff, Learn and Serve America
      Amy Meuers, CEO, National Youth Leadership Council
      Aaron Dworkin, CEO, National Summer Learning Association
      Ally Talcott, Step Up Advocacy for the National Summer Learning
    Association
      Kate Cumbo, Executive Director, PeaceJam Foundation
      Kaira Esgate, CEO, States for Service and America's Service
    Commissions
      Susan Abravanel, President, Susan Abravanel Consulting
      Michael Minks, Vice President of Operations, Youth Service America
      Steven A. Culbertson, President & CEO, Youth Service America

    Coalition Members--National Organizations

      Erik Peterson, Senior Vice President of Policy, Afterschool Alliance
      Gary Kosman, CEO, America Learns
      Dr. Ariel King, President, Ariel Foundation International
      Abby Robinson, Acting CEO, Atlas Corps
      Sage Learn, National Director of Government Relations, Boys & Girls
    Clubs of America
      Shawna Rosenzweig, Chief Strategy Officer, Camp Fire National
    Headquarters
      Andrew Seligsohn, President, Campus Compact
      Kei Kawashima-Ginsberg, Director, The Center for Information &
    Research on Civic Learning & Engagement, Jonathan M. Tisch College at
    Tufts University
      John Bridgeland, Founder &CEO, Civic
      Robert Hackett, President, Corella & Bertram F. Bonner Foundation
      Sanjli Gidwaney, Director, Design for Change USA
      Marly Leighton, Chief of Staff, DoSomething.org
      Vince Meldrum, President/CEO, Earth Force
      Tamara Roske, Executive Director, Earth Guardians
      Donna Ritter, Executive Director, Educators Consortium for Service
    Learning
      Adam Fletcher, Director, Freechild Institute
      Amanda Antico, Founder, EvolvED Global
      Stefonie Sebastian, Senior Service Engagement Specialist, National
    FFA Organization
      Donna Butts, Executive Director, Generations United
      Linda Staheli, Founding Director, Global Collaboration Lab Network
      Rick Lathrop, Founder/Executive Director, Global Service Corps
      Sam Fankuchen, Founder & CEO, Golden
      Patricia Hall, Founder, H2O for Life
      Nichole Cirillo, Executive Director, IAVE
      Serita Cox, CEO, iFoster
      Doug Bolton, CEO, Cincinnati Cares, Inspiring Service
      Bradley Hill, Director of Growth and Strategic Partnership, Junior
    State of America
      Betsy Peterson, Executive Director, Learning to Give
      Robert Jackson, Sr. Director of Development, Martin Luther King Jr.
    Center for Nonviolent Social Change
      Abbie Evans, Senior Director, Government Relations, MENTOR
      Sarah Fanslau, VP, Youth Programs, Multiplying Good
      Gina Warner, President & CEO, National Afterschool Association
      Kuna Tavalin, Consultant, National Center for Families Learning
      Lawrence Paska, Executive Director, National Council for the Social
    Studies
      McClellan Hall, Founder, CEO, National Indian Youth Leadership
    Project
      Stephanie Grove, President, National Senior Corps Association (NSCA)
      Fish Stark, Global Director of Programs, Peace First
      Moran Banai, Managing Director, Policy and Government Relations,
    Service Year Alliance
      Lee Arbetman, Executive Director, Street Law
      Derek Summerville, Director of Youth Engagement, YMCA of the USA
      Adam Fletcher, Vice-President, Youth and Educators Succeeding
      David Battey, President and Founder, Youth Volunteer Corps

    Coalition Members--State & Local Organizations (listed alphabetically
            by State)

      Kids 1st Awareness Community Center (AL)
      Blue Crew (CA)
      California Campus Compact (CA)
      CBK Associates (CA)
      Cooline Team of East Palo Alto (CA)
      Norte Vista High School (CA)
      Playable Agency (CA)
      S.C.R.A.P. Gallery (CA)
      1 Sacred Place (CO)
      Billig Consulting (CO)
      Goldey (DE)
      American University Center for Community Engagement & Service (DC)
      Center for Social Justice Research Teaching & Service (DC)
      Griffin Legacy & Associates (DC)
      LearnServe International (DC)
      Raising A Village Foundation (DC)
      Beyond Before Community Development Corporation (FL)
      Florida Atlantic University (FL)
      FSU Center for Leadership and Social Change (FL)
      Jacksonville University (FL)
      Chautauqua Learn and Serve Charter School (FL)
      Intentional Icon Inc (FL)
      Miami Dade College Institute for Civic Engagement and Democracy (FL)
      AFRD Georgia (GA)
      Favor House (GA)
      John & JeJuan Stewart Jr. Foundation (GA)
      KIPP South Fulton Academy Beta Club (GA)
      The Bridge Foundation (GA)
      Making Dreams Come True Valley of Rainbows (HI)
      Hawaii Pacific Islands Campus Compact (HI)
      University of Hawaii Office of Civic and Community Engagement (HI)
      Serve Illinois Commission (IL)
      ProAct Indy (IN)
      Serve Indiana Commission (IN)
      Volunteer Center of Story County (IA)
      Bluebird Experience (KY)
      Kentucky Campus Compact (KY)
      LSU AgCenter 4 (LA)
      3Levels.org (ME)
      Bates College (ME)
      Harkins Consulting (ME)
      Maine Campus Compact (ME)
      Saint Joseph's College of Maine (ME)
      Loyola University Maryland Center for Community (MD)
      The Giving Square (MD)
      University of Maryland College Park (MD)
      Campus Compact Mid (MD)
      No Struggle No Success (MD)
      Notre Dame of Maryland University (MD)
      The WordSmith (MD)
      UMBC The Shriver Center (MD)
      Wicomico County Public Schools MD (MD)
      Jonathan M. Tisch College of Civic Life at Tufts University (MA)
      Action 2 Achieve (MA)
      Brandeis Center for Youth and Communities University (MA)
      LEAP Arlington (MA)
      Michigan Community Service Commission (MI)
      West Michigan Consulting Services (MI)
      Peacebunny Islands Inc/Peacebunny Foundation (MN)
      Youthprise (MN)
      Black Girls Rock of MS (MS)
      CryOut Teen Organization (MS)
      Missouri Community Service Commission (MO)
      Center of Effort LLC (MO)
      Montana Education Partnership (MT)
      Boulder Elementary School (MT)
      New Generation for a New World (NJ)
      New Jersey Campus Compact (NJ)
      Operation Grow Inc. (NJ)
      Rider University (NJ)
      Campus Compact of NY & PA (NY)
      Grandma's Love Inc. (NY)
      Hobart and William Smith Colleges/Geneva 2030 (NY)
      Wagner College (NY)
      GenerationNation (NC)
      Ladies of Purpose Social Group Inc. (NC)
      North Carolina Campus Compact (NC)
      North Carolina Service Learning Coalition (NC)
      Northern Marianas College (MP)
      John Carroll University Center for Service & Social Action (OH)
      Ohio Campus Compact (OH)
      The Hero Within You Network (OH)
      Oklahoma AmeriCorps (OK)
      Camp Fire Central Oregon (OR)
      Campus Compact of Oregon (OR)
      Ecumenical Ministries of Oregon: Northeast Emergency Food Program
    (OR)
      Drexel University School Improvement Project (OR)
      Drexel University Lindy Center for Civic Engagement (OR)
      My New Journeys (PA)
      University of Pennsylvania Netter Center for Community Partnerships
    (PA)
      Blackstone Academy (RI)
      Carter County Drug Prevention (TN)
      Carter County Drug Prevention/Keep Carter County Beautiful (TN)
      Volunteer Tennessee (TN)
      CAVALRY (TX)
      City of Houston Volunteer Initiative Programs Office (TX)
      El Paso Community College (TX)
      Student Advocacy Coalition (TX)
      The Leaders Readers Network (TX)
      Sunrise High School (UT)
      FYR is LIT (VI)
      EDGE Consulting Partners (VA)
      Independent Consultant K (VA)
      OccupyFaith (WA)
      Washington Campus Compact (WA)
      Volunteer Center of Racine County (WI)

                                     ______

          Prepared Statement of College on Problems of Drug Dependence
        Thank you for the opportunity to submit testimony in support of the
    National Institute on Drug Abuse (NIDA). The College on Problems of
    Drug Dependence (CPDD), a membership organization with over 1000
    members, has been in existence since 1929. It is the longest standing
    group of scholars in the U.S. addressing problems related to substance
    use disorders. CPDD serves as an interface among government, industry
    and academic communities maintaining liaisons with regulatory and
    research agencies as well as education, treatment, and prevention
    facilities in the substance use disorder field.
        In the Fiscal Year 2022 Labor, Health and Human Services
    Appropriations bill we request that the subcommittee include the
    President's requested level of $51 billion for the National Institutes
    of Health (NIH), including no less than $46.1 billion for NIH's base
    program level budget. In addition, we greatly appreciate the President
    Budget's recognition of the need to significantly increase our nation's
    investment in the National Institute on Drug Abuse (NIDA) and its
    response to the opioid epidemic. The President's Fiscal 2022 Budget
    recommends a $372.2 million increase in NIDA's budget, a 25 percent
    increase. We strongly encourage the Subcommittee to include the
    President's recommended funding level of $1.852 billion for NIDA in the
    Senate version of the Fiscal Year 2022 Labor, Health and Human Services
    Appropriations bill.
        We also respectfully request the inclusion of the following NIDA
    specific report language.
        Opioid Initiative. The Committee continues to be concerned about
    the opioid overdose epidemic and appreciates the important role that
    research plays in the various federal initiatives aimed at this crisis.
    The Committee is also aware of the most recent data from the Centers
    for Disease Control and Prevention that shows opioid overdose
    fatalities increasing from 2018 to 2019, with the primary driver being
    the increased overdose deaths involving synthetic opioids, primarily
    illicitly manufactured fentanyls. To combat this crisis the Committee
    has provided within NIDA's budget no less than $270,295,000 for the
    Institute's share of the HEAL Initiative and in response to rising
    rates of stimulant use and overdose, the Committee has included
    language expanding the allowable use of these funds to include research
    related to stimulant use and addiction.
        Methamphetamine and Other Stimulants. The Committee is concerned
    that, according to data released by the Centers for Disease Control and
    Prevention, 32,000 overdose deaths involved drugs in the drug
    categories that include methamphetamine and cocaine in 2019, an
    increase of over 700%. The sharp increase has led some to refer to
    stimulant overdoses as the ``fourth wave'' of the current drug
    addiction crisis in America following the rise of opioid-related deaths
    involving prescription opioids, heroin, and fentanyl-related
    substances. Methamphetamine is highly addictive and there are no FDA-
    approved treatments for methamphetamine and other stimulant use
    disorders. The Committee continues to support NIDA's efforts to address
    the opioid crisis, has provided continued funding for the HEAL
    Initiative, and supports NIDA's efforts to combat the growing problem
    of methamphetamine and other stimulant use and related deaths.
        Barriers to Research. The Committee is concerned that restrictions
    associated with Schedule I of the Controlled Substance Act which
    effectively limits the amount and type of research that can be
    conducted on certain Schedule I drugs, especially opioids, marijuana or
    its component chemicals and new synthetic drugs and analogs. At a time
    when we need as much information as possible about these drugs and
    antidotes for their harmful effects, we should be lowering regulatory
    and other barriers to conducting this research. The Committee
    appreciates NIDA's completion of a report on the barriers to research
    that result from the classification of drugs and compounds as Schedule
    I substances including the challenges researchers face as a result of
    limited access to sources of marijuana including dispensary products.
        COVID Pandemic and Impact on Substance Use Disorders. The Committee
    is acutely aware of the risks that the ongoing COVID-19 pandemic poses
    to individuals with substance use disorders. According to the Centers
    for Disease Control and Prevention, drug overdose deaths accelerated
    during the pandemic which saw over 81,000 drug overdose deaths in the
    United States in the 12 months ending in May 2020, the highest number
    of overdose deaths ever recorded in a 12-month period. Moreover,
    research supported by the National Institute on Drug Abuse found that
    individuals with substance use disorders are at increased risk for
    COVID-19 and its more adverse outcomes. The Committee commends NIDA for
    conducting research on the adverse impact of the pandemic on SUDs and
    encourages the Institute to expand its research on these issues.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment. Education is a critical
    component of any effort to curb drug use and addiction, and it must
    target every segment of society, including healthcare providers
    (doctors, nurses, dentists, and pharmacists), patients, and families.
    Medical professionals must be in the forefront of efforts to curb the
    opioid crisis. The Committee continues to be pleased with the NIDAMED
    initiative, targeting physicians-in-training, including medical
    students and resident physicians in primary care specialties (e.g.,
    internal medicine, family practice, and pediatrics). NIDA should
    continue its efforts in this area, providing physicians and other
    medical professionals with the tools and skills needed to incorporate
    substance use and misuse screening and treatment into their clinical
    practices. The Committee recommends that NIDA increase its support for
    the education of scientists and practitioners to find improved
    prevention and treatments for substance use disorders as the Institute
    has done for the COVID-19 pandemic.
        Marijuana Research. The Committee is concerned that marijuana
    policies on the federal level and in the states (medical marijuana,
    recreational use, etc.) are being changed without the benefit of
    scientific research to help guide those decisions. NIDA is encouraged
    to continue supporting a full range of research on the health effects
    of marijuana and its components, including research to understand how
    marijuana policies affect public health.
        Electronic Cigarettes. The Committee understands that electronic
    cigarettes (e-cigarettes) and other vaporizing equipment are
    increasingly popular among adolescents, and requests that NIDA continue
    to fund research on the use and consequences of these devices.
        In addition, we request the following report language within the
    Office of the Director account:
        The HEALthy Brain and Child Development (HBCD) Study. The Committee
            recognizes and supports the NIH HEALthy Brain and Child
            Development Study, which will establish a large cohort of
            pregnant women from regions of the country significantly
            affected by the opioid crisis and follow them and their
            children for at least 10 years. This knowledge will be critical
            to help predict and prevent some of the known impacts of pre-
            and postnatal exposure to drugs or adverse environments,
            including risk for future substance abuse, mental disorders,
            and other behavioral and developmental problems. The Committee
            recognizes that the HBCD Study is supported in part by the NIH
            HEAL Initiative, and NIH Institutes, Centers, and Offices
            (ICOs), including OBSSR, ORWH, NIMHD, NIBIB, NIMHD, NIEHS,
            NICHD, NINDS, NIAAA, NIMH, and NIDA, and encourages other NIH
            ICOs to support this important study.
        Substance use disorders (SUD) are costly to Americans; it ruins
    lives, while tearing at the fabric of our society and taking a
    financial toll on our resources. Over the past three decades, NIDA-
    supported research has revolutionized our understanding of SUD as a
    chronic, often-relapsing brain disease -this new knowledge has helped
    to correctly emphasize the fact that SUD is a serious public health
    issue that demands strategic solutions.
        NIDA supports a comprehensive research portfolio that spans the
    continuum of basic neuroscience, behavior and genetics research through
    medications development and applied health services research and
    epidemiology. While supporting research on the positive effects of
    evidence-based prevention and treatment approaches, NIDA also
    recognizes the need to keep pace with emerging problems. We have seen
    encouraging trends in strategies to address these problems, but areas
    of continuing significant concern include the recent increase in
    fatalities due to heroin and synthetic fentanyl, as well as continued
    illicit use of prescription opioids. Our knowledge of how drugs work in
    the brain, their health consequences, how to treat people with SUDs,
    and what constitutes effective prevention strategies has increased
    dramatically due to research. However, because the number of
    individuals who are affected is still rising, we need to continue the
    work until this disease is both prevented and eliminated from society.
        We understand that the FY2022 budget cycle will involve setting
    priorities and accepting compromise, however, in the current climate we
    believe a focus on substance use disorders deserves to be prioritized
    accordingly. Thank you for your support for the National Institute on
    Drug Abuse.
                                     ______

        Prepared Statement of the Congressional Fire Services Institute
        Dear Chair Murray and Ranking Member Blunt,
        On behalf of the nation's fire and emergency services, we write to
    urge your support for a vital program addressing the health and safety
    of our nation's firefighters. As you consider the Fiscal Year (FY) 2022
    Labor, Health and Human Services, Education, and Related Agencies
    Appropriations bill, we urge you to fully fund the National Firefighter
    Registry at the authorized level of $2.5 million. We very much
    appreciate the program being funded at this level in FY2021 and we ask
    that it be maintained this year.
        During the 115th Congress, both the House and Senate unanimously
    approved the Firefighter Cancer Registry Act (P.L. 115-194). The
    bipartisan legislation created a specialized national registry to
    provide researchers and epidemiologists with the tools and resources
    needed to improve research collection activities related to the
    monitoring of cancer incidence among firefighters.
        Studies have indicated a strong link between firefighting and an
    increased risk of several major cancers. However, certain studies
    examining cancer risks among firefighters have been limited by the
    availability of important data and relatively small sample sizes that
    have an underrepresentation of women, minorities, and volunteer
    firefighters. As a result, public health researchers are unable to
    fully examine and understand the broader epidemiological cancer trends
    among firefighters. The National Firefighter Registry is an important
    resource to better understand the link between firefighting and cancer,
    potentially leading to better prevention and safety protocols.
        Thank you for your consideration, and your continued leadership and
    support for America's fire and emergency services.
        Sincerely,

        Congressional Fire Services Institute
        International Association of Arson Investigators
        International Association of Fire Chiefs
        International Association of Fire Fighters
        International Fire Service Training Association
        International Society of Fire Service Instructors
        National Fallen Firefighters Foundation
        National Fire Protection Association
        National Volunteer Fire Council

        [This statement was submitted by Michaela Campbell, Director of
    Government Affairs, Congressional Fire Services Institute.]
                                     ______

      Prepared Statement of the Consortium of Social Science Associations
        On behalf of the Consortium of Social Science Associations (COSSA),
    I offer this written testimony for inclusion in the official committee
    record. For fiscal year (FY) 2022, COSSA urges the Committee to
    appropriate:
      --$46.1 billion for the National Institutes of Health;
      --$10 billion for the Centers for Disease Control and Prevention,
            including $200 million for the National Center for Health
            Statistics;
      --$500 million for the Agency for Healthcare Research and Quality;
      --$800 million for the Bureau of Labor Statistics;
      --At least $700 million for the Institute of Education Sciences; and
      --$151.4 million for the Department of Education's International
            Education and Foreign Language programs.
        First, allow me to thank the Committee for its long-standing,
    bipartisan support for scientific research. Strong, sustained funding
    for all U.S. science agencies is essential if we are to make progress
    toward improving the health and economic competitiveness of the nation.
    As you know, the need for increased investment in science has become
    even more pronounced by the disruptions caused over the past year by
    the COVID-19 pandemic.
                         national institutes of health
        COSSA joins more than 360 organizations in support of $46.1 billion
    for the National Institutes of Health (NIH) in FY 2022. COSSA
    appreciates the Subcommittee's leadership and its long-standing
    bipartisan support of NIH, especially during difficult budgetary times.
    However, recent public health events continue to underscore the need
    for additional investment.
        To be truly transformative, NIH will need to continue to embrace
    research from a wide range of scientific disciplines, including the
    social and behavioral sciences. The Office of Behavioral and Social
    Sciences Research (OBSSR), housed within the Office of the NIH
    Director, coordinates basic, clinical, and translational research in
    the behavioral and social sciences in support of the NIH mission, and
    co-funds highly rated grants in the behavioral and social sciences in
    partnership with individual institutes and centers. Unfortunately,
    OBSSR's budget has been held roughly flat for several years despite the
    sizable increases to the NIH budget. Knowledge about contagion and
    social influences on health are needed now more than ever. In addition,
    understanding behavioral influences on health is needed to battle the
    leading causes of morbidity and mortality, namely, obesity, heart
    disease, cancer, AIDS, diabetes, age-related illnesses, accidents,
    substance abuse, and mental illness. We urge the Senate to emphasize
    support for OBSSR and encourage NIH to increase the Office's budget in
    FY 2022.
                   centers for disease control and prevention
        COSSA urges the Subcommittee to appropriate $10 billion for the
    Centers for Disease Control and Prevention (CDC), including $200
    million for CDC's National Center for Health Statistics (NCHS). Social
    and behavioral science research plays a crucial role in helping the CDC
    carry out its mission by informing the CDC's behavioral surveillance
    systems, public health interventions, and health promotion and
    communication programs that help protect Americans and people around
    the world from disease. One needs only to look at the varied responses
    across different communities to COVID-19 guidance and policies
    surrounding social distancing, mask-wearing, and vaccination to
    understand the critical role understanding the social aspects of public
    health plays in keeping Americans safe and healthy. As the Department
    of Health and Human Services' principal statistical agency, NCHS
    produces data on all aspects of our health care system, including
    opioid and prescription drug use, maternal and infant mortality,
    chronic disease prevalence, health care disparities, emergency room
    use, health insurance coverage, teen pregnancy, and causes of death. As
    a result of the rising costs of conducting surveys and years of flat or
    near-flat funding, NCHS has had to focus nearly all of its resources on
    continuing to produce the high-quality data that communities across the
    country rely on to understand their health. Additional funding would
    allow NCHS to respond to rising costs, declining response rates, and an
    ever-more complex health care system and capitalize on opportunities
    surrounding advances in statistical methodology, big data, and
    computing to produce better information more quickly and efficiently,
    while reducing the reporting burden on local data providers.
                   agency for healthcare research and quality
        COSSA urges the Subcommittee to appropriate $500 million for the
    Agency for Healthcare Research and Quality (AHRQ), which would allow
    AHRQ to rebuild portfolios terminated as a result of years cuts and
    expand its research and training portfolio to address our nation's
    pressing and evolving health care challenges. AHRQ funds research on
    improving the quality, safety, efficiency, and effectiveness of
    America's health care system. It is the only agency in the federal
    government with the expertise and explicit mission to fund research on
    improving health care at the provider level (i.e., in hospitals,
    nursing homes, and other medical facilities). Its work is
    complementary--not duplicative--of other HHS agencies and requires
    robust support, especially given the critical role hospitals and group
    care settings have played in the COVID-19 pandemic.
                           bureau of labor statistics
        COSSA urges the Subcommittee to appropriate $800 million for the
    Bureau of Labor Statistics (BLS) for its core programs. BLS produces
    economic data that are essential for evidence-based decision-making by
    businesses and financial markets, federal and local officials, and
    households faced with spending and career choices. The BLS, like every
    federal statistical agency, must modernize in order to produce the gold
    standard data on jobs, wages, skill needs, inflation, productivity and
    more that our businesses, researchers, and policymakers rely on so
    heavily. The requested funding level would allow BLS to continue to
    support evidence-based policymaking, smart program evaluation, and
    confident business investment.
                        institute of education sciences
        COSSA requests at least $700 million for the Institute of Education
    Sciences (IES) in FY 2022. Within the Department of Education, IES
    supports research and data to improve our understanding of education at
    all levels, from early childhood and elementary and secondary
    education, through higher education. Research further examines special
    education, rural education, teacher effectiveness, education
    technology, student achievement, reading and math interventions, and
    many other areas. IES-supported research has improved the quality of
    education research, led to the development of early interventions for
    improving child outcomes, generated and validated assessment measures
    for use with children, and led to the establishment of the What Works
    Clearinghouse for education research, highlighting interventions that
    work and identifying those that do not. With increasing demand for
    evidence-based practices in education, adequate funding for IES is
    essential to support studies that increase knowledge of the factors
    that influence teaching and learning and apply those findings to
    improve educational outcomes.
             international education and foreign language programs
        The Department of Education's International Education and Foreign
    Language programs play a major role in developing a steady supply of
    graduates with deep expertise and high-quality research on foreign
    languages and cultures, international markets, world regions, and
    global issues. COSSA urges a total appropriation of $151.4 million
    ($134.3 million for Title VI and $17.1 million for Fulbright-Hays),
    which would help make up for lost investment and purchasing power over
    many years of flat-funding. In addition to broadening opportunities for
    students in international and foreign language studies, such support
    would also strengthen the nation's human resource capabilities in
    strategic areas of the world that impact our national security and
    global economic competitiveness.
        Thank you for the opportunity to present this testimony on behalf
    of the social and behavioral science research community.

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

         Prepared Statement of the Council of Academic Family Medicine
        The member organizations of the Council of Academic Family Medicine
    (CAFM) are pleased to submit testimony on behalf of programs under the
    jurisdiction of the Health Resources and Services Administration (HRSA)
    and the Agency for Healthcare Research and Quality (AHRQ). CAFM
    collectively includes family medicine medical school and residency
    faculty, community preceptors, residency program directors, medical
    school department chairs, and research scientists. We urge the
    Committee to appropriate (1) at least $125 million for the HRSA Primary
    Care Training and Enhancement (PCTE) program and (2) at least $500
    million for AHRQ, specifically funding $5 million to AHRQ's Center for
    Primary Care Research.
        More than 44,000 primary care physicians will be needed by 2035;
    however, current primary care production rates will not meet demand,
    according to the authors of Annals of Family Medicine (Petterson, et al
    Mar/Apr 2015). The PTCE programs and AHRQ research enhance our nation's
    workforce and health infrastructure, creating better health outcomes
    and lower costs.
    Primary Care Training and Enhancement--Title VII
        The PCTE Program (Title VII, Section 747 of the Public Health
    Service Act) has a long history of funding training of primary care
    physicians. As experimentation with new or different models of care
    continues, departments of family medicine and family medicine residency
    programs will rely further on Title VII, Section 747 grants to help
    develop curricula and research training methods for transforming
    practice delivery. Future training needs include: training in new
    clinical environments that include integrated care with other health
    professionals (e.g. behavioral health, care coordination, nursing, oral
    health); development and implementation of curricula to give trainees
    the skills necessary to build and work in inter-professional teams that
    include diverse professions; and development and implementation of
    curricula to develop leaders and teachers in practice transformation.
        We are concerned that the President's FY2022 Budget did not include
    additional funding for the Primary Care Training and Enhancement
    program. Additional funding for the PCTE program can help address many
    of the failings and flaws of the current primary health care and public
    health infrastructure that have been identified in the COVID-19
    pandemic. For example, additional funding is needed for both
    residencies and departments to help address faculty retention, public
    health competencies, recruit and retain students into primary care,
    develop new, innovative curriculum related to the pandemic and to
    address segmented primary care workforce to reduce delivery system
    division and increase full scope primary care providers.
        A 2021 report by The National Academy of Science, Engineering and
    Medicine (NASEM) on Implementing High-Quality Primary Care: Rebuilding
    the Foundation of Health Care, identified the problems with under-
    funding Title VII programs finding that despite the demonstrably better
    patient outcomes that have resulted from Title VII investments, Title
    VII funding remains only a tiny fraction of the total GME funding;
    reduced to less than 10% since the 1960s. Primary care training grants
    under Title VII are vital to the continued development of a workforce
    designed to care for the most vulnerable populations, including
    concerns related to health equity.
        We urge your continued support for this program and an increase in
    funding levels to $125 million in FY 2022 to allow for a robust
    competitive funding cycle to fund new initiatives to help address
    issues related to the COVID-19 pandemic, and a shortage of primary care
    providers. An example of the type of program supported by the PCTE
    program was the Danbury and Griffin Hospital programs in Connecticut
    who used it to develop innovative programs and curricula related to
    interdisciplinary training.
    Agency for Health Care Research and Quality (AHRQ)
        Primary care clinical research (PCR) is a core function of AHRQ.
    Primary care research includes: translating science into patient care,
    better organizing health care to meet patient and population needs,
    evaluating innovations to provide the best health care to patients, and
    engaging patients, communities, and practices to improve health. AHRQ
    has proved to be uniquely positioned to support best practice primary
    care research and to help disseminate the research nationwide. However,
    reduced levels of AHRQ funding in the past have exacerbated disparities
    in funding primary care research. Important primary care research
    initiatives have been unfunded in recent years such as research for
    patients with Multiple Chronic Conditions (MCC) and the statutorily
    authorized Center for PCR.
        AHRQ is in a unique position to further PCR as well as the
    implementation science to identify how to deploy new knowledge into the
    hands of primary care providers and systems in communities. However,
    more funding, above FY2021 levels, is needed to accomplish these goals.
    For this reason, we are supporting additional overall funding increases
    for FY 2022 to $500 million as well as specific funding for the Center
    for Primary Care Research of $5 million to help coordinate and direct
    primary care research funding at AHRQ. We hope additional funding will
    continue and expand the following goals: (1) development of clinical
    primary care research and researchers (2) real-world application of
    evidence, (3) the process of practice and health system transformation,
    (4) how high functioning primary care systems and practices should
    look, (5) how primary care practices serving rural and other
    underserved populations adapt and survive, while expanding their
    ability to address health inequities, and (6) how health extension
    systems serve as connectors of research institutions with practices and
    communities.
    President's FY2022 Budget Request for AHRQ
        The recently released Fiscal Year 2022 Budget request includes a
    major, new primary care initiative at AHRQ totaling $10 million. The
    Congressional Justification (CJ) for AHRQ, reminds Congress that ``AHRQ
    is the only PHS agency that supports clinical, primary care research
    which includes translating science into patient care and better
    organizing health care to meet patient and population needs.''
        We support the CJ's assertion that ``primary care research is
    critical to AHRQ's mission to make health care safer, higher quality,
    more accessible, equitable, and affordable.'' We are also pleased that
    the primary care initiative discussed in the CJ would support the work
    of practice-based research networks (PBRNs.) In order to fulfill the
    promise of this initiative, we recommend a related initiative--that at
    least $5 million of the amount Congress provides to AHRQ be directed to
    the statutorily authorized Center for Primary Care Research within the
    Agency. This would support the needed coordination and prioritization
    of primary care research investments within AHRQ, as two recent
    national studies have recommended.
    Two Recent National Studies Support this Funding Request
        In 2020, the RAND Corporation published a report appropriated by
    Congress and commissioned by AHRQ that assessed federally funded PCR
    since 2012 regarding gaps and to recommend improvements. The report
    emphasized the significant role AHRQ plays in PCR. RAND made several
    recommendations, including to provide targeted funds to create a proper
    hub for federal PCR. This is important because PCR is a distinct
    science that differs from health services research. With $5 million in
    dedicated funds for PCR, AHRQ could prioritize and coordinate
    investments in PCR directly improving the health and wellbeing of
    Americans. In 2021, The NASEM report on High Quality Primary Care
    concurs with RAND's assessment on the importance of targeted funding
    for PCR and recommends prioritization of funding for AHRQ's Center for
    Primary Care Research.
        A real-world example of successful AHRQ work supporting primary
    care practice and patient safety is funding to the Oregon Health &
    Science University, the Rural Practice-based Research Network helped
    lead Healthy Hearts Northwest by recruiting 100 primary care practices
    to develop team-based quality improvement infrastructure improvements
    in small to medium-size practices. The Evidence Now Initiative operated
    as health extension agents in Oregon's frontier communities. In another
    example, AHRQ funding has allowed the University of Missouri to build
    infrastructure for patient-centered outcomes research in three arenas.
    The first study evaluated the advantages and disadvantages of
    endovascular vs. open surgery for legs with inadequate blood flow. The
    second project focused on improved discharge plans from skilled nursing
    facilities through improved primary care connections. Missouri
    partnered with the AAFP to create a national research network to
    improve chronic pain for the third project.
        In conclusion, we support increased funding for AHRQ at the level
    of $500 million for FY 2021 which would support important primary care
    and health services research efforts. We also support $5 million in new
    funding for the Center for Primary Care Research. CAFM looks forward to
    working with the Subcommittee to protect HRSA primary care programs and
    AHRQ--both entities enhance our nation's primary care workforce and
    infrastructure.
                                     ______

             Prepared Statement of the Covenant House International
        Dear Chairwoman Murray and Ranking Member Blunt:
        Covenant House is the largest charitable organization in North and
    Central America housing and serving children and youth facing
    homelessness including survivors of human trafficking. Every year, we
    reach tens of thousands of young people in 33 cities in six countries:
    The United States, Guatemala, Honduras, Mexico, Nicaragua, and Canada.
    Since our founding, we have reached more than 1.5 million children and
    youth. Our high-quality programs are designed to empower young people
    to overcome adversity, today and in the future.
        Covenant House strongly supports the Runaway and Homeless Youth and
    Trafficking Prevention Act (RHYTPA) administered by HHS's ACF and
    McKinney-Vento Act's Education for Homeless Youth program (ECHY)
    administered by Department of Education, which have both proven to be
    effective in addressing child and youth homelessness. Covenant House is
    requesting significant investment increases in these main federal
    programs reaching children and youth facing homelessness.
        Across our 23 U.S. communities which currently benefit from these
    programs, in FY20:
      --9,300 youth were served through street outreach programs. 7,400
            youth were served in residential programs and 6,400 youth were
            reached in drop-in centers and non-residential programs.
      --49 percent of youth served by Covenant House across the United
            States reported a mental health diagnosis, nearly 50 percent
            had not yet completed high school, and 33 percent have a
            history of foster care.
      --Over 80% of youth served were of young people of color, including
            Black/African American and Latino. And based on our
            groundbreaking research reported out in 2018:
        --1 in 5 of youth interviewed reported being survivors of
                trafficking, and
        --22% of youth interviewed were offered money for sex on their
                first night experiencing homelessness.
        In addition to meeting basic needs, RHYTPA provides youth with
    housing stability and the necessary supports of mental health
    counseling, employment and training, education, and physical health
    services-needed to ensure youth remain stable, health and connected to
    caring adults. EHCY grants provide school stability and support to
    proactively mitigate the risk of homelessness--more critical than ever
    as schools recover from COVID. Covenant House also supports the Runaway
    and Homeless Youth's Street Outreach program to outreach and engage
    youth who are in unsafe living conditions.
        Covenant House has received $4.8 million in RHYTPA grants since
    2017 in regular grants and $861,000 from the CARES Act emergency
    funding. While this funding has been critical to our network
    maintaining services, the overall annual Runaway and Homeless Youth
    program does not have nearly enough resources to meet the demand in the
    field. Last year, there were 545 applications to the program but only
    179 awards granted (less than 33 percent). The vast majority of these
    applications scored at the highest level and were worthy of funding if
    resources were available. As a result of this unmet demand, RHYA
    programs often turn away thousands of youth each year due to lack of
    available beds, leaving these children vulnerable without safe and
    stable housing and increasing their risk of predation and harm.
        As for EHCY, even prior to the COVID-19 pandemic, the U.S.
    Department of Education reported record numbers of youth homelessness
    in the 2018-2019 academic year, with more than 1.4 million youth
    experiencing homelessness. The COVID-19 pandemic has only exacerbated
    this issue. With only a quarter of school districts receiving support
    through the EHCY program in a given year, it is clear that homeless
    children and youth are still under-identified and face significant
    barriers to school enrollment and education continuity.
        The President's FY22 budget requested $145 million for RHYTPA
    consolidated programs, including the Street Outreach Program.
      --Covenant House is joining with our coalition partners in requesting
            $300 million for RHYTPA to meet the basic safety and housing
            needs of youth experiencing or at risk of homelessness.
        The President's FY22 budget requested level funding at $106 million
    for the McKinney-Vento Education for Homeless Children and Youth Act
    program.
      --Covenant House is joining with our coalition partners in requesting
            $300 million for EHCY.
        For additional information please contact Lori Maloney, SVP of
    Advocacy at Covenant House, at lmaloney@covenanthouse.org or Sally
    Schaeffer, consultant, at sally@uncorkedadvocates.com.

        [This statement was submitted by Kevin Ryan, President and CEO,
    Covenant House International.]
                                     ______

         Prepared Statement of the Creutzfeldt-Jakob Disease Foundation
        Chairwoman Murray, Ranking Member Blunt, and Members of the
    Subcommittee:
        We appreciate the opportunity to submit this testimony in strong
    support for funding of the crucial prion disease work being undertaken
    by the Centers for Disease Control and Prevention in partnership with
    public health agencies around the country and the National Prion
    Disease Pathology Surveillance Center (NPDPSC). We request
    Congressional support in increasing the Prion Disease Surveillance
    appropriation through the CDC, Emerging and Zoonotic Infectious
    Diseases, by $1 million, for a total of $7.5 million.
    Overview
        Creutzfeldt-Jakob Disease (CJD), is a rare,100% fatal, degenerative
    brain disease that causes rapidly progressive dementia. CJD is
    transmissible and presently has no treatment or cure. Approximately 1
    in 6,200 individuals will die from this disease in their lifetime;
    however, the unreported and undiagnosed number of cases remains
    unclear.
        CJD is caused by the presence of an abnormal ``prion'' protein in
    the brain and is known as a prion disease. CJD/prion disease
    surveillance receives modest support through the Centers for Disease
    Control and Prevention (CDC). We need your support to strengthen and
    continue the coordination of CJD and other prion disease surveillance
    activities and to assure the safety of the American public.
    Variant CJD (vCJD), and Bovine Spongiform Encephalopathy (BSE)
        One form of this disease in humans, variant CJD (vCJD), is known to
    be caused by ingesting tissues in beef contaminated with Bovine
    Spongiform Encephalopathy (BSE), commonly known as ``mad cow'' disease.
    The most recent U.S. case of variant CJD was announced in 2013 and
    confirmed by the National Prion Disease Pathology Surveillance Center
    (NPDPSC) in 2014. Limited BSE testing by the USDA adds another layer to
    the already deepening concerns regarding possible risks to humans. In
    recent years, the USDA has decreased random testing for BSE from 40,000
    to 25,000 tests per year (12,719 tests in 6 months, or 1 test per 3,302
    live cows). Hence, surveillance of BSE in this country is largely
    dependent on demonstrating the lack of transmission to humans through
    human disease surveillance. The vCJD case identified by NPDPSC in 2014
    exemplifies the persistent risk for vCJD acquired in unsuspected
    geographic locations and highlights the need for continuing prion
    disease surveillance and awareness to prevent further dissemination of
    vCJD. The two most recent cases of vCJD in Europe are believed to be
    due to occupational exposure and several cases of vCJD have been
    transmitted between individuals via blood transfusions. Hence, vCJD
    risk is not confined to eating contaminated food.
    Chronic Wasting Disease (CWD)
        Emerging laboratory data show that Chronic Wasting Disease (CWD), a
    naturally occurring prion disease of deer and elk, could potentially
    transmit to humans and other mammals, posing a new threat to public
    health. Human surveillance through brain tissue examination is the only
    way to definitely diagnose human prion diseases, determine their
    origin, and determine whether the spread of CWD found in elk and deer
    in 26 states in the U.S. and in 3 Canadian provinces has become a human
    risk. A study in progress has shown that CWD was transmitted to
    macaques (primates that are genetically similar to humans) by feeding
    them contaminated deer meat. Unlike the BSE outbreak in cattle, CWD
    prions are highly infectious and the disease transmits by contact and
    through contaminated environment, including soil and plants, in free
    ranging animals. Additionally, multiple lines of experimental evidence
    indicate that sheep and cows are susceptible to CWD. Since CWD has been
    proven to cross several species barriers, this opens up the possibility
    of oral transmission to humans as well, either directly by eating
    contaminated venison or indirectly through infected domestic animals.
    Continued prion disease surveillance, particularly through examination
    of human brain tissue, is imperative to evaluate whether CWD has or can
    spread to humans.
        The NPDPSC, funded by the CDC and located at Case Western Reserve
    University in Cleveland, Ohio, is our line of defense against the
    possibility of an undetected U.S. human prion disease epidemic as
    experienced in the United Kingdom.
        Prion disease surveillance is funded at $6.5 million/year. That
    figure has increased by just $500,000 over the past six years, despite
    increasing costs of surveillance. Expenses have since risen for the
    resources required to perform adequate surveillance such as increasing
    number of cases as expected by the aging American population,
    increasing autopsy costs over time, screening for COVID19, and taking
    extra precautions necessary for COVID19. Without an increase in funding
    commensurate with these increased expenses, surveillance will be
    compromised.
    Request:
        We ask for Congressional support in increasing prion disease
    surveillance's appropriation by $1 million, for a total of $7.5
    million. This would allow the NPDPSC to meet increasing autopsy costs
    and continue to develop more efficient detection methods while
    providing an acceptable level of prion surveillance. Reduction of
    funding or maintaining static funding to the NPDPSC would eliminate an
    important safety net to U.S. public health, making the U.S. the only
    industrialized country lacking prion surveillance, which in turn would
    jeopardize the export of U.S. beef. The increase in funding would allow
    the NPDPSC to expand its scope to address the growth in CWD among deer
    and elk, and explore whether CWD could spread to humans. Additionally,
    increasing prion disease surveillance in the U.S. increases
    surveillance at the national (CDC) and state (state public health
    departments) levels, which has been severely affected by competing
    concerns within the CDC division (e.g., COVID19).
    Background:
        The NPDPSC is funded entirely by the CDC from funds allocated by
    Congress. The CDC traditionally keeps approximately half of the
    appropriation for national surveillance projects and funding prion
    disease surveillance at the state level.
        Increasing the appropriation from $6.5M to $7.5M will allow the
    NPDPSC to persist and continue to develop more efficient detection
    methods while providing an acceptable level of prion disease
    surveillance. Acceptable national surveillance is not possible at a
    lower level of funding. The requested $1M addition to the appropriation
    (total of $7.5M) would enable the NPDPSC to maintain appropriate
    surveillance, tissue collection, diagnostics and diagnostic test
    development of prion disease cases from CWD endemic states to determine
    whether CWD is transmissible to humans and if so, to what extent this
    poses to public health (e.g., transmission risks from human to human).
        The National Prion Disease Pathology Surveillance Center is the
    only laboratory based organization in the U.S. that monitors human
    prion diseases and is able to determine whether a patient acquired the
    disease through the consumption of prion contaminated beef (``mad cow''
    disease) or meat from elk and deer affected by chronic wasting disease
    (CWD).
        The NPDPSC also monitors all cases in which a prion disease might
    have been acquired by infected blood transfusion, from the use of
    contaminated surgical instruments, or from contaminated human growth
    hormone. Because standard hospital sterilization procedures do not
    completely inactivate prions that transmit the disease, these incidents
    put a number of patients under unnecessary risk and require costly
    replacement of contaminated surgical equipment.
        The NPDPSC also plays a decisive role in resolving suspected cases
    or clusters of cases of food-acquired and medically transmitted prion
    disease that are often magnified by the media, stirring intense public
    alarm. To date, the NPDPSC has examined over 7,500 suspected incidents
    of suspected prion diseases and has definitely confirmed presence and
    type of prion disease in more than 4,600 cases.
        The NPDPSC is the primary line of defense in safeguarding U.S.
    public health against prion diseases because the U.S., unlike other BSE
    affected countries such as the UK, the European Union, and Japan, does
    not have a sufficiently robust animal prion disease surveillance
    system.
        The NPDPSC offers assurances, to countries that import (or are
    considering importing) meat from the United States, that the U.S. is
    free of indigenous human cases of ``mad cow'' disease. In the past,
    South Korean and Chinese health officials resumed importation of U.S.
    beef to their country after a visit to the NPDPSC provided assurances
    regarding rigorous human prion surveillance.
        Since its inception in 1997, the NPDPSC has collected and stored
    over 7,500 brains and many more samples of cerebrospinal fluid from
    cases of suspected prion disease, making it the largest prion disease
    biobank in the world. Increased funding is required to continue to
    preserve these precious specimens for future international research
    efforts as well as to serve as reference materials to evaluate
    potential emerging prion diseases (e.g., chronic wasting disease).
        Thank you for the opportunity to submit this testimony.

        [This statement was submitted by Deborah R. Yobs, President/
    Executive Director, Creutzfeldt-Jakob Disease Foundation.]

                                     ______

                 Prepared Statement of Crowley Amanda Peel deg.
                   Prepared Statement of Amanda Peel Crowley
        Madam Chairwoman,
        It is an honor to provide testimony to the Subcommittee on behalf
    of the thousands of children across the country who have had their
    lives turned upside down by Childhood Post-Infectious Neuroimmune
    Disorders, or CPINDs. These medical conditions develop after illnesses
    and are thought to reflect a misguided immune system and inflammatory
    response to infection.
        I ask that the Committee consider providing language in the
    Committee's fiscal year 2022 report under the Department of Health and
    Human Services, Office of the Director, Multi-Institute Research Issues
    account, directing the National Institutes of Health (NIH) to identify
    research priorities for CPINDs, including PANDAS and PANS, and to
    investigate these disorders across disciplines, including neurobiology,
    neurology, immunology, rheumatology, infectious disease, and mental
    health. We are also asking that NIH report to the Committee on the
    incidence, causes, diagnostic criteria, and treatment of these
    conditions, especially including ways to advance understanding and
    improve clinical care. This year, there is an urgent need to better
    understand post-infectious conditions because of COVID-19 and for NIH
    to prioritize and fund CPINDs' research.
        In 2020, the world woke up to the notion of post-infectious
    complications as we witnessed the impact of COVID-19 in daily reports
    of patients with chronic and delayed-onset symptoms. Growing research
    data has confirmed the association of debilitating psychiatric and
    neurological symptoms with the SARS-CoV-2 virus in both adults and
    children. A significant number of children have developed neurological
    symptoms with COVID-19 infection, including altered mental status. New
    research describing late-developing psychiatric changes, including
    anxiety, OCD, and aggression, in children following COVID-19 infection
    concludes that SARS-CoV-2 should in fact be considered in the
    differential diagnosis of a CPIND known as Pediatric Acute-onset
    Neuropsychiatric Syndrome (PANS). The time has come to connect the
    dots--it is more than clear that infections lead to neurological and
    psychiatric symptoms. Robust research is under way, and we ask for
    CPINDs to be included. We firmly believe that investigations into the
    mechanism of CPINDs will have a far-reaching impact.
        Children with CPINDs experience the onset of debilitating
    neuropsychiatric and behavioral disorders following illness such as
    influenza, ``strep throat,'' and COVID-19. Studies indicate that
    misdirected antibodies and immune cells assault structures in a region
    of the brain involved in emotion, cognition, and movement. It is not
    surprising that, as in well-described types of autoimmune encephalitis,
    the symptoms signal dysfunction is this same brain region.
        Two neuroimmune conditions, Pediatric Autoimmune Neuropsychiatric
    Disorders Associated with Streptococcal Infections (PANDAS) and
    Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), were described
    in 1998 and 2010, respectively. PANDAS is believed to be a variation of
    rheumatic fever. Rheumatic fever can develop if streptococcal
    infections are not treated properly, setting off an immune response
    where antibodies and immune cells attack the heart, kidneys, joints, or
    brain. The term PANS was developed as a broader diagnosis than PANDAS,
    with the same symptoms arising from infections other than strep. These
    disorders are often misdiagnosed as purely psychiatric, and early
    opportunities to treat medically, by targeting the underlying
    infections, inflammation, and immune dysfunction, are missed or delayed
    leading to escalating severity and associated costs.
        Families like mine are blindsided when children's personalities
    completely change, and our kids are suddenly overcome by crippling
    fears, obsessive thinking, compulsive behaviors and tragically,
    suicidal thoughts. Some children are unable to separate from parents
    and many cannot attend school, or even leave the house. When children
    are unable to participate in school, they often experience learning
    impairments and significant academic declines. Previously successful
    students now need special education services, including aides to
    support their learning and behavior. Children who previously wrote
    legibly have such serious declines that they are no longer able to hold
    a pencil. Some children are beset by severe motor and vocal tics
    leading to further educational and social challenges. There is no part
    of life that escapes unscathed.
        There are other serious physical consequences to illness in these
    children. Some, as young as four or five, suddenly appear anorexic,
    restricting their eating to near starvation because of worries about
    contaminated food or fear of choking. In extreme cases, children have
    to be placed on feeding tubes.
        Children experience massive mood swings and fly into aggressive
    rages, full of irrational explosive anger. Even seven- or eight-year-
    old children can become suicidal, with an obsessive feeling that they
    have to die. Several children have ended their lives, and many others
    have been hospitalized when their symptoms become serious or life-
    threatening.
        All three of my children have PANDAS, and our family's journey is,
    sadly, typical. Their stories illustrate the need for standardized
    clinical care and for accurate early diagnosis and education concerning
    risks to children and the many burdens on families, schools, and health
    care systems.
        My two older children acquired multiple misdiagnoses as their
    behaviors and symptoms worsened over years. We finally arrived at the
    true cause of their illness: an undiagnosed, untreated strep infection,
    the same bacteria that causes a sore throat. When they received medical
    treatment, they showed improvements far beyond traditional psychiatric
    therapies.
        My children also exemplify the contrast between early diagnosis and
    misdiagnosis. My youngest child was treated successfully when her
    symptoms were new, but my oldest children have suffered more serious
    complications and required more extensive treatment. They have lost
    critical time between the onset of their symptoms and medical
    intervention that they cannot completely regain.
        With delays in diagnosis and care, children are at risk for further
    decline and potential long-term disability as their brain inflammation
    remains untreated. As symptoms escalate, the burden on families,
    healthcare systems, and schools grows exponentially. Caregivers endure
    significant lost work time and out-of-pocket medical costs. Insurers
    pay for emergency room visits and inpatient treatment, as well as
    ongoing pharmacological and behavioral treatment to manage unlivable
    symptoms. Educational systems face an enormous financial burden when
    putting special education services into place for children who need
    increased academic and behavioral support.
        There is a significant lack of NIH funding to support research into
    these disorders and to understand their true cost and prevalence. To
    date, the avenues for identifying, treating, and tracking post-
    infectious neuroimmune patients are minimally developed. Only through
    targeted research can we determine why some children develop
    psychiatric symptoms after infection, find diagnostic biomarkers, and
    demonstrate which treatments are most effective. We cannot achieve this
    alone. Action needs to be taken by NIH to increase funding for research
    into the causes and treatments of these conditions.
        This year my family faced not only the ongoing trauma of PANDAS,
    but the horrors of COVID-19, first-hand. My father, who was in good
    health, was diagnosed last August and just weeks later was fighting for
    his life. He continues his long road to recovery, 10 months later. Like
    my children, the lasting damage was not done by the infection itself,
    but by the immune response. If we knew how to recognize and treat this
    complication early, we would have vastly different outcomes, not just
    for COVID-19 patients but for the thousands of children not in the
    spotlight who have CPINDs.
        I want my family's experience with these devastating post-
    infectious conditions to help other families who are suffering. SARS-
    CoV-2 highlights both a pressing need and an opportunity for
    collaborative research across disciplines to better understand how
    neuropsychiatric complications develop and to find tools and treatments
    for early diagnosis and treatment. The world has rallied medicine and
    science in an unprecedented way this year. Let us also widen the scope
    to continue work on CPINDs, including PANDAS and PANS. The time to act
    is now--funding research will be a vital next step for the health of
    our country and the future of our children. Parents are doing all we
    can to support our children. Won't you please join with us to help
    solve this nationwide health crisis?

        [This statement was submitted by Amanda Peel Crowley, Founding
    Member,
    Massachusetts Coalition for Pans/Pandas Legislation.]
                                     ______

                Prepared Statement of the Cure Alzheimer's Fund
        Chairwoman Murry, Ranking Member Blunt, and members of the Senate
    Labor, Health & Human Services, Education, and Related Agencies (LHHSE)
    Appropriations Subcommittee, I am Tim Armour, President and CEO of Cure
    Alzheimer's Fund. I want to thank Congress for past funding for
    Alzheimer's disease research at the National Institutes of Health
    (NIH), and to submit this written testimony to respectfully request at
    least an additional $289 million in Fiscal Year 2022 above the final
    enacted amount for Fiscal Year 2021 for Alzheimer's disease research at
    the NIH. Additionally, Cure Alzheimer's Fund respectfully requests at
    least $560 million in total appropriations for the Brain Research
    through Advancing Innovative Neurotechnologies (BRAIN) Initiative. The
    BRAIN Initiative is playing an increasingly important imaging role in
    the early detection and diagnosis of Alzheimer's disease.
        Cure Alzheimer's Fund is a national nonprofit, based in
    Massachusetts, that funds research with the highest probability of
    preventing, slowing, or reversing Alzheimer's disease. Since its
    founding more than 15 years ago, Cure Alzheimer's Fund has invested
    more than $126 million in research through 530 grants in twenty-one
    states.
        With the sustained commitment this Subcommittee has shown to
    Alzheimer's disease research at NIH, targeted investments into basic
    research made by private organizations such as Cure Alzheimer's Fund,
    have been leveraged into larger-scale research projects at NIH. An
    analysis by Cure Alzheimer's Fund found that the close to $17 million
    it invested in research in 2018, led to an additional investment of
    close to $121 million by NIH in the next two years. This shows the
    importance of continued and sustained investment for the Alzheimer's
    disease research portfolio at NIH because discoveries happening today
    will need to be funded in the future.
    https://curealz.org/wp-content/uploads/2020/11/PV_Cure_Leverage_Annual
            AppealInsert_R5V1.pdf
        Without the ongoing commitment demonstrated by this Subcommittee,
    investments made by private organizations, and the discoveries spurred
    by these investments, would not be able to be further explored,
    examined, and validated. The public-private partnership between groups
    like Cure Alzheimer's Fund and NIH is vital to Alzheimer's disease
    research because Cure Alzheimer's Fund can target investment in novel
    research ideas, allow researchers to collect initial data and
    strengthen their hypothesis, and then ``hand-off'' the project to NIH
    for larger-scale investment and research that is beyond the scope of
    Cure Alzheimer's Fund. The robust research portfolio at NIH allows this
    continuum of research to continue and thrive.
        Two concrete examples of this are the brain lymphatic system and
    the role of the innate immune system in the development of Alzheimer's
    disease. As I described in my written testimony last year, as far back
    as 2010, Cure Alzheimer's Fund has supported research into the beta-
    amyloid protein and its role in fighting infection. This was a novel
    research concept that was not receiving federal support. However,
    because of the investment made by Cure Alzheimer's Fund, the role of
    the innate immune system and infection are now NIH research targets.
        As Dr. Francis Collins, Director of the NIH, mentioned at a House
    LHHSE Subcommittee NIH hearing on March 4, 2020, one of the most
    promising areas of Alzheimer's disease research is the role of the
    innate immune system in the development of Alzheimer's disease.
        NIH has convened meetings (September 23-24, 2019) around the topic
    of infection and viruses in the development of Alzheimer's disease.
    This would not have happened without early investment in research and
    the availability of larger-scale research funding made possible by this
    Subcommittee.
    https://curealz.org/news-and-events/abeta-may-have-beneficial-function-
            as-part-of-the-innate-immune-system/
    https://www.nia.nih.gov/about/naca/january-2020-directors-status-report
        In the past, I have also highlighted the work of Dr. Jonathan
    Kipnis and the role of the brain lymphatic system, and I want to again
    highlight this research as an example of the importance of basic
    research supported by Cure Alzheimer's Fund becoming a larger research
    project at NIH.
        In 2016, Cure Alzheimer's Fund supported research by Dr. Kipnis and
    the role of Meningeal Lymphatics in cleansing the brain.
    https://curealz.org/research/foundational-genetics/the-role-of-
            meningeal-lymphatics-in-cleansing-the-brain-implications-for-
            alzheimers-disease/
    Cure Alzheimer's Fund's commitment to this research has continued while
    the research has also been supported by NIH. NIH recently highlighted
    this research in a press release at the end of April. Or five years
    after Cure Alzheimer's Fund made its initial investment.
    https://www.nia.nih.gov/news/brains-waste-removal-system-may-offer-
            path-better-outcomes-alzheimers-therapy
        Without Cure Alzheimer's Fund's first investment in 2016, and NIH's
    larger-scale investment after that, this research would not have been
    able to have been pursued so thoroughly. And this would not have been
    possible without the sustained and continued commitment to Alzheimer's
    disease research funding at NIH demonstrated by this Subcommittee.
        As Cure Alzheimer's Fund continues to invest in research into novel
    research targets, there are more opportunities for NIH to be able to
    provide larger-scale research funding to help us better understand the
    pathology of Alzheimer's disease.
        Cure Alzheimer's Fund has supported research by Dr. Caleb Finch
    into the role pollution and particulate matter play in the development
    of Alzheimer's disease. The first investment Cure Alzheimer's Fund made
    into this research was in 2014.
    https://curealz.org/research/translational-research/air-pollution-and-
            app-processing/
        Last year, the National Academies of Sciences, Engineering, and
    Medicine had a day-long symposium on Advancing the Understanding of
    Chemical Exposures Impact Brain Health and Disease. Dr. Finch was a
    presenter during this symposium.
    https://www.nap.edu/read/25937/chapter/1
        NIH is now supporting this research and it is becoming increasingly
    important to not only Alzheimer's disease research, but environmental
    justice research as well. We know that disadvantaged communities
    experience higher rates of Alzheimer's disease; research like Dr.
    Finch's is helping to identify environmental drivers like air-borne
    pollutants.
        Cure Alzheimer's Fund is supporting research into vascular
    contributors to the development of Alzheimer's disease; African
    Americans have higher risk of neurovascular issues that are risk
    factors for Alzheimer's Disease as well as medical conditions of
    concern in and of themselves.
    https://curealz.org/research/amyloid/the-role-of-picalm-in-vascular-
            clearance-of-amyloid-b-and-neuronal-injury/
    https://curealz.org/research/foundational-genetics/neurobiological-
            basis-of-cognitive-impairment-in-african-americans-deep-
            phenotyping-of-older-african-americans-at-risk-of-dementia/
        This is important research for both the understanding of
    Alzheimer's disease and reducing health disparities for disadvantaged
    communities. With sustained and continued support from this
    Subcommittee, Cure Alzheimer's Fund will be able to continue to invest
    in basic research knowing that NIH will have the necessary resources to
    be able to provide larger-scale investment into these important
    research topics.
        Thank you for your continued support of Alzheimer's disease
    research, and for the opportunity to submit this written testimony and
    to respectfully request at least an additional $289 million above the
    final enacted level in Fiscal Year 2021 for Fiscal Year 2022 for
    Alzheimer's disease research at NIH, and at least $560 million in total
    appropriations for the BRAIN Initiative. Cure Alzheimer's Fund has
    worked closely with the Subcommittee in the past and looks forward to
    being your partner as we work toward Alzheimer's disease research
    having the necessary resources to end this awful disease.
        Respectfully Submitted June 24, 2021.

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

    Prepared Statement of Dave Purchase Project, the North American Syringe
        Exchange Network, Tacoma Needle Exchange, and Coalition Partners
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee, my name is Dr. Paul LaKosky and I serve as the Executive
    Director of Dave Purchase Project, the North American Syringe Exchange
    Network (NASEN), and the Tacoma Needle Exchange in Tacoma, Washington.
    I am pleased to submit testimony on behalf of these organizations and
    as a member of a large coalition of public health, HIV, viral
    hepatitis, and harm reduction organizations to urge Congress to
    appropriate $120 million for the Infectious Diseases and the Opioid
    Epidemic program at the Centers for Disease Control and Prevention
    (CDC) at the Department of Health and Human Services (HHS) to save
    lives and address the overdose crisis by supporting and expanding
    access to syringe services programs (SSPs).
        Named in honor of its late, pioneering founder, Dave Purchase, Dave
    Purchase Project houses the nation's first legal syringe services
    program, created in 1988 at the height of the HIV epidemic in the
    United States. The program seeks to stop the spread of bloodborne
    pathogens, such as HIV and hepatitis C, among people who use drugs and
    to reduce the harm to individuals and communities associated with drug
    use. Although initially intended to address the spread of HIV, Dave
    Purchase Project now provides national leadership in its response to
    the opioid crisis. It also facilitates syringe services in Tacoma and
    throughout Pierce County, Washington.
        Dave Purchase Project also houses the North American Syringe
    Exchange Network (NASEN). In 1992, NASEN formed to support syringe
    services programs (SSPs) and to expand the network of organizations and
    individuals that advocate for these life-saving programs. NASEN is the
    first and largest supplier of low-cost harm reduction resources in the
    US. In 2020, NASEN acquired and distributed approximately $18 million
    in harm reduction resources to the approximately 400 SSPs in the US,
    Puerto Rico, and the US Virgin Islands. NASEN also provided support
    valued at $25,000 to 28 newly emerging and/or struggling SSPs through
    start-up grant packages. As the Executive Director of these
    organizations, I am familiar with providing direct services to people
    who use drugs in Washington State, and with the significant gaps and
    need for resources and services nationwide.
        The United States is experiencing an urgent and unprecedented drug
    overdose crisis, with approximately 100,000 overdose deaths expected to
    be counted in 2020 and potentially more in 2021. This would be an
    increase of more than 40% over the previous record year of 2019.
    According to the Washington State Department of Health, overdose deaths
    accelerated in 2020, increasing by 38% in the first half of 2020 as
    compared to the first half of 2019.
        Overdose deaths have increased more dramatically among Black people
    and communities of color. From 2015 to 2018, overdose deaths among
    African Americans more than doubled (by 2.2 times) and among Hispanic
    people increased by 1.7 times while increasing among white, non-
    Hispanic people by 1.3 times. In Washington State, the increase in
    overdose deaths was highest among groups already dealing with
    inequitable health outcomes: American Indian/Alaska Natives, Hispanic/
    Latinx, and Black people. While overdose deaths affect all racial and
    ethnic groups, American Indian and Alaskan Native (AI/AN) populations
    are disproportionately impacted in Washington State. The death rate
    among AI/AN is more than 3 times the rate of overdose in the state (9.6
    per 100,000). Preliminary 2019 data suggest that this pattern is
    continuing, with AI/AN having the highest opioid overdose death rate
    among all race/ethnic groups. (Washington State Opioid Overdose
    Prevention Data Brief: DOH 971-043 October 2020.)
        SSPs are an essential component of preventing overdose deaths.
    Tacoma Needle Exchange provides sterile syringes, which helps prevent
    the spread of infectious diseases such as HIV, as well as services such
    as opioid overdose prevention and awareness training, naloxone training
    and distribution, wound care, and referrals for medication assisted
    treatment and other medical and social services. Our outreach staff
    meets people where they are and helps them address their needs in the
    safest and healthiest way possible, free of judgement and stigma.
        The following is but one example of what we do, and why we do it.
    On Saturday, August 24, 2019, Tacoma Needle Exchange participated in an
    event sponsored by the Pierce County Recovery Coalition. At this event
    we conducted opioid overdose reversal trainings and distributed free
    Narcan, a nasal version of naloxone (a drug which reverses an opioid
    overdose), to any individual who requested it. Approximately 1 month
    later, at another community event, I was approached by an individual
    who had attended the August event. He told me that as he was driving
    home the night of the 24th, just after the event, when he stopped for
    gas. As he was filling his car, a panicked woman came out of the gas
    station and stated that someone had overdosed in the restroom. He ran
    to the restroom and using the training and naloxone we had given him
    just 2 hours earlier, saved the life of that individual. He stated how
    grateful he was to us for providing him with the tools to save a life.
        SSPs are the most effective way to get naloxone into the hands of
    people who use drugs and who are most likely to be at the scene of an
    overdose. In 2019/2020, our team distributed approximately 18,000 doses
    of naloxone and 1,259 overdose reversals were reported back to us (and
    many more occurred that went unreported). People who use drugs are
    essential partners in preventing overdose fatalities and are best
    reached by SSPs. In fact, more than 99% of the reported overdose
    reversals were performed by laypersons--other drug users, family
    members, friends, bystanders--not by first responders. With additional
    resources, SSPs can reach more people with naloxone, which would help
    reduce the dramatically increasing number of overdose deaths.
        Congress must respond to the overdose crisis, as well as work to
    prevent and reduce infectious diseases related to drug use, such as HIV
    and hepatitis C, by supporting and expanding access to SSPs. Infectious
    diseases associated with opioid and other drug use have dramatically
    increased across the U.S. Since 2010, the number of new hepatitis C
    infections has increased by 380%. Outbreaks of viral hepatitis and HIV
    among people who inject drugs continue to occur nationwide. The CDC has
    documented over 30 years of studies that show that SSPs reduce overdose
    deaths and infectious diseases transmission rates as well as increase
    the number of individuals entering substance use disorder treatment.
    These studies also confirm that SSPs do not increase illicit drug use
    or crime and save money.
        SSPs are among the only health care services trusted and used by
    people who use drugs and so can effectively engage this highly
    stigmatized population. SSPs help protect the community (including
    first responders) by ensuring safe disposal of syringes, reducing rates
    of infectious diseases, and can help providing a pathway to effective
    mental health and substance use treatment and other medical care.
        Unfortunately, the nation has insufficient access to SSPs and the
    COVID-19 pandemic has decreased access to these life-saving services
    when the need for services has increased dramatically. In January 2021,
    Drug Policy Alliance conducted a survey of SSPs that showed that 91% of
    respondents experienced an increase in clients in 2020, many as a
    result of the COVID-19 pandemic. During this time of skyrocketing need,
    42% of respondents experienced funding cuts in 2020 and expect such
    shortfalls to continue in 2021. In response to funding shortfalls, many
    SSPs have been forced to lay off staff and reduce services.
    Consequently, because of decreased and limited resources, SSPs cannot
    reach the millions of people who may benefit from their life-saving
    services.
        Federal funding would expand access to critical and effective SSP
    programs. NASEN's own data show that there are only approximately 400
    SSPs operating nationwide. Experts estimate that to sufficiently expand
    access to SSP programs, the U.S. would require at least 2,000
    programs--5 times the number in existence now. NASEN routinely provides
    program support packages with essential harm reduction supplies to
    organizations wishing to start SSPs. We consistently have a wait list
    of 25-30 organizations seeking assistance, no matter how many support
    packages we distribute.
        A recent study that assessed the startup costs of an individual
    program estimated that it would cost (in 2020 dollars) $490,000 for a
    small rural program and $2.1 million for a large urban program,
    resulting in an average start-up cost of $1.3 million per program.
    Based on these numbers, the requested funding could provide modest
    increases to currently operating SSPs to help address funding
    shortfalls and help expand the number of SSPs nationwide.
        Finally, expanding access to SSPs would reduce health care costs,
    including for infectious diseases treatment. Hepatitis C treatment can
    cost more than $30,000 per person, while HIV treatment can cost upwards
    of $560,000 per person. Averting even a small number of cases would
    save millions of dollars in treatment costs in a single year.
        The Infectious Diseases and Opioid Epidemic Program at CDC helps to
    eliminate infections related to injection drug-use and improve their
    prevention, surveillance, and treatment. It also strengthens and
    expands access to SSPs. In FY2019, CDC provided technical assistance to
    help ensure high-quality, comprehensive services and best practices for
    SSPs.
        With additional FY22 funding, CDC could significantly expand SSPs
    at this critical time to help prevent overdose deaths, the spread of
    HIV and viral hepatitis, and connect people to life-saving medical
    care. Unfortunately, with just months in office during a historic
    COVID-19 pandemic and lacking a budget director, a director of the
    Office of National Drug Control Policy, and other key officials needed
    to respond to the overdose epidemic, the President's budget has only
    increased funding by $6.5 million. This amount is inadequate to reverse
    the dramatic increase in overdose deaths and to prevent continuing
    outbreaks of HIV and hepatitis. Congress must respond now and
    forcefully to this crisis or more lives will be lost to overdose and
    countless people will continue to contract infectious diseases that
    seriously compromise their personal health as well as the public
    health, creating long-term costs for all.
        Finally, on a personal note, I speak to you as a public health
    researcher and SSP supporter and provider, but also--and more
    importantly--as the older brother of someone who has struggled with
    addiction his entire adult life and recently overdosed on fentanyl, but
    thankfully survived. Over the years I have given him money and I have
    paid his rent. I have purchased him clothes and bought him food. Yes,
    there are days when I just did not have the emotional energy to pick up
    the phone when I knew it was him calling. I admit this sadly and
    shamefully. On those days, and particularly on those days, I am
    thankful for the kind of people who work at syringe services programs.
    They give without expectation of return and without judgement. They
    give when others cannot or will not. It is with this experience and the
    life of my brother in mind that I respectfully urge you to increase
    funding for these life-saving programs.
        Thank you for your time and consideration of my testimony, and
    please do not hesitate to contact me or Jenny Collier at
    jcollier@colliercollective.org if you have questions or need additional
    information.

        [This statement was submitted by Paul LaKosky, Ph.D., Executive
    Director, Dave Purchase Project, the North American Syringe Exchange
    Network.]
                                     ______

             Prepared Statement of the Deadliest Cancers Coalition
        On behalf of the Deadliest Cancers Coalition, a collaboration of
    national nonprofit organizations and industry focused on addressing
    issues related to our nation's most lethal cancers, we submit this
    statement in support of strengthening the federal investment in
    deadliest cancers research conducted and supported by the National
    Institutes of Health (NIH) and the National Cancer Institute (NCI). For
    Fiscal Year 2022, we respectfully request $46.111 billion for the NIH's
    base program budget level, including $7.9 billion for the NCI, as well
    as the funding needed to establish a new Advanced Research Projects
    Agency for Health (ARPA-H) that includes a focus on finding tools to
    help patients diagnosed with one of the deadliest cancers. We further
    request report language in the LHHS bill that continues to hold NCI
    accountable for making progress on the goals and ideals of the
    Recalcitrant Cancer Research Act (RCRA).
        In his address to Congress, President Biden called for an ``end to
    cancer as we know it''. As the national coalition that represents the
    cancers for which we've seen the least amount of progress, we
    wholeheartedly endorse this statement. We deeply appreciate Congress'
    continued strong leadership in support of cancer research through the
    steady increases you have provided to the NIH and NCI over the last six
    years. Funding for the existing components of the NIH and NCI is a
    critical component of making the goal of ``ending cancer'' a reality,
    which is why we have joined with our partners in the One Voice Against
    Cancer Coalition to support the funding requests for NIH and NCI listed
    above.
        We also support President Biden's call for a new ARPA-H that has an
    initial focus on cancer and other diseases for the purpose of driving
    transformational innovation in health research and speeding application
    and implementation of health breakthroughs. As representatives of
    patients who have been diagnosed with our nation's most lethal cancers
    and those who currently have the fewest early detection and treatment
    options available, we believe that ARPA-H has the potential to provide
    a vital bridge between this dearth of effective tools and the improved
    survival rates that are so desperately needed.
        The discussion between physicians and patients diagnosed with a
    deadliest cancer are currently focused on end-of-life instead of
    exploring treatment options that will provide the best quality of life
    and the extension of life. These cancers exemplify areas where medical
    practice would be dramatically changed through the technologies and
    platforms that could be developed under ARPA-H. For these reasons, we
    urge Congress and the Administration to ensure that ARPA-H focuses on
    the hardest problems and areas where medical practice will be
    dramatically changed, including the deadliest cancers, as it develops
    authorizing language.
        We know that this Subcommittee will face many difficult decisions
    as it is developing the FY 2022 Appropriations Bills. As you are
    considering these bills, we further encourage you to structure ARPA-H
    so that no funding is diverted from the core mission and budgets of the
    NIH and NCI, but also allows for true innovation.
        It is also essential that critical stakeholders in the cancer
    community be involved at the earliest outset in the design, structure
    and budget of these endeavors. ``Cancer'' is not one disease, so it is
    therefore vital that stakeholders representing the range of the
    ``cancer experience'' be involved in these efforts. For this reason,
    the Deadliest Cancers Coalition respectfully requests to be involved in
    the process, starting in the initial phase.
        The deadliest cancers offer a powerful example of the need for
    continuing the path of sustained and robust increases for the NIH and
    NCI. While the overall five-year relative survival rate for all cancers
    combined has risen from 50 percent when the War on Cancer was first
    declared in 1971 to 67 percent today, we have seen relatively little
    success in improving survival for the deadliest cancers. Multiple
    myeloma is one of the few ``success'' stories among this group as the
    five-year survival rate was 34 percent when the coalition was founded
    in 2008 and is now 54 percent.
        Next year (2022) will mark the 10-year anniversary of the passage
    of the RCRA, which requires that the NCI develop long-term strategic
    plans for addressing recalcitrant cancers beginning with pancreatic
    adenocarcinoma and small-cell lung cancer. The NCI has made progress in
    implementing the statute, particularly with respect to pancreatic
    adenocarcinoma and small-cell lung cancer. As a result of report
    language in the FY 2020 and FY 2021 LHHS Appropriations bills, NCI will
    undertake a scientific framework process for glioblastomas and
    gastroesophageal cancers and recently issued a notice of intent to
    publish a funding opportunity announcement for a Program on the Origins
    of Gastroesophageal Cancers. It is therefore crucial that Congress
    continue to shine a light on all recalcitrant cancers so they do not
    slip back into the shadows and so progress on implementing the RCRA for
    all of the deadliest cancers continues.
        The Deadliest Cancers Coalition deeply appreciates the inclusion of
    report language focusing on these cancers in years past, including the
    FY 2021 language that reiterated Congress' intention that NCI develop a
    scientific framework using the process outlined in the RCRA for stomach
    and esophageal cancers and directed the NCI to identify future goals
    for each of the deadliest cancers in the fiscal year 2022 CJ.
        We are seeking language in the FY 2022 LHHS Appropriations bills
    that continues to hold NCI accountable to the FY20 and FY21 language
    and the goals and ideals of the RCRA. Given that NCI has been
    responsive, to some degree, when Congress directs them to focus on
    specific cancers, we ask the language identify liver cancer as the next
    focus area. We are asking that the language specifies that the process
    should include cholangiocarcinoma, which is cancer that originates in
    the bile duct, but is grouped together with liver cancer, but want NCI
    to have flexibility on which other liver cancer subtype(s) should be
    included.
        In addition, we continue to believe that it is critical that NCI
    stipulates how it will continue the goals of the RCRA to develop and
    implement strategic plans for the full range of recalcitrant cancers.
    The 2012 legislation was first introduced by Representatives Anna Eshoo
    and Leonard Lance and Senator Whitehouse and gained significant bi-
    partisan support because it was clear that just following ``standard
    procedure'' with respect to recalcitrant cancers was not working and
    there needed to be a specific focus on determining research priorities
    for these diseases. That need has not diminished.
        The Deadliest Cancers Coalition was founded because we believe in a
    future in which there is no form of cancer for which a diagnosis is an
    automatic death sentence. All cancer patients should be able to select
    the best treatment option for them in consultation with their physician
    from a variety of effective treatments. Unfortunately, this year,
    approximately 44 percent of all cancer-related deaths will be due to
    one of the deadliest cancers, which means that we clearly have a long
    road ahead of us before that future is more than a dream. We therefore
    urge the Subcommittee to continue its leadership to ensure that NIH
    receives $46.111 billion for the NIH's base program budget level for FY
    2022, including $7.9 billion for the NCI, as well as the funding needed
    to establish a new ARPA-H that includes a focus on the deadliest
    cancers. We further urge you to continue to hold the Institute
    accountable to making progress on the deadliest cancers through report
    language in the FY 2022 bill.
                                     ______

        Prepared Statement of the Department of Preventive Medicine and
                  Department of Medicine, Infectious Diseases
        Dear Committee Members,
        I am writing in support of a FY 2022 budget request for Department
    of Health and Human Services to develop a national strategy and
    implementation plan for the prevention, control and treatment of Herpes
    Simplex Virus, Types 1 and 2.
        It is a critical public health imperative to address Herpes Simplex
    Virus (HSV), a chronic viral infection that impacts nearly half of
    Black women in our country, disproportionately impacts LGBTQ
    populations, and is a widely recognized driver of the HIV epidemic.
    Approximately 40% of new cases of HIV infection are attributable to
    chronic HSV infection. HSV also kills approximately 1,000 infants
    annually as a result of neonatal herpes which is currently not a
    reportable condition. Additionally, there is a growing body of research
    indicating HSV as a contributing factor to Alzheimer's Disease,
    Encephalitis, Bell's Palsy, among other neurodegenerative diseases.
        There is currently no centralized national strategy to address HSV,
    it is not tracked or routinely tested for, and the majority of spread
    is via asymptomatic carriers unaware of their status. We can and should
    be doing more to stop the spread and provide better treatment to the
    nearly 1 in 3 Americans with this chronic condition.
        If we prioritize women's and maternal health, the health of Black,
    Hispanic, LGBTQ, indigenous and other at-risk communities, we must
    prioritize Herpes Simplex Virus treatment and prevention. If we
    prioritize mental health, biomedical research for incurable diseases
    such as Alzheimer's or HIV, and dismantling systemic racism in
    healthcare, we must also prioritize Herpes Simplex Virus control.
    Addressing HSV addresses all of these national priorities and can
    improve the health, quality of life, and reduce the economic burden for
    millions of Americans.
        Sincerely.

        [This statement was submitted by Jeffrey D. Klausner, MD MPH,
    Clinical
    Professor, Department of Preventive Medicine and Department of
    Medicine,
    Infectious Diseases.]
                                     ______

                       Prepared Statement of Duke Health
        Duke Health (the conceptual integration of the Duke University
    Health System, the schools of Medicine and Nursing, the Private
    Diagnostic Clinic as the independent, multi-specialty physician
    practice, and other health and health research centers across Duke
    University) would like to express appreciation for federal support
    provided to academic health centers across the United States,
    especially during the COVID-19 public health emergency. COVID-19 has
    illustrated how vital the investments from this Subcommittee are for
    strengthening a health care infrastructure in the United States that
    can research and develop new vaccines and therapeutics and provide
    high-quality care to patients at all times.
        Duke Health is committed to conducting innovative basic and
    clinical research, rapidly translating breakthrough discoveries to
    patient care and population health, providing a unique educational
    experience to future clinical and scientific leaders, improving the
    health of populations, and actively seeking policy and intervention-
    based solutions to complex global health challenges. Underlying these
    ambitions is a belief that Duke Health is a destination for outstanding
    people and a dedication to continually explore new ways to help people
    grow, collaborate, and succeed.
        Reflecting Duke Health's mission of ``Advancing Health Together,''
    this written testimony outlines Duke Health's biomedical research and
    health care priorities that represent sound investments in vital
    programs at HHS that make a difference in the lives of patients across
    the United States. Thank you for this opportunity to submit written
    testimony.
                      national institutes of health (nih)
        Duke Health is grateful for Congress' robust investments in NIH,
    which has kept the United States on the cutting edge of new biomedical
    advances. For FY 2022, Duke Health respectfully requests at least $46.1
    billion for the NIH. This represents a $3.177 billion increase over the
    comparable FY 2021 funding level for the NIH, which would allow for the
    NIH's base budget to keep pace with the biomedical research and
    development price index (BRDPI) and allow meaningful growth of 5%.
        At Duke, NIH funding plays a critical role in the advancement of
    research and clinical care. NIH has supported research at the Duke
    Clinical Research Institute, the world's largest academic research
    organization working to improve patient care through innovative
    clinical research; the Duke Human Vaccine Institute, a national and
    international leader in the fight against major infectious diseases and
    home to one of 12 Regional Biocontainment Labs; and the Duke Cancer
    Institute, a top comprehensive cancer center in peer-reviewed research
    support.
        We are grateful for the emergency investments made by Congress over
    the past year to meet historical challenges, and it is critical that we
    continue to build upon the current foundation to sustain and grow our
    nation's research enterprise.
        We also are deeply grateful for the $40 million appropriated to the
    National Institute of Allergy and Infectious Disease for Regional
    Biocontainment Laboratories (RBLs) in the Consolidated Appropriations
    Act, 2021. This investment bolstered the nation's preparedness for
    biodefense and emerging infectious disease agents, including COVID-19,
    as RBLs continue to provide some of the major advancements in
    understanding and combating the coronavirus through the development of
    vaccines, prophylactic and therapeutic treatments, and diagnostic tests
    for SARS-CoV-2 and COVID-19 disease. We respectfully request that RBLs
    be considered for an annual appropriation of $60 million to be shared
    evenly among the 12 RBL research institutions beginning in FY 2022. The
    assays for live virus neutralization for all the monoclonal antibodies
    at Duke are done in the Duke RBL and it is where all live virus
    cultures are done for CoV2 work. Additionally, Duke researchers have
    created a vaccine with the potential to protect against all forms of
    coronavirus that move from animals to humans, now and in the future.
    The new vaccine has been 100 percent effective in non-human tests.
        Finally, Duke Health asks the Subcommittee to not include language
    that would limit the use of nonhuman primates in research that could
    cripple the search for treatments and cures for many human diseases,
    especially therapeutics and vaccines for COVID-19.
                centers for disease control and prevention (cdc)
        The CDC serves as the command center for the nation's public health
    defense system against emerging and reemerging infectious diseases.
    Now, more than ever, investments in the nation's public health
    infrastructure and public health defense systems are critical. Duke
    Health urges the Subcommittee to provide at least $10 billion for the
    CDC in FY 2022. Among the CDC's many programs, the Prevention
    Epicenters Program connects CDC's Division of Healthcare Quality
    Promotion with academic investigators to conduct innovative infection
    control and prevention research. The Duke-UNC Epicenter has
    considerable experience and research expertise in hospital
    epidemiology, infection control, antimicrobial stewardship,
    epidemiologic studies of multidrug-resistant organisms, disinfection,
    and sterilization. In addition, the Duke Infection Control Outreach
    Network (DICON) and Duke Antimicrobial Stewardship Outreach Network
    (DASON) engage over 60 community hospitals in the United States.
              health resources and services administration (hrsa)
        Duke Health appreciates the Subcommittee's continued investment in
    Title VII health professions and training programs and Title VIII
    Nursing Workforce Development programs at HRSA. These programs ensure a
    well-trained pipeline of health professionals to meet the increasing
    health needs facing the United States. For FY 2022, Duke Health
    respectfully requests that the Subcommittee provide $1.51 billion for
    Title VII and VIII programs overall, including $980 million to Title
    VII programs and $530 million to Title VIII programs. Title VII and
    Title VIII are the only federal programs that support education/
    training opportunities for an array of aspiring and practicing health
    professionals, both facilitating career opportunities and bringing
    health care services to rural and underserved communities.
        Duke Health urges the Subcommittee to provide $23 million in FY
    2022 for the National Cord Blood Inventory (NCBI) at HRSA. This program
    is charged with building a genetically and ethnically diverse inventory
    of at least 150,000 new units of high-quality umbilical cord blood for
    transplantation. These cord blood units, as well as other units in the
    inventories of participating cord blood banks, are made available to
    physicians and patients for blood stem cell transplants through the
    C.W. Bill Young Cell Transplantation Program. Cord blood banks
    participating in the NCBI Program, including the Carolinas Cord Blood
    Bank in the Duke University School of Medicine, also make cord blood
    units available for preclinical and clinical research focusing on cord
    blood stem cell biology and the use of cord blood stem cells for human
    transplantation and cellular therapies.
        Blood stem cell transplantation is potentially a curative therapy
    for many individuals with leukemia and other life-threatening blood and
    genetic disorders. Each year, nearly 18,000 people in the U.S. are
    diagnosed with illnesses for which blood stem cell transplantation from
    a matched donor is their best treatment option. Often, the first-choice
    donor is a sibling, but only 30 percent of people have a fully tissue-
    matched brother or sister. For the other 70 percent, a search for a
    matched unrelated adult donor or a matched umbilical cord blood unit
    must be performed. The success of cord blood stem cell therapies in
    treating diseases and alleviating suffering makes an urgent and
    compelling case for funding this program.
        Duke Health respectfully requests the Subcommittee provide $31
    million for the C.W. Bill Young Cell Transplantation Program through
    the NCBI at HRSA in FY 2022. The Carolinas Cord Blood Bank (CCCB) at
    Duke is a member bank of the NCBI of the C.W. Bill Young Cell
    Transplantation Program. The goal of this program is to increase the
    number of transplants for recipients suitably matched to biologically
    unrelated donors of bone marrow and umbilical cord blood. The CCBB is
    one of the largest cord blood banks in the world. Cord blood units that
    are banked at CCBB are listed on the National Marrow Donor Program
    (NMDP) Be the Match(r) Registry, an accumulated listing of donated cord
    blood units from participating banks that are available to provide
    donors for patients needing a hematopoietic stem cell transplant to
    treat cancer or certain genetic diseases.
        Thousands of mothers have donated their cord blood to the CCBB.
    Banked units are comprised of African-American, Hispanic-American,
    Asian-American, and Caucasian samples. This diversity helps patients of
    all racial and ethnic backgrounds find suitable matches for
    transplantation. The CCBB has distributed cord blood units for
    transplantation to several thousand patients since 1999. Cord blood
    recipients of CCBB units include children and adult patients facing
    life-threatening illnesses who need a ``stem cell'' transplant from an
    unrelated donor to provide them with healthy blood cells. Many of these
    patients have been affected by leukemia, lymphoma, severe aplastic
    anemia, or other fatal diseases of the blood or immune system, or
    certain inherited metabolic diseases. In addition to life-saving
    transplants, the CCBB also provides cord blood units for research.
    These units are made available to investigators for critical research
    in the area of cord blood and stem cell biology. The impact of funding
    has far reaching impacts, and Duke Health urges the Subcommittee to
    support this request.
               agency for healthcare research and quality (ahrq)
        Duke Health urges the Subcommittee to provide $500 million for the
    Agency for Healthcare Research and Quality in FY 2022. This funding
    level is consistent with the FY 2010 level adjusted for inflation and
    would allow AHRQ to rebuild portfolios terminated as a result of years
    of past cuts and expand its research and training portfolio to address
    our nation's pressing and evolving health care challenges. As the
    agency that provides funding for health systems research, AHRQ is vital
    to improving health, safety, and health outcomes for patients. AHRQ is
    forward thinking, addressing issues such as data analytics, and is
    providing important resources for healthcare professionals during
    COVID-19.
        Patients with sickle cell disease (SCD), an inherited red blood
    cell disorder, often have intense pain that brings them to hospital
    emergency departments (EDs) for immediate treatment. Their care can be
    fragmented, with frequent hospitalizations and specialist care,
    infrequent follow-up with primary care doctors, and repeat ED visits.
    Funding from AHRQ supports activities at the Duke University School of
    Nursing to improve the care of these patients in the ED department,
    particularly through the development and use of evidence-based decision
    support tools. In addition, 80 to 90 percent of medical center leaders
    at the Private Diagnostic Clinic (PDC), a multispecialty physician
    practice affiliated with Duke Health, reported fewer communications
    breakdowns and better handling of disagreements after using AHRQ's
    TeamSTEPPS(r) team training curriculum.
       substance abuse and mental health services administration (samhsa)
        Duke Health appreciates investments in the National Child Traumatic
    Stress Network (NCTSN) grant program at SAMHSA, especially efforts to
    provide additional funding for this program during COVID-19. For FY
    2022, Duke Health urges the Subcommittee to provide $81.9 million for
    NCTSN.
        NCTSN, which is coordinated by the UCLA-Duke University National
    Center for Child Traumatic Stress, increases access to services for
    children and families who experience or witness traumatic events. This
    unique network of frontline providers, family members, researchers, and
    national partners is committed to changing the course of children's
    lives by improving their care and moving scientific gains quickly into
    practice across the U.S. In recent years, estimates from the NCTSN
    Collaborative Change Project (CoCap) have indicated that each quarter
    about 35,000 individuals--children, adolescents, and their families--
    directly benefited from services through this Network. Since its
    inception, the NCTSN has trained more than one million professionals in
    trauma-informed interventions. Hundreds of thousands more are
    benefiting from the other community services, website resources,
    educational products, community programs, and more. Over 10,000 local
    and state partnerships have been established by NCTSN members in their
    work to integrate trauma-informed services into all child-serving
    systems, including child protective services, health and mental health
    programs, child welfare, education, residential care, juvenile justice,
    courts, and programs serving military and veteran families.
     office of the assistant secretary for preparedness and response (aspr)
        Duke Health requests that the Subcommittee provide $11.5 million,
    full authorized funding, for the Military and Civilian Partnership for
    the Trauma Readiness Grant Program for FY 2022 within ASPR. Originally
    known as MISSION ZERO, this critical program would provide funding to
    ensure trauma care readiness by integrating military trauma care
    providers into civilian trauma centers. These partnerships allow
    military trauma care providers to gain exposure to treating critically
    injured patients in communities and keep their skills sharp to increase
    readiness for deployment. Additionally, they allow civilian trauma care
    providers to gain insight into best practices from the battlefield that
    can be integrated into civilian care. Fully funding this program will
    help to improve the nation's response to public health and medical
    emergencies.
                                     ______

         Prepared Statement of the Dystonia Medical Research Foundation
                summary of recommendations for fiscal year 2022
    _______________________________________________________________________

      --Provide $46.1 billion for the National Institutes of Health (NIH)
            and proportional increases across its Institutes and Centers.
      --Continue dystonia research supported by NIH through the National
            Institute on Neurological Disorders and Stroke (NINDS), the
            National Institute on Deafness and other Communication
            Disorders (NIDCD), and the National Eye Institute (NEI).
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $10 billion to facilitate timely public health
            efforts.
      --Please provide $5 million for the new Chronic Disease Education and
            Awareness Program at CDC.
    _______________________________________________________________________

        Dystonia is a neurological movement disorder that causes muscles to
    contract and spasm involuntarily. It affects men, women and children.
    Dystonia can be generalized, affecting all major muscle groups, and
    resulting in twisting, repetitive movements and abnormal postures or
    focal, affecting a specific part of the body such as legs, arms, hands,
    neck, face, mouth, eyelids and vocal cords. Currently, it is estimated
    that at least 300,000 individuals in North America suffer from
    dystonia, making it more common than Huntington's, muscular dystrophy,
    and ALS. There is no known cure for dystonia.
        In 1967 at the age of 10, I lost the ability to write with either
    hand. Five years later, my father (at the age of 53) and I were
    diagnosed with focal dystonia, affecting our hands, which spasm and
    twist when we attempt to write. My sister, her son, and my daughter
    were later given the same diagnosis. Unlike the others, with every
    passing year, my daughter's dystonia began to affect other regions. By
    19, she was unable to walk or feed herself. Later that year, she
    underwent deep brain stimulation (DBS) surgery which changed her life.
    She was later able to return to and graduate from college and now lives
    a relatively normal and active life.
        I realized at the time of my daughter's diagnosis that I needed to
    do more. I became a clinical trial participant at the NIH and
    volunteered for any studies that could help researchers in finding a
    cure and or better treatments. I also became a passionate advocate for
    dystonia research funding.
          dystonia research at the national institutes of health (nih)
        The Dystonia Medical Research Foundation urges the Subcommittee to
    continue its support for natural history studies on dystonia that will
    advance the pace of clinical and translational research to find better
    treatments and a cure. In addition, we encourage Congress to continue
    supporting NINDS, NIDCD, and NEI in conducting and expanding critical
    research on dystonia.
        Currently, dystonia research at NIH is supported by the National
    Institute of Neurological Disorders and Stroke (NINDS), the National
    Institute on Deafness and Other Communication Disorders (NIDCD), and
    the National Eye Institute (NEI).
        The majority of dystonia research at NIH is supported by NINDS.
    NINDS has utilized a number of funding mechanisms in recent years to
    study the causes and mechanisms of dystonia. These grants cover a wide
    range of research including the genetics and genomics of dystonia, the
    development of animal models of primary and secondary dystonia,
    molecular and cellular studies in inherited forms of dystonia,
    epidemiology studies, and brain imaging. We continue to work with the
    leadership of NINDS on the recommendations stemming from our 2018
    meeting that focused on defining emerging opportunities in dystonia
    research.
        Key findings include 1) noting that the heterogeneity of dystonia
    poses challenges to research and therapy development. 2) There is more
    to be learned from genetic subtypes, along clinical, etiology, and
    pathophysiology axes. 3) In order to facilitate key advancements in
    research technology, there needs to be more research collaboration. 4)
    New research priorities should include the generation and integration
    of high-quality phenotypic and genotypic data. 5) Reproducing key
    features in cellular and animal models, both of basic cellular
    mechanisms and phenotypes, leveraging new research technologies. 6)
    Collaboration is necessary both for collection of large data sets and
    integration of different research methods.
        It is of great significance that a number of dystonia patient
    advocacy group, led by the Dystonia Medical Research Foundation,
    actively took part in the meeting and are working to ensure that
    Congress continues to support robust NIH funding.
        NIDCD and NEI also support research on dystonia. NIDCD has funded
    many studies on brainstem systems and their role in spasmodic
    dysphonia, or laryngeal dystonia. Spasmodic dysphonia is a form of
    focal dystonia which involves involuntary spasms of the vocal cords
    causing interruptions of speech and affecting voice quality. NEI
    focuses some of its resources on the study of blepharospasm.
    Blepharospasm is an abnormal, involuntary blinking of the eyelids which
    can render a patient legally blind due to a patient's inability to open
    their eyelids. We were pleased to see that Congress has encouraged both
    NIDCD and NEI to expand their research into both spasmodic dysphonia
    and blepharospasm.
        We thank the committee for the increase for NIH in fiscal year
    2021. We know firsthand that this will further NIH's ability to fund
    meaningful research that benefits our patients.
             cdc's chronic disease education and awareness program
        We strongly support and thank the Subcommittee for the creation of
    the new Chronic Disease Education and Awareness Program at CDC. This
    critical program would provide a dedicated pool of resources that could
    be deployed to support meritorious public health projects with
    stakeholders. This program seeks to provide collaborative opportunities
    for chronic disease communities that lack dedicated funding from
    ongoing CDC activities. Such a mechanism allows public health experts
    at the CDC to review project proposals on an annual basis and direct
    resources to high impact efforts in a flexible fashion.
                              patient perspectives
    Blepharospasm
        I drive through Atlanta's brutal traffic when suddenly, my eyes
    clamp shut. I pry my left eye open with thumb and forefinger, steer
    with my right hand. My eyes open for a few seconds, then close with no
    warning. What is happening? Over the next few months, these spasms
    progress from eyes to lower face, neck and shoulders. A year later I am
    diagnosed with Dystonia, a debilitating, little-known disease. A
    healthy 49-year-old mother of three, I now fight constant pain; can no
    longer work, drive or perform basic activities. Even walking our dog is
    a dangerous fall risk.
    Spasmodic dysphonia
        Spasmodic dysphonia (SD), a focal form of dystonia, is a
    neurological voice disorder that involves ``spasms'' of the vocal cords
    causing interruptions of speech and affecting voice quality. My voice
    sounds strained or strangled with breaks where no sound is produced.
    When untreated, it is difficult for others to understand me. I receive
    injections of botulinum toxin into my vocal cords every three months
    for temporary relief of symptoms. This has worked well for me for over
    a decade. At the start of this year, my insurance coverage changed when
    my husband's company changed providers. As a result, I had to undergo
    an extensive review process and change methods for obtaining my
    medicine. The review lasted for four weeks. Multiple times during this
    time period, my doctor and I were told that I had been denied coverage.
    We had to make numerous phone calls to encourage the company and
    specialty pharmacy to review my case again and again. These phone calls
    were extremely difficult as my voice deteriorated from the delay in
    treatment. The automated phone systems were the worst, but the
    representatives also had trouble understanding my broken voice and I
    had to repeat my information over and over. Finally, the company
    determined my treatment is medically necessary and has approved it for
    one year. After a seven week delay, I am scheduled for my injection and
    am looking forward to a period of spasm-free speaking.
        We are grateful to those persons who share their stories with the
    DMRF and other dystonia patient groups to help raise awareness of
    dystonia. The DMRF was founded in 1976 and since its inception, the
    goals have remained to advance research for more effective treatments
    of dystonia and ultimately find a cure; to promote awareness and
    education; and support the needs and wellbeing of affected individuals
    and their families.
        Thank you for the opportunity to present the views of the dystonia
    community, we look forward to providing any additional information.

        [This statement was submitted by Carole Rawson, Vice President of
    Public Policy, Dystonia Medical Research Foundation.]
                                     ______

                Prepared Statement of Education Finance Council
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee on Labor, Health and Human Services, Education and Related
    Agencies, Education Finance Council (EFC) is submitting this testimony
    because we have great concerns over the fast-approaching expiration of
    the COVID-19 payment pause on federally-owned student loans and the
    lack of certainty and guidance surrounding the September 30, 2021 date.
    There is speculation about an extension of that pause, and we must be
    cognizant of the herculean task of assisting more than 40 million
    borrowers in transitioning back into repayment. We request that you
    seek such certainty from the U.S. Department of Education (Department)/
    Federal Student Aid (FSA) and require them to provide servicers of
    federally-owned student loans, borrowers, and other stakeholders with
    the date when the COVID-19 payment pause for federally-owned loans will
    end.
        This date certain must come as soon as possible as federal student
    loan servicers need appropriate time to hire and train staff and begin
    communication to borrowers in order to be fully prepared to
    successfully transition borrowers into repayment. The pause, which
    began in March 2020, is currently scheduled to end on September 30,
    2021, and servicers are currently prohibited from communicating with
    affected borrowers regarding entering repayment.
        It is imperative that FSA communicate clearly and consistently, as
    early as possible, with federal student loan servicers, borrowers, and
    all stakeholders about when the COVID-19 payment pause on federally-
    owned student loans will end. Borrowers need to have certainty about
    when their loans will enter repayment, and communication about this
    needs to begin as soon as possible with unified messaging. It all
    begins with the Department/FSA providing servicers, borrowers, and
    other stakeholders certainty of the end of the payment pause date so
    that the information borrowers receive from servicers and other sources
    is consistent.
        This document describes what EFC members that service federally-
    owned student loans must do to help borrowers prepare for the start of
    repayment, ensure a smooth transition, and remain in compliance with
    FSA requirements--a process that takes several months.
                          communication with borrowers
        There are approximately 40 million borrowers that will enter
    repayment when the COVID-19 payment pause for federally-owned student
    loans ends. Outreach to these borrowers must begin many months before
    repayment begins, particularly to those who are at a high risk for
    falling into delinquency when payments resume,\1\ and to borrowers who
    completed undergraduate study during the payment pause and have never
    had to make student loan payments. However, servicers have been
    instructed to temporarily cease communication with borrowers until
    notified differently by the Department. It is critical that servicers
    are allowed to begin this outreach as soon as possible to provide the
    borrowers the information they need to prepare to enter repayment on
    their student loans, especially certainty of the date that repayment
    will begin.
    ---------------------------------------------------------------------------
        \1\ The Department of Education's Congressional Budget
    Justification for Student Aid Administration for Fiscal Year 2022
    acknowledges this risk for certain groups of borrowers:
    ``...approximately 3.9 million borrowers shifted out of delinquency
    status through the government-provided-forbearance. The Department
    acknowledges that these borrowers are at high risk of re-entering
    delinquency, and eventually defaulting, once the payment pause ends. In
    addition, many borrowers who completed undergraduate study during the
    payment pause have never had to make student loan payments at all,
    which could also present special challenges. Further, some Americans
    have experienced unemployment or decreased earnings during the
    pandemic, and as a result, some borrowers who were current on their
    payments prior to the pause may be at higher risk of delinquency.''
    (Department of Education, Congressional Budget Justification for
    Student Aid Administration for Fiscal Year 2022, AA-28).
    ---------------------------------------------------------------------------
        Informing borrowers that they will be entering repayment, when it
    will occur, and what will be required of them as early as possible and
    via as many channels as possible will prevent unnecessary delinquencies
    and default. Borrowers need time to budget and update their accounts.
    For example, borrowers using direct debits need to know as soon as
    possible if the direct debit will be automatically reapplied and the
    amount and date of when the first debit will occur. If it is not
    automatically reapplied, the borrower needs to know when and how to
    reestablish that process long before payment becomes due.
        Furthermore, the pandemic has disrupted the living situation of
    many borrowers, making early outreach more important than ever. Many
    borrowers have experienced changes in their living situations. Some may
    have moved home with parents or relocated due to employment changes or
    for other reasons but may not have updated their contact information
    with servicers. It takes time to find those borrowers and ensure they
    receive the proper notifications. Servicers must comply with
    regulations that dictate how early different types of notices regarding
    repayment and repayments plans must be sent to borrowers, which is an
    impossibility until they are permitted to resume borrower
    communications.
                             staffing and it needs
        Many servicers experienced a reduction in staff during the COVID-19
    pandemic and payment pause period due to attrition and the need for
    fewer employees. Servicers need to begin hiring and training additional
    staff as soon as possible to ensure that borrowers experience a smooth
    transition back into repayment. However, uncertainty about whether the
    payment pause will end on September 30, 2021, as scheduled is delaying
    this process.
        It takes time to locate, hire, train and prepare individuals to
    service federal student loans. This process includes advertising and
    interviewing appropriate candidates, completing federally required
    background checks, completing application for and receiving FSA
    security clearance (a process that can take weeks to months), and
    training of new employees. Federal student loan programs and repayment
    options and rules are very complex and servicing federal student loans
    requires specialized training that can span 4 to 8 weeks, depending on
    the servicer's training process and the employees' position with the
    organization. In most cases, training will need to begin by mid-July to
    be completed in time. Ongoing training occurs with personnel even after
    they are released to communicate with borrowers to ensure they remain
    current with any regulatory or statutory changes that may impact a
    borrower.
        There are also system changes that need to be implemented to get
    millions of accounts back into repayment. This will require IT staff
    time, and servicers need to know as soon as possible when this process
    can begin.
        We appreciate your consideration of this request for timely
    communication to all parties in order to ensure we are collectively
    prepared to best communicate and assist federal student loan borrowers
    as they transition back to active repayment.
        About Education Finance Council (EFC): EFC is the national trade
    association representing nonprofit and state-based higher education
    finance organizations that, as mission-driven, public purpose
    organizations, are dedicated to improving college access, success, and
    affordability in their states and nationwide. EFC members operate as
    loan servicers and supplemental loan originators and provide a wide
    array of college access and student success and support services and
    resources.

        [This statement was submitted by Gail daMota, President, Education
    Finance Council.]
                                     ______

                  Prepared Statement of the Endocrine Society
        The Endocrine Society thanks the Subcommittee for the opportunity
    to submit the following testimony regarding Fiscal Year (FY) 2022
    federal appropriations for biomedical research and public health
    programs. The Endocrine Society is the world's oldest and largest
    professional organization of endocrinologists representing
    approximately 18,000 members worldwide. The Society's membership
    includes basic and clinical scientists who receive support from the
    National Institutes of Health (NIH) for research on endocrine diseases
    that affect millions of Americans, such as diabetes, thyroid disorders,
    cancer, infertility, aging, obesity and bone disease. Our membership
    also includes clinicians who depend on new scientific advances to
    better treat and cure these diseases. The Society is dedicated to
    promoting excellence in research, education, and clinical practice in
    the field of endocrinology. The impact of the coronavirus is a
    compelling illustration of why we must increase funding for the NIH and
    CDC to protect public health. To support necessary advances in
    biomedical research to improve health, the Endocrine Society recommends
    the NIH receive funding of at least $46.1 billion for fiscal year (FY)
    2021; to facilitate the translation of these advances to improve public
    health, the Endocrine Society recommends the Centers for Disease
    Control and Prevention (CDC) receive funding of at least $10 billion;
    and to ensure that women have access to appropriate health services, we
    recommend that the Title X program be funded at $737 million. This
    request does not reflect emergency supplemental funds or new programs
    situated in NIH including the Advanced Research Projects Agency for
    Health proposed by the administration.
                   endocrine research improves public health
        Sustained investment by the United States federal government in
    biomedical research has dramatically advanced the health and improved
    the lives of the American people. The United States' NIH-supported
    scientists represent the vanguard of researchers making fundamental
    biological discoveries and developing applied therapies that advance
    our understanding of, and ability to treat human diseases. Their
    research has led to new medical treatments, saved innumerable lives,
    reduced human suffering, and launched entire new industries.
        Endocrine scientists are a vital component of our nation's
    biomedical research enterprise and are integral to the healthcare
    infrastructure in the United States. Endocrine Society members study
    how hormones contribute to the overall function of the body and how the
    glands and organs of the endocrine system work together to keep us
    healthy. Physiological functions governed by the endocrine system are
    essential to overall wellbeing: endocrine functions include
    reproduction, the body's response to stress and injury, sexual
    development, energy balance and metabolism, and bone and muscle
    strength. Endocrinologists also study interrelated systems, for example
    how hormones produced by fat influence the development of cancer or
    susceptibility to infections.
           endocrine research is supported by numerous nih institutes
        Endocrine diseases and disorders are studied by researchers funded
    by multiple NIH Institutes and Centers (ICs). As such, it is critical
    for NIH to receive a strong base appropriation with proportional
    increases for all ICs. For example:
      --Diabetologists funded by the National Institute of Diabetes and
            Digestive and Kidney Diseases (NIDDK) are advancing knowledge
            of inequities contribute to health disparities in outcomes
            associated with COVID-19.\1\ Despite the critical importance of
            this issue, NIDDK received a much lower increase in funding in
            FY 2021, relative to other ICs.
    ---------------------------------------------------------------------------
        \1\ Ebekozien, O., et al., The Journal of Clinical Endocrinology &
    Metabolism, Volume 106, Issue 4, April 2021, Pages e1755-e1762, https:/
    /doi.org/10.1210/clinem/dgaa920.
    ---------------------------------------------------------------------------
      --Endocrine researchers funded by the National Institute of Aging
            increased our understanding of how hormonal treatment for
            menopause might improve stress responses in women.\2\
    ---------------------------------------------------------------------------
        \2\ https://www.endocrine.org/news-room/press-release-archives/
    2017/treating-menopausal-symptoms-can-protect-against-stress-negative-
    effects Accessed March 11, 2018.
    ---------------------------------------------------------------------------
      --Researchers funded by the Eunice Kennedy Shriver National Institute
            of Child Health and Human Development (NICHD) are discovering
            how hormones influence the gut microbiome, which in turn can
            influence the development of polycystic ovarian syndrome
            (PCOS).\3\
    ---------------------------------------------------------------------------
        \3\ Torres, PJ, et al., The Journal of Clinical Endocrinology &
    Metabolism, jc.2017-02153.
    ---------------------------------------------------------------------------
      --Endocrine oncologists supported by the National Cancer Institute
            (NCI) discovered how certain drugs used during pregnancy can
            contribute to cancer risk in offspring.\4\
    ---------------------------------------------------------------------------
        \4\ https://www.endocrine.org/news-and-advocacy/news-room/featured-
    science-from-endo-2021/drug-used-during-pregnancy-may-increase-cancer-
    risk-in-mothers-adult-children.
    ---------------------------------------------------------------------------
      --National Institute of Environmental Health Science (NIEHS)-funded
            researchers are investigating how chemicals found in cosmetic
            products can disrupt endocrine systems resulting in increased
            cancer risk.\5\
    ---------------------------------------------------------------------------
        \5\ https://endocrinenews.endocrine.org/edc-exposure-during-
    pregnancy-may-reduce-breast-cancer-protection/.
    ---------------------------------------------------------------------------
               nih requires steady, sustainable funding increases
        The Endocrine Society appreciates increases to the NIH budget in
    recent fiscal years; however, the biomedical research community
    requires steady, sustainable increases across the biomedical research
    enterprise in funding to ensure that the promise of scientific
    discovery can efficiently be translated into new cures. Research
    budgets have been further stretched across NIH to drive research to
    help us address the COVID-19 pandemic, and emergency supplemental funds
    have not provided sufficient resources to advance necessary research on
    COVID-19 while also sustaining progress on other national priorities.
    Consequently, NIH grant success rates are predicted to remain close to
    historically low averages, meaning highly skilled scientists will
    continue to spend more time writing highly meritorious grants that will
    not be funded. Young scientists will also continue to be driven out of
    biomedical research careers due to the lack of funding.
     adequate funding of cdc programs is necessary to protect the public's
                                     health
        The CDC plays a critical role in protecting the public's health by
    applying new knowledge to the promotion of health and prevention of
    chronic diseases, including diabetes. The Division of Diabetes
    Translation administers the National Diabetes Prevention Program
    (National DPP), which addresses the increasing burden of prediabetes
    and Type 2 Diabetes in the United States. The National DPP creates
    public and private partnerships to provide evidence-based, cost-
    effective interventions that prevent diabetes in community-based
    settings. Through structured lifestyle change programs at local YMCAs
    or other community centers, individuals with prediabetes can reduce the
    risk of developing diabetes by 58% in those under 60 and by 71% in
    those 60 and older.\6\ In addition to supporting public health and
    prevention activities, CDC's Clinical Standardization Programs in the
    Center for Environmental Health are critical to improving accurate and
    reliable testing of hormones, appropriate diagnosis and treatment of
    disease, and reproduceable public health research. Adequate funding is
    critically important to ensure that CDC has the capacity to address
    existing and emerging threats to public health in the United States and
    around the world.
    ---------------------------------------------------------------------------
        \6\ The Diabetes Prevention Program (DPP) Research Group Diabetes
    Care. 2002 Dec;25(12):2165-71.
    ---------------------------------------------------------------------------
      title x funding provides necessary services and reduces healthcare
                                     costs
        Title X is an important source of funding for ensuring reproductive
    health benefits including both contraceptive and preventive services to
    women. In 2015, a study found that Title X-funded health centers
    prevented 822,000 unintended pregnancies, resulting in savings of $7
    billion to federal and state governments. Offering affordable access to
    contraception can have a measurable impact on these costs. For every
    public dollar invested in contraception, short-term Medicaid
    expenditures are reduced by $7.09 for the pregnancy, delivery, and
    early childhood care related to births from unintended pregnancies,
    resulting in savings of $7 billion to federal and state governments.\7\
    Title X is the main point of care for low income, under- or un-insured,
    adults and adolescents for affordable contraception, cancer screenings,
    sexually transmitted disease testing and treatment, and medically-
    accurate information on family planning options. However, to provide
    these services to the over 4 million people who depend on Title X-
    funded centers, Title X is significantly underfunded.
    ---------------------------------------------------------------------------
        \7\ Frost JJ, et al., Publicly Funded Contraceptive Services at
    U.S. Clinics, 2015, New York: Guttmacher Institute, 2017.
    ---------------------------------------------------------------------------
                       fiscal year 2022 funding requests
        In conclusion, to avoid loss of promising research opportunities,
    allow budgets to keep pace with inflation, support our public health
    infrastructure, and assure high-quality, evidence-based, and patient-
    centered family planning care, the Endocrine Society recommends that
    the Subcommittee provide at least the following funding amounts through
    the FY 2022 Labor, Health and Human Services, Education, and Related
    Agencies appropriations bill:
      --$46.1 billion for the National Institutes of Health
      --$10 billion for the Centers for Disease Control and Prevention
      --$737 million for Title X
                                     ______

           Prepared Statement of the Entomological Society of America
        The Entomological Society of America (ESA) respectfully submits
    this statement for the official record in support of funding for
    vector-borne diseases (VBD) research at the U.S. Department of Health
    and Human Services (HHS). ESA joins the research community by
    requesting $46.1 billion in fiscal year (FY) 2022 for the National
    Institutes of Health (NIH), including increased support for vector-
    borne disease (VBD) research at the National Institute of Allergy and
    Infectious Diseases (NIAID); $10 billion for the Centers for Disease
    Control and Prevention (CDC), including investments in the budgets for
    VBD, global health, and core infectious diseases; and robust funding
    for the Institute of Museum and Library Services (IMLS), including
    $42.7 million for the Office of Museum Services.
        ESA urges the subcommittee to support VBD research programs that
    incorporate the entomological sciences as part of a comprehensive
    approach to addressing infectious diseases. These efforts can help
    mitigate the enormous impact that insect carriers of disease have on
    human health. NIH, the nation's premier medical research agency,
    advances human health by supporting research on basic human and
    pathogen biology and by developing prevention and treatment strategies.
    Cutting-edge research in the biological sciences, including in the
    field of entomology, is essential for addressing societal needs related
    to environmental and human health. Many species of insects and
    arachnids, including ticks and mites, are carriers or vectors of an
    array of infectious diseases that threaten the health and well-being of
    people worldwide. This threat impacts citizens in every U.S. state and
    territory, as well as military personnel serving at home and abroad.
    The mosquitoes that carry and transmit diseases are responsible for
    more human deaths than all other animal species combined, including
    other humans.\1\ VBD can be particularly challenging to manage due to
    insect and arachnid mobility and their propensity to develop pesticide
    resistance. Further, effective preventative treatments, including
    vaccines, are not available for most VBD.
    ---------------------------------------------------------------------------
        \1\ https://www.gatesnotes.com/Health/Most-Lethal-Animal-Mosquito-
    Week.
    ---------------------------------------------------------------------------
        Within NIH, NIAID conducts and supports fundamental and applied
    research related to understanding, preventing, and treating infectious
    diseases. The risk of emerging infectious diseases grows as global
    travel increases in speed and frequency and as environmental conditions
    conducive to population growth of vectors, like mosquitoes and ticks,
    continue to expand globally. Entomological research to understand and
    characterize the relationships between insect vectors and the diseases
    they transmit is essential to enable scientists to reliably monitor and
    predict outbreaks, prevent disease transmission, and rapidly diagnose
    and treat diseases. For example, NIAID-funded researchers are working
    to understand how common prevention tools like mosquito repellent work
    at the molecular level. Although topical mosquito repellents such as
    DEET are a popular tool for preventing mosquito bites and mosquito-
    borne diseases like malaria, the mechanism they use to repel mosquitoes
    is not understood. Using grant funding from NIAID, researchers from
    Johns Hopkins University have determined that DEET is an effective
    mosquito repellent because it masks human odors from female
    mosquitoes.\2\ Researchers can use these findings to develop similar
    safe, low-cost mosquito repellents to prevent mosquito bites, reducing
    the burden of mosquito-borne diseases.
    ---------------------------------------------------------------------------
        \2\ https://www.sciencedirect.com/science/article/abs/pii/
    S0960982219311674.
    ---------------------------------------------------------------------------
        ESA requests robust support for CDC programs addressing VBD and
    support for the Centers of Excellence on VBD as authorized by the Kay
    Hagan Tick Act in 2022 and beyond with at least $10 million per year as
    well as $20 million for the Epidemiology and Laboratory Capacity (ELC)
    program. CDC, serving as the nation's leading health protection agency,
    conducts research and provides health information to prevent and
    respond to infectious diseases and other global health threats. Within
    the core infectious diseases budget of CDC, the Division of Vector-
    Borne Diseases (DVBD) aims to protect the nation from the threat of
    viruses, bacteria, and parasites transmitted primarily by mosquitoes,
    ticks, and fleas. DVBD's mission is carried out by a staff of experts
    in several scientific disciplines, including entomology.
        CDC plays a key role in tracking new and emerging diseases, as well
    as in supporting health care professionals in identifying and
    diagnosing these diseases. From 2016 to 2017, there was a 46% increase
    in reported cases of a group of tick-borne diseases known as spotted
    fever rickettsioses (spotted fevers), which includes the notably fatal
    Rocky Mountain spotted fever (RMSF).\3\ Disability and death from RMSF
    are preventable if the antibiotic doxycycline is administered within
    the first five days of illness: without treatment, 1 in 5 RMSF cases
    lead to death.\4\ Importantly, spotted fevers have non-specific
    symptoms, and fewer than 1% of the spotted fever cases reported in
    2016-2017 had sufficient laboratory evidence for diagnosis. In response
    to this issue, the CDC has created a first-of-its-kind education module
    that will help healthcare providers recognize the early symptoms of
    RMSF and distinguish it from other diseases, enabling affected patients
    to get the life-saving treatment they need as quickly as possible.\5\
    CDC funding is crucial in the development of this and other educational
    tools that equip health care providers to effectively combat tick-borne
    diseases.
    ---------------------------------------------------------------------------
        \3\ https://www.ncbi.nlm.nih.gov/pubmed/?term=30969821.
        \4\ https://www.cdc.gov/media/releases/2019/p0513-rocky-mountain-
    spotted-fever-training.html.
        \5\ https://www.cdc.gov/rmsf/resources/module.html.
    ---------------------------------------------------------------------------
        Using funding appropriated during the 2016 Zika crisis to help
    respond to that emergency and develop the necessary future workforce,
    CDC awarded $50 million to five universities to establish regional
    Centers of Excellence (COE) to address existing and emerging VBD. The
    five centers, for which current funding expires in 2021, generate
    research, education, outreach, and capacity to enable appropriate and
    timely local public health action for VBD throughout the U.S. The COE
    model requires collaboration between the research institutions and the
    local and regional departments of health (DOH), important relationships
    which have not generally arisen organically. This is critical given
    significant regional differences in vector ecology, disease
    transmission dynamics, and resources.
        The Kay Hagan Tick Act also expands authorized support for the ELC
    program, critical to supporting state and local departments of health
    vector surveillance and management. For the last several years, the CDC
    has only been able to fund a third of the $50 million in requests they
    receive from states to meet these needs. ESA supports fully funding the
    $20 million authorized in the Kay Hagan Tick Act to support the ELC
    grants.
        ESA requests robust funding for IMLS, including no less than $42.7
    million for the Office of Museum Services in FY 2022. The services and
    funding provided by IMLS are critical in several areas--research
    infrastructure, workforce development, and economic impact. IMLS
    provides for the expansion of collections capabilities at American
    museums, which are key for the identification, documentation of
    locations, and classification of entomological species. The 21st
    Century Museum Professionals Program provides opportunities for diverse
    and underrepresented populations to become museum professionals,
    expanding participation in an industry with an annual economic
    contribution of $21 billion. Museums are critical to the public
    understanding of science through exhibits and programs, and in so
    doing, support science education as an integral part of the nation's
    educational infrastructure. They also make significant long-term
    contributions to economic development in their local communities.
        Thank you for the opportunity to offer the Entomological Society of
    America's support for NIH, CDC, and IMLS research programs.

        [This statement was submitted by Michelle S. Smith, BCE, President,

    Entomological Society of America.]
                                     ______

                 Prepared Statement of the Epilepsy Foundation
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --Please provide $10 billion for the Centers for Disease Control and
            Prevention (CDC) including:
        --$13 million for the National Center for Chronic Disease
                Prevention and Health Promotion's Epilepsy program, an
                increase of $2.5 million over FY 2021.
        --$5 million for the CDC's National Neurological Conditions
                Surveillance System (NNCSS).
      --Please provide at least $46.1 billion for the National Institutes
            of Health (NIH).
        --Please provide proportional increases for various NIH Institutes
                and Centers, including the National Institute of
                Neurological Disorders and Stroke (NINDS).
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of the
    Epilepsy Foundation and the people with the epilepsies whom we serve.
    Chairwoman Murray, Ranking Member Blunt, and distinguished members of
    the subcommittee, we deeply appreciate the robust investments in
    medical research and public health programs over recent years which are
    helping us better understand and treat the epilepsies and better
    support people with epilepsy and their families day-to-day. As you and
    your colleagues work on appropriations for FY 2022, please continue
    this commitment and provide timely investments in the NIH and public
    health and research programs at the CDC. Thank you for your time and
    for your consideration of these requests.
                         about the epilepsy foundation
        The Epilepsy Foundation is the leading national voluntary health
    organization that speaks on behalf of the approximately 3.4 million
    living with epilepsy and seizures. We foster the wellbeing of children
    and adults affected by seizures through research programs, educational
    activities, advocacy, and direct services.
                              about the epilepsies
        Epilepsy is a disease or disorder of the brain which causes
    reoccurring seizures affecting a variety of mental and physical
    functions. It is a spectrum disease comprised of many diagnoses
    including an ever-growing number of rare epilepsies. There are many
    different types of seizures and varying levels of seizure control.
        3.4 million Americans live with active epilepsy including 470,000
    children and teenagers. Thirty to forty percent of people with epilepsy
    live with uncontrolled seizures despite available treatments. Delayed
    recognition of seizures and inadequate treatment increase a person's
    risk of subsequent seizures, brain damage, disability, and death.
    Epilepsy imposes an annual economic burden of $19.4 billion on the
    country.
    Please provide $10 billion for CDC including $13 million for CDC's
            Epilepsy program.
        The Institute of Medicine's (IOM) report on epilepsy, Epilepsy
    Across the Spectrum: Promoting Health and Understanding, identifies the
    Epilepsy Foundation and the CDC as leaders in addressing many of its
    national recommendations to eliminate stigma, improve awareness and
    education and better connect people with the epilepsies to health and
    community services. The CDC Epilepsy program is the only public health
    program specifically related to epilepsy with a national scope and
    community programs. Focus areas requiring continued and increased
    investment include:
      --In FY 20, 481 law enforcement and first responders, 5,033 school
            nurses, 214,702 school personnel, and 4,071 students have been
            trained on seizure recognition and seizure first aid. On-demand
            training modules are being developed to scale up training of
            these key, frontline community members.
      --10,000 people have been certified in seizure first aid, though more
            focus is needed on rural and ethnically and racially diverse
            communities as nearly 40% of persons diagnosed with epilepsy
            are African American or Hispanic and many people with epilepsy
            in those communities have poorer health outcomes.
      --To improve care in rural and underserved communities, Project ECHO
            has educated more than 400 healthcare providers about managing
            epilepsy, though more focus is needed on management of severe,
            drug-resistant epilepsy and quality of care improvement
            methods.
      --60 community health workers in Texas and Illinois have been trained
            to implement self-management programs resulting in improved
            health outcomes for people with epilepsy. More funding could
            scale up this evidence-based training in other states.
      --By screening and addressing barriers to medication adherence, an
            Epilepsy Learning Healthcare System is reducing healthcare
            utilization and costs.
      --Mental health screenings have been implemented and people with
            epilepsy are being connected to self-management programs that
            prevent and decrease depression since people with epilepsy at
            increased risk for depression and anxiety.
    Testimonials from Participants in CDC Epilepsy Program-Funded Efforts
        Margaret, Fairfield, CT: ``Participating in HOBSCOTCH and learning
    more about epilepsy and the brain helped me realize this diagnosis is
    not something to be afraid or embarrassed of. By facing and dealing
    with my diagnosis head on, I can take control of certain aspects of
    epilepsy and improve my quality of life. HOBSCOTCH taught me strategies
    that I now use every day to improve my memory.''
        Kelsey, Seattle, WA: ``During the 8 weeks that I participated in
    the PACES program, I learned a lot valuable information and had a
    wonderful time meeting other people experiencing similar struggles as
    me. I loved that the program integrated both a personable, solidarity
    like approach while providing evidence-based information with the most
    up to date epilepsy research. Having had epilepsy for over 15 years, I
    thought that I had a strong grasp on most epilepsy topics. However, the
    PACES program brought up different areas which I hadn't considered
    before and I found really useful for personal introspection and to
    share with other people in my life. I believe the PACES program is a
    wonderful opportunity for individuals who both have either been
    recently diagnosed or lived with epilepsy for a long time to share
    their own experiences in a way that might change another person's life
    and to learn important facts about the condition.''
        Nancy Tindell, Geneva County, Alabama: After taking the school
    nurse seizure training program myself in 2020, I strongly encouraged
    all school nurses and school personnel in my county to take the course
    because even I, as a nurse, learned a lot about both seizure types, new
    rescue therapies on the market and more. As a school nurse in a small
    town in Alabama, I am thankful for the support and trainings that
    empower us to support the students with seizures and epilepsy in our
    classroom and extracurricular settings.
        Jon D. Brown, Founder and Chief Advocate, Black Men's Health,
    Tallahassee, FL: We had an opportunity to collaborate with the Epilepsy
    Foundation to not only bring awareness to and educate on the topic of
    Epilepsy, but together we were able to specifically leverage June, as
    Men's Health Month, to focus on a Seizure First Aid Certification
    Training. Throughout virtual discussions with Lowell Evans, who spoke
    on ``Living with Epilepsy While Changing the World,'' and Michael
    Brown, who spoke on ``Are You Certified in Epilepsy First Aid? You
    Should and Can Be,'' I learned so much vital information that provided
    me new-found awareness, information, education, and confidence (key!)
    to act if I am to find myself in the presence of someone having a
    seizure. And, the subsequent training, facilitated by Michael Brown and
    Luis Garcia, emphasized that this scenario might likely happen, as we
    learned that 1 in 10 people will experience a seizure in their
    lifetime. Mind-blowing, life-changing, and potentially life-saving
    information; important conversations that I am committed to continue
    having for broader reach throughout communities of color.
        Fernando A., Columbus, Indiana: Project Uplift was very helpful to
    help my wife understand my daily struggles. It helped me learn ways to
    cope with my anxiety and to better communicate my thoughts and needs. I
    feel that Project Uplift is a very valuable resource to spread
    knowledge and awareness about the epilepsy community. I know that if
    the program continues, it will help reduce the stigma around what it
    means to be epileptic and create a safe community for those of us who
    just want to feel heard and understood.
    Also as part of the $10 billion for the CDC, please provide $5 million
            for the CDC's National Neurological Conditions Surveillance
            System.
        In 2016, Congress authorized the CDC to establish the NNCSS and it
    first received funding in FY 2019. The CDC is initially focusing on MS
    and Parkinson's, in order to learn through the process before extending
    to other neurological conditions. Extending to additional neurological
    conditions such as the epilepsies is contingent on continued funding
    for this program so the Foundation requests $5 million for the NNCSS in
    FY 2022.
    Please provide at least $46.1 billion for NIH along with proportional
            increases for various NIH Institutes and Centers, including
            NINDS.
        As a result of sustained investment in NIH, the epilepsy research
    portfolio has grown from about $150 million in FY 2017 to over $200
    million in FY 2020. These resources have fueled scientific advancement
    and led to support for a variety of research initiatives including:
    Epilepsy Centers without Walls, The Epilepsy 4,000 (Epi4K)
    collaborative, The Center for Sudden Unexplained Death in Epilepsy
    (SUDEP) Research, The Epilepsy Bioinformatics Study for
    Antiepileptogenic Therapy (EpiBiosS4Rx), The Channelopathy Associated
    Epilepsy Research Center (CAREC), The Epilepsy Multiplatform Variant
    Prediction (EpiMVP) Center.
        https://www.ninds.nih.gov/Current-Research/Focus-Disorders/Epilepsy
        Much more can be done though, particularly in the area of bold
    cross-cutting initiatives and multi-center efforts. For FY 2022, we ask
    the subcommittee to include key committee recommendations, like the
    language below, to encourage additional epilepsy research in emerging
    areas.
            national institute of neurological disorders and stroke
        Epilepsy.--The Committee notes the significant opportunities for
    the NINDS to advance research on the epilepsies through multi-center,
    multidisciplinary approaches like the Epilepsy Centers Without Walls
    that help address the need for biomarkers of epilepsy and precision
    medicine for new treatments and prevention for etiologically-defined
    populations. This approach is also suited for nation-wide, coordinated
    clinical and translational research frameworks to advance disease
    modifying or prevention strategies for the epilepsies.
        The Epilepsy Foundation thanks the subcommittee for its
    consideration of these requests. If you have any questions, please
    contact me.

        [This statement was submitted by Laura Weidner, Esq., Vice
    President,
    Government Relations & Advocacy.]
                                     ______

                         Prepared Statement of Evermore
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Committee, thank you for the opportunity to provide testimony
    pertaining to fiscal year (FY) 2022 appropriations for the Centers for
    Disease Control and Prevention (CDC). Your leadership has resulted in
    major advances in the health and wellbeing of Americans, as well as
    ensuring that our taxpayer dollars are appropriated to our nation's
    most pressing health and human needs.
        I submit this testimony on behalf of Evermore, a nonprofit
    dedicated to making the world a more livable place for bereaved
    families by raising awareness of the consequences and implications of
    bereavement for society, advancing sound research that drives policy
    and program investments, and advocating on behalf of bereaved families
    for whom very limited legal protections are available in the aftermath.
    The purpose of my testimony today is to alert you to an emerging public
    health concern--bereavement--and its impact on millions of families
    throughout the nation. Bereavement shares a powerful intersectionality
    with multiple national public health emergencies, including COVID-19,
    overdose, homicide, and suicide. As such, bereavement plays a key
    gatekeeping role in determining whether we as a nation can turn the
    corner on these ongoing public health crises towards national recovery
    and wellbeing. This watershed moment offers us a rare opportunity to
    effect long-needed and long-awaited systemic changes. These changes can
    bring together a diverse array of seemingly disconnected, separately
    raging crises to support our nation's grieving individuals, families,
    and communities; compassionately lighten the burden of bereavement that
    encumbers and shortens so many lives, and re-enable them to reach their
    full potential.
        Bereavement is a pernicious social concern threatening nearly every
    aspect of family wellbeing and solvency for millions across the
    country. The unexpected death of a loved one poses a dual threat to our
    national well-being, as it is both among the most common major life
    stressors, and the single worst lifetime experience, reported by
    Americans in national surveys. Losing a loved one is not only a
    personal tragedy, but casts a long shadow that can extend for decades
    as it places surviving parents, children, siblings, and spouses at
    significant risk for impaired health, premature death, and
    underachievement. Some additional risks include serious mental health
    disorders, teen pregnancy, violent crime involvement, youth
    delinquency, substance abuse, diminished academic attainment,
    diminished lifetime income, and less purpose in life, among many
    others.
        Perhaps most concerning, our national life expectancy--an index of
    overall population health--has dropped by more than one full year. This
    last happened nearly 80 years ago following the United States' entry
    into World War 2. The implications of these statistics are sobering:
    They not only indicate that many middle-aged people of child-bearing
    and child-rearing years are dying, but that many children and
    adolescents are losing their parents, grandparents, aunts, uncles, and
    mentors. Recurring bereavement under tragic and often-traumatic
    circumstances has now become a commonplace fact of life for many US
    residents. Further, COVID and our other spiking epidemics have set back
    progress in closing the racial health disparities gap by some 20 years.
    Racial inequalities in bereavement are magnified across the life course
    as Black Americans are more likely than White Americans to experience
    the death of children, spouses, siblings, and parents. Black Americans
    are three times as likely as White Americans to have two or more family
    members die by the time they reach the age of 30. Black children are
    three times as likely to lose a mother and more than twice as likely to
    lose a father by age 10 when compared to White children.
        To facilitate and inform future policymaking and national
    investments, as well as develop an evidenced-based bereavement care
    response system, Evermore encourages a budget increase of $2.5 million
    in CDC's Office of Surveillance, Epidemiology, and Laboratory Services/
    Division of Behavioral Health to collect bereavement prevalence and
    incidence data via its Behavioral Risk Factor Surveillance Survey
    (BRFSS). BRFSS is the nation's premier survey tool collecting data from
    400,000 adults living in the 50 states, the District of Columbia, and
    three U.S. territories. It is the largest continuously-conducted health
    survey in the world.
        The CDC is one the nation's most-trusted sources of data and
    evidence on population and public health. Our nation requires
    consistent and reliable data on the prevalence and sequelae of
    bereavement on which to formulate sound policy and practice. Today, the
    CDC collects mortality data, but not data pertaining to the bereaved
    families who survive these death events, and what the ramifications
    are. With five million individuals losing a loved one to COVID-19,
    including an estimated 46,000 children who lost a parent, the need for
    sound data collection to frame a federal response has never been
    greater. Indeed, we have relied on private researchers--including
    Ashton Verdery, Ph.D. of The Pennsylvania State University and Emily
    Smith-Greenaway of the University of Southern California--to provide
    these estimation models because the federal government does not measure
    bereavement exposure.
        By extension, bereavement prevalence and incidence for homicide,
    suicide or overdose are currently unavailable, leaving us with no
    accurate means of capturing its impact (perhaps better designated as
    shockwaves) on individuals, families, and communities. This is a major
    missed opportunity for our social and health systems to surveil,
    monitor, and learn from our national epidemics and mount an effective
    response. Adding bereavement exposure to BRFSS would provide key
    demographic data, trends by race and geography, resulting in both a
    better understanding of the scope of the problem and informing future
    policymaking and program priorities and investments.
        In 2019, Toni Miles, M.D., Ph.D. of the University of Georgia
    piloted three bereavement exposure questions in Georgia's BRFSS module,
    prior to the COVID-19 epidemic (see Figure 1). Her work found that 45
    percent of Georgia BRFSS respondents were bereaved in the previous two
    years. Extrapolating this figure to the overall state population, she
    estimates that 3.7 million Georgian adults were recently bereaved. Her
    work also estimates that approximately 400,000 Georgia adults had two
    or more close family members die. African American adults are at
    particular risk, with 58 percent reporting a loss. Those in their prime
    working years are affected, with 48 percent of adults ages 35-64
    experiencing a loss. Preliminary evidence indicates that bereavement
    exposure may undermine capacity to work; 53 percent of those newly out
    of work had experienced a family death.

        Dr. Miles and her team found that persons who experienced any
    family loss in the past two years were at a heightened risk of
    reporting poor health, as well as physical and mental health problems
    over the past two weeks within taking the survey. Persons experiencing
    three or more losses were at the greatest risk of multiple health
    concerns, ranging from obesity to binge drinking, relative to those
    with no losses.

                     additional justification for requests
        Publicly-available bereavement dataset. We request the creation of
    a publicly available bereavement dataset enabling social and health
    scientists to extrapolate risk factors and potential implications for
    U.S.-based populations. Researchers will be able to examine
    interrelationships between exposure and outcomes, ask new research
    questions and begin to integrate this data into their existing research
    endeavors intended to help individuals reach their fullest potential.
    To that end, these data may influence CDC's Healthy People 2030 goals.
        CDC's Health US, 2022. We request a special highlight section in
    CDC's 2022 health status report to the nation, Health, United States.
    This report presents key highlights and findings from federal health
    data systems.
                                   conclusion
        To date, there is no national dataset capturing bereavement
    prevalence and incidence as our nation is facing unprecedented loss.
    Unequivocally, COVID-19 has reshaped our national landscape and is a
    seminal moment detailing how lack of quality bereavement care taxes
    individuals, families and the nation. Bereavement and its unintended
    outcomes are inextricably linked to many of our federal health agencies
    missions, priorities, and programs.
        With more than millions of individuals in the United States
    suffering the loss of a loved one to COVID-19 and countless others who
    have lost a loved one to suicide, homicide, overdose, and chronic
    disesaes like cancer and Alzheimer's disease, combined with the growing
    evidence base about the profound long-lasting effects of bereavement on
    individuals and community health, bereavement (as a marker of risk) and
    quality bereavement care should be a priority for CDC and the federal
    government. Bereavement exposure and by extension its care is an
    essential element to any comprehensive public health strategy.
        Thank you for the opportunity to present this testimony on behalf
    of millions of bereaved Americans and thank you for your continued
    leadership.
        Sincerely.

        [This statement was submitted by Joyal Mulheron, Executive
    Director, Evermore.]
                                     ______

       Prepared Statement of the Evidence-Based Leadership Collaborative
        Chair Murray and Ranking Member Blunt, and members of the
    Subcommittee, first, thank you for the opportunity to submit testimony
    to the Subcommittee to outline critical federal funding priorities for
    FY 2022. As we emerge from the health and economic crisis of the last
    year, the funding decisions that federal lawmakers make in FY 2022 will
    determine whether we have learned from the devastating consequences of
    the COVID-19 pandemic, or whether we default to a perilous status quo.
    It is with optimism that we will collectively improve upon the tragic
    lessons of the coronavirus crisis that we submit our funding requests
    for FY 2022.
        In this sprit, we sincerely hope that Congressional Appropriators
    will recognize the value of evidence-based programs (EBPs) to promote
    health and prevent disease among older adults and make investments that
    increase support for, and expand access to, these vital activities. On
    behalf of the Evidence-Based Leadership Collaborative (EBLC)--a 501c3
    organization that represents EBP developers, administrators, and
    providers with more than 200 combined years in developing, evaluating,
    scaling, implementing, and sustaining EBPs--we urge Subcommittee
    Members to include relatively modest, but meaningful, funding increases
    for the following programs within the Administration for Community
    Living (ACL):
      --$50,000,000 for Older Americans Act Title III D, Preventative
            Health Services
      --$16,000,000 for Older Americans Act Title IV, Chronic Disease Self-
            Management Education (CDSME) Programs
      --$10,000,000 for Older Americans Act Title IV Falls Prevention
            Programs
        Additionally, within the Centers for Disease Control and Prevention
    (CDC), we urge the Subcommittee to make important additional
    investments in chronic disease prevention programs, which are
    especially important given the significant impact of COVID-19 on older
    adults living with multiple chronic diseases.
        These funding requests align with those of other national aging
    advocacy organizations and coalitions that focus on disease prevention,
    health promotion, and home and community-based services (HCBS)
    provision for older Americans, including the National Council on Aging
    (NCOA), the National Association of Area Agencies on Aging (n4a), and
    the Leadership Council of Aging Organizations (LCAO).
           the case for evidence-based programing for older americans
        Evidence-based programs offer proven ways to promote health and
    prevent disease among older adults. These interventions have a decades-
    long track record of improving health and reducing costs when delivered
    within community settings across the country. Community and home-based
    delivery means improved access to quality care for older adults who are
    traditionally underserved, by organizations that also address those
    social needs that drive poor health and costs of care. These evidence-
    based programs include, but are not limited to:
      --the Chronic Disease Self-Management suite of programs, which teach
            individuals how to manage ongoing health conditions;
      --a Matter of Balance, EnhanceFitness, and Fit & Strong!, which
            increase awareness of and target interventions to help prevent
            fall-related injuries;
      --Healthy IDEAS and PEARLS, which help to address and identify the
            underlying symptoms of depression; and
      --Healthy MOVES and other programs focused on improving physical and
            emotional health through physical activity.
        All of these programs, which are represented by the Evidence-Based
    Leadership Collaborative, meet the Administration for Community
    Living's criteria for the highest level of evidence. In addition to
    ACL, the Centers for Disease Control and Prevention Arthritis Program,
    Substance Abuse and Mental Health Services Administration's (SAMHSA)
    National Registry of Evidence-Based Programs, and the Agency for
    Healthcare Research and Quality Innovations Exchange recommend these
    programs and find them to be the strongest of evidence-based programs.
        The scale and scope of the challenges that the suite of EBPs
    address demonstrates the importance of investing in effective
    interventions. For example, chronic diseases are the leading causes of
    death and disability in the U.S., whose costs constitute 90 percent of
    the nation's $3.8 trillion in health expenditures. Older Americans are
    disproportionately affected by chronic conditions; 80 percent have at
    least one chronic condition, and nearly 70 percent of Medicare
    beneficiaries have two or more. Older adults living with chronic
    conditions, particularly Black, Indigenous, and other Persons of Color
    (BIPOC), were more vulnerable to COVID-19 hospitalizations and deaths,
    highlighting inequities in both health outcomes and access to quality
    care.
        Furthermore, falls are the primary cause of injuries and deaths
    from injuries among older adults. Each year, an estimated one in four
    older adults falls. Annually, more than three million fall injuries are
    treated in emergency departments, resulting in nearly 800,000
    hospitalizations. Yearly spending to treat injuries resulting from
    falls totals $50 billion, 75 percent of which is paid for by Medicare
    and Medicaid. These costs are expected to exceed $101 billion by 2030.
        The pandemic exacerbated these challenges and contributed to other
    emerging widespread concerns. For example, social isolation and
    loneliness-a major contributor to poor physical, behavioral, and
    cognitive health-increased drastically for high-risk older Americans
    adhering to long-term stay-at-home orders and community shut-downs. The
    spike in social isolation and loneliness among older adults also
    spurred declines in physical functioning for many older Americans
    because of reduced access to community supports and evidence-based
    programs health promotion programs.
      opportunities to expand evidence-based health promotion and disease
             prevention programs with increased federal investments
        Despite the growing and widespread barriers to EBP delivery during
    COVID-19, program developers and community-based providers were quick
    to adapt to the new reality and adopt program delivery models suitable
    to a virtual world. Rapidly pivoting previously in-person programs to
    online and telephonic delivery methods ensured that many of these
    trusted, proven, and popular health promotion and disease prevention
    strategies could continue and remain accessible during the health
    crisis. Additionally, adapting EBPs to remote delivery demonstrated
    long-term potential to address program participation barriers for
    especially high-risk and historically marginalized populations
    including rural and home-bound older adults.
        Increasing FY 2022 investments in evidence-based disease prevention
    and health promotion programs will allow providers to expand their
    reach to older Americans whose health conditions worsened because of
    the prolonged pandemic. Increased investments will also allow EBP
    interventions to continue to offer, expand, and improve upon remote
    program delivery options to overcome long-standing barriers for older
    adults lacking access to in-person programing and to reaching
    underserved communities with culturally and linguistically appropriate
    services. This opportunity is a potential paradigm shift for these
    proven, trusted, cost-effective interventions.
        Given the potential to expand these programs as we recover from the
    pandemic, we respectfully request that the Subcommittee prioritize the
    following FY 2022 federal investments to support these important
    disease prevention and health promotion programs.
                   oaa title iii d preventive health services
        Title III D of the Older Americans Act delivers evidence-based
    health promotion and disease prevention programs to prevent or better
    manage the conditions that most affect quality-of-life, drive up health
    care costs and reduce an older adult's ability to live independently.
    However, investments have not been sufficient to ensure the diverse
    array of proven, cost-effective interventions can be implemented in
    communities nationwide, nor do they allow the to-date underfunded
    network to amass the critical evidence-based data lawmakers seek.
    Additional resources are needed to maintain the new reach and means of
    both in-person and remote delivery so older adults maintain access to
    these key services. We urge Congress to double appropriations funding
    for OAA Title III D programs in FY 2022 to $50 million.
         oaa title iv chronic disease self-management education (cdsme)
        CDSME is a low-cost, evidence-based disease management intervention
    which studies show to be effective at helping people with all types of
    chronic conditions adopt healthy behaviors, improve health status, and
    reduce use of hospital stays and emergency room visits. Prevention and
    Public Health Fund allocations to ACL for CDSME have remained at $8
    million since FY 2016, supporting over 14,000 community-based delivery
    sites which have provided services to more than 550,000 individuals.
    However, given that nearly 200 million people report having a chronic
    disease, the reach of these programs has been only 0.25 percent of the
    full population reach potential. We urge appropriators to increase FY
    2022 funding for these programs to $16 million to expand access to
    evidence-based, cost-effective chronic disease management programs to a
    greater number of states and older adults in need across the country.
                         oaa title iv falls prevention
        Evidence-based fall prevention programs offer cost-effective
    interventions by reducing or eliminating risk factors, promoting
    behavior change, and leveraging community networks to link clinical
    treatment and community services. These programs have been shown to
    reduce the incidence of falls by as much as 55 percent and produce a
    return on investment of as much as 509 percent. In fact, in an October
    2019 report on falls prevention, the Senate Special Committee on Aging
    recommended continued investment and expanded access to EBPs aimed at
    mitigating the risk of falls among older adults. Despite this
    bipartisan support, falls prevention has been flat funded while the
    incidence and costs of falls continues to climb. Therefore, we urge
    your Subcommittee to increase the investment in these cost-effective
    programs to $10 million to make these programs more widely available to
    at-risk older Americans in every community.
        In closing, these vital federal efforts that support health
    promotion and disease prevention interventions across the country have
    a profound impact on the quality-of-life of older Americans. On behalf
    of myself, the Evidence-Based Leadership Collaborative, and other
    national aging advocates, I implore you and your Subcommittee to
    support FY 2022 funding levels for these programs that recognize the
    value of, and expand access to, proven solutions for older Americans.

        [This statement was submitted by Paul Hepfer, CEO, Project Open
    Hand &
    Evidence-Based Leadership Collaborative Board Chair.]
                                     ______

     Prepared Statement of the Federal AIDS Policy Partnership's Research
                                   Work Group
        On behalf of the Federal AIDS Policy Partnership's Research Working
    Group, we thank Chairwoman Senator Murray, Ranking Member Senator
    Blunt, and members of the subcommittee for the opportunity to submit
    testimony to the Senate LHHS Subcommittee on Fiscal Year 2022 (FY 2022)
    Appropriations for the National Institutes of Health (NIH) in regards
    to protecting, strengthening, and expanding our nation's HIV/AIDS
    research agenda. The Research Work Group (RWG) of the Federal AIDS
    Policy Partnership (FAPP) is a coalition of more than 60 national and
    local HIV/AIDS research advocates, patients, clinicians and scientists
    from across the country. Our goal is to advance and support U.S.
    leadership to accelerate progress in the field of HIV/AIDS research.
    The FAPP RWG urges the subcommittee to recommend a FY 2022 budget
    request level of at least $46.1 billion for the NIH consistent the
    request of the Ad Hoc Group for Medical Research. We also ask that
    $3.845 billion be allocated for HIV research at the NIH in FY 2022,
    which is the research need identified by the Office of AIDS Research in
    their Congressionally mandated FY 21 Professional Judgment Budget.
        Public investments in health research via NIH have paid enormous
    dividends in the health and wellbeing of people in the U.S. and around
    the world, particularly for people living with, or vulnerable to, HIV.
    NIH funded AIDS research has supported innovative basic science for
    better drug therapies, and evidence-based behavioral and biomedical
    prevention interventions which have saved and improved the lives of
    millions. NIH funding has contributed to over 210 approvals for a range
    of novel therapeutics between 2010 through 2016, with new anti-
    infectives for HIV and HCV receiving the second largest fraction of
    those approvals. Additionally, NIH support was crucial in the
    development of pre-exposure prophylaxis (PrEP), an HIV prevention tool
    that is upwards of 99% effective in preventing sexual transmission.
    NIH-supported HIV research is now critical to advancement of possible
    treatments and several vaccines against COVID-19.
        HIV research advances at the NIH hold the potential to end the AIDS
    epidemic, as well as update prevention approaches and improve outcomes
    along the treatment cascade--a cornerstone of the initiative to End the
    HIV Epidemic in the U.S. In addition, the average age of people living
    with HIV in the United States is increasing, so it also remains
    critically important to make substantial investments in research on co-
    morbidities and new antiretroviral therapies. NIH research is critical
    to ensuring that aging population stays healthy and virally suppressed.
        Since 2003, funding for NIH HIV research has failed to keep up with
    our existing research needs--damaging the success rate of approved
    grants and leaving very little money to fund promising new research--
    despite increases to the overall NIH budget. According to the
    Biomedical Research and Development Price Index (BRDI)--which
    calculates how much the NIH budget must change each year to maintain
    purchasing power--between FY 2003 and FY 2020, the NIH budget in
    constant dollars according to BRDI will have declined by almost half.

        Investment by the NIH has transformed the HIV epidemic from a
    terrible, untreatable disease to a chronic condition that can be
    managed through once-a-day drug regimens. Now is the time to increase
    investment for the NIH to finish the job and end the HIV epidemic
    through strategic, science-based interventions. NIH funding of HIV/AIDS
    research provides an example of innovation at work where investment in
    basic and translational research, working in partnership with industry
    and community, can move quickly to develop solutions. NIH investments
    in HIV/AIDS research add value by seeding ideas later taken up in
    industry partnerships and creating innovation incubators for important
    medical advances with significant health impact.
        Federal support for HIV/AIDS research has also led to new
    treatments for other diseases, including cancer, COVID-19, heart
    disease, Alzheimer's, hepatitis, osteoporosis, and a wide range of
    autoimmune disorders. Several HIV/AIDS treatments have been researched
    as treatments for the novel coronavirus--saving months of research time
    and, in the process, potentially countless lives. Coronavirus vaccine
    research is now ongoing using platforms and technology, such as Ad26
    and mRNA, previously developed for use as an HIV vaccine.
        Robust funding for NIH overall enables research universities to
    pursue scientific opportunity, advance public health, and create jobs
    and economic growth. NIH funding puts approximately 300,000 scientists
    to work at research institutions across the country. According to NIH,
    each of its research grants creates or sustains six to eight jobs and
    NIH-supported research grants and technology transfers have resulted in
    the creation of thousands of new independent private sector companies.
        The race to find better treatments and a cure for cancer,
    Alzheimer's, heart disease, HIV/AIDS, and other diseases, and for
    controlling global epidemics like AIDS, tuberculosis, coronavirus, and
    malaria, all depend on a robust long-term investment strategy for
    health research at NIH. There can be no innovation without reliable and
    adequate research funding. Congress should ensure the nation does not
    delay vital HIV/AIDS research progress. We must protect HIV/AIDS
    research funding to sustain research capacity and maintain our
    worldwide leadership in HIV/AIDS research and innovation.
        To that end, we urge the subcommittee to consider a needed increase
    to the overall FY 2022 budget request level of at least $46.1 billion
    for the National Institutes of Health (NIH) consistent with the request
    of the Ad Hoc Group for Medical Research. While this increase may get
    us closer to meeting the OAR By-Pass Budget Estimate for FY 2022, we
    ask the committee direct that increased funding be allocated for HIV
    research at the NIH in FY 2022. We urge the subcommittee to consider
    approaches to ensure the HIV research budget receives increases
    alongside other important and intersecting biomedical research at NIH.
        In conclusion, the RWG calls on Congress to continue the bipartisan
    federal commitment towards combating HIV as well as other chronic and
    life-threatening illnesses by increasing funding for NIH in FY 2022. A
    meaningful commitment towards maintaining the U.S. pre- eminence in HIV
    research and fostering innovation cannot be met without prioritizing
    the research investment at NIH that will lead to tomorrow's lifesaving
    vaccines, treatments, and cures that are needed to end the HIV epidemic
    here and abroad. Thank you for the opportunity to provide these written
    comments.
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology
        My testimony is in support of FY22 funding for the National
    Institutes of Health under the Department of Health and Human Services
    , Agency Subdivision: National Institutes of Health, Account: 550.
                                    summary
        Federal investments in fundamental research have led to remarkable
    progress in the biological and biomedical sciences. Basic research was
    the groundwork for the speed--months instead of years--in the
    development of COVID-19 vaccines, and pre-clinical research, such as
    animal studies, has been essential to every step of achieving medical
    progress.
        Despite Congress' bipartisan support for investing in science,
    federal funding for research has not kept pace, posing a threat to our
    nation's competitiveness. We face a real threat of losing our edge in
    industries such as biotechnology if we do not prioritize increasing
    investments in science and building a diverse workforce \1\ The U.S.
    spends less on research and development (R&D) than many countries. If
    the U.S. is to be prepared to respond to future threats, our scientific
    leadership must progress. According to Science Is Us, there is the
    added benefit of jobs. STEM supports 69 percent of U.S. gross domestic
    product, touches two out of three workers, and generates $2.3 trillion
    in tax revenue.\2\
    ---------------------------------------------------------------------------
        \1\ NSF Science Indicators 2018.
        \2\ STEM and the American Workforce. You've heard it before: STEM
    jobs--... | by Science is US | Medium.
    ---------------------------------------------------------------------------
        The federal government should commit to robust, predictable, and
    sustained funding increases for science agencies.
                         national institutes of health
        The NIH is the nation's largest funder of biomedical research,
    providing competitive grants to support the work of 300,000 scientists
    at universities, medical centers, independent research institutions,
    and companies nationwide. NIH supports biomedical discoveries,
    innovations, and treatments that were made possible because of
    scientific research using animals.
        Congress has renewed its commitment to this critical research
    agency, providing robust, sustained, and predictable budget increases
    over the last five fiscal years (Table 1).\3\ With these resources, NIH
    has accelerated progress across all areas of medical science, including
    regenerative medicine, cancer immunotherapy, and neurological
    health.\4,5,6\ The agency is also committed to supporting the next
    generation of our biomedical research enterprise.\7\
    ---------------------------------------------------------------------------
        \3\ FASEB Federal Funding Data.
        \4\ NIH Regenerative Medicine Innovation Project, National
    Institutes of Health, Bethesda, MD.
        \5\ NCI's Role in Immunotherapy Research, National Cancer
    Institute, Bethesda, MD.
        \6\ The BRAIN Initiative Summary, National Institutes of Health,
    Bethesda, MD.
        \7\ NIH Grants and Funding, Next Generation Research Initiative,
    National Institutes of Health, Bethesda, MD.
    ---------------------------------------------------------------------------
        Though the NIH is in a stronger position than it was a few years
    ago, Congress must continue to increase biomedical research funding.
    Our nation is confronting public health threats, especially given
    global climate change negatively impacting biodiversity and geohealth--
    the intersection of biological science, Earth sciences, and ecology--on
    mankind. More research will be needed to address increased risks posed
    by future pandemics, infectious diseases, and greater exposure to
    environmental pollutants.\8\
    ---------------------------------------------------------------------------
        \8\ IPCC AR5 Climate Change 2014, Chapter 11: Human Health:
    Impacts, Adaptation, and Co-Benefits.
    ---------------------------------------------------------------------------
        In the U.S., we continue to address the needs of an aging
    population and obesity.\9,10\ NIH research is developing therapies for
    a whole spectrum of age-related disorders.\11\ Obesity impacts 42% of
    the U.S. population and increases the likelihood of developing costly
    medical conditions.\12\
    ---------------------------------------------------------------------------
        \9\ https://www.census.gov/newsroom/press-releases/2018/cb18-41-
    population-projections.html.
        \10\ NIDDK Health Information.
        \11\ Aging Well in the 21st Century: Strategic Directions for
    Research on Aging, National Institute on Aging, Bethesda, MD.
        \12\ CDC Obesity Data.
    ---------------------------------------------------------------------------
        Our recommendation of $46.11 billion is $3.2 billion above FY 2021
    allowing NIH to continue support for the Next Generation Researchers
    Initiative; provide a five percent increase across NIH institutes and
    centers; and expand dual purpose research in biomedicine and
    agriculture among NIH and other federal agencies.\13\
    ---------------------------------------------------------------------------
        \13\ BILLS-116RCP68-JES-DIVISION-H.pdf (house.gov) pg. 63.
    ---------------------------------------------------------------------------
        FASEB FY 2022 Recommendation: at least $46.11 billion for NIH
    (chart below):

        [This statement was submitted by Ellen Kuo, Associate Director,
    Legislative
    Affairs, Federation of American Societies for Experimental Biology.]
                                     ______

            Prepared Statement of the Federation of Associations in
                         Behavioral and Brain Sciences
        Chairwoman Murray, Ranking Member Blunt, and Members of the
    Subcommittee:
        The Federation of Associations in Behavioral and Brain Sciences
    (FABBS) is grateful for the opportunity to submit testimony for the
    record in support of the National Institutes of Health (NIH) and the
    Institute of Education Sciences (IES) budgets for fiscal year (FY)
    2022. FABBS represents twenty-seven scientific societies and over sixty
    university departments whose members and faculty share a commitment to
    advancing knowledge of the mind, brain, and behavior. For fiscal year
    (FY) 2022, FABBS encourages your subcommittee to provide the National
    Institutes of Health (NIH) with a budget of at least $52 billion and
    the Institute of Education Sciences (IES) within the Department of
    Education a budget of $700 million.
        Our members are thankful that appropriators were able to secure
    $42.9 billion for NIH and over $646 million for IES in FY21. We also
    appreciate the supplemental appropriations to NIH and IES included in
    COVID-19 response legislation. At NIH, these funds have played a
    central role in the pandemic response, not only developing vaccines and
    treatments but also supporting behavioral research to inform public
    health strategies. At IES, these investments are already helping to
    conduct essential research into the learning disruptions caused by the
    pandemic and providing educators the tools to chart a path forward for
    students. We hope to see similar success funding these agencies' vital
    contributions in FY22.
                         national institutes of health
        We sincerely thank the Subcommittee for its diligent work and
    considerable increases to NIH in recent years. As members of the Ad Hoc
    Group for Medical Research and the Coalition for Health Funding, FABBS
    recommends at least $52 billion for NIH in FY 2022. FABBS members
    contribute to the NIH mission of seeking fundamental knowledge about
    the behavior of living systems and the application of that knowledge to
    enhance health, lengthen life, and reduce illness and disability. FABBS
    members contribute to the advances in numerous NIH Institutes and
    Centers (IC).
        FABBS members have a particular interest in the Office of
    Behavioral and Social Science Research. OBSSR was created to coordinate
    and promote basic, clinical, and translational behavioral and social
    science research at NIH and plays an essential role, enhancing trans-
    NIH investments in longitudinal datasets, technology in support of
    behavior change, innovative research methodologies, and promoting the
    inclusion of behavioral science in initiatives in partnership with ICs.
    OBSSR co-funds highly rated grants that the ICs cannot fund alone.
    OBSSR is an integral component of many high-profile NIH programs and
            initiatives:
      --OBSSR has played a role in the fight against COVID-19, supporting
            behavioral and social science research to address the pandemic
            and disseminating best practices to encourage uptake of COVID-
            19 vaccines. The Office, for example, has made over 50 awards
            to study mitigation efforts, the long-term health and health
            care effects of the resulting economic downturn, and potential
            interventions to limit these effects.
      --The Office also coordinates NIH's high-priority program on gun
            violence prevention research, identifying effective public
            health interventions to prevent firearm violence, and the
            trauma, injuries, and mortality resulting from it.
      --Additionally, OBSSR is central to the NIH UNITE initiative to end
            structural racism and racial inequalities in health research. A
            working group of the Behavioral and Social Sciences Research
            Coordinating Committee is responsible for examining OBSSR-
            funded research on racism and health to inform broader agency-
            wide efforts to promote inclusion within NIH and in the
            research it funds.
        While the NIH budget has grown in recent years, funding for OBSSR
    has not seen commensurate increases. We recognize that, located in the
    Office of the Director, OBSSR does not have a specific appropriation.
    Nonetheless, FABBS appreciates the opportunity to express support for
    OBSSR and highlight that additional funding should enable the Office to
    expand its work addressing the behavioral, social, and economic impacts
    of the COVID-19 pandemic, measuring the effects of mitigation
    strategies on vulnerable individuals and communities in preparation for
    future pandemics, while maintaining its broad work in support of the
    NIH mission.
      institute of education sciences (ies), u.s. department of education
        As members of the Friends of IES, FABBS encourages the subcommittee
    to appropriate at least $700 million to IES in FY 2022. At this
    critical juncture, a significant increase in IES funding is essential
    to addressing learning loss caused by the COVID-19 pandemic and better
    preparing American students for the future.
        IES is a semi-independent, nonpartisan branch of the U.S.
    Department of Education and is the research foundation for improving
    and evaluating teaching and learning. The four centers-the National
    Center for Education Statistics (NCES), National Center for Education
    Research (NCER), National Center for Special Education Research (NCSER)
    and National Center for Education Evaluation (NCEE)-work
    collaboratively to efficiently and comprehensively produce and
    disseminate rigorous research and high-quality data and statistics.
        Already, the Institute has done important work to gauge the impact
    of school closures on students, teachers, and school leaders, while
    providing evidence-based guidance and technical assistance to inform
    school reopening plans and support instruction in remote and hybrid
    learning. IES launched Operation Reverse the Loss to identify specific
    and actionable interventions that can reverse learning losses for
    clearly identified populations of students.
        Robust funding for IES in FY22 will allow the Institute to continue
    its important work studying the effects of and developing strategies to
    address learning loss due to COVID-19 and create a stronger educational
    system.
        Thank you for considering this request.
    FABBS Member Societies:
        Academy of Behavioral Medicine Research, American Educational
    Research Association, American Psychological Association, American
    Psychosomatic Society, Association for Applied Psychophysiology and
    Biofeedback, Association for Behavior Analysis International, Behavior
    Genetics Association, Cognitive Neuroscience Society, Cognitive Science
    Society, International Congress of Infant Studies, International
    Society for Developmental Psychobiology, Massachusetts
    Neuropsychological Society, National Academy of Neuropsychology, The
    Psychonomic Society, Society for Behavioral Neuroendocrinology, Society
    for Computation in Psychology, Society for Judgement and Decision
    Making, Society for Mathematical Psychology, Society for
    Psychophysiological Research, Society for the Psychological Study of
    Social Issues, Society for Research in Child Development, Society for
    Research in Psychopathology, Society for the Scientific Study of
    Reading, Society for Text & Discourse, Society of Experimental Social
    Psychology, Society of Multivariate Experimental Psychology, Vision
    Sciences Society
    FABBS Affiliates:
        APA Division 1: The Society for General Psychology; APA Division 3:
    Experimental Psychology; APA Division 7: Developmental Psychology; APA
    Division 28: Psychopharmacology and Substance Abuse; Arizona State
    University; Binghamton University; Boston University; California State
    University, Fullerton; Carnegie Mellon University; Columbia University;
    Cornell University; Duke University; East Tennessee State University;
    Florida International University; Florida State University; George
    Mason University; George Washington University; Georgetown University;
    Georgia Institute of Technology; Harvard University; Indiana University
    Bloomington; Indiana University--Purdue University Indianapolis; Johns
    Hopkins University; Kent State University; Lehigh University;
    Massachusetts Institute of Technology; Michigan State University; New
    York University; North Carolina State University; Northeastern
    University; Northwestern University; The Ohio State University, Center
    for Cognitive and Brain Sciences; Pennsylvania State University;
    Princeton University; Purdue University; Rice University; Southern
    Methodist University; Stanford University; Syracuse University; Temple
    University; Texas A&M University; Tulane University; University of
    Arizona; University of California, Berkeley; University of California,
    Davis; University of California, Irvine; University of California, Los
    Angeles; University of California, Riverside; University of California,
    San Diego; University of Chicago; University of Colorado, Boulder;
    University of Delaware; University of Houston; University of Illinois
    at Urbana-Champaign; University of Iowa; University of Maryland,
    College Park; University of Massachusetts Amherst; University of
    Michigan; University of Minnesota; University of Minnesota, Institute
    of Child Development; University of North Carolina at Greensboro;
    University of Pennsylvania; University of Pittsburgh; University of
    Texas at Austin; University of Texas at Dallas; University of
    Washington; Vanderbilt University; Virginia Tech; Wake Forest
    University; Washington University in St. Louis; Yale University

        [This statement was submitted by Juliane Baron, Executive Director,
    Federation of Associations in Behavioral and Brain Sciences.]
                                     ______

                  Prepared Statement of Florida A&M University
        Chairman Leahy, Chair Murray, Vice Chairman Shelby, Ranking Member
    Blunt, and Members of the Labor, Health and Human Services, and
    Education, and Related Agencies Subcommittee, thank you for the
    opportunity to submit public testimony on the subcommittee's Fiscal
    Year (FY) 2022 appropriations bill. Florida A&M University (FAMU)
    supports maintaining or enhancing funding for programs of interest to
    the University and our students, including the Department of
    Education's Historically Black Colleges and Universities (HBCU)
    programs, the HBCU Capital Financing Program, and the federal Pell
    Grants program. FAMU also supports two programs at the Department of
    Health and Human Services--the National Institutes of Health's Research
    Centers in Minority Institutions and the Health Resources and Services
    Administration's Health Careers Opportunity Program. These federal
    programs provide critical support to the University, our students as
    well as other institutions of higher education and the nation.
        Florida A&M University, based in the State capitol of Tallahassee,
    Florida, was founded in 1887 with only 15 students and two instructors.
    Today, FAMU has grown to nearly 10,000 students and we are proud to be
    the highest ranked among public Historically Black Colleges and
    Universities (HBCU) according to the U.S. News and World Report
    National Public Universities. Our University offers 56 bachelor's
    degrees, 29 master's degrees, 12 doctoral degrees and three
    professional degrees. We are a leading land-grant research institution
    with an increased focus on science, technology, research, engineering,
    agriculture, and mathematics. As noted by Diverse Issues, FAMU is a top
    producer of African American doctoral degrees in pharmacy and
    pharmaceutical sciences.
        Federal support is critical for institutions of higher education,
    particularly HBCUs, which are historically under-resourced. Robust
    federal funding for programs that help to improve our institutions,
    broaden access for students, and improve student success is paramount.
    The Department of Education HBCU programs help us achieve these goals
    and the federal Pell Grant program is an imperative resource for our
    students as the majority of our students are Pell-eligible.
    Furthermore, the Department of Health and Human Services' research and
    career development programs that support minority students also benefit
    FAMU, our students, and the nation. FAMU strongly supports funding for
    these vital federal programs.
     department of education historically black colleges and universities
                                    programs
        FAMU strongly supports robust funding for the Department of
    Education HBCU programs under the Higher Education, Aid for
    Institutional Development Programs account. These programs, authorized
    under Title III of the Higher Education Act, provide critical support
    to higher education institutions that enroll large proportions of
    minority and financially disadvantaged students. One of the primary
    missions of the Title III programs has been to support the nation's
    HBCUs. The Strengthening Historically Black Colleges and Universities
    program and the Historically Black Graduate Institutions program
    provide FAMU and other HBCUs with formula grants to help strengthen our
    academic, administrative, and fiscal capabilities.
        The President's FY 2022 budget requests $402.6 million for the
    Strengthening Historically Black Colleges and Universities program.
    These formula grants provide critical support to HBCUs that help to
    improve our facilities, develop faculty, support academic programs,
    strengthen institutional management, enhance our development and
    recruitment activities, and provide tutoring and counseling services to
    students. In FY 2019, FAMU received $7 million under the program.
        We also support the President's FY 2022 budget request of $102.3
    million for the Strengthening Historically Black Graduate Institutions,
    which funds five-year grants to provide for scholarships for
    disadvantaged students, academic and counseling services to improve
    student success, and supports infrastructure and facilities
    improvements. FAMU received $3.8 million under the current five-year
    grant period for this program.
        FAMU, like other HBCUs, has a critical need for funding to support
    equipment upgrades and purchases, construction and renovation of our
    facilities, and development of our academic programs. This includes a
    wide variety of projects to strengthen the University and its programs,
    such as expansion of our online education offerings to enhance pathways
    to degree attainment, upgrading our information technology
    infrastructure, construction of laboratories, research and education
    facilities, and upgrading our health sciences and technology equipment
    and facilities. Continued funding for these HBCU programs and other Aid
    for Institutional Development programs is essential to postsecondary
    institutions, like FAMU, that educate the nation's minority students.
     department of education historically black colleges and universities
                           capital financing program
        FAMU supports maintaining the FY 2021 enacted level of $48.848
    million for the Department of Education's HBCU Capital Financing
    Program, which provides low-cost capital to finance improvements to the
    infrastructure of the nation's HBCUs. Specifically, the program
    provides accredited HBCUs with access to capital financing or
    refinancing for the repair, renovation, and construction of classrooms,
    libraries, laboratories, dormitories, instructional equipment, and
    research instrumentation.
        FAMU, like other HBCUs, has a critical need to upgrade and
    rehabilitate our aging facilities. This program makes capital available
    for HBCUs to improve our academic facilities, which will enhance the
    learning experience for our students. The requested funding would be
    used to pay the loan subsidy costs in guaranteed loan authority under
    the program. We urge the Subcommittee to maintain the current level of
    funding for FY 2022, which will allow HBCUs to continue to refinance
    previous capital project loans, renovate existing facilities, or build
    new facilities to improve our institutions.
                   department of education pell grant program
        FAMU supports robust funding for the Pell Grant program under the
    Department of Education's Student Financial Assistance account. The
    federal Pell Grant program, authorized by Title IV of the Higher
    Education Act, is the largest source of federal grant aid supporting
    college students. The Pell Grant Program provides need-based grants to
    low-income undergraduate students to promote access to postsecondary
    education.
        For 2017-2018, there were 5,543 Pell Grant recipients attending
    FAMU, amounting to $27.7 million in Pell Grant awards. Over 60% of our
    enrolled students rely on Pell grants to attend our institution. Given
    the ongoing coronavirus crisis, which will have devastating impacts on
    the economy for the foreseeable future, we expect that our current and
    prospective students will be dependent on financial assistance,
    including Pell Grants, in order to continue pursuing their
    postsecondary education goals.
        The President's FY 2022 budget requests $25.475 billion for
    Discretionary Pell Grants and proposes an increase in the maximum award
    to $8,370 in academic year 2021-2022. FAMU would encourage Congress to
    support the President's budget request substantially increasing the
    total maximum Pell grant award in FY 2022 to provide critical support
    for economically disadvantaged college students as we continue to
    rebound from one of the most challenging periods in our nation's
    history.
    national institutes of health research centers in minority institutions
        FAMU supports funding at the FY 2022 President's budget request of
    $80 million for the NIH National Institute on Minority Health and
    Health Disparities (NIMHD), Research Centers in Minority Institutions
    (RCMI) Program. The RCMI Program, established in 1985, supports
    critical infrastructure development and scientific discovery in
    historically minority graduate and health professional schools. The
    program serves the dual purpose of bringing more racial and ethnic
    minority scientists into mainstream research and promoting minority
    health research because many of the investigators at RCMI institutions
    study diseases that disproportionately affect minority populations. The
    RCMI Program develops and strengthens the research infrastructure
    necessary to conduct state-of-the-art biomedical research and foster
    the next generation of researchers from underrepresented populations.
        Since program inception, the FAMU RCMI Center has received over $85
    million from NIH, which has provided critical infrastructure to enable
    the College to achieve national prominence and become a competitive
    biomedical research center nationally. The RCMI support of FAMU led the
    College to implement four doctoral tracks in pharmaceutical sciences,
    including pharmacology/toxicology, medicinal chemistry, pharmaceutics,
    and environmental toxicology. Moreover, as an outcome of the RCMI
    support, our College of Pharmacy has graduated more than 60 percent of
    the African American doctoral recipients in the pharmaceutical sciences
    nationally.
    department of health and human services, health resources and services
           administration (hrsa), health careers opportunity program
        FAMU supports the President's budget request of $15 million for
    HRSA's Health Careers Opportunity Program (HCOP). First authorized in
    1972, the HCOP competitive grant program aims to provide individuals
    from disadvantaged backgrounds an opportunity to develop the skills
    needed to successfully compete for, enter, and graduate from health or
    allied health professions schools. HCOP focuses on three key milestones
    of education: high school completion; acceptance, retention and
    graduation from college; and acceptance, retention and completion of a
    health professions degree program. The ultimate goal of the HCOP
    program is to diversify the health professions workforce by narrowing
    the educational achievement gaps between individuals from higher-income
    and lower-income households.
        The Health Careers Opportunity Program (HCOP) High School Summer
    Institute, conducted on FAMU's campus, is designed for high school
    students interested in pursuing a career in a health profession. The
    four-week program provides a wide-range of educational and social
    experiences for rising 10th, 11th and 12th grade students. The entire
    experience is designed to enhance participants' academic abilities,
    social skills, and other competencies to increase their competitiveness
    for admission to a post-secondary health professions program.
        The President's FY 2022 budget maintains funding for HRSA's Health
    Workforce, Training for Diversity Programs, including the HCOP.
    Continued funding is critical for these programs that help to increase
    the supply of underrepresented minorities in health professions.
        We urge the Subcommittee to support continued and/or enhanced
    funding for these critical education programs at the Departments of
    Education and Health and Human Services. We thank you for your
    continued support of federal postsecondary initiatives that not only
    directly benefit the University and our students, but the region and
    the nation as well. Thank you for your consideration.

        [This statement was submitted by Larry Robinson, Ph.D., President,
    Florida A&M University.]
                                     ______

        Prepared Statement of the Fred Hutchinson Cancer Research Center
        The Fred Hutchinson Cancer Research Center (Fred Hutch) is grateful
    to Congress for providing robust, reliable funding for the National
    Institutes of Health (NIH), a key national priority. The nation's
    investment in NIH research pays a lifetime of dividends in better
    health and improved quality of life for all Americans. The impact of
    the COVID-19 pandemic on the nation has demonstrated the importance of
    a well-funded research enterprise. Thanks to decades of strong
    congressional support for NIH, the scientific community was well-
    equipped to rapidly respond to COVID-19. In fiscal year (FY) 2022, Fred
    Hutch recommends at least $46.1 billion for the NIH. As the research
    enterprise recovers from pandemic-related disruptions, now, more than
    ever, it is essential to continue the trend of recent budget increases
    to NIH to support lifesaving research.
        Through strong, bipartisan leadership over the last six budget
    cycles, the Appropriations Subcommittee on Labor, Health and Human
    Services, Education and Related Agencies (Labor-HHS) has helped the NIH
    regain lost ground after a period of effectively flat budgets. In the
    FY 2021 omnibus bill, the Subcommittee's leadership continued this
    trajectory by providing a substantial increase to all NIH institutes
    and centers in addition to supplemental funding dedicated to COVID-19
    research.
        The federal investment in biomedical research has yielded a
    significant number of scientific advances that improve health outcomes
    for patients. Fred Hutch is committed to working with Labor-HHS,
    Congress and the Administration to further bipartisan support for
    increasing federal investment in biomedical science and ensuring NIH
    remains a top priority in FY 2022. Because of NIH funding, Fred Hutch
    can pursue fearless science and collaborations across its five
    scientific divisions.
        Founded in 1975, Fred Hutchinson Cancer Research Center is guided
    by a mission to eliminate cancer and related diseases as causes of
    human suffering and death. Fred Hutch's interdisciplinary teams of
    world-renowned scientists and humanitarians work together to prevent,
    diagnose, and treat cancer, HIV/AIDS and emerging infectious diseases.
    Our Nobel Prize winning discoveries began in the 1970s with Dr. E.
    Donnall Thomas' work in bone marrow transplantation, providing the
    first definitive and reproducible example of the power of the human
    immune system's ability to cure cancer. The leadership, depth and
    breadth of Fred Hutch's transdisciplinary research makes the center one
    of the National Cancer Institute's 51 designated Comprehensive Cancer
    Centers, serving patients in five northwestern states.
        In addition to groundbreaking discoveries in science, Fred Hutch is
    investing in research to help narrow health inequities, implementing
    initiatives that embrace diversity and inclusion in science and
    empowering early career researchers. Below are some examples of how NIH
    funding fuels Fred Hutch innovation and fosters future generations of
    scientists:
      --Responding to COVID-19. Researchers across Fred Hutch have moved at
            lighting speed to test and develop potential therapies and
            vaccines, increase and expand testing capacity, model the
            course of the pandemic and emerging variants and study the
            molecular interactions between SARS-CoV-2 and the human body.
            Utilizing the expertise and clinical infrastructure of the HIV
            Vaccine Trials Network (HVTN), headquartered at Fred Hutch, the
            center also leads operations for the COVID-19 Prevention
            Network (CoVPN), funded by the National Institute of Allergy
            and Infectious Diseases, and co-leads the five large-scale
            COVID-19 vaccine efficacy trials with over 200 clinical trial
            sites in the U.S. and abroad.
      --Mitigating Health Inequities. Fred Hutch understands the importance
            of community engagement to overcome the pandemic and the HVTN's
            community engagement experts have worked tirelessly for
            inclusive and diverse participation in each of the CoVPN's
            30,000 person vaccine trials. In just six months, the team
            registered nearly 600,000 volunteers and has expanded
            recruitment to volunteers for pediatric COVID-19 trials, long
            COVID, and anticipated trials testing vaccines for variants.
            Fred Hutch is also utilizing the decades-long work of its
            public health scientists to disrupt the flood of misinformation
            during the pandemic, so underrepresented communities receive
            reliable, scientifically sound and understandable information
            about COVID-19 and the vaccines.
      --Embracing Diversity and Inclusion in Science. Fred Hutch recognizes
            the importance of programs that promote diversity, equity and
            inclusion. As the first U.S. Cancer Center to commit to the CEO
            Action for Diversity & Inclusion plan and a member of the
            Washington Employers for Racial Equity, Fred Hutch strives to
            establish itself as a national exemplar in academia for its
            Diversity, Equity and Inclusion (DEI) approaches and practices.
            DEI is integrated as core values, principles and practices in
            Fred Hutch's approach to research, its workforce development,
            workplace culture and the communities Fred Hutch engages with.
            The NIH's emphasis on DEI, including the Agency's DEI
            initiative, UNITE and the FIRST faculty cohort program for
            early career researchers are instrumental in ensuring the most
            creative minds have the opportunity to contribute to the
            nation's research and health goals. Congress' continued support
            of the NIH funds vital efforts to increase representation and
            promote varied perspectives throughout the entire biomedical
            research enterprise.
      --Empowering Early Career Researchers. Fred Hutch is inspiring the
            next generation of researchers who will work at the frontiers
            of life sciences. The center invests $2 million annually on
            science education programs ranging from internship
            opportunities for high school and college students, to
            development resources and mentorship for graduate students,
            postdoctoral fellows and early career faculty. The COVID-19
            pandemic had an acute impact on these early career researchers,
            and it revealed the need for a well-trained, motivated
            scientific workforce. Ongoing investment in the NIH improves
            the quality and cultural proficiency of science by increasing
            access to scientific research and prepares young scientists to
            become tomorrow's leaders.
        The federal government has an irreplaceable role in supporting
    biomedical research. No other public, corporate or charitable entity is
    willing or able to provide the broad and sustained funding for cutting-
    edge research that catalyzes innovative breakthroughs. The partnership
    between NIH and America's research institutions and scientists is
    highly productive.
        As an independent research institute (IRI) with a mission to
    eliminate cancer and related diseases, Fred Hutch depends on NIH
    funding to conduct basic, translational, clinical, public health and
    infectious disease research, and to respond quickly to the research
    needs of the country. In addition to supporting robust funding, Fred
    Hutch opposes provisions--such as directives to reduce salary support
    for extramural researchers--which would harm the appeal of academic
    research and disproportionately affect IRIs. Policies to cut salary
    support undermine Fred Hutch's ability to recruit and retain the
    talented researchers who keep U.S. institutions at the vanguard of
    biomedical sciences.
        Robust increases to the NIH budget do more than bolster important
    research programs; it secures the future of science. Budget increases
    enable initiatives that reduce barriers to academia, provides training
    and education for young scientists starting independent careers and
    encourages culturally inclusive research. Fred Hutch supports these
    initiatives and principles and is applying them to its own workplace
    and research pursuits.
        Fred Hutch thanks the Labor-HHS Subcommittee for its leadership and
    dedication to ensuring the health of the nation and your unwavering
    support for NIH funding in FY 2022. We appreciate the opportunity to
    urge the Subcommittee to provide at least $46.1 billion in FY 2022 for
    NIH. Advances in bioscience, technology and data science have given the
    life sciences tremendous momentum. This is not a time to pull back.
    Given the abundance of scientific opportunity, this recommendation
    represents a minimum investment to sustain progress that would be
    amplified through an even more robust commitment.

        [This statement was submitted by Thomas J. Lynch Jr., MD, President
    and
    Director, Fred Hutchinson Cancer Research Center.]
                                     ______

        Prepared Statement of the Fred Hutchinson Cancer Research Center
        Dear Senator Murray,
        I am writing in support of the FY 2022 budget request for the
    Department of Health and Human Services (DHHS) to develop a strategic
    plan and national strategy for herpes simplex virus requested by Herpes
    Cure Advocacy, an international patient-oriented nonprofit group
    dedicated to alleviate the morbidity and mortality from herpes simplex
    virus type-1 & type 2 (HSV-1 & HSV-2). While HSV as an infectious
    disease is more than worthy of a public health research effort to
    develop vaccines and curative therapies, recent work has suggested HSV
    may also be a major player in Alzheimer's disease. Specifically, the
    strategic plan and national strategy will request $2.5 billion from the
    NIH and CDC over the next 3 years to address the immediate and critical
    need for research into prevention, treatment and cure options to end
    this silent pandemic of herpes simplex infections in our country.
        I have been an advocate and investigator on herpesviruses for over
    40 years, having founded the first patient advocacy group for genital
    herpes (THE HELPER). Over 400 million new cases of genital herpes occur
    each year. The disease is underappreciated due to its asymptomatic
    spread, and in the normal host, HSV-2 mucosal ulcerations are normally
    self-limited. However, systemic complications such as recurrent
    meningitis, hepatitis, and pneumonitis occur during acquisition or
    reactivation of infection, particularly among patients with poor T-cell
    immunity due to AIDS, organ transplantation or chemotherapy. The major
    complication of HSV worldwide is it increases the risk of HIV
    acquisition 3-4 fold. The HIV prevention literature indicates that 40%
    of HIV acquisitions are HSV-related; thus, 420,000 of the 1.2 million
    new HIV cases yearly.
        Recent epidemiological observations suggest many causes of
    Alzheimer's disease are HSV-1-related. This is a plausible hypothesis
    as HSV resides in the brain and the concept is that its presence
    spreads the development of the protein plaques associated with
    Alzheimer's. There are suggestions that treating HSV early may slow
    progression of Alzheimer's. Better research is needed to define this
    and see if novel therapies can be developed. The first antiviral drug--
    acyclovir--invented by Dr. Gertrude Elion, one of the first women
    scientists to receive a Nobel Prize, was developed in the early 1980s.
    I was lucky enough to be a disciple of Dr. Elion and did the first
    studies of the drug for genital herpes. It paved the way for HIV drugs,
    yet it's 40 years later and we have the tools to make better drugs and,
    more importantly, vaccines; vaccines to provide a cure and vaccines to
    prevent HSV from being acquired. Imagine a vaccine that reduces HIV and
    Alzheimer's disease. This is possible by preventing HSV infection.
        One thing the COVID-19 pandemic has done is brought the injustice
    and inequality of health care and resources for infectious diseases to
    light in a way not previously advertised. We are at a crossroads now
    with great levels of advocacy and the ability to make real change with
    new technologies to tackle these silent epidemics.
        Sincerely.

        [This statement was submitted by Lawrence Corey, MD, Past President
    and
    Director, Fred Hutchinson Cancer Research Center.]
                                     ______

    Prepared Statement of the Friends of the Health Resources and Services
                                 Administration
        The Friends of HRSA coalition is a nonpartisan coalition of nearly
    170 national organizations representing tens of millions of public
    health and health care professionals, academicians and consumers
    invested in the Health Resources and Services Administration's mission
    to improve health outcomes and achieve health equity. We are pleased to
    submit our request of at least $9.2 billion for the Health Resources
    and Services Administration in FY 2022. We are grateful for the
    increases provided for HRSA programs in FY 2021 and for the emergency
    supplemental funding to battle the COVID-19 pandemic, but HRSA's
    discretionary budget authority is far too low to effectively address
    the nation's current public health and health care needs. We urge
    Congress to continue efforts to build upon these investments to
    strengthen all of HRSA's programs.
        HRSA's 90-plus programs and more than 3,000 grantees support tens
    of millions of geographically isolated, economically or medically
    vulnerable people, in every state and U.S. territory, to achieve
    improved health outcomes by increasing access to quality health care
    and services; fostering a health care workforce able to address current
    and emerging needs; enhance population health and address health
    disparities through community partnerships; and promote transparency
    and accountability within the health care system. The agency is a
    national leader in improving the health of Americans by addressing the
    supply, distribution and diversity of health professionals and
    supporting training in contemporary practices, and providing high-
    quality health services to populations who may otherwise not have
    access to health care.
        HRSA programs work in coordination with each other to maximize
    resources and leverage efficiencies. For example, Area Health Education
    Centers, a health professions training program, was originally
    authorized at the same time as the National Health Service Corps to
    increase the number of primary care providers at health centers and
    other direct providers of health care services for underserved areas
    and populations. AHECs play an integral role to recruit providers into
    primary health careers, diversify the workforce and develop a passion
    for service to the underserved among future providers.
        HRSA's programs also work in collaboration across the federal
    government to enhance health outcomes. For example, HRSA's HIV/AIDS
    Bureau partners with the Office of the Assistant Secretary for Health,
    the Centers for Disease Control and Preventions, the Substance Abuse
    and Mental Health Services Administration, the Centers for Medicare and
    Medicaid Services, the Indian Health Services, the National Institutes
    of Health, the Agency for Healthcare Research and Quality, the
    Department of House and Urban Development, the Department of Veterans
    Affairs and the Department of Justice to ensure an effective use of
    resources, and a coordinated and focused public health response to the
    HIV epidemic. This federal response has contributed to the number of
    annual diagnosed HIV infections dropping 7 percent between 2014 and
    2018, with HRSA's Ryan White HIV/AIDS Program serving as the foundation
    for delivering health care and support services to reach the public
    health goal of ending the HIV epidemic. Despite this success, an
    estimated 1.2 million people in the U.S. are living with HIV today, and
    approximately 36,400 become newly infected every year--1 in 7 of whom
    are unaware of their infection. HRSA programs will play an integral
    role in achieving the public health goal of ending the HIV epidemic.
        HRSA grantees also play an active role in addressing emerging
    health challenges. For example, HRSA's grantees provide outreach,
    education, prevention, screening and treatment services for populations
    affected by health emergencies such as the opioid epidemic. However,
    much of this work required additional funding to increase capacity in
    health centers, support National Health Service Corps providers to
    deliver relevant care and expand rural health services. Strong,
    sustained funding would allow HRSA to quickly and effectively respond
    to emerging and unanticipated future health needs across the U.S.,
    while continuing to address persistent health challenges.
        HRSA programs and grantees are providing innovative and successful
    solutions to some of the nation's greatest health care challenges
    including the rise in maternal mortality, the severe shortage of health
    professionals, the high cost of health care, and behavioral health
    issues related to substance use disorder--including opioid misuse. We
    recommend Congress build upon the important increases they provided for
    HRSA programs in FY 2021 and provide at least $9.2 billion for HRSA's
    total discretionary budget authority in FY 2022. Additional funding
    will allow HRSA to pave the way for new achievements and continue
    supporting critical HRSA programs, including:
      --Primary care programs support nearly 13,000 health center sites in
            every state and territory, improving access to preventive and
            primary care for nearly 30 million people in geographic areas
            with few health care providers. Health centers coordinate a
            full spectrum of health services including medical, dental,
            vision, behavioral and social services in the nation's most
            underserved communities. Health centers reach 1 in 3 people
            living at or below the federal poverty line; 1 in 5 rural
            residents; 1 in 4 uninsured persons; and 1 in 8 children.
      --Health workforce programs at HRSA support the entire training
            continuum by strengthening the workforce and connecting skilled
            professionals to communities in need. Programs such as the
            Public Health Training Centers assess and respond to critical
            workforce needs through training, technical assistance and
            student support.
      --Maternal and child health programs, including the Title V Maternal
            and Child Health Block Grant, Healthy Start and others, support
            initiatives designed to promote optimal health, reduce
            disparities, combat infant and maternal mortality, prevent
            chronic conditions and improve access to quality health care
            for mothers and babies. MCH programs help assure that nearly
            all babies born in the U.S. are screened for a range of serious
            genetic or metabolic diseases, and that coordinated long-term
            follow-up is available for babies with a positive screen. They
            also help improve early identification and coordination of care
            for children with sensory disorders, autism and other
            developmental disabilities. The MCH Block Grants funded 59
            states and jurisdictions to provide health care and public
            health services for an estimated 60 million people, reaching
            92% of pregnant women, 98% of infants, and 60% of children
            nationwide.
      --HIV/AIDS programs provide the largest source of federal
            discretionary funding assistance to states and communities most
            severely affected by HIV/AIDS. The Ryan White HIV/AIDS Program
            delivers comprehensive care, prescription drug assistance, and
            support services to more than 519,000 people impacted by HIV/
            AIDS. HRSA's Ryan White HIV/AIDS Program effectively engages
            clients in comprehensive care and treatment, including
            increasing access to HIV medication, which has resulted in
            88.1% of clients achieving viral suppression, compared to just
            64.7% of all people living with HIV nationwide. Additionally,
            the program provides education and training for health
            professionals treating people with HIV/AIDS, and works toward
            addressing the disproportionate impact of HIV/AIDS on
            communities of color.
      --Title X ensures access to a broad range of reproductive, sexual and
            related preventive health services for over 3.1 million women,
            men and adolescents, with priority given to low-income
            individuals. Services include patient education and counseling
            for family planning; provision of contraceptive methods;
            cervical and breast cancer screenings; sexually transmitted
            disease prevention education, testing and referral; and
            pregnancy diagnosis. This program helps improve maternal and
            child health outcomes and promotes healthy families.
      --Rural health programs improve access to care for people living in
            rural areas. The Office of Rural Health Policy serves as the
            nation's primary advisor on rural policy issues, conducts and
            oversees research on rural health issues and administers grants
            to support health care delivery in rural communities. Rural
            health programs support community-based disease prevention and
            health promotion projects and expand health information
            technology and telehealth.
      --Special programs include the Organ Procurement and Transplantation
            Network, the National Marrow Donor Program, the C.W. Bill Young
            Cell Transplantation Program and National Cord Blood Inventory.
            These programs facilitate organ marrow and cord blood donation,
            support transplantation and research and increase organ
            donation rates. The Poison Control Program oversees poison
            control centers which contribute to decreasing a patient's
            length of stay in a hospital and save the government $1.8
            billion each year in medical costs and lost productivity.
      --HRSA is well positioned to respond to infectious disease outbreaks
            and has been active in the COVID-19 pandemic response, awarding
            billions of dollars to health centers to administer COVID-19
            tests and reimbursing providers who offer COVID-19 care to
            uninsured individuals.
        To meet the many ongoing public health challenges facing the
    nation, including those outlined above, we urge you to support at least
    $9.2 billion for HRSA's programs in FY 2022.

        [This statement was submitted by Jordan Wolfe, Manager of
    Government
    Relations, American Public Health Association.]
                                     ______

        Prepared Statement of the Friends of the Institute of Education
                                    Sciences
        Chair Murray, Ranking Member Blunt, and Members of the
    Subcommittee, thank you for the opportunity to submit written testimony
    on behalf of the Friends of IES, a consortium of scientific and
    professional societies, research universities, and independent research
    organizations committed to supporting the mission of IES and the use of
    research and statistics. We recommend $737.47 million for the Institute
    of Education Sciences (IES) in the FY 2022 Labor, Health and Human
    Services, and Education Appropriations bill. This request is aligned
    with the top line amount included for IES in the president's budget
    request.
        IES is the independent and nonpartisan statistics, research, and
    evaluation arm of the U.S. Department of Education charged with
    supporting and disseminating rigorous scientific evidence on which to
    ground education policy and practice. As such, it serves as the
    critical federal source for funding groundbreaking research in myriad
    aspects of teaching and learning, as well as rigorous analysis of
    educational programs and initiatives. Throughout the pandemic, IES has
    sought to meet the demand for evidence-based resources to help
    facilitate remote instruction, address academic and socioemotional
    needs of students, and support teachers and school leaders in adapting
    to the ever-changing conditions resulting from the pandemic.
        Its four centers-the National Center for Education Statistics
    (NCES), National Center for Education Research (NCER), National Center
    for Special Education Research (NCSER), and National Center for
    Education Evaluation (NCEE)-work collaboratively to efficiently and
    comprehensively deliver rigorous research and high-quality data and
    statistics to educators, parents, and policymakers.
        Our member organizations rely on IES to support vital research that
    addresses many of the most important issues in our nation's schools. We
    are deeply thankful for the increases provided to IES in recent years
    to further invest in the education research and statistical
    infrastructure and to respond to the impact of COVID-19 on our most
    marginalized populations.
        At the same time, IES remains constrained in its flexibility to
    fully fund emerging research areas and scale up promising interventions
    and resources. Only one of every ten grant proposals receives funding
    support, limiting the ability of IES to tackle pressing questions in
    education, such as what can be done to support student learning in
    informal settings, address challenges facing rural districts, and
    improve literacy for adult learners. Additional investment in Research,
    Development, and Dissemination could support new high-risk, high-reward
    research with the potential for transforming education, along with
    funding research in foundational and emerging areas in education and
    supporting the synthesis of research findings for use by all education
    stakeholders.
        The National Center for Education Statistics (NCES) is the primary
    federal entity dedicated to collecting data related to education and is
    the only principal statistical agency dedicated to this mission. NCES
    compiles and disseminates important, trustworthy, and scientifically
    valid data on the condition of education that is essential to policy,
    practice, and research being conducted across the nation. Most
    recently, NCES' pivoting and partnering with the Census Bureau and four
    other federal statistical agencies to get weekly estimates of the
    impact of COVID-19 is just one palpable example of its vital role.
    Sufficient funding for NCES can enhance the ability of NCES to develop
    and administer surveys, analyze data on timely education issues, and
    link administrative education data to health and employment data for
    evidence-based policymaking and to understand the broader context of
    outcomes.
        NCES importantly provides the funding support and infrastructure
    for the Statewide Longitudinal Data Systems (SLDS), providing critical
    investment for states to link K-12, postsecondary, and workforce
    systems to gain a better understanding of education and workforce
    outcomes. IES is also promoting the research use of SLDS to measure the
    effects of interventions on long-term student outcomes. Additional
    resources for SLDS can support states in linking data across education
    and workforce systems.
        In addition to the research supported by the National Center for
    Education Research, the Regional Educational Laboratories (RELs)
    conduct applied research that is directly relevant to state and
    district administrators, principals and teachers. RELs also ensure that
    research is shared widely through its deep dissemination networks.
    During the pandemic, the RELs have provided a wide range of evidence-
    based resources to guide teachers, school leaders, and state and local
    officials on COVID-19 response. This work is all driven by the state
    education agencies and other stakeholders in the regions. Additional
    funding is needed to research and support growing local and regional
    needs to respond to the impact of the pandemic on academic, social and
    emotional learning.
        The National Center for Special Education Research (NCSER) is the
    only federal agency specifically designated to develop and provide
    evaluations for programs for students with disabilities. Research
    funded by NCSER has resulted in programs such as those that support
    youth with high functioning autism experiencing high levels of anxiety,
    individuals with Down syndrome learning to read, and students with
    learning disabilities studying to master math word problems. NCSER also
    provides special educators and administrators research-based resources
    that support the provision of a free appropriate public education and
    interventions to foster self-determination in students with
    disabilities as they transition into adulthood. COVID-19 has had a
    disproportionate impact on students with or at-risk of disabilities who
    have faced significant barriers to educational access over the past
    year. Although funding from the American Rescue Plan will support such
    research in an FY 2022 grant competition, NCSER will not hold a
    competition for non-pandemic-related research due to limited funding.
    With additional funding, NCSER could support data and evidence-based
    resources to guide teachers, administrators, and policymakers in state
    and local agencies.
        Alongside the recommendation regarding the investment in IES, we
    encourage you to include language in the Program Administration line to
    allow for IES to hire additional staff. Understanding that the
    Department of Education approves hiring authority, IES can be more
    innovative and flexible in carrying out its mission and support
    emerging areas of research and statistical collection with additional
    staff. As one example, NCES staff have technical expertise but are also
    responsible for managing contracts for its surveys. Providing authority
    for NCES to hire more staff can allow the agency to fully discharge its
    responsibilities, including the integration of new forms of massive and
    fast data. To execute these functions effectively requires staff of
    adequate size.
        To this end, we recommend that the Committee provide IES $737
    million in FY 2022. As our country emerges from a year of the greatest
    national disruption our schools have ever seen, it is clear that there
    is a demand for evidence-based resources for our teachers, school
    leaders, students, and families to support learning and instruction. A
    commitment at this level will enable IES to more fully support research
    that addresses the challenges of preparing young Americans to succeed
    in the knowledge-based economy that is not only upon us now, but also
    the key to future American prosperity.

        [This statement was submitted by Felice J. Levine, Chair, Friends
    of the Institute of Education Sciences.]
                                     ______

     Prepared Statement of the Friends of the National Institute of Child
                          Health and Human Development
        I write on behalf of the Friends of NICHD, a coalition of more than
    100 organizations representing patients, providers, scientists, and
    caregivers who are united in our support for ensuring the health and
    welfare of women, children, families, and people with disabilities
    through research funded by the Eunice Kennedy Shriver National
    Institute of Child Health and Human Development (NICHD) and the
    National Institutes of Health (NIH). We urge the subcommittee to
    provide NICHD with no less than $1.7 billion in Fiscal Year (FY) 2022,
    an increase of $117 million over FY 2021. We also respectfully ask the
    subcommittee to maintain its commitment to increasing funding for the
    National Institutes of Health (NIH) by providing no less than $46.1
    billion in FY 2022.
        We are pleased to support the extraordinary achievements of NICHD
    in meeting the objectives of its biomedical, social, and behavioral
    research mission, including research on child development before and
    after birth; women's health throughout the life cycle; maternal, child,
    and family health; learning and language development; reproductive
    biology; population health; and medical rehabilitation. With these
    necessary resources, NICHD can ensure proportional growth to that of
    its counterpart institutes and build upon the initiatives we've listed
    below to provide new insights and solutions to benefit women, children,
    and families in your districts and states.
        COVID-19: NICHD has played a key role in understanding the impact
    of the COVID-19 pandemic on the institute's populations, including
    pregnant and postpartum women, children and adolescents, people with
    intellectual and developmental disabilities, and people with physical
    disabilities and mobility impairments. This work includes intramural
    research studies, collaborations with other NIH institutes and centers,
    and major undertakings like the Gestational Research Assessments for
    COVID-19 (GRAVID) study and the Predicting Viral-Associated
    Inflammatory Disease Severity in Children with Laboratory Diagnostics
    and Artificial Intelligence (PreVAIL kIds) which are advancing our
    knowledge of understudied COVID-19 research questions. NICHD also
    continues to advocate for inclusion of its key populations in major
    trans-NIH programs like the Rapid Acceleration of Diagnostics (RADx)
    initiative.
        Maternal Mortality: The Pregnancy and Perinatology Branch, through
    networks including the Maternal-Fetal Medicine Units (MFMU) Network,
    supports research to improve the health of women before, during and
    after pregnancy. Maternal mortality rates are at an unprecedented high
    in the United States and significant racial and ethnic disparities
    persist. Research to better understand the mechanisms of disparities,
    to include social determinants of health and genetic factors that
    adversely affect pregnancy outcomes, are vitally needed.
        Data on Pediatric Enrollment in NIH Trials: NIH requires
    investigators to submit deidentified demographic data on study
    participants, including age at enrollment. It is important for NIH to
    analyze and publicly report on this data to ensure that all
    populations, including children, benefit from research. This data
    should be used proactively NIH-wide to address recruitment issues in
    ongoing studies in real time and to drive forward the inclusion of
    individuals across the lifespan, including children. NICHD should play
    a leading role in the implementation of this policy vis-a-vis age.
        Infant and Childhood Health: Through the Best Pharmaceuticals for
    Children Act (BPCA), NICHD funds the study of old, off-patent drugs
    important to children but inadequately studied in pediatric
    populations. We urge continued funding for this research and for
    training the next generation of pediatric clinical investigators. We
    also strongly support NICHD's ongoing research into the causes and
    prevention strategies for the major causes of death in infancy and
    childhood, including sudden unexpected infant death, accidents, and
    suicide.
        Behavioral Health Research: NICHD supports a range of research on
    child development and behavior and has made great progress developing
    sophisticated tools to measure children's cognitive, emotional, and
    social functioning. To build on these successes, we encourage more
    integrated behavioral and biobehavioral work on child developmental
    trajectories, across infancy, childhood, and adolescence, in both
    normative and at-risk environments, across diverse contexts (school,
    home, and community) and including underrepresented and vulnerable
    groups. More research is also needed on integrated behavioral health in
    primary care settings, including cost effectiveness comparisons, and
    the impact of behavioral interventions on mental health, physical
    health, and quality of life. Child health would also benefit from
    additional work on the role of technology to support optimal
    development in children, including those with disabilities, and
    increased access to and engagement with effective psychological and
    behavioral interventions for childhood conditions.
        Poverty and Child Health: Poverty can be especially detrimental in
    childhood and adolescence, leading to adverse impacts on physical
    health, mental health, social well-being, cognitive and emotional
    development, and the acquisition of motor and language skills. NICHD is
    in the unique position to examine the biological, psychological,
    social, cultural, and environmental factors that impact the developing
    child in high-poverty environments--including challenges due to chronic
    stress, neighborhood safety, school environments, family health status,
    education, job instability, unstable family structures, and substandard
    living conditions--and to evaluate interventions aimed at improving the
    developmental trajectories of these children.
        Reproductive Sciences: Research on the basic biological mechanisms
    of reproduction is a crucial foundation for all NICHD's work.
    Understanding reproductive biology and associated biological phenomena
    provides the foundation for innovative medical therapies and
    technologies and improves existing treatment options for gynecologic
    conditions. Often, this research focuses on serious conditions that are
    overlooked and underfunded, even though they impact many women. Future
    work could address infertility and the need for treatments for
    endometriosis, polycystic ovarian syndrome (PCOS) and uterine fibroids.
        Pelvic Floor Disorders Network (PFDN): Female pelvic floor
    disorders represent a major public health burden with high prevalence,
    impaired quality of life and substantial economic costs affecting 25%
    of American women. The PFDN conducts research to improve treatment of
    these painful gynecological conditions. Current research aims to
    improve female urinary incontinence outcome measures and ensure high-
    quality outcomes.
        PregSource: NICHD's PregSource\TM\ Initiative enables pregnant
    women to track their health data from gestation to early infancy and
    access evidence-based information about healthy pregnancies. It will
    also allow researchers to utilize aggregated data and potentially
    recruit participants for clinical trials so that knowledge gaps can be
    eliminated and care for pregnant and post-partum women can be improved.
        Task Force Specific to Research in Pregnant Women and Lactating
    Women (PRGLAC): We urge Congress to continue its strong support of the
    NICHD-led PRGLAC Task Force, and to support the recommendations
    contained in the report to achieve broader inclusion of pregnant and
    lactating women in research and expansion of the workforce of
    clinicians and researchers with expertise in obstetric and lactation
    pharmacology and therapeutics, so that lifesaving treatments for this
    population are known to be safe and effective.
        NIH Pediatric Research Consortium (N-PeRC): N-PeRC is an NICHD-led,
    trans-NIH initiative that aims to harmonize pediatric research and
    training activities across the NIH. N-PeRC capitalizes on pediatric
    expertise at the NIH by enabling collaboration to explore gaps in the
    overall pediatric research portfolio and share best practices to
    advance science. N-PeRC has played a vital role throughout the COVID-19
    pandemic in identifying key child and adolescent research needs related
    to SARS-CoV-2.
        Human Development, Infancy Through Adulthood: NICHD supports
    research on infant-through-adult development, including how father-
    child relationships and co-parenting positively impacts children's
    socio-emotional development and decreases behavior problems; children's
    adjustment after the birth of a sibling; pathways and outcomes
    associated with mothers' postseparation co-parenting relationships,
    with a particular focus on experiences of intimate partner violence and
    negative outcomes; and the health and well-being across three
    generations of lesbians, gay men, and bisexuals.
        Intellectual and Developmental Disabilities Research Centers
    (IDDRC): The IDDRCs are a critical national resource for basic research
    into the genetic and biological basis of human brain development,
    greatly improving our understanding of the causes of developmental
    disabilities and contributing to the development and implementation of
    evidence-based practices by evaluating the effectiveness of biological,
    biochemical, and behavioral interventions. These centers have
    contributed to new treatments for genetic disorders through the study
    of intellectual and developmental disabilities, such as Everolimus for
    epilepsy in TSC. We must build on progress in the understanding and
    treating this class of disorders that affect so many. We urge resources
    and support for the IDDRCs for research infrastructure and expansion to
    conduct basic and translational research to develop effective
    prevention, treatment and intervention strategies for children and
    adults with developmental disabilities.
        Preterm Birth: NICHD supports a comprehensive research program on
    the causes, prevention and treatment of preterm birth, the leading
    cause of infant mortality and intellectual and physical disabilities.
    Research shows the survival rate and neurological outcomes may be
    improving for very early preterm infants, but continued prioritization
    is needed through extramural preterm birth prevention research, the
    MFMU Network, the Neonatal Research Network, and intramural research
    program. Robust funding is needed for research to determine the complex
    interaction of behavioral, social, environmental, genetic, and
    biological influences on preterm birth with the goal of developing the
    interventions necessary to decrease prematurity.
        Population Dynamics: The NICHD Population Dynamics Branch supports
    research on how population change affects the health, development, and
    well-being of children and their families. Longitudinal surveys, such
    as the Fragile Families and Child Wellbeing Study, have demonstrated
    the role that family stability and parental involvement play in the
    long-term health and development of children, facilitating tremendous
    progress in the population sciences. NICHD also supports the Population
    Dynamics Centers Research Infrastructure Program, which supports
    research and research training in demographic or population research.
    These centers focus on research such as family demography and
    intergenerational relationships; education, work, and inequality;
    population health; and reproductive health.
        Male Infertility: Male infertility is another relevant area of
    inquiry that would benefit from NICHD-sponsored research. For instance,
    the biological mechanisms associated with common causes of male
    infertility, such as varicoceles, remain poorly understood. These
    research domains represent important opportunities to develop better
    treatments for male infertility.

        [This statement was submitted by KJ Hertz, 2021 Chair, Friends of
    the National Institute of Child Health and Human Development.]
                                     ______

    Prepared Statement of the Friends of the National Institute of Diabetes
                       and Digestive and Kidney Diseases
        On behalf of the 35 patient, physician, and research organizations
    that are members of the Friends of the National Institute of Diabetes
    and Digestive and Kidney Diseases (NIDDK), we want first to thank you
    for your ongoing bipartisan investment in the National Institutes of
    Health (NIH). We ask you to support our FY 2022 NIH funding
    recommendation of at least $46.111 billion, a $3.177 billion increase
    over the comparable FY 2021 funding level for the NIH, which would
    allow for the NIH's base budget to keep pace with the biomedical
    research and development price index of 2.3% and allow meaningful
    growth of 5%. We also request a proportionate increase for the NIDDK of
    at least $157 million for a total of $2.289 billion in FY 2022. This
    level of increase over its FY 2021 funding is necessary for NIDDK to
    fulfill its mission to conduct and support medical research, research
    training, and to disseminate science-based information on diabetes and
    other endocrine and metabolic diseases; digestive diseases, nutritional
    disorders, and obesity; and kidney, urologic, and hematologic diseases
    and to support the Institute's multi-pronged efforts toward the goal of
    health equity. We also strongly encourage you to provide supplemental
    emergency funding of $10 billion for NIH, ensure dedicated support for
    the NIDDK to enable critical COVID-related research, and support
    research recovery from the impact of the pandemic.
        NIDDK supports and conducts research to combat a portfolio of
    diseases that encompass some of the most chronic, common,
    consequential, and costly diseases and conditions affecting people in
    this country. Many of these diseases and disorders are also associated
    with health disparities. These disparities are exacerbated by the
    COVID-19 pandemic, with increased rates of infection and poor outcomes
    from COVID-19 seen in people with these same conditions.
        We want to share just a few NIDDK-supported research highlights to
    demonstrate the great impact and promise of NIDDK research to improve
    people's health and quality of life (more thorough descriptions are in
    NIDDK's Recent Advances & Emerging Opportunities):
      --Research on an immune-targeting drug has delayed type 1 diabetes
            progression in high-risk individuals for at least 3 years. This
            is the first time ever that early preventive therapy was found
            to delay onset of clinical type 1 diabetes.
      --Research defining subgroups of people with chronic kidney disease
            is paving the way for kidney precision medicine.
      --Adult and pediatric studies are testing potential therapies and
            uncovering genetic and racial/ethnic risk factors for
            nonalcoholic fatty liver disease and nonalcoholic
            steatohepatitis.
      --The Intestinal Stem Cell Consortium is studying intestinal stem
            cells' roles in intestinal health and disease, aiming to
            identify and develop novel therapies to regenerate the human
            intestine.
      --The NIDDK sponsored Symptoms of Lower Urinary Tract Dysfunction
            Research Network (LURN) is working to improve the lives of
            patients affected by lower urinary tract dysfunction (LUTD)
            through overcoming barriers to diagnosis and treatment.
      --Innovative research by NIDDK scientists showed the potential
            importance of speech-generated droplets in SARS-CoV-2
            transmission.
      --NIDDK research has led to better treatments such as new drugs that
            can dramatically reduce disease burden for many with cystic
            fibrosis; increased understanding and treatment of inflammatory
            bowel diseases such as Crohn's disease and ulcerative colitis;
            and to new Type 2 diabetes drugs that provide cardiovascular
            health benefits in people with diabetes.
        Our organizations are grateful for the funding that you have
    provided to the NIH and the NIDDK as part of the appropriations process
    and the support Congress has given to the NIH, including several of its
    institutes and centers, to respond to the public health emergency.
    However, we note that NIDDK's FY 2021 appropriation was proportionally
    less than other Institutes and NIDDK and has not received any emergency
    funding despite researching diseases that are associated with increased
    risk of severe COVID-19 outcomes and are themselves public health
    crises.
        As health professionals and researchers continue to respond to this
    pandemic, our understanding of COVID-19 continues to evolve. What we
    originally understood to be an infectious, respiratory virus, we now
    know disproportionately impacts individuals with diabetes, obesity,
    liver diseases and kidney diseases. COVID-19 infection damages a
    variety of organ systems, including the kidneys and it may even
    contribute to new onset of kidney failure and diabetes. Patients also
    are experiencing hematologic complications, including issues related to
    coagulation and blood cell production. Yet, without additional funding,
    NIDDK will be forced to continue to divert crucial funds from its
    existing priorities to better understand these characteristics of
    COVID-19, a loss to the patients who ultimately benefit from research
    funded by NIDDK.
        With emergency supplemental funding, NIDDK will be able to support
    research on SARS-CoV-2/COVID-19 as it intersects with and affects
    people with or at risk for diabetes and other metabolic diseases,
    obesity, and endocrine, digestive, hepatobiliary, pancreas, kidney,
    urological and hematologic diseases. Specific areas of research
    include: determining the basis for the link between COVID-19 severity
    and diseases in the NIDDK's portfolio; identifying novel pathogenic
    pathways and potential translational targets for the treatment or
    prevention of kidney, gastrointestinal, and endocrine/metabolic
    diseases associated with SARS-CoV-2 infection; and understanding the
    roles of health disparities associated with SARS-CoV-2 infection, organ
    injury, and adverse disease outcomes.
        Further, the occurrence of Post-Acute Sequelae of SARS-CoV-2
    infection (PASC), in which individuals experience persistent symptoms
    involving multiple body systems after recovering from their initial
    illness, shows that while new infections with SARS-CoV-2 have decreased
    in the US, our understanding of the long-term consequences of COVID-19
    is far from over and creates another important and emerging research
    opportunity.
        In addition to new areas of research, the pandemic has created
    additional barriers and expenses that complicate restarting research.
    Supplemental funds are needed to:
      --Restart research projects, programs, and clinical trials that were
            underway before the onset of the pandemic and were stopped or
            delayed for safety reasons, consequently stalling or delaying
            new discoveries.
      --Support early-stage investigators as they face uncertainties and
            challenges in making progress in their careers, especially
            women investigators and others who are disproportionately
            affected by caregiving roles during the pandemic and members of
            groups underrepresented in research.
      --Provide financial support so that critical research support staff
            can be retained and to accelerate the eventual resumption of
            research activities post-pandemic.
      --Address increasing research costs. The burden of restarting
            clinical trials, animal colonies, and other programs and
            resources has made conducting research more challenging and
            expensive during the pandemic. Costs for personal protective
            equipment (PPE), comprehensive cleaning, and ``time sharing''
            in laboratories are a few examples.
        All of this leads to a simply put yet challenging goal: While
    addressing the immediate challenges of COVID-19, we also need to
    continue to combat the diseases within NIDDK's mission, which will
    continue to place an enormous personal and financial toll on this
    country long after the pandemic is over. Bolstering support for NIDDK
    will help ensure that critical research in these areas continues and
    will support the institute's commitment to understanding the roles of
    social determinants of health and health disparities with the goal of
    improving health for all. Our nation's progress against COVID-19--and
    every other health threat--is built on the longstanding bipartisan
    commitment to medical research. Preserving that investment will be key
    to continued advances. We urge you to support the NIH with a $3.1
    billion increase for FY 2022 with a proportionate increase of $157
    million for NIDDK and provide emergency supplemental funds for NIH,
    including dedicated support for the NIDDK, to ensure we lead the world
    in providing new and better cures, diagnostics, and treatments while
    protecting all patients and the research enterprise.
                                     ______

        Prepared Statement of the Friends of the National Institute of
                                 Mental Health
        Chair Murray, Ranking Member Blunt, and Members of the
    Subcommittee:
        I write on behalf of the Friends of NIMH, a newly formed coalition
    of more than 30 organizations representing scientists, physicians,
    health care providers, individuals, families, and communities. The
    members of the Friends of NIMH are dedicated to supporting the mission
    of the National Institute of Mental Health (NIMH) to transform the
    understanding of mental health and the treatment of mental illnesses
    through basic biomedical, behavioral, and clinical research, to best
    inform prevention, early intervention, recovery, and cures. We write to
    encourage you to provide robust funding for NIMH in FY 2022 so that the
    institute can build upon the significant achievements to advance the
    behavioral, biomedical, and social research mission and important
    initiatives to provide new insights and solutions to benefit your
    constituents. Our member organizations represent communities with
    interest across the National Institutes of Health (NIH). Individually
    and collectively, our members also belong to the Ad Hoc Group for
    Medical Research, a coalition of over 330 patient and voluntary health
    groups, medical and scientific societies, academic and research
    organizations, and industry that support enhancing the federal
    investment in the behavioral and biomedical research conducted and
    supported by the NIH. Aligned with the Ad Hoc request, we respectfully
    request that the subcommittee provide at least $46.1 billion for the
    agency in Fiscal Year (FY) 2022, $3.2 billion above the final FY21
    funding level.
        Thank you for considering this request.

                                     ______

      Prepared Statement of the Friends of the National Institute on Aging
        On behalf of the Friends of the National Institute on Aging
    (FoNIA), we are grateful for your leadership in advancing the mission
    of National Institutes of Health (NIH), and the research supported and
    conducted by the National Institute on Aging (NIA). FoNIA is a
    coalition of more than 50 academic, patient-centered and non-profit
    organizations supporting NIA's mission to understand the nature of
    aging and the aging process, and diseases and conditions associated
    with growing older in order to extend the healthy, active years of
    life.
        We are writing to request that federal resources continue to be
    dedicated to sustaining and enhancing timely and promising aging
    research at NIA and across NIH.
        Specifically, FoNIA requests:
      --No less than $46.1 billion--a $3.3 billion increase--in fiscal year
            (FY) 2022 for total spending at NIH for current institutes and
            operations, including funds from the 21st Century Cures Act for
            targeted initiatives which corresponds with the overall
            recommendation of the Ad Hoc Group for Medical Research.
      --An increase of least $500 million specifically dedicated to support
            cross-Institute aging research at the NIH, including but not
            limited to biomedical, behavioral and social sciences aging
            research. This increase must be separate from whatever funds
            are allocated to the Advanced Research Projects Agency for
            Health (ARPA-H) at NIH. Investment in ARPA-H should not come at
            the cost of the existing NIH institutes and centers conducting
            and supporting research on aging.
      --A minimum increase of $289 million specific to research on
            Alzheimer's disease and related dementias (ADRD). NIA is the
            primary federal agency supporting and conducting Alzheimer's
            disease and related dementias research.
        FoNIA understands that during this time, Congress is working hard
    to stem fallout of both the human and fiscal toll of COVID. In this
    rapidly evolving crisis, NIH/NIA has played an extremely vital role in
    examining how COVID impacts older adults, why they may be more
    susceptible to the virus, how they can be protected, and the social and
    economic effects of the pandemic on older adults.
        NIA sponsors and conducts the lion's share of federal aging-related
    research, and this pioneering science contributes significantly to the
    improved care and quality of life of older adults. A key NIA priority
    is translating research into better and more efficient care through the
    development of effective interventions that are disseminated to health
    care providers, patients, and caregivers. These interventions for the
    prevention, early detection, diagnosis, and treatment of disease will
    help reduce the burden of illness for older adults and reduce the cost
    of care.
        NIA's COVID response has been wide and varied. NIA has been heavily
    involved in the work of the Rapid Acceleration of Diagnosis (RADx)
    program designed to speed innovation in the development,
    commercialization, and implementation of technologies for COVID
    testing. NIA is especially active in the RADx Underserved Populations
    (RADx-UP) program, which strives to understand the factors associated
    with disparities in COVID morbidity and mortality.
        In the area of dementia, NIA supports vital research where more
    scientific investigation is needed to improve AD/ADRD prevention,
    diagnosis, treatment and care; basic science approaches to illuminate
    neurodegenerative mechanisms/pathways; and computational/biological
    systems approaches to identify, model and predict the architecture and
    dynamics of the molecular interactions underlying AD/ADRD pathogenesis.
        NIH's Brain Research through Advancing Innovative Technologies
    (BRAIN) Initiative works to develop a dynamic picture of how neurons
    act, both individually and together in circuits. The initiative
    revolutionizes our understanding of the human brain and provides
    insight into how to treat, prevent and cure brain disorders. In
    addition to NIH, this public-private partnership involves other federal
    agencies such as the National Science Foundation (NSF), Defense
    Advanced Research Projects Agency (DARPA), Intelligence Advanced
    Research Projects Activity (IARPA), the Food and Drug Administration
    (FDA) and the Department of Energy (DOE).
        Lastly, NIH funding provides a vital economic boost to local
    economies. Most of NIH/NIA funding is distributed as grants to
    universities and other research institutions across the US, and acts as
    an economic engine and multiplier in local and regional communities.
    According to United for Medical Research, total FY 2020 NIH research
    spending of $34.65 billion supported more than 536,338 American jobs
    and generated nearly $91.35 billion in economic activity across the
    country.
        Thanks to your support, NIH/NIA is continuing to accelerate
    scientific discoveries which will benefit us all as we age. Only
    through continued, and meaningful investments in NIH/NIA will it be
    possible to enhance the quality of care for older adults across the
    nation.
        Thank you for your consideration of this funding request. Should
    you need additional information, feel free to contact me at
    esokol@alzfdn.org.
        Sincerely.

        [This statement was submitted by Eric W. Sokol, Chair, Friends of
    the National Institute on Aging.]
                                     ______

        Prepared Statement of the Friends of the National Institute on
                                   Drug Abuse
        Thank you for the opportunity to submit testimony in support of the
    National Institute on Drug Abuse (NIDA). The Friends of the National
    Institute on Drug Abuse is a coalition working with about 150 scholarly
    organizations with a total membership of at least 2 million scholars,
    clinicians and educators who are committed to eliminating substance use
    disorders in society. We coordinate the opinions of the participating
    organizations, who also actively participate on their own to provide
    important information to policy makers to make decisions that will lead
    to the elimination of this disease which now is killing so many of our
    citizens. For example, former research which led to the creation of
    drugs such as naloxone and buprenorphine has provided important
    mechanisms which have prevented the death rate from being even much
    higher. We need more research in all areas of basic and clinical
    science to make additional advances.
        In the Fiscal Year 2022 Labor, Health and Human Services
    Appropriations bill we request that the subcommittee include the
    President's requested level of $51 billion for the National Institutes
    of Health (NIH), including no less than $46.1 billion for NIH's base
    program level budget. In addition, we greatly appreciate the President
    Budget's recognition of the need to significantly increase our nation's
    investment in the National Institute on Drug Abuse (NIDA) and its
    response to the opioid epidemic. The President's Fiscal 2022 Budget
    recommends a $372.2 million increase in NIDA's budget, a 25 percent
    increase. We strongly encourage the Subcommittee to include the
    President's recommended funding level of $1.852 billion for NIDA in the
    Senate version of the Fiscal Year 2022 Labor, Health and Human Services
    Appropriations bill.
        We also respectfully request the inclusion of the following NIDA
    specific report language.
        Opioid Initiative. The Committee continues to be concerned about
    the opioid overdose epidemic and appreciates the important role that
    research plays in the various federal initiatives aimed at this crisis.
    The Committee is also aware of the most recent data from the Centers
    for Disease Control and Prevention that shows opioid overdose
    fatalities increasing from 2018 to 2019, with the primary driver being
    the increased overdose deaths involving synthetic opioids, primarily
    illicitly manufactured fentanyls. To combat this crisis the Committee
    has provided within NIDA's budget no less than $270,295,000 for the
    Institute's share of the HEAL Initiative and in response to rising
    rates of stimulant use and overdose, the Committee has included
    language expanding the allowable use of these funds to include research
    related to stimulant use and addiction.
        Methamphetamine and Other Stimulants. The Committee is concerned
    that, according to data released by the Centers for Disease Control and
    Prevention, 32,000 overdose deaths involved drugs in the drug
    categories that include methamphetamine and cocaine in 2019, an
    increase of over 700%. The sharp increase has led some to refer to
    stimulant overdoses as the ``fourth wave'' of the current drug
    addiction crisis in America following the rise of opioid-related deaths
    involving prescription opioids, heroin, and fentanyl-related
    substances. Methamphetamine is highly addictive and there are no FDA-
    approved treatments for methamphetamine and other stimulant use
    disorders. The Committee continues to support NIDA's efforts to address
    the opioid crisis, has provided continued funding for the HEAL
    Initiative, and supports NIDA's efforts to combat the growing problem
    of methamphetamine and other stimulant use and related deaths.
        Barriers to Research. The Committee is concerned that restrictions
    associated with Schedule I of the Controlled Substance Act which
    effectively limits the amount and type of research that can be
    conducted on certain Schedule I drugs, especially opioids, marijuana or
    its component chemicals and new synthetic drugs and analogs. At a time
    when we need as much information as possible about these drugs and
    antidotes for their harmful effects, we should be lowering regulatory
    and other barriers to conducting this research. The Committee
    appreciates NIDA's completion of a report on the barriers to research
    that result from the classification of drugs and compounds as Schedule
    I substances including the challenges researchers face as a result of
    limited access to sources of marijuana including dispensary products.
        COVID Pandemic and Impact on Substance Use Disorders. The Committee
    is acutely aware of the risks that the ongoing COVID-19 pandemic poses
    to individuals with substance use disorders. According to the Centers
    for Disease Control and Prevention, drug overdose deaths accelerated
    during the pandemic which saw over 81,000 drug overdose deaths in the
    United States in the 12 months ending in May 2020, the highest number
    of overdose deaths ever recorded in a 12-month period. Moreover,
    research supported by the National Institute on Drug Abuse found that
    individuals with substance use disorders are at increased risk for
    COVID-19 and its more adverse outcomes. The Committee commends NIDA for
    conducting research on the adverse impact of the pandemic on SUDs and
    encourages the Institute to expand its research on these issues.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment. Education is a critical
    component of any effort to curb drug use and addiction, and it must
    target every segment of society, including healthcare providers
    (doctors, nurses, dentists, and pharmacists), patients, and families.
    Medical professionals must be in the forefront of efforts to curb the
    opioid crisis. The Committee continues to be pleased with the NIDAMED
    initiative, targeting physicians-in-training, including medical
    students and resident physicians in primary care specialties (e.g.,
    internal medicine, family practice, and pediatrics). NIDA should
    continue its efforts in this area, providing physicians and other
    medical professionals with the tools and skills needed to incorporate
    substance use and misuse screening and treatment into their clinical
    practices. The Committee recommends that NIDA increase its support for
    the education of scientists and practitioners to find improved
    prevention and treatments for substance use disorders as the Institute
    has done for the COVID-19 pandemic.
        Marijuana Research. The Committee is concerned that marijuana
    policies on the federal level and in the states (medical marijuana,
    recreational use, etc.) are being changed without the benefit of
    scientific research to help guide those decisions. NIDA is encouraged
    to continue supporting a full range of research on the health effects
    of marijuana and its components, including research to understand how
    marijuana policies affect public health.
        Electronic Cigarettes. The Committee understands that electronic
    cigarettes (e-cigarettes) and other vaporizing equipment are
    increasingly popular among adolescents, and requests that NIDA continue
    to fund research on the use and consequences of these devices.
        In addition, we request the following report language within the
    Office of the Director account:
        The HEALthy Brain and Child Development (HBCD) Study. The Committee
            recognizes and supports the NIH HEALthy Brain and Child
            Development Study, which will establish a large cohort of
            pregnant women from regions of the country significantly
            affected by the opioid crisis and follow them and their
            children for at least 10 years. This knowledge will be critical
            to help predict and prevent some of the impacts of pre- and
            postnatal exposure to drugs or adverse environments, including
            risk for future substance abuse, mental disorders, and other
            behavioral and developmental problems. The Committee recognizes
            that the HBCD Study is supported in part by the NIH HEAL
            Initiative, and NIH Institutes, Centers, and Offices (ICOs),
            including OBSSR, ORWH, NIMHD, NIBIB, NIMHD, NIEHS, NICHD,
            NINDS, NIAAA, NIMH, and NIDA, and encourages other NIH ICOs to
            support this important study.
        Substance use disorders (SUD) are costly to Americans; it ruins
    lives, while tearing at the fabric of our society and taking a
    financial toll on our resources. Over the past three decades, NIDA-
    supported research has revolutionized our understanding of SUD as a
    chronic, often-relapsing brain disease -this new knowledge has helped
    to correctly emphasize the fact that SUD is a serious public health
    issue that demands strategic solutions.
        NIDA supports a comprehensive research portfolio that spans the
    continuum of basic neuroscience, behavior and genetics research through
    medications development and applied health services research and
    epidemiology. While supporting research on the positive effects of
    evidence-based prevention and treatment approaches, NIDA also
    recognizes the need to keep pace with emerging problems. We have seen
    encouraging trends in strategies to address these problems, but areas
    of continuing significant concern include the recent increase in
    fatalities due to heroin and synthetic fentanyl, as well as continued
    illicit use of prescription opioids. Our knowledge of how drugs work in
    the brain, their health consequences, how to treat people with SUDs,
    and what constitutes effective prevention strategies has increased
    dramatically due to research. However, because the number of
    individuals who are affected is still rising, we need to continue the
    work until this disease is both prevented and eliminated from society.
        We understand that the FY2022 budget cycle will involve setting
    priorities and accepting compromise, however, in the current climate we
    believe a focus on substance use disorders deserves to be prioritized
    accordingly. Thank you for your support for the National Institute on
    Drug Abuse.
                                     ______

                       Prepared Statement of FSHD Society
        Honorable Chairwoman Murray, Ranking Member Blunt, and
    distinguished members of the Subcommittee, thank you for the
    opportunity to testify. We are requesting the FY2022 appropriation of
    an amount of $33 million for the agency U.S. DHHS National Institutes
    of Health (NIH) program on research specifically directed at
    facioscapulohumeral disease and facioscapulohumeral muscular dystrophy
    (hereafter called FSHD).
        FSHD is a heritable disease and one of the most common
    neuromuscular disorders with a prevalence of 1:8,000.\1\ It affects
    934,000 children and adults of both sexes worldwide. FSHD is
    characterized by progressive loss of skeletal muscle strength that is
    asymmetric in pattern and widely variable. Muscle weakness typically
    starts at the face, shoulder girdle and upper arms, often progressing
    to the legs, torso and other muscles. In addition to affecting muscle
    it can bring with it respiratory failure and breathing issues,\62\
    mild-profound hearing loss, eye problems and cardiac bundle blockage
    and arrhythmias.\79\ FSHD causes significant disability and death
    according the U.S. Centers for Disease Control and Prevention (CDC),
    National Center on Birth Defects and Developmental Disabilities,
    Atlanta, Georgia and others.\80,81\
        FSHD is associated with epigenetic changes on the tip of human
    chromosome 4q35 in the D4Z4 DNA macrosatellite repeat array region
    leading to an inappropriate gain of expression (function) of the D4Z4-
    embedded double homeobox 4 (DUX4) gene.\2\ DUX4 is a transcription
    factor that kick starts the embryonic genome during the 2- to 8-cell
    stage of development.\3-5\ Ectopic expression of DUX4 in skeletal
    muscle is associated with the disease and the disease's pathophysiology
    that leads to muscle death. DUX4 is never expressed in 'healthy'
    muscle. FSHD has had few clinical trials,\6-10\ and currently there is
    no cure or therapeutic option available to patients. DUX4 requires and
    needs to activate its direct transcriptional targets for DUX4-induced
    gene aberration and muscle toxicity.\11-24\ The genetics of FSHD are so
    remarkable, that NIH Director Dr. Francis Collins said on the front
    page of the New York Times, ``If we were thinking of a collection of
    the genome's greatest hits, this [FSHD] would go on the list.'' \78\
        Blocking DUX4's DNA, DUX4's RNA or DUX4's protein ability to
    activate its targets has profound therapeutic relevance.\25\ The FSHD
    scientific community has in recent years pioneered inroads to treating
    FSHD using the enormous potential of genomic sequencing, genomic
    medicine, gene editing and next generation diagnostics. Table 1 lists a
    dozen approaches detailed in thirty-eight proof-of-concept publications
    that molecular and genetic treatment approaches work in cellular and
    animal models for FSHD. All with the central paradigm of the reduction
    of: DUX4, DUX4 expression, DUX4 protein activity, or the effects of
    DUX4-mediated toxicity. Strategies include modulating DUX4 repressive
    pathways, targeting DUX4 mRNA, DUX4 protein, or cellular downstream
    effects of DUX4 expression. Simply unfathomable as to why NIH funding
    is this area is not increasing with the pace of discovery.
    TABLE 1: Genetic Approaches with Potential to Treat FSHD
      --Targeting the DUX4 gene itself by repression using CRISPR/dSaCas9
            or CRISPR/dCas9-KRAB;
      --Targeting and correcting the FSHD2 SMCHD1 gene mutation with
            CRISPR/Cas9;
      --Knockdown and silencing of the DUX4 gene by going after DUX4 mRNA
            with antisense oligonucleotides and with RNA interference; U7-
            asDUX4 snRNAs;
      --Targeting DUX4 protein expression using through DNA aptamers;
            proteins homologous to DUX4; and DNA decoys;
      --Going after and controlling expression target downstream [post-
            expression] of DUX4;
      --Going after genetic modifiers of DUX4 expression and DUX4-mediated
            toxicity between the DUX4 gene and DUX4 mRNA; G-quadruplexes
            (GQs); and
      --Targeting proteins that perturb DUX4-mediated toxicity or secondary
            features of FSHD pathology.\26-63\
        The clinical trials readiness priorities remain similar to last
    year's testimony. The FSHD scientific community has listed emphasis
    areas as: 1.) clinical trials readiness infrastructure and
    therapeutics; 2.) direct and surrogate biomarkers; 3.) genetic testing,
    genetics and epigenetics; 4.) imaging and outcome measures; and, 5.)
    registries and patient focused and reported outcomes.\73\ The way to
    measuring disease progression and the effectiveness and safety of drugs
    remains deep and hard-going for industry, clinical partners and
    patients.
        Serendipitously, new NextGen genomic sequencing and diagnostic
    technologies, as well as gene-targeted therapeutic approaches have
    emerged that will be game changing for FSHD patients and families.
    Understanding one's disease or condition is key for both mental and
    physical health. This can also aid with family and life planning
    decisions. With certainty many barriers to matching FSHD disease
    severity to outcome measures would rapidly fall. We could better align
    drug and therapeutic modalities with proper phenotypic/genotypic silos
    of FSHD based on repeat unit, methylation ranges and other requisites
    for FSHD. The current testing approach in the US, albeit excellent, has
    created a drag on the momentum towards clinical trials. With therapies
    on the way, identifying asymptomatic carriers and those that will
    decades later have later onset or mild symptoms, will allow us to then
    halt the disease in its early formative stages.\64,66-69,72\
        Recently in 2021, two excellent papers were published on FSHD and
    DUX4. Both were outstanding--one was using Oxford Nanopore long read
    sequencing of direct-RNA to locate DUX4 gene targets and the other was
    a careful study of DUX4 expression in its endogenous [native] form
    versus the more common recombinant [created] form used in the
    laboratory.\70,71\ As I read, I asked myself of each: ``does this tell
    us anything more about what DUX4's function is? No. How DUX4 works?
    Nada. Or how DUX4 causes FSHD pathophysiology? Nothing at all. How and
    if DUX4 itself is toxic to skeletal muscle? Zilch. If all research
    using FSHD transgenic cells an animals is simply result of an artifact?
    Not sure now.'' Both papers yield the same thought: though DUX4 is the
    prime therapeutic target--we know next to nothing about it. It is still
    a complete black box; yet the central focus for FSHD therapy. Questions
    and areas of research interest emerge from these publications and
    allied considerations; flowing fast--each one hypothesis worthy of
    several NIH grants. ``Is DUX4 cytotoxicity pathogenic in vivo? How does
    expression of DUX4 lead to muscle loss? What is the role of non-muscle
    cells in FSHD pathology? Can muscle pathology be stopped once it has
    started (as visualized via MRI images) or is it too late? How is DUX4
    bursting regulated in vivo? What other cell types express DUX4 in FSHD
    and/or healthy individuals? Does the DUX4 mRNA play a nuclear role in
    FSHD? Are there noncoding RNA roles for DUX4? Are DUX4 induced protein
    aggregates cause or consequence for FSHD? Does autoimmunity play a role
    in FSHD? Are there other DUX4-dependent therapeutic targets?'' NIH
    should certainly encourage proposals here. New data/information
    generated on the basic mechanism of DUX4 and how it causes muscle
    disease has the potential to focus the design of future clinical trials
    on muscles and measurements that will increase the rigor of the design
    and decrease the number of individuals necessary for initial tests of
    drug activity. It is absolutely necessary to increase our resolution,
    clarity and understanding of what DUX4 is and what it does to muscle in
    FSHD. The gains in this area will effectively unpin or untether FSHD
    from the difficulty category of ``slowly progressing neuromuscular
    diseases remaining recalcitrant'' to timely ascertainment that a
    clinical intervention can work.
        Your Subcommittee and Congress in partnership with NIH, patients
    and scientists have made truly outstanding progress in understanding
    and treating the nine major types of muscular dystrophy through the
    Muscular Dystrophy Community Assistance, Research and Education
    Amendments of 2001 (MD-CARE Act, Public Law 107-84). Since passing the
    MD CARE Act in 2001, NIH funding for FSHD has not kept up pace with
    scientific opportunities listed herein. The NIH is the principal
    worldwide source of funding of research on FSHD. Currently active
    projects are $16.554 million FY2022 (current actual 23June2021), a 21%
    portion of the estimated $80 million spent on all muscular dystrophies.
    (source: NIH Research Portfolio Online Reporting Tools (RePORT) keyword
    'FSHD or facioscapulohumeral or landouzy-dejerine').

                                      FSHD RESEARCH DOLLARS & FSHD AS A PERCENTAGE OF TOTAL NIH  MUSCULAR DYSTROPHY FUNDING
                                                                      [Dollars in millions]
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                     Fiscal Year                    2009    2010    2011    2012    2013    2014    2015    2016    2017    2018     2019     2020     2021
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    All MD ($ millions)..........................     $83     $86     $75     $75     $76     $78     $77     $79     $81     $81      $83     $88e     $80e
    FSHD ($ millions)............................      $5      $6      $6      $5      $5      $7      $8      $9     $11     $11      $10     $11e     $10e
    FSHD (% total MD)............................      6%      7%      8%      7%      7%      9%     10%     11%     14%     14%      12%      13%      13%
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Sources: NIH/OD Budget Office & NIH OCPL & NIH RePORT RCDC (e=estimate, a=actual)

        We request for FY2022, a doubling of the NIH FSHD research
    portfolio to $33 million. At this moment in time, FSHD needs an
    infusion of NIH grants both submitted and funded. NIH needs to increase
    funding by adding exploratory/developmental research grants (parent
    R21) and research project grants (parent R01) in areas outlined by
    experts both in this testimony and in the 2015 DHHS NIH MD Plan.\77\
    NIH can issue targeted funding announcements covering FSHD. These
    efforts will help NIH receive more grant applications. This is NIH's
    wheelhouse and forte without a doubt.
        Madam Chairman, this is my sixty-second testimony before the U.S.
    Congress' Appropriations Subcommittee on this matter. My FSHD is a
    strong fort; it has lasted my lifetime of fifty-nine years. That is a
    long time to live with a disease of this burden.\80\ I hope with your
    help and action to be able to outlive my disease. I need your help, my
    friends and fellow FSHD patients and families need your help. Please
    implore NIH to double funding on FSHD and kindly remember that our
    lives matter. Madam Chairman, thank you again for your help and
    efforts.
    References
        \1\ Deenen, J. C. W. et al. Population-based incidence and
    prevalence of facioscapulohumeral dystrophy. Neurology 83, 1056-9
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        \2\ Wang, L. H. & Tawil, R. Facioscapulohumeral Dystrophy. Curr.
    Neurol. Neurosci. Rep. 16, 66 (2016).
        \3\ Hendrickson, P. G. et al. Conserved roles of mouse DUX and
    human DUX4 in activating cleavage-stage genes and MERVL/HERVL
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        \6\ Tawil, R. et al. A pilot trial of prednisone in
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        \7\ Passerieux, E. et al. Effects of vitamin C, vitamin E, zinc
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        \8\ Kissel, J. T. et al. Randomized, double-blind, placebo-
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        \9\ Elsheikh, B. H. et al. Pilot trial of diltiazem in
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    expression in FSHD myotubes is sufficient to cause cell death and
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        \12\ Sandri, M. et al. Caspase 3 expression correlates with
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    expression and prevents apoptosis of FSHD muscle cells. Hum. Mol.
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        \14\ Statland, J. M. et al. Immunohistochemical Characterization of
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    expression in FSHD myotubes is sufficient to cause cell death and
    disrupts RNA splicing and cell migration pathways. Hum. Mol. Genet. 24,
    5901-14 (2015).
        \16\ Kowaljow, V. et al. The DUX4 gene at the FSHD1A locus encodes
    a pro-apoptotic protein. Neuromuscul. Disord. 17, 611-23 (2007).
        \17\ Bosnakovski, D. et al. An isogenetic myoblast expression
    screen identifies DUX4-mediated FSHD-associated molecular pathologies.
    EMBO J. 27, 2766-79 (2008).
        \18\ Wallace, L. M. et al. DUX4, a candidate gene for
    facioscapulohumeral muscular dystrophy, causes p53-dependent myopathy
    in vivo. Ann. Neurol. 69, 540-52 (2011).
        \19\ Geng, L. N. et al. DUX4 activates germline genes,
    retroelements, and immune mediators: implications for
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        [This statement was submitted by Daniel Paul Perez, Co-Founder &
    Director Emeritus and past Chairman, President & Chief Executive
    Officer, Chief Scientific Officer, FSHD Society.]
                                     ______

          Prepared Statement of the GBS|DCIDP Foundation International
                summary of recommendations for fiscal year 2022
    _______________________________________________________________________

      --Provide $46.1 billion for the National Institutes of Health (NIH)
            and proportional increases across its Institutes and Centers
      --Continue expanding GBS research supported by NIH with proportional
            funding increases for the National Institute of Neurological
            Disorders and Stroke (NINDS), and the National Institute of
            Allergy and Infectious Diseases (NIAID)
      --Provide $10 billion for the Centers for Disease Control and
            Prevention (CDC) and $5 million for the Chronic Disease
            Education and Awareness Program
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt and distinguished members
    of the Subcommittee, thank you for your time and your consideration of
    the priorities of the community of individuals impacted by Guillain-
    Barre Syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy
    (CIDP), and related conditions as you work to craft the FY2022 L-HHS
    Appropriations Bill.
               about gbs, cidp, variants, and related conditions
    Guillain-Barre Syndrome
        Guillain-Barre Syndrome (GBS) is an inflammatory disorder of the
    peripheral nerves outside the brain and spinal cord. GBS is
    characterized by the rapid onset of numbness, weakness, and often
    paralysis of the legs, arms, breathing muscles, and face. Paralysis is
    ascending, meaning that it travels up the limbs from fingers and toes
    towards the torso. Loss of reflexes, such as the knee jerk, are usually
    found. Usually, a new case of GBS is admitted to ICU (Intensive Care)
    to monitor breathing and other body functions until the disease is
    stabilized. Plasma exchange (a blood ``cleansing'' procedure) and high
    dose intravenous immune globulins are often helpful to shorten the
    course of GBS. The acute phase of GBS typically varies in length from a
    few days to months. Patient care involves the coordinated efforts of a
    team such as a neurologist, physiatrist (rehabilitation physician),
    internist, family physician, physical therapist, occupational
    therapist, social worker, nurse, and psychologist or psychiatrist.
    Recovery may occur over six months to two years or longer. A
    particularly frustrating consequence of GBS is long-term recurrences of
    fatigue and/or exhaustion as well as abnormal sensations including pain
    and muscle aches.
    Chronic Inflammatory Demyelinating Polyneuropathy
        CIDP is a rare disorder of the peripheral nerves characterized by
    gradually increasing weakness of the legs and, to a lesser extent, the
    arms. It is the gradual onset as well as the chronic nature of CIDP
    that differentiates it from GBS. Like GBS, CIDP is caused by damage to
    the covering of the nerves, called myelin. It can start at any age and
    in both genders. Weakness occurs over two or more months. Unlike GBS,
    CIDP is chronic, with symptoms constantly waxing and waning. Left
    untreated, 30% of CIDP patients will progress to wheelchair dependence.
    Early recognition and treatment can avoid a significant amount of
    disability. Post-treatment life depends on whether the disease was
    caught early enough to benefit from treatment options. The gradual
    onset of CIDP can delay diagnosis by several months or even years,
    resulting in significant nerve damage that may take several courses of
    treatment before benefits are seen. The chronic nature of CIDP
    differentiates long-term care from GBS patients. Adjustments inside the
    home may need to be made to facilitate a return to normal life.
                              about the foundation
        The Foundation's vision is that every person afflicted with GBS,
    CIDP, or variants has convenient access to early and accurate
    diagnosis, appropriate and affordable treatments, and dependable
    support services.
        The Foundation's mission is to improve the quality of life for
    individuals and families across America affected by GBS, CIDP, and
    their variants by:
      --Providing a network for all patients, their caregivers and families
            so that GBS or CIDP patients can depend on the Foundation for
            support, and reliable up-to-date information.
      --Providing public and professional educational programs worldwide
            designed to heighten awareness and improve the understanding
            and treatment of GBS, CIDP and variants.
      --Expanding the Foundation's role in sponsoring research and engaging
            in patient advocacy.
                   centers for disease control and prevention
        CDC and the National Center for Chronic Disease Prevention and
    Health Promotion (NCCDPHP) have resources that could be brought to bear
    to improve public awareness and recognition of GBS, CIDP and related
    conditions. The Foundation supports a meaningful increase to the
    Centers for Disease Control and Prevention as well as continued support
    of the Chronic Disease Education and Awareness Program. This program
    seeks to provide collaborative opportunities for chronic disease
    communities such as ours that lack dedicated funding from ongoing CDC
    activities. Such a mechanism allows public health experts at the CDC to
    review project proposals on an annual basis and direct resources to
    high impact efforts in a flexible fashion.
                         national institutes of health
        NIH hosts a modest research portfolio focused on GBS, CIDP,
    variants, and related conditions. This research has led to important
    scientific breakthroughs and is well positioned to vastly improve our
    understanding of the mechanism behind these conditions. We ask that
    resources continue to be used to support the important collaboration
    between NIAID, NINDS and the GBS|DCIDP community. Last May we
    participated in a conference with NINDS that discussed how intramural
    and extramural researchers can develop a roadmap that would lead
    research into these conditions into the next decade, and encourage
    younger investigators to apply for grants that lead to sustained
    research activities. We are continuing to have conversations with the
    leadership of both institutes to facilitate follow up and plan for a
    more robust agenda and list of goals for a future in person conference.
    In our meetings with the leadership, we also spoke about the
    possibilities of cross-institute work between NINDS and NIAID to expand
    the research and understanding of the link between Zika and GBS. While
    such a conference would not require additional appropriations, the
    Foundation urges you to provide NIH with meaningful funding increases
    to facilitate growth in the GBS, CIDP, and related conditions research
    portfolio.
                                 patient access
        As we have seen from communities that currently have access to home
    infusion, such as primary immunodeficiency diseases, the ability to
    choose the home as the preferred site of care has tremendous benefit in
    terms of health outcomes and overall convenience for patients.
    Individuals with CIDP and MMN often face mobility issues as limbs
    suffer nerve damage. Traveling to receive an infusion presents a
    tremendous hardship to many patients and their families. This hardship
    greatly affects rural patients who have to travel hundreds of miles to
    major cities in order to receive treatment, which can be both
    inconvenient and costly. The Foundation has seen that when there are
    obstacles to receiving regular infusions, patients tend to skip
    scheduled infusions, which leads to progressive disability. Many CIDP
    and MMN patients have access to IVIG home infusion through private
    insurance, which allows them to lead productive and active lives. When
    these individuals age on to Medicare, they can face disruption in their
    routine and suboptimal circumstances when managing their condition.
    Further, because the body's immune system is depressed at the end of an
    infusion cycle, CIDP and MMN patients face an elevated risk of
    contracting illness from visiting well-traveled sites of care for
    infusions. Most importantly, patients and physicians should have the
    authority to choose their preferred site of care. We hope that members
    of this subcommittee and Congress as a whole support legislation that
    will grant our patients this important access.
        The Foundation was founded 40 years ago, and the four pillars that
    guide our mission are: support, education, advocacy, and research. Our
    patients rely on the premier research that is carried out at the NIH to
    improve the diagnosis and treatment process of these devastating
    illnesses. Without appropriate funding to the NIH and CDC, my fear as a
    parent of a GBS survivor and the Executive Director of the Foundation,
    is that many patients will needlessly suffer. There is so much to
    learn; there is no bio-marker and we do not know why the immune system
    reacts to trigger these conditions. I ask the Committee to provide
    $46.1 billion to the NIH with proportional increases to NIAID and NINDS
    to continue the potentially lifesaving work being done for our
    community, and ask for Congressional support of our initiative to
    improve access to life-saving treatments.

        [This statement was submitted by Lisa Butler, Executive Director,
    GBS|DCIDP Foundation International.]
                                     ______

                         Prepared Statement of GEAR UP
        Distinguished members of the Senate Labor-Health and Human
    Services-Education Appropriations Subcommittee, thank you for the
    giving me the opportunity to provide testimony on the profound impact
    that the Gaining Early Awareness and Readiness for Undergraduate
    Programs (GEAR UP) initiative has had on my life. My name is William
    Ruiz, and it is my honor and pleasure to be writing this testimonial on
    behalf of GEAR UP alumni and over half a million GEAR UP students
    across the country. Given the program's return on investment, I urge
    the committee to appropriate $435,000,000 for GEAR UP in fiscal year
    2022 to support an additional 100,000 students across our country so
    that they, too, can have the support I received through GEAR UP.
        GEAR UP provides 6- or 7-year grants to states and partnerships
    comprised of K-12, higher education, and community-based organizations
    that strengthen pathways to college and careers in low-income
    communities. GEAR UP exposes students, and their families, starting in
    the 7th grade to comprehensive interventions that follow them through
    high school graduation and optionally through the first year of
    postsecondary education. GEAR UP uses early and sustained interventions
    to ensure that students are successful in rigorous courses, are
    prepared for life beyond high school, and ultimately enroll in a high-
    quality certificate, associates', or bachelors' degree program that
    suits their goals. In the most recent year in which we had a large
    class of graduating seniors, the postsecondary enrollment rates of GEAR
    UP students were over 31% higher than the rates for low-income students
    nationally.\1\ Considering that GEAR UP achieves this critical goal at
    a cost of approximately $694 per student, per year, I strongly believe
    that the investment in GEAR UP pays significant dividends. GEAR UP is a
    powerful catalyst for sustained community improvement.
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Education (2016). FY 2017 Department of
    Education Justifications of Appropriation Estimates to the Congress:
    Higher Education (Volume II). Retrieved from: https://www2.ed.gov/
    about/overview/budget/budget17/justifications/index.html.
    ---------------------------------------------------------------------------
        Being the son of immigrant parents and growing up in a low-
    socioeconomic neighborhood in Los Angeles, California, I never
    envisioned myself going to college. My parents worked exceptionally
    hard to provide for my siblings and me, but because they had to drop
    out of school at a very young age to leave Mexico and move to the
    United States, they had very little knowledge of the education system.
    While I wasn't introduced to higher education by my family, my parents
    did teach me about the value of hard work and made sure that I attained
    good grades throughout my time in K-12 education. As I navigated my way
    through elementary and middle school, I always looked forward to high
    school graduation because I thought that that would be the end of my
    educational journey. It was always my plan to graduate high school and
    enter the workforce full-time, just like how my older siblings did. It
    wasn't until I was introduced to the GEAR UP program in 7th grade that
    I was exposed to college. At that time, college was the last thing on
    my mind, but the GEAR UP staff continued to remind us that they would
    pack up their office and follow us to our local high school.
        Fast forwarding to my first day at Benjamin Franklin High School, I
    remember the first adult I saw on campus: GEAR UP Counselor Mr. Burton.
    I was shocked to see that they were serious when they said they would
    follow us. Throughout the rest of my freshman year, we would
    participate in various workshops with GEAR UP. I always enjoyed talking
    to the GEAR UP team, but I still couldn't see myself pursuing higher
    education. At the end of my first year of high school, GEAR UP started
    recruiting students for their peer mentor and summer programs.
        After signing up for summer school and participating in the peer
    mentor camps with GEAR UP, I immersed myself in all things GEAR UP. At
    the beginning of my sophomore year, I met an individual who, to this
    day, has a special place in my heart. I can never truly thank Mr.
    Robert Aguirre for all the help and support he has provided me with
    since 2009. While I had the grades to attend college and pursue a
    degree, Mr. Aguirre provided me with the structure and gave me all the
    resources I needed to pursue higher education. Growing up in a
    neighborhood with a lot of gang violence and having friends who dropped
    out of school a young age, it was reassuring to have a positive male
    role model that I could look up to. I always heard that it only takes
    one adult to care for a student to do well in school. I can undoubtedly
    say Mr. Aguirre was that person for me. I always knew that if I had any
    issues regarding school, I could easily walk to the GEAR UP office to
    talk to him.
        I wouldn't have gone to a 4-year university if it wasn't for Mr.
    Aguirre and GEAR UP. Not only did GEAR UP teach me about admission
    requirements and financial aid, but they also exposed me to different
    colleges and universities. One of my fondest memories of high school
    was traveling up the California coastline on a bus to visit colleges in
    Northern California. Because of the field trips and the exposure to
    colleges, I began to imagine myself on college campuses. When I started
    my senior year of high school, the GEAR UP staff sat me down in the
    school's computer lab to apply to college. As someone who had simply
    gone through the motions, I really appreciated GEAR UP for giving me
    that extra push to take education more seriously.
        I will always be grateful for all the love and support that GEAR UP
    provided as I navigated high school. Yes, GEAR UP is an acronym and a
    federally funded program, but to me, GEAR UP is family.
        Because of what GEAR UP gave me, I wanted to give back to GEAR UP.
    I currently have the honor and privilege of working with over 800
    students in the Compton Unified School District as a GEAR UP Program
    Coordinator. I am also a Founding Board Member of the GEAR UP Alumni
    Association. The GEAR UP Alumni Association aims to support GEAR UP
    Alumni so that GEAR UP students can not only get to college but also
    graduate. Our vision is to eventually branch out and support GEAR UP
    students across the country.
        I am also happy to share with you that beginning in August 2021, I
    will be pursuing my Master of Arts in Diverse Community Development
    Leadership (DCDL) at California State University, Northridge. As a GEAR
    UP alum and current educator, I want to continue my educational journey
    so that I can best assist students like me. My initial goal was only to
    graduate high school. Now, I am proud of the fact that I am the first
    in my family to graduate college and will be the first to receive a
    graduate degree.
        None of this would have been possible without GEAR UP. I will
    always be open and honest about my journey because there are a lot of
    students who have similar backgrounds as me. I wake up every day
    grateful that I was able to be a GEAR UP student because it changed my
    life for the better.
        As you take on the work of preparing for the fiscal year 2022
    appropriations, I urge you to consider increasing the investment in the
    GEAR UP program to $435,000,000 so that 100,000 more students just like
    me can benefit from the program. Thank you to the committee for taking
    the time to read my testimony.
                  Prepared Statement of Global Health Council
        Global Health Council (GHC) is the leading membership organization
    for nonprofits, businesses, universities, and individuals dedicated to
    saving lives and improving the health of people worldwide. GHC thanks
    the Subcommittee for the opportunity to share this testimony in support
    of global health programs under the jurisdiction of the Departments of
    Labor and Health and Human Services. For Fiscal Year (FY) 2022, GHC
    encourages continued support for global health at a minimum of FY21
    levels enacted by Congress. However, in order to achieve U.S. global
    health goals and commitments, we ask that you support a greater
    investment in global health programs for FY22, which includes at a
    minimum: $6,356,000,000 for the National Institute of Allergy and
    Infectious Disease (NIAID), $3,845,000,000 for the Office of AIDS
    Research, and $91,000,000 for the Fogarty International Center at the
    National Institutes of Health (NIH); an investment of $735,000,000 for
    the Center for Emerging Zoonotic and Infectious Diseases, $300,000,000
    for the Infectious Diseases Rapid Response Fund, and no less than
    $898,000,000 for the Center for Global Health at the Centers for
    Disease Control and Prevention (CDC).
        In light of the COVID-19 pandemic, we must urge Congress to
    appropriate funds to sustain America's legacy abroad and to support
    existing programs in their ongoing response to the coronavirus. It is
    our hope that appropriators will consider the additional needs and
    negative effects of the COVID-19 pandemic when making appropriations
    for FY22. We have seen significant declines across global health
    programs in their capacity to reach the same or more people for
    preventative care, ongoing care for diseases ranging from HIV/AIDS,
    tuberculosis, non-communicable diseases, malaria, and more.
        We know that these programs work and have secured their place as
    some of the most critical and successful tools for U.S. global health.
    By investing in these programs, the United States is continuing to
    build healthier and more self-reliant communities, which ultimately
    become economically and politically stable. We have seen the COVID-19
    pandemic exacerbate weak points in health systems in rich and poorer
    countries alike, ultimately weakening our own health system. It
    highlighted inefficiencies and a sheer lack of access to care around
    the world. We cannot afford to lose more ground on the progress that
    the United States has already made towards building healthier
    communities. A failure to backstop these investments would roll back
    the progress we have spent decades achieving and ultimately undermine
    U.S. foreign policy and global health priorities.
        We undeniably live in a global environment. Global health is
    important for medical professionals here at home, too. Every year, more
    than 500 million people cross borders in planes, and with them the
    potential for infectious diseases to enter our country, demanding more
    of our health workforce. But U.S.-based providers and other responders
    have the opportunity to learn from health programs abroad about how
    best to tackle diseases whenever they arrive. We have an opportunity
    here, to mobilize everyone involved in health, from scientists,
    pharmaceutical companies, frontline workers, advocates, and
    policymakers, to create a world where health threats can become a thing
    of the past.
        We must continue to build upon the hard work and achievements of
    previous years in order to prevent the persistent global health
    challenges of our time and ensure a healthy future for citizens around
    the world. In our current environment, in response to COVID-19, we must
    consider increasing investments in global health and development
    assistance funding. We have a moral obligation to resolve the
    challenges that U.S. global health programs now face in light of the
    pandemic. And it is in our national interest to demonstrate that these
    are essential commitments.
        Thank you for your consideration of this request.

        [This statement was submitted by Kiki Kalkstein, Director of
    Advocacy &
    Engagement, Global Health Council.]
                                     ______

         Prepared Statement of the Global Health Technologies Coalition
        On behalf of the Global Health Technologies Coalition (GHTC), a
    group of 37 nonprofit organizations, academic institutions, and aligned
    businesses advancing policies to accelerate the creation of new drugs,
    vaccines, diagnostics, and other tools that bring healthy lives within
    reach for all people, I am providing testimony on fiscal year 2022
    (FY22) appropriations for the National Institutes of Health (NIH), the
    Centers for Disease Control and Prevention (CDC), and the Biological
    Advanced Research and Development Authority (BARDA). These
    recommendations reflect the needs expressed by our members working
    across the globe to develop new and improved technologies for the
    world's most pressing health issues. We appreciate the Committee's
    support for global health, particularly for continued research and
    development (R&D) to advance new drugs, vaccines, diagnostics, and
    other tools for long-standing and emerging health challenges, including
    COVID-19. To accelerate progress toward lifesaving tools for a range of
    health threats, we respectfully request increased funding for NIH,
    including an additional $10 million for the Fogarty International
    Center (FIC); funding to match CDC's increased responsibilities in
    global health and global health security-in line with the overall
    increase for CDC proposed in the President's Discretionary Budget
    Request, which should be reflected in increases for the Center for
    Global Health (CGH) and National Center for Emerging Zoonotic and
    Infectious Diseases (NCEZID)--and the creation of a new, dedicated
    funding line to support BARDA's critical work in emerging infectious
    diseases (EIDs), which accelerated to unprecedented levels over the
    past year and should be sustainably funded beyond the COVID-19
    pandemic.
        GHTC members strongly believe that sustainable investment in R&D
    for a broad range of neglected diseases and health conditions is
    critical to tackling both long-standing and emerging global health
    challenges that impact people around the world and in the United
    States. Coordination is also key: we urge the Committee to request that
    leaders of Department of Health and Human Services agencies work with
    counterparts at the State Department and the US Agency for
    International Development to develop a cross-government global health
    R&D strategy to ensure that US investments are efficient, coordinated,
    and streamlined.
        While we have made tremendous gains in global health over the past
    15 years, millions of people around the world are still threatened by
    neglected diseases and conditions. In 2019, tuberculosis (TB) killed
    1.4 million people, surpassing deaths from HIV/AIDS, while 1.7 million
    people were newly diagnosed with HIV. Nearly half the global population
    remains at risk for malaria, and drug-resistant strains are growing.
    Women and children remain the most vulnerable with around 68 percent of
    all global maternal and child deaths occurring in sub-Saharan Africa
    and 1 out of every 13 children in the region dying before the age of 5.
    These figures highlight the tremendous global health challenges that
    remain and the need for sustained investment in global health R&D to
    deliver new tools, both to address unmet global health needs and to
    address challenges of drug resistance, toxic treatments, and health
    technologies that are difficult to administer in poor, remote, and
    unstable settings.
        The COVID-19 pandemic has again demonstrated that we do not have
    all the tools needed to prevent, diagnose, and treat many neglected and
    EIDs--a reality foreshadowed by the recent Zika and Ebola epidemics.
    The lifesaving effects of the first COVID-19 vaccines demonstrate the
    power of having the right tools to respond to a health emergency. These
    new vaccines, developed with critical funding from BARDA, NIH, and
    other US government partners, are highly effective and built upon past
    global health research advances. Notably, the Johnson & Johnson vaccine
    is based on technology used in its Ebola vaccine and Zika, respiratory
    syncytial virus, and HIV/AIDS vaccine candidates, and the Moderna-
    National Institute of Allergy and Infectious Diseases (NIAID) vaccine
    platform was previously being used to develop vaccines against other
    respiratory viruses and the chikungunya virus. This demonstrates how
    strong, sustained investment in R&D allows us to tackle today's health
    threats and prepare for those of the future. The United States remains
    at the forefront of global health innovation because of long-term
    investments in R&D agencies such as NIH, CDC, and BARDA.
        NIH: The groundbreaking science conducted at NIH has long
    underpinned US leadership in biomedical research. Within NIH, NIAID,
    the Office of AIDS Research, and FIC all play critical roles in
    developing new health technologies that save lives at home and around
    the world. FIC, in particular, is a leader in accelerating global
    scientific progress through international research partnerships,
    technical assistance, and training. Many FIC-trained scientists have
    led their countries' responses to COVID-19, Zika, and Ebola, as well as
    long-standing challenges such as HIV/AIDS. COVID-19 has underscored
    that science capacity gaps remain between low- and middle-income
    countries and high-income countries. With additional funding, FIC could
    leverage its extensive network and training capacity to improve global
    genomic surveillance and coordination. We urge Congress to request
    information from FIC on how it might address global scientific capacity
    gaps in modeling, genomic surveillance, researcher training, and
    pandemic preparedness and urge appropriators to consider sustainably
    increasing FIC's relatively modest budget by $10 million dollars in
    each of the next five fiscal years to enable work in new areas.
        Across NIAID, FIC, and other institutes and centers, NIH leadership
    has long supported the vital role the agency plays in global health R&D
    and has named global health as one of the agency's top five priorities.
    It remains critical that support for NIH extend to all pressing areas
    of research--including research in neglected diseases and EIDs.
        CDC: CDC makes significant contributions to global health research,
    particularly through CGH and NCEZID. CDC's ability to respond to
    disease outbreaks is essential to protecting the health of citizens
    both at home and abroad, and the work of its scientists is vital to
    advancing the development of tools, technologies, and techniques to
    detect, prevent, and respond to urgent public health threats. CDC
    monitors 30 to 40 international public health threats each day, has
    identified disease outbreaks in more than 150 countries, responded to
    more than 2,000 public health emergencies, and discovered 12 previously
    unknown pathogens--and in complement to these disease monitoring and
    detection functions, plays a leading role in related R&D. Important
    work at NCEZID includes the development of diagnostics, including the
    first diagnostic test for COVID-19 with authorization from the US Food
    and Drug Administration and Trioplex, a diagnostic that can
    differentiate Zika, dengue, and chikungunya viruses. NCEZID is a leader
    in early-stage R&D for vaccines for infectious diseases such as Nipah
    virus and dengue, Lassa, and Rift Valley fevers. The Center also plays
    a leading role in the National Strategy for Combating Antibiotic-
    Resistant Bacteria, to prevent, detect, and control outbreaks of
    antibiotic-resistant pathogens, such as drug-resistant TB.
        In complement, CGH is a global leader in immunization, public
    health capacity-building, and preventing, detecting, and responding to
    infectious diseases. Programs at CGH--including the Divisions of Global
    HIV and TB, Global Immunization, Parasitic Diseases and Malaria, and
    Global Health Protection--have yielded advances in the development of
    vaccines, drugs, and other tools to combat HIV/AIDS, TB, malaria, and
    neglected tropical diseases like leishmaniasis and dengue fever. CGH
    develops and validates innovative tools for use by US bilateral and
    multilateral global health programs and leads laboratory efforts to
    monitor and combat drug and insecticide resistance to ensure that
    global health programs are tailored for maximum impact.
        As global disease outbreaks have grown in frequency and intensity,
    CDC's work in novel technology development and global health security
    has only become more important. This includes the agency's work to end
    the recent Ebola outbreaks in Africa through its international
    leadership on the Global Health Security Agenda. GHTC supports the
    funding increase to CDC proposed by the administration for FY22 and
    urges the Committee to increase funding for CDC's critical global
    health R&D work at CGH and NCEZID.
        BARDA: BARDA plays an unmatched role in global health R&D by using
    unique contracting authorities and targeted incentive mechanisms to
    advance the development and purchase of critical medical technologies
    for public health emergencies. BARDA partners with diverse stakeholders
    from industry, academia, and nonprofits to bridge the valley of death
    between basic research and advanced-stage product development for
    medical countermeasures--an area where other R&D agencies do not
    operate. BARDA has been a critical funder of countermeasures for
    naturally occurring health security threats including EIDs such as
    COVID-19, Ebola, and Zika, as well as pandemic influenza and
    antimicrobial resistance. To date, BARDA's work in advancing tools for
    EIDs has largely been funded through emergency supplemental funding. A
    dedicated funding line of at least $300 million annually for EID R&D
    would ensure that BARDA is resourced to respond quickly to future
    threats, rather than wait on haphazard infusions of supplemental
    funding during health emergencies.
        In addition to bringing lifesaving tools to those who need them
    most, investment in global health R&D is also a smart economic
    investment in the United States with 89 cents of every US dollar
    invested in global health R&D going directly to US-based researchers.
    US government investment in global health R&D between 2007 and 2015
    generated an estimated 200,000 new jobs and $33 billion in economic
    growth. Investments in global health R&D today can help achieve
    significant cost-savings in the future--a fact made plain by the
    economic devastation of the COVID-19 pandemic.
        Now more than ever, Congress must make smart investments. Global
    health R&D, which improves the lives of people around the world while
    supporting US health security, creating jobs, and spurring economic
    growth, is a win-win.
                                     ______

                   Prepared Statement of Harvey Friedman, MD
        I am an Infectious Disease physician scientist on faculty at the
    Perelman School of Medicine of the University of Pennsylvania. My
    research interest is herpes simplex virus. I am working on a vaccine
    that uses messenger RNA technology for the herpes vaccine that is like
    that applied to COVID 19 messenger RNA vaccines by Pfizer and Moderna.
        My research has caught the interest of the public. I have received
    thousands of emails from people globally expressing their hope that the
    vaccine works. Most of the people are already infected with genital
    herpes. Their stories are heart-wrenching! Genital herpes is not a
    life-threatening infection; however, for many people, it is a life
    altering infection, while for some it leads to life ending decisions.
        My laboratory has focused on preventing genital herpes, but we are
    now turning our attention to preventing oral herpes (HSV-1) and the
    many dreaded complications of both viruses, including fever blisters,
    infection of the cornea (eye), infection of the brain (encephalitis),
    infection of newborns, genital herpes, increasing susceptibility to HIV
    infection, and possibly contributing to dementia.
        Medical research is at a point that we have the tools to come up
    with vaccines that will prevent genital herpes for those not yet
    infected, and approaches to rid the body of the dormant (latent) virus
    as a cure for subjects already infected.
        Please set a priority to establish a strategic plan and national
    strategy for treating and preventing herpes infections, particularly
    genital herpes.
        Sincerely,
        Harvey Friedman, MD, Email: hfriedma@pennmedicine.upenn.edu, Office
    address: Infectious Disease Division, 522E Johnson Pavilion, 3610
    Hamilton Walk, Philadelphia, PA 19104-6073.
                                     ______

      Prepared Statement of the Health Professions and Nursing Education
                                   Coalition
        The Health Professions and Nursing Education Coalition (HPNEC) is
    an alliance of over 90 national organizations representing schools,
    students, health professionals, and communities dedicated to ensuring
    that the health care workforce is trained to meet the needs of our
    diverse population. Together, the members of HPNEC advocate for
    adequate and continued support for the health professions and nursing
    workforce development programs authorized under Titles VII and VIII of
    the Public Health Service Act and administered by the Health Resources
    and Services Administration (HRSA). For fiscal year (FY) 2022, HPNEC
    encourages the subcommittee to adopt at least $1.51 billion for HRSA
    Titles VII and VIII programs.
        The HRSA Titles VII and VIII programs are essential to educating
    our health care workforce to manage health care crises, such as the
    COVID-19 pandemic. The immense challenges of the pandemic have
    underscored the need to increase and reshape our health workforce, and
    the HRSA Titles VII and VIII programs successfully recruit, train, and
    support public health practitioners, nurses, geriatricians, advanced
    practice registered nurses, mental health providers, and other
    frontline health care workers critical to addressing COVID-19.
    Additionally, HRSA tasked Title VII and Title VIII grantees to utilize
    innovative models of care, such as training providers in telehealth, to
    improve patients' access to care during the pandemic.
        The U.S Census Bureau projects that by 2045:
      --the US population will grow by over 18%,
      --more than half the country will come from a racial or ethnic
            minority group, and
      --one in five Americans will be over 65.
        To prepare for these changing demographics, we urge Congress to
    increase funding for the HRSA Title VII and Title VIII programs to
    educate current and future providers that serve these ever-growing
    needs while preparing for the health care demands of tomorrow.
        Diversity Pipeline Programs.--The COVID-19 pandemic has underscored
    the pervasive health inequities facing minority communities, as well as
    gaps in care for our most vulnerable patients, including an aging
    population that requires more health care services. The HRSA Title VII
    and Title VIII programs play an essential role in improving the
    diversity of the health workforce and connecting students to health
    careers by supporting recruitment, education, training, and mentorship
    opportunities. Inclusive and diverse education and training experiences
    expose providers to backgrounds and perspectives other than their own
    and heighten cultural awareness in health care, resulting in benefits
    for all patients.
        HRSA diversity programs include the Health Careers Opportunity
    Program (HCOP), Centers of Excellence (COE), Faculty Loan Repayment,
    Nursing Workforce Diversity, and Scholarships for Disadvantaged
    Students (SDS). Studies have demonstrated the effectiveness of such
    pipeline programs in strengthening students' academic records,
    improving test scores, and helping minority and disadvantaged students
    pursue careers in the health professions. Title VII diversity pipeline
    programs reached over 13,500 students in the 2019-2020 academic year
    (AY), with SDS graduating nearly 1,400 students, and COE reaching
    nearly 5,000 health professionals, 72% of which were located in
    medically underserved communities.
        Title VIII's Nursing Workforce Diversity Program increases nursing
    education opportunities for individuals from disadvantaged backgrounds
    through stipends and scholarships and a variety of pre-entry and
    advanced education preparation. In AY 2019-20, the program supported
    more than 11,000 students, with approximately 45% of the training sites
    located in underserved communities.
        Primary Care Workforce.--The Primary Care Medicine Programs expand
    the primary care workforce, including general pediatrics, general
    internal medicine, family medicine, and physician assistants through
    the Primary Care Training and Enhancement (PCTE) and Primary Care
    Medicine and Dentistry Career Development programs. The primary care
    programs are also intended to encourage health professionals to work in
    underserved areas. In AY 2019-20, PCTE grantees trained over 14,000
    individuals at over 1,100 sites, with 54% in medically underserved
    communities and 26% in rural areas; 30% of sites trained providers in
    telehealth services.
        The Medical Student Education program, which supports the health
    care workforce by expanding training for medical students to become
    primary care clinicians, targets higher education institutions in
    states with the highest primary care workforce shortages. The program
    help develop partnerships among institutions, federally recognized
    tribes, and community-based organizations to train medical students to
    provide primary care that improves health outcomes for those living in
    rural and other underserved communities. In AY 2019-2020, Medical
    Student Education grantees trained over 1,100 health professionals, 88%
    of which located in primary care settings, 68% in medically underserved
    communities, and 66% in rural areas.
        Interdisciplinary, Community Based Linkages.--Support for
    community-based training of health professionals in rural and urban
    underserved areas is funded through Title VII. By assessing the needs
    of the local communities they serve, HRSA Title VII programs can fill
    gaps in the workforce and increase access to care for all populations.
    The programs emphasize interprofessional education and training,
    bringing together knowledge and skills across disciplines to provide
    effective, efficient, and coordinated care.
        Programs such as Graduate Psychology Education (GPE), Opioid
    Workforce Enhancement Program, Mental and Behavioral Health, and
    Behavioral Health Workforce Education and Training (BHWET) respond to
    changing delivery systems and models of care, and timely address
    emerging health issues in their communities. The BHWET and Mental and
    Behavioral Health programs, provide training to expand access to mental
    and behavioral health services for vulnerable and underserved
    populations. In AY 2019-20, nearly 50% of all BHWET and GPE grantees
    provided substance use disorder treatment services.
        Area Health Education Centers (AHEC) support the recruitment and
    training of future physicians in rural areas and provide
    interdisciplinary health care delivery sites, which respond to
    community health needs. In AY 2019-20, AHECs supported 192,000 pipeline
    program participants and provided over 34,000 clinical training
    rotations for health professions trainees.
        Title VII Geriatric Workforce programs integrate geriatrics and
    primary care to provide coordinated and comprehensive care for older
    adults. These programs offer training across the provider continuum,
    focusing on interprofessional and team-based care and academic-
    community partnerships to address gaps in health care for older adults.
    To advance the training of the current workforce, the Geriatrics
    Workforce Enhancement Program (GWEP) provided 2,068 unique continuing
    education courses to over 200,000 faculty and practicing professionals
    in AY 2019-20, including 906 courses on Alzheimer's and dementia-
    related diseases.
        Nursing Workforce Development.--HRSA Title VIII nursing workforce
    development programs provide federal support to address all aspects of
    nursing workforce demands, including education, practice, recruitment,
    and retention, focusing on rural and medically underserved communities.
    These programs include Advanced Nursing Education; Nursing Workforce
    Diversity; Nurse Education, Practice, Quality, and Retention; NURSE
    Corps; and Nurse Faculty Loan Program. In AY 2019-2020, the Title VIII
    Advanced Education Nursing programs supported more than 8,000 nursing
    students in primary care, anesthesia, nurse-midwifery, and other
    specialty care, all of whom received clinical training in primary care
    in medically underserved communities and/or rural settings.
        Oral Health.--The Primary Care Dentistry program invests in
    expanding programs in primary dental care for pediatric, public health,
    and general dentistry. The Pre- and Postdoctoral Training, Residency
    Training, Faculty Development, and Faculty Loan Repayment programs
    encourage integrating dentistry into primary care.
        Public Health.--Public Health Workforce Development programs
    support education and training in public health and preventive medicine
    through different initiatives, including the only funding for
    physicians to work in state and local health departments. Public health
    student trainees partnered with 278 sites in AY 2019-20, with 74% of
    these training sites located in medically underserved communities and
    29% in primary care settings.
        Workforce Information and Analysis.--The Workforce Information and
    Analysis program provides funding for the National Center for Health
    Workforce Analysis as well as grants to seven Health Workforce Research
    Centers across the country that perform and disseminate research and
    data analysis on health workforce issues of national importance.
        While HPNEC's members acknowledge the competing demands facing
    appropriators, funding for HRSA's workforce development programs is
    critical to creating a culturally competent workforce that can respond
    to future health threats and challenges facing all Americans.
    Therefore, HPNEC encourages the subcommittee to provide at least $1.51
    billion in the FY 2022 appropriations bill for HRSA's Title VII and
    VIII programs to continue the nation's investment in our health
    workforce.
                                     ______

       Prepared Statement of the Hearing Industries Association and the
                      Hearing Loss Association of America
        Dear Chairwoman Murray, Ranking Member Blunt, and Members of the
    Subcommittee,
        Thank you for the opportunity to submit testimony concerning Fiscal
    Year 2022 (FY22) Labor, Health and Human Services, Education and
    Related Agencies appropriations. The Hearing Industries Association
    (HIA) and the Hearing Loss Association of America (HLAA) are requesting
    inclusion of report language to direct the National Institutes of
    Health (NIH) Office of the Director to provide an accounting of funds
    currently used for hearing screening research and encourage NIH to
    prioritize funding for studies that address the research needs and gaps
    identified by the U.S. Preventive Services Task Force (USPSTF).
        HIA is the national organization of the manufacturers, suppliers
    and distributors of hearing aids, implants, assistive listening
    devices, component parts and power sources. HIA's mission is to be a
    trusted voice on product innovation, patient safety and education, and
    public policy. HLAA is the nation's leading organization representing
    consumers with hearing loss and seeks to enable people with hearing
    loss to live life fully and without compromise. We are pleased to work
    together to support the more than 38 million individuals in the United
    States with untreated hearing loss,\1\ including one in three people
    between the ages of 65 and 74 and over half of those older than 75.
    Hearing loss is associated with many comorbidities, including cognitive
    decline, dementia, falls, depression, reduced quality of life, and an
    increased number of emergency department visits and hospitalizations.
    ---------------------------------------------------------------------------
        \1\ ``How Many People Have Hearing Loss in the United States?'',
    Johns Hopkins Cochlear Center for Hearing and Public Health, https://
    www.jhucochlearcenter.org/how-many-people-have-hearing-loss-unaited-
    states.html.
    ---------------------------------------------------------------------------
        In March 2021, the USPSTF, a volunteer panel of national experts in
    prevention and evidence-based medicine tasked with providing
    recommendations regarding preventive screening and services, issued its
    final recommendations regarding hearing screening for older adults over
    the age of 50. The USPSTF ultimately declined to make a recommendation
    in support of hearing screening, finding that ``current evidence is
    insufficient to assess the balance of benefits and harms of screening
    for hearing loss in older adults.'' \2\ The final recommendation notes
    that more research is needed.
    ---------------------------------------------------------------------------
        \2\ https://www.uspreventiveservicestaskforce.org/uspstf/
    recommendation/hearing-loss-in-older-adults-screening.
    ---------------------------------------------------------------------------
        We understand the gaps in research identified by the USPSTF's
    recommendations and agree that additional research to support a
    universal hearing screening recommendation for older adults is needed.
    Given the significant associated comorbidities of hearing loss
    discussed below, we also believe this research should be prioritized.
    Therefore, we urge this Subcommittee to support inclusion of report
    language to convey the importance of building the research base for
    older adult hearing screening, as follows:
        Hearing Health Screening. The Committee recognizes the associated
    comorbidities and costs of untreated hearing loss and, with the growing
    aging population, the importance of hearing screening for older
    Americans. The Committee directs the National Institutes of Health
    (NIH) Office of the Director to provide an accounting of all funds used
    for hearing screening research across all Institutes within 90 days of
    enactment of this Act. The Committee encourages NIH to prioritize
    funding through the Office of the Director and engage appropriate
    Institutes like the National Institute on Deafness and Other
    Communication Disorders (NIDCD) and National Institute on Aging (NIA)
    for studies that address the research needs and gaps identified by the
    U.S. Preventive Services Task Force (USPSTF). These research needs may
    include gaps identified in USPSTF review of hearing screening
    recommendations for older Americans.
        Earlier diagnosis of hearing loss and appropriate intervention are
    crucial to avoiding the negative social, emotional, and health
    consequences of hearing loss. Age-related hearing loss is the third
    leading cause of chronic disability in older adults and has shown to be
    associated with predisposing cognitive impairment and dementia.\3\
    According to the Lancet Commission, as of 2020, there are twelve
    behaviorally modifiable risk factors associated with dementia
    prevention, accounting for approximately 40 percent of dementias
    globally. Of note, hearing impairment accounts for approximately nine
    percent of the modifiable risk and the Lancet Commission recommends
    reducing noise-related hearing loss and treating hearing loss with the
    use of hearing aids.\4\ Additionally, a recent study found that mild
    hearing loss doubled the risk of dementia, moderate loss tripled risk,
    and those with severe hearing impairment were five times more likely to
    develop dementia.\5\ Emerging evidence indicates that hearing
    interventions can delay the onset or reduce the rate of cognitive
    decline.\6,7\ Additional studies, including the Aging and Cognitive
    Health Evaluation in Elders (ACHIEVE) study,\8\ are expected to further
    address the role and efficacy of hearing treatment in reducing
    cognitive decline in older adults.
    ---------------------------------------------------------------------------
        \3\ Jafari Z, Kolb BE, Mohajerani MH. Age-Related Hearing Loss and
    Tinnitus, Dementia Risk, and Auditory Amplification Outcomes. Ageing
    research reviews. 2019:100963.
        \4\ Livingston G, Huntley J, Sommerland A, et al. Dementia
    prevention, intervention, and care: 2020 report of the Lancet
    Commission. Lancet. 20202 [Aug 8]; 396 (10248); 413-446.
        \5\ ``The Hidden Risks of Hearing Loss'', Johns Hopkins Medicine,
    https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-
    hidden-risks-of-hearing-loss.
        \6\ Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N, on
    behalf of the SENSE-Cog WP1 group. Am Geriatr Soc. 2018;66(6):1130-
    1136. https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/
    jgs.15363.
        \7\ Sarant J, Harris D, Busby P, Maruff P, Schembri A, Lemke U, &
    Launer S (2020). The Effect of Hearing Aid Use on Cognition in Older
    Adults: Can We Dely Decline or Even Improve Cognitive Function? Journal
    of Clinical Medicine, 9(1), 254.
        \8\ https://clinicaltrials.gov/ct2/show/NCT03243422.
    ---------------------------------------------------------------------------
        As hearing loss progresses, it manifests via profound consequences
    on verbal communication and social, functional, and psychological
    wellbeing of the person. The National Institutes of Health (NIH) has
    found that over 78 percent of participants with insufficient or poor
    hearing suffered from at least one additional chronic condition,
    leading to increased health care costs in any given year.\9\ For adults
    over 60 years of age, untreated hearing loss is associated with
    approximately 46 percent higher total health care costs over a 10-year
    period compared with costs for those without hearing loss.\10\ People
    with even a mild hearing loss are also three times more likely to fall,
    compared to individuals with normal hearing.\11\ When hearing loss does
    occur, early diagnosis and intervention are crucial for avoiding the
    negative social, emotional, and health consequences already described.
    ---------------------------------------------------------------------------
        \9\ Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N, on
    behalf of the SENSE-Cog WP1 group. Am Geriatr Soc. 2018;66(6):1130-
    1136. https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/
    jgs.15363.
        \10\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439810/.
        \11\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518403/.
    ---------------------------------------------------------------------------
        There is evidence that rates of hearing loss begin to rise around
    the age of 50, but the prevalence of hearing loss dramatically
    increases as an individual grows older (Figure 1).\12\ Individuals may
    underestimate their hearing difficulty and fail to pursue potentially
    beneficial treatment for their hearing loss that could lead to better
    health outcomes. Thus, hearing screening should be a part of every
    wellness check or physical exam for older adults, the population most
    at risk of age-related hearing loss.
    ---------------------------------------------------------------------------
        \12\ Jorgensen, L. & Novak, M. (2020). Factors Influencing Hearing
    Aid Adoption. Seminars in Hearing, 41(1), 7. https://doi.org/10.1055/s-
    0040-1701242.
    ---------------------------------------------------------------------------
        Figure1.

        As the Subcommittee develops its FY22 Labor-HHS-Education
    appropriations bill and accompanying report language, we respectfully
    request your support for the millions of Americans suffering from
    hearing loss by encouraging NIH to pursue hearing screening research.
    Hearing health is essential and hearing screening is the first step. We
    look forward to working with you and appreciate your attention to this
    important issue.

        [This statement was submitted by Kate Carr, President, Hearing
    Industries
    Association, and Barbara Kelley, Executive Director, Hearing Loss
    Association of America.]
                                     ______

                Prepared Statement of the Hepatitis B Foundation
          hepatitis b foundation recommendations for fiscal year 2021
                                 appropriations
    _______________________________________________________________________

    National Institutes of Health
      --Along with the biomedical research community, the Hepatitis B
            Foundation (HBF) supports the President's request for $51
            billion for the National Institutes of Health. While we are
            anxious to see the details of the President's request,
            specifically the details of the proposed ARPA-H initiative, we
            appreciate President Biden's commitment to allowing for
            meaningful growth in the base budget and expanding NIH's
            capacity to support promising science in all disciplines.
      --HBF commends NIAID, NIDDK, NCI for the development of a Trans-NIH
            Strategic Plan to Cure Hepatitis B and urges the Institutes to
            issue targeted calls for research to implement and fund the
            Strategic Plan.
    Centers for Disease Control and Prevention
      --HBF supports $10 billion for the Centers for Disease Control and
            Prevention programs in FY 2021, and within that $134 million
            for the Division of Viral Hepatitis. HBF further urges the CDC
            to allocate the necessary resources to address serious
            surveillance shortcoming without adversely impacting other CDC
            hepatitis B programs.
      --HBF urges the Division of Viral Hepatitis to fund both the
            Hepatitis B and the Hepatitis C community infrastructure grants
            in order to maintain and grow progress to address the public
            health threats of both hepatitis B and hepatitis C.
    HHS Office of the Secretary
      --HBF supports the newly released Viral Hepatitis National Strategic
            Plan and urges the establishment of an office or initiative to
            lead this elimination strategy and the provision of adequate
            staff and other resources needed for success.
    _______________________________________________________________________

        Mrs. Chairwoman and Members of the Subcommittee, thank you for the
    opportunity to provide testimony as you consider funding priorities for
    Fiscal Year (FY) 2022. I am Tim Block, President of the Hepatitis B
    Foundation (HBF). The Hepatitis B Foundation and its associated Baruch
    S. Blumberg Institute in Bucks County, Pennsylvania has grown to more
    than 100 researchers and public health professionals and has one of the
    largest, if not the largest, concentration of nonprofit scientists
    working on the problem of hepatitis B and liver cancer in the United
    States. The Foundation is a national disease advocacy organization that
    has become the world's leading portal for patient-focused information
    about hepatitis B. The Baruch S. Blumberg Institute is internationally
    recognized, and we believe, home to some of the most exciting and
    promising work in the field.
        Mrs. Chairwoman, HBF strongly supports the President's $51 billion
    request for NIH funding in FY 2022. HBF further urges that NIH increase
    investments in hepatitis B research in order to find a cure for the 2.4
    million Americans infected with the hepatitis B virus (HBV) and more
    than 10 deaths each day as a direct result of hepatitis B.
        In addition to the NIH, there are a number of programs within the
    jurisdiction of the subcommittee that are important to HBF, including
    the Centers for Disease Control and Prevention. We join the CDC
    Coalition, an advocacy coalition of more than 140 national
    organizations, in recommending $10 billion for the Centers for Disease
    Control and Prevention in the FY 2022 bill. Within that total, we join
    the Hepatitis Appropriations Partnership in urging $134 million for the
    CDC's Division of Viral Hepatitis.
        Finally, we would urge that the newly released Viral Hepatitis
    National Strategic Plan be led and funded fully as necessary to move us
    toward the goal of the elimination of viral hepatitis in the United
    States.
                 recognizing the leadership of the subcommittee
        Mrs. Chairwoman, HBF appreciates your leadership and the leadership
    of this Subcommittee in supporting public health service programs. Your
    support is greatly recognized and appreciated. We applaud the
    Committee's leadership in making progress in these important areas and
    to allocating increased funding to these programs during periods of
    fiscal austerity.
                         national institutes of health
        As previously noted, HBF supports the President's request for $51
    billion for the NIH. We look forward to learning more about the
    proposed ARPA-H initiative to accelerate the implementation of research
    findings. While we appreciate the President's bold vision to promote
    transformational innovations against the range of diseases facing
    humankind, we want to be sure that new investments are not made at the
    expense of the important basic science that is critical to our
    scientific enterprise. In addition to overall funding for the NIH, HBF
    urges that NIH investments in hepatitis B research be increased at
    least $38.7 million a year for 6 years to fund identified research
    opportunities that would help cure and eliminate the disease once and
    for all. The Hepatitis B Foundation appreciated the creation of the
    Hepatitis B Trans-NIH Working Group and was even more encouraged by the
    release of a Strategic Plan for Trans-NIH Research to Cure Hepatitis B
    in December of 2019. Report language is requested in the FY 2022 Report
    urging the NIAID and NIDDK to issue targeted calls for hepatitis B
    research proposals in FY 2022 focused on the many new research
    opportunities identified by the Strategic Plan.
        In the U.S., an estimated 2.4 million are chronically infected with
    hepatitis B virus (HBV). Worldwide, HBV is associated with 840,000
    deaths each year, making it the 10th leading cause of death in the
    world. Left undiagnosed and untreated, 1 in 4 of those with chronic HBV
    infection will die prematurely from cirrhosis, liver failure and/or
    liver cancer. Although HBV is preventable and treatable, there is still
    no cure for this disease. In view of the epidemic scope of hepatitis B
    and the fact that the virus was discovered 50 years ago, it is
    disappointing that funding for HBV research at the NIH is only expected
    to be funded at $66 million in FY 2021.
        There is the need, the know- how, and the tools to find a cure that
    will bring hope to almost 300 million people worldwide suffering from
    chronic hepatitis B. A cure was accomplished for hepatitis C with
    increased federal attention and funding. It can be accomplished for
    hepatitis B as well. Each year, despite an effective vaccine, 3-7
    million people worldwide are infected, and the epidemic continues to
    grow. Moreover, despite the availability of seven approved medications
    to manage chronic HBV infection, none are curative, most require
    lifelong use, and only reduce the likelihood of developing liver cancer
    by 40-60%.
        In addition to the devastating toll on patients and their families,
    ignoring hepatitis B is costing the United States an estimated $4
    billion per year in medical costs. By increasing the NIH budget for
    hepatitis B we have a good chance of success in finding a cure in the
    next few years. There are exciting new research developments and
    opportunities in the field that make finding a cure very possible.
        Centers for Disease Control and Prevention
        Given the challenges and burdens of chronic disease and disability,
    public health emergencies, new and reemerging infectious diseases and
    other unmet public health needs, HBF joins the 140 organizations in the
    CDC Coalition and urges a funding level of at least $10 billion for
    CDC's programs in FY 2022. This is $1.3 billion more than the
    Administration's request. The CDC serves as the command center for the
    nation's public health defense system against emerging and reemerging
    infectious diseases. States, communities, and the international
    community rely on CDC for accurate information and direction in a
    crisis or outbreak. While recent emergency funding has supported
    efforts to defeat COVID-19, we must provide stable, sufficient public
    health preparedness funding to allow our state and local health
    departments to maintain a standing set of core capabilities, so they
    are ready when needed, regardless of the next challenge or threat.
        The CDC's Division of Viral Hepatitis (DVH) is part of the National
    Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)
    at CDC. In collaboration with domestic and global partners, DVH
    provides the scientific and programmatic foundation and leadership for
    the prevention and control of hepatitis virus infections and their
    manifestations. HBF joins the Hepatitis Appropriations Partnership in
    recommending $134 million for the DVH in FY 2022 and within this level
    urges the Division to fund both the Hepatitis B and Hepatitis C
    community infrastructure grants. To discontinue one of these grants
    would be a step backward in the progress being made.
        The CDC Division of Viral Hepatitis spends less than 10% of its
    budget on HBV focused projects, despite hepatitis B infected patients
    comprising more than 35% of all those infected with viral hepatitis in
    the U.S. Furthermore, tremendous HBV-related health disparities exist
    for Asian Americans and Pacific Islanders and recent African
    immigrants. These groups represent less than 6% of the U.S. population
    but make up 50%-80% of the U.S. burden of chronic HBV infection. CDC
    has not adequately addressed the issue of chronic HBV infections among
    high-risk, foreign-born populations and their children. Of particular
    concern is that the CDC surveillance program is not robust enough to
    accurately report the prevalence of hepatitis B in high incidence
    states such as California and Hawaii. In view of the fundamental
    importance of good surveillance data to develop, manage and analyze
    public health programs and interventions, HBF urges CDC to allocate the
    necessary resources to address this shortcoming without adversely
    impacting other CDC hepatitis B programs.
        HBF is further concerned that despite the availability of an
    effective hepatitis B (HBV) vaccine, less than 25% of adults age 19 and
    older are vaccinated. According to CDC's most recent survey of
    Vaccination Coverage Among Adults, this poor vaccination rate remains
    flat and has not improved in several years. We are encouraged that CDC
    is evaluating new universal HBV vaccination recommendations including a
    comprehensive plan to increase adult HBV vaccinations. The CDC is
    further urged to promote awareness about the importance of hepatitis B
    vaccination among medical and health professionals, communities at high
    risk, and the public, and to improve collaboration and coordination
    across CDC to achieve this goal.
                             summary and conclusion
        Mrs. Chairwoman, again we wish to thank the Subcommittee for its
    past leadership. Significant progress has been made in meeting the many
    public health concerns facing this Nation, due to your efforts. HBF
    appreciates the opportunity to provide testimony to you on behalf of
    these paramount needs of the Nation.

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

               Prepared Statement of the HIV Medicine Association
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee, my name is Dr. Marwan Haddad, MD, MPH, Chair-elect of the
    HIV Medicine Association (HIVMA), and I serve as the Medical Director
    of the Center for Key Populations at the Community Health Center, Inc.
    (CHCI), in Middletown, Connecticut, one of the largest Federally
    Qualified Health Center in the country. I am pleased to submit
    testimony on behalf of HIVMA. HIVMA represents nearly 5,000 physicians,
    scientists, and other health care professionals around the country on
    the frontlines of the HIV epidemic. Our members provide care and
    treatment to people with HIV, lead HIV prevention programs, and conduct
    research in communities across the country. Many of them have been on
    the frontlines of their community's coronavirus (COVID-19) response.
        For the FY2022 appropriations process, we urge you to increase
    funding for the Ryan White HIV/AIDS Program at the Health Resources and
    Services and Administration (HRSA); increase funding for the Centers
    for Disease Control and Prevention's (CDC) HIV, hepatitis, and STD
    prevention programs; increase investments in HIV research supported by
    the National Institutes of Health (NIH); appropriate additional funding
    to support the ``Ending the HIV Epidemic'' (EHE) Initiative; and the
    implementation of the EHE initiative as well as the response to the
    COVID-19 pandemic. As the United States responds to the global COVID-19
    pandemic, it is paramount to provide robust funding for public health,
    including these vital programs which support global and domestic health
    security measures and our public health infrastructure.
        The funding requests in our testimony largely reflect the consensus
    of the Federal AIDS Policy Partnership, a coalition of HIV
    organizations from across the country. For a chart of current and
    historical funding levels, along with coalition requests for each
    program, please click here.
            ending the hiv epidemic initiative--u.s. department of
                           health and human services
        Over the last two years, on a bipartisan basis, Congress has
    appropriated funding for the EHE Initiative, which sets the goal of
    reducing new HIV infections by 50% by 2025, and 90% by 2030. We
    recommend funding the EHE initiative at least at the President's budget
    request for $670 million in support of ending HIV as an epidemic to be
    used for expanded access to antiretroviral treatment and PrEP to
    prevent HIV transmissions as well as improved access to routine and
    critical health services.
         health resources and services administration--hiv/aids bureau
        HRSA's Ryan White HIV/AIDS Program provides medical care and
    treatment services to over half a million people living with HIV. Over
    three-quarters of Ryan White clients are Black, Latinx or other people
    of color, and nearly two-thirds have incomes under the federal poverty
    level. To continue providing comprehensive, life-saving treatment and
    to bring many more people into care through the EHE Initiative, we urge
    Congress to fund the Ryan White HIV/AIDS Program at a total of $2.768
    billion in FY2022, an increase of $345 million over FY2021. We strongly
    recommend providing at least $222 million in EHE funding for the Ryan
    White Program.
        HIVMA urges an allocation of $225.1 million, or a $24 million
    increase over current funding, for Ryan White Part C programs. The
    flexibility of the Ryan White Program and its providers' expertise has
    also allowed Part C clinics to respond to the changing needs of
    patients and the health care system throughout the COVID-19 pandemic.
    Ryan White clinics serve a significant number of individuals living
    with both substance use disorder and HIV, delivering a range of medical
    and support services, including overdose prevention and harm reduction
    services, needed to prevent, intervene, and treat substance use
    disorder as well as related infectious diseases, including HIV, HCV,
    and sexually-transmitted infections (STI).
    CHCI's Ryan White-Funded Clinic in Connecticut is Leading on Expanding
            Access to HIV Prevention, Care, & Treatment
        CHCI's Center for Key Populations, Ryan White-funded Early
    Intervention Services Program, has served as the leading source of HIV
    primary care in Connecticut for 22 years. Each year our Ryan White
    program serves more patients from almost every city and town across
    Connecticut.
        The needs of both established and newly diagnosed patients with HIV
    are growing more complex. In 2020, even as HIV care was innovatively
    transformed to mostly telehealth due to COVID-19, CHCI experienced an
    increase in the number of patients living with HIV who accessed
    services at our sites. Of all new patients enrolled in care at CHCI in
    2020, 69% self-reported as racial and ethnic minorities and 56%
    reported food and housing insecurity as major barriers to achieving
    optimal healthcare. Additionally, 4% of all Ryan White patients were
    uninsured, 87.9% had at least one clinical co-morbidity, and 62%
    reported unmet mental health needs at the time of intake. Among Ryan
    White Program patients at CHCI, 12% reported unstable housing, which
    means they were living in a shelter, vehicle, or completely
    unsheltered, creating additional challenges to retention in care.
        CHCI's Ryan White Program eligible patients who are engaged in care
    are screened for substance use disorders routinely and 63% screened
    positive with 11% considering those needs urgent or severe. CHCI, like
    most Ryan White Part C programs, also receives funding from other parts
    of the Ryan White Program, and these help us provide support services
    that were particularly important during the COVID-19 pandemic. These
    services included home medical monitoring equipment, transportation,
    case management, patient navigation, home-delivered meals, grocery
    delivery, check-in phone calls, and other key components of care unique
    to the Ryan White Program care model and contribute to optimal
    healthcare outcomes for all patients.
            health resources and services administration--bureau of
                              primary health care
        We recommend appropriating $152 million in new funding for HRSA's
    Community Health Center program for the EHE initiative. In those
    community health centers funded by the EHE Initiative, they were able
    to increase PrEP uptake from 19,000 in 2020 to nearly 50,000 people in
    early 2021. CDC estimates only 10% of those who could benefit from PrEP
    have had it prescribed to them, and those who need it most--black and
    Latino gay and bisexual men at high risk--are prescribed it at a much
    lower rate. Scaling up PrEP among the most affected populations is
    critical to reducing health disparities and ending HIV as an epidemic.
      centers for disease control and prevention--national center for hiv/
    aids, viral hepatitis, sexually transmitted diseases, and tuberculosis
                                   prevention
        From the CDC's leadership role in responding to the COVID-19
    pandemic to its ongoing efforts to address persistent public health
    epidemics and threats, such as HIV, STIs, and viral hepatitis, the CDC
    is a critical national and global expert resource and response center.
    To meaningfully address these epidemics and the co-occurring crisis of
    substance use disorder--especially injection drug use--we request a
    $731 million overall increase above FY2021 levels for a total of $2.045
    billion.
        For the Division of HIV/AIDS Prevention (DHAP), we request a total
    of $1.293 billion, which is a $328 million increase over FY2021 levels.
    DHAP conducts our national HIV surveillance and funds state and local
    health departments and communities to conduct evidence-based HIV
    prevention activities. CDC's national surveillance system is critical
    to monitoring populations and regions impacted by the HIV epidemic and
    identifying outbreaks. We also strongly recommend appropriating at
    least the $371 million requested by the Administration for the EHE
    initiative, allowing the CDC to scale up HIV testing to ensure early
    diagnosis and care linkage and PrEP programs to prevent new infections.
        Additionally, we urge the appropriation of $120 million for the CDC
    to fund surveillance and programming to monitor and prevent opioid-
    related infectious diseases as well as expand access to syringe
    services programs, harm reduction, and overdose prevention. Funding for
    CDC's Infectious Diseases and Opioid Epidemic programming is critical
    to respond to increases in serious infections linked to substance use,
    including HIV, hepatitis B and C, and life-threatening bacterial
    infections such as endocarditis.
        For the Division of Viral Hepatitis (DVH), we request a total of
    $134 million, which is a $94.5 million increase over FY2021 levels. We
    have the tools to prevent this growing epidemic, but increased funding
    is urgently needed to expand testing and screening, prevention, and
    surveillance to put the U.S. on the path to eliminate hepatitis as a
    public health threat.
        For the Division of STD Prevention (DSTDP), we request a total of
    $272.9 million, which is a $111.1 million increase over FY2021 levels.
    For the sixth year in a row, the CDC reports dramatic increases in STIs
    in the U.S. These historic increases have created a public health
    emergency with devastating long-term health consequences, including
    infertility, cancer, HIV transmission, and infant and newborn deaths.
             national institutes of health--office of aids research
        In order to advance discoveries important to end HIV epidemic as an
    epidemic, including improved HIV prevention modalities and treatment
    options and ultimately a cure and a vaccine, we ask that at least
    $3.854 billion be allocated for HIV research in FY2022, an increase of
    $755 million over FY2021. The return on investment in HIV research
    extends beyond HIV and includes contributing to the record-breaking
    timelines for the development of COVID-19 vaccines.
       indian health service--eliminating hiv and hepatitis c in indian
                                    country
        Between 2011 and 2015, there was a 38% increase in new HIV
    diagnoses among the American Indian/Alaska Native population overall,
    and a rise of 58% among AI/AN gay and bisexual men. We urge for the
    Indian Health Service component of the EHE Initiative to be funded at
    $27 million.
                                   conclusion
        The COVID-19 pandemic highlights the importance of preparing for
    infectious diseases outbreaks by fully funding programs that support
    public health services, infrastructure and workforce so that we are
    better prepared for the next pandemic. Thank you for your time and
    consideration of these important requests and for strengthening our
    nation's ability to end the HIV epidemic in the U.S. Please contact me
    or HIVMA's Senior Policy & Advocacy Manager, Jose A. Rodriguez, at
    JRodriguez@hivma.org, if you have any questions or need additional
    information. HIVMA is located at 4040 Wilson Boulevard Suite 300,
    Arlington, VA 22203.

        [This statement was submitted by Marwan Haddad, MD, Chair-elect,
    HIV
    Medicine Association, MPH.]
                                     ______

            Prepared Statement of the HIV+Hepatitis Policy Institute
        On behalf of the HIV+Hepatitis Policy Institute, we respectfully
    submit this testimony in support of increased funding for domestic HIV
    and hepatitis programs in the FY 2022 Labor, HHS spending bill. The
    HIV+Hepatitis Policy Institute is a leading HIV and hepatitis policy
    organization promoting quality and affordable healthcare for people
    living with or at risk of HIV, hepatitis, and other serious and chronic
    health conditions.
        This June 5th our nation commemorated the 40th anniversary of AIDS.
    Over the last four decades the U.S. has made great advances in HIV
    prevention, care, and treatment; but much work remains. While between
    2015 and 2019 the U.S. saw slight decreases in the number of new HIV
    infections, disparities continue to exist, and some populations saw
    increases in infections. HIV continues to disproportionately impact
    Black and Latino gay men, Black women, people who inject drugs, and who
    live in the South. The Centers for Disease Control and Prevention (CDC)
    reports that over half of all new HIV infections in 2019 were in the
    South. Recently, the Department of Health and Human Services released
    updated strategic plans to guide our nation in responding to the HIV
    and hepatitis epidemics, including for the first time ever calling for
    the elimination of viral hepatitis. In each of the plans, the need to
    address the syndemics of HIV and hepatitis is prioritized.
        As our country continues to respond and recover from the COVID-19
    pandemic, which has impacted HIV and hepatitis services, we know we
    have the science to end two other infectious diseases that have been
    impacting our country for decades: HIV and hepatitis C. While there
    still is no cure or vaccine for HIV, we have preventive tools along
    with treatments that suppress the virus, and together can bring the
    number of new infections down to a point that we can end HIV. For
    hepatitis C, there are curative treatments. However, federal leadership
    and funding for our public health system is necessary to ramp up
    efforts to address these two epidemics. The programs and funding
    increases detailed below are pivotal to our nation's ability to end
    both HIV and hepatitis.
                      ending the hiv epidemic in the u.s.
        Over the past two years, Congress has appropriated over $400
    million in new funding for the Ending the HIV Epidemic in the U.S.
    initiative, which sets the goal of reducing new HIV infections by 75
    percent by 2025, and 90 percent by 2030. Priority jurisdictions have
    used initial funding to develop ending HIV plans with the help of
    community partners that build on existing HIV programs and utilize new
    innovations and strategies. Even while battling COVID, the Ryan White
    HIV/AIDS Program reports that in these priority jurisdictions, with the
    additional funding, they were able to bring nearly 6,300 new clients
    into the program and re-engage an additional 3,600 between March and
    August of 2020. In the community health centers funded by the EHE
    initiative, they were able to increase pre-exposure prophylaxis (PrEP)
    uptake from 19,000 in 2020 to nearly 63,000 people within 11 months.
        We are pleased that President Biden has proposed to increase
    funding for the Ending the HIV Epidemic initiative by $267 million as
    part of his FY22 budget. Additionally, the Biden administration has
    proposed increases in other domestic HIV programs. Since many of these
    increases fall short of what was proposed last year and what is needed,
    we urge the Congress to do better and significantly increase funding
    for the Ending the HIV Epidemic in the U.S. initiative for FY2022 so
    that this important work can be properly ramped up. In particular we
    ask for increased funding for the following programs:
      --CDC Division of HIV/AIDS Prevention for testing, linkage to care,
            and prevention services, including PrEP (+$196 m);
      --HRSA Ryan White HIV/AIDS Program to expand comprehensive treatment
            for people living with HIV (+$107 m); and
      --HRSA Community Health Centers to increase clinical access to
            prevention services, particularly PrEP (+$50 m)
        The success of the EHE initiative rests upon our underlying public
    health prevention, care, and treatment programs at the CDC and HRSA.
    Congress must ensure that these are adequately funded to provide
    services in all areas of the country.
        The Ryan White HIV/AIDS Program at the Health Resources and
    Services Administration provides medical care, medications, and
    essential coverage completion services to over 567,000 low-income,
    uninsured, and/or underinsured individuals with HIV. For over 30 years,
    the Ryan White program has pioneered innovative models of care which
    has resulted in 88 percent of Ryan White clients achieving viral
    suppression, a critical marker for decreasing new infections in the
    U.S. Currently Ryan White Programs, and particularly the AIDS Drug
    Assistance Programs (ADAPs), are facing increased demand as people have
    lost health coverage and incomes due to the economic impact of COVID-
    19, and state and local budgets have become increasingly stressed.
    Without increased funding some ADAPs may be forced to institute wait
    lists for medications or other cost containment measures. We urge
    Congress to fund the Ryan White HIV/AIDS Program at a total of $2.768
    billion in FY2022, an increase of $345 million over FY2021 including an
    increase of $68 million for ADAPs for total funding of $968.3 million.
        In addition, HIV+Hep opposes any efforts through the appropriations
    process to alter the intent of the program to use Ryan White-derived
    funds for activities outside the scope of the original intent of
    current legislative language.
        The CDC Division of HIV Prevention funds state and local public
    health departments and community-based organizations to implement and
    enhance targeted, tailored, and high-impact prevention programs aimed
    at addressing racial and geographic health disparities. This includes
    HIV testing, condom distribution programs, and other HIV awareness
    campaigns. CDC also funds our national surveillance system which is
    critical to identifying new HIV clusters and outbreaks and provides the
    data necessary to tailor resources and programming. Funding from the
    CDC also allows communities to focus on increasing access to and use of
    PrEP, which is critical to ending the HIV epidemic. Recent CDC data
    show that in 2019, nearly 285,000 or 23 percent of people eligible for
    PrEP were prescribed it, up from 3 percent in 2015. While this increase
    is moving in the right direction, some of the communities most in need
    of PrEP are not receiving it and we must continue building programs to
    provide outreach to communities and education about PrEP.
        A holistic response to the HIV epidemic also depends on fully
    funding other priority programs at HHS, including the CDC's Division of
    School and Adolescent Health and STI Prevention, the Minority HIV/AIDS
    Initiative, AIDS Research at the NIH, the Title X Family Planning
    Program, and the Teen Pregnancy Prevention Program (TPPP).
                                viral hepatitis
        We respectfully request that you provide increased funding for
    viral hepatitis programs at the CDC. The CDC estimates that more than
    4.5 million people in the United States live with hepatitis B (HBV) or
    hepatitis C (HCV), with nearly half unaware they are living with the
    disease. The opioid epidemic has significantly increased the number of
    viral hepatitis cases in the United States, with available data
    suggesting that more than 70 percent of new HCV infections are among
    people who inject drugs. There are several curative treatments
    available for HCV, but individuals must have access to screening and
    linkage to care programs to be able to take advantage of these
    medications. The number of acute hepatitis C cases reported in the U.S.
    has increased every year since 2012. CDC recently reported an increase
    of 63 percent in acute hepatitis C cases between 2015 and 2019, with 67
    percent of the cases in 2019 associated with injection drug use.
    CDC Division of Viral Hepatitis
        The viral hepatitis programs at the CDC are severely underfunded,
    receiving only $39.5 million-far short of what is needed to build and
    strengthen our public health response and to eventually end hepatitis.
    States' ability to conduct enhanced HCV surveillance activities is
    severely hampered by a lack of funding. Additional resources would
    allow the CDC to enhance testing and screening programs, link people to
    treatment, conduct additional provider education, and increase services
    related to hepatitis outbreaks and injection drug use. We urge you to
    provide the CDC Division of Viral Hepatitis with $134 million, an
    increase of $94.5 million over FY 2021 enacted levels.
    CDC's Eliminating Opioid-Related Infectious Diseases Program
        This CDC program focuses on addressing the infectious disease
    consequences of increased rates of injection drug use due to the opioid
    crisis. Providing full support for this program is another key step in
    preventing new cases of viral hepatitis and HIV and putting the country
    on the path towards elimination. We urge the committee to fund this
    program to eliminate opioid-related infectious diseases at no less than
    $120 million, an increase of $107 million.
                        syringe service programs (ssps)
        We also ask that the committee support ending any prohibition on
    the use of federal funds to purchase sterile needles or syringes for
    SSPs. A wealth of scientific evidence has shown that SSPs reduce the
    spread of infectious diseases, such as HIV and hepatitis. Full federal
    funding for these programs will only serve to make the programs
    stronger and more effective.
        In conclusion, we urge the committee to continue its investment in
    our nation's public health infrastructure specifically as it relates to
    addressing the ongoing HIV and HCV epidemics. Fortunately, we have the
    tools available to end both these epidemics; however, we must provide
    the necessary resources to achieve these goals.

        [This statement was submitted by Carl Schmid, Executive Director,
    HIV+Hepatitis Policy Institute.]
                                     ______

         Prepared Statement of the Human Factors and Ergonomics Society
        On behalf of the Human Factors and Ergonomics Society (HFES), we
    are pleased to provide this written testimony to the Senate
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies for the official record. HFES urges the Subcommittee
    to provide no less than $500 million for the Agency for Healthcare
    Research and Quality (AHRQ) and a minimum of $375.3 million for the
    National Institute for Occupational Safety and Health (NIOSH),
    including $34 million for the Education and Research Centers (ERCs), in
    fiscal year (FY) 2022.
        AHRQ supports research to improve health care quality, reduce
    costs, advance patient safety, decrease medical errors, and broaden
    access to essential services. As the lead federal agency for funding
    health services research (HSR) and primary care research (PCR), AHRQ is
    the bridge between cures and care, and ensures that Americans get the
    best health care at the best value. The RAND Corporation released a
    report in 2020 as called for by the Consolidated Appropriations Act of
    2018, which identified AHRQ as ``the only agency that has statutory
    authorizations to generate HSR and be the home for federal PCR, and the
    unique focus of its research portfolio on systems-based outcomes (e.g.,
    making health care safer, higher quality, more accessible, equitable,
    and affordable) and approaches to implementing improvement across
    health care settings and populations in the United States.''
        HFES requests a minimum of $500 million for AHRQ, which is
    consistent with the FY 2010 level adjusted for inflation and reflects
    the demonstrated needs of pandemic response. This funding level will
    allow AHRQ to rebuild portfolios terminated after years of cuts. AHRQ
    is the federal vehicle for studying and improving the United States
    healthcare system, and it needs the resources to meet its mission and
    this moment. Through this appropriation level, AHRQ will be better able
    to fund the ``last mile'' of research from cure to care.
        Additionally, HFES requests $375.3 million for NIOSH, including $34
    million for the Education and Research Centers (ERCs). NIOSH supports
    education and research in occupational health through academic degree
    programs and research opportunities. With an aging occupational safety
    and health workforce, ERCs are essential for training the next
    generation of professionals. The Centers establish academic, labor, and
    industry research partnerships to achieve these goals. Currently, ERCs
    are responsible for supplying many of the country's OSH graduates who
    will go on to fill professional roles.
        HFES strongly believes that investment in scientific research
    serves as an important driver for innovation and the economy as well as
    for protecting and promoting the health, safety, and well-being of
    Americans. We thank the Subcommittee for its longtime recognition of
    the value of scientific and engineering research and its contribution
    to innovation and public health in the U.S.
               the value of human factors and ergonomics science
        HFES is a multidisciplinary professional association with over
    3,000 individual members worldwide, including psychologists and other
    scientists, engineers, and designers, all with a common interest in
    designing safe and effective systems and equipment that maximize and
    adapt to human capabilities.
        For over 50 years, the U.S. federal government has funded
    scientists and engineers to explore and better understand the
    relationship between humans, technology, and the environment.
    Originally stemming from urgent needs to improve the performance of
    humans using complex systems such as aircraft during World War II, the
    field of human factors and ergonomics (HF/E) works to develop safe,
    effective, and practical human use of technology. HF/E does this by
    developing scientific approaches for understanding this complex
    interface, also known as ``human-systems integration.'' Today, HF/E is
    applied to fields as diverse as transportation, architecture,
    environmental design, consumer products, electronics and computers,
    energy systems, medical devices, manufacturing, office automation,
    organizational design and management, aging, farming, health, sports
    and recreation, oil field operations, mining, forensics, and education.
        With increasing reliance by federal agencies and the private sector
    on technology-aided decision-making, HF/E is vital to effectively
    achieving our national objectives. While a large proportion of HF/E
    research exists at the intersection of science and practice--that is,
    HF/E is often viewed more at the ``applied'' end of the science
    continuum--the field also contributes to advancing ``fundamental''
    scientific understanding of the interface between human decision-
    making, engineering, design, technology, and the world around us. The
    reach of HF/E is profound, touching nearly all aspects of human life
    from the health care sector to the ways we travel and to the hand-held
    devices we use every day.
                                   conclusion
        HFES urges the Subcommittee to provide $500 million for AHRQ and
    $375.3 million for NIOSH, including $34 million for the Education and
    Research Centers (ERCs) in FY 2022. These investments fund important
    research studies, enabling an evidence base, methodology, and
    measurements for improving healthcare, safety, and public health for
    Americans.
        On behalf of the HFES, we would like to thank you for the
    opportunity to provide this testimony. Please do not hesitate to
    contact us should you have any questions about HFES or HF/E research.
    HFES truly appreciates the Subcommittee's long history of support for
    scientific research and innovation.

        [This statement was submitted by Peter Hancock, DSc, PhD,
    President, and
    Steven C. Kemp, CAE, Executive Director, Human Factors and Ergonomics
    Society.]
                                     ______

                         Prepared Statement of I AM ALS
        Chairwoman Murray, Ranking Member Blunt thank you for the
    opportunity to submit written testimony. My name is Brian Wallach and I
    have enjoyed the opportunity to work with both of you and your
    colleagues in the Senate ALS Caucus over the past several years.
        I am grateful for all you and your colleagues have done for the ALS
    community. Thanks to you and others like Senators Dick Durbin, Lisa
    Murkowski, Chris Coons, and Mike Braun, and our incredible ALS
    grassroots advocates, we have increased federal spending on ALS
    research by $83 million in just two years. And this past December,
    Congress overwhelmingly passed a bill to give ALS patients access to
    SSDI benefits upon diagnosis, averting bankruptcy for so many.
        As a result of this work, the path towards ending ALS is clearer.
    The question now is when do we reach the end of that path and will any
    of those of us living with ALS now be here to see that day?
        I desperately want to be here, but my body is failing. You can hear
    it in my voice and see it in the videos I post on Twitter. Odds are
    that unless something changes, I won't be. The average patient lives 2-
    5 years post-diagnosis and of those diagnosed in 2017 with me, four out
    of five-80%-are dead.
        So I come with two urgent asks. Ones that if you make real will
    change my and millions of others' futures.
        First, fund ARPA-H and include ALS among its core disease areas.
    During the 2020 campaign then-candidate Joe Biden promised ALS patient
    Ady Barkan that he would seek to create ARPA-H, modeled after DARPA, to
    solve issues relating to the diagnosis and treatment of disease. He
    also promised that ALS-along with cancer, diabetes and Alzheimer's-
    would be among the first diseases it tackled.
        I was elated when President Biden's administration submitted a
    proposal to fund ARPA-H to Congress. I was devastated when I saw that
    only ALS was left out of the list of identified diseases it would
    target.
        To cure ALS, we need an ARPA-H. We need both a focus on high risk/
    high reward research and to break down the antiquated, bureaucratic red
    tape facing ALS patients seeking promising therapies. Moreover, if we
    cure ALS, we can help unlock cures for Alzheimer's, Parkinson's,
    Frontotemporal Dementia and beyond.
        Today, despite the increases in funding over the last 2 years, our
    government still spends less than $6,000 on ALS research per year per
    person in the U.S. living with ALS. You have the power to fix this by
    putting ALS back into ARPA-H.
        Second, we need you to hold the FDA accountable for failing ALS
    patients by denying any type of approval for two promising therapies
    this year. On June 7th, we watched the FDA grant accelerated approval
    of aducanumab for the treatment of Alzheimer's disease and wondered why
    that same urgency has not been applied to ALS.
        In September 2019, FDA released an updated Guidance for ALS
    Clinical Trials. It stressed the need for ``regulatory flexibility in
    applying the statutory standards to drugs for serious diseases with
    unmet medical needs.'' The Guidance explicitly stated that ``[w]hen
    making regulatory decisions about drugs to treat ALS, FDA will consider
    patient tolerance for risk and the serious and life-threatening nature
    of the condition in the context of statutory requirements for safety
    and efficacy.''
        The first two tests of FDA's promise of regulatory flexibility and
    urgency for ALS came this year with AMX0035, an oral medication, and
    NurOwn, a stem cell therapy. The Phase II/III trial for AMX0035 showed
    that AMX0035 slowed the progression of ALS and enabled patients on
    average to live 6.5 months longer. NurOwn's Phase III trial did not
    show the same overall benefit, but did show a ``clinically meaningful''
    slowing of progression for a subgroup of ALS patients.
        FDA's response: No approval for either therapy. No regulatory
    flexibility. No consideration of the terminal nature of ALS. No regard
    for the tens of thousands of patients, caregivers and advocates who
    signed petitions to the FDA pleading for access to these therapies.
        Instead, the FDA reverted to the same inflexible position for both
    therapies: they asked each company to run another large, long placebo-
    controlled trial and then come back. Let me make crystal clear what
    these two decisions by FDA mean: at best these therapies won't be
    accessible to patients for 4 years. By then nearly every ALS patient
    alive today will be dead.
        Why weren't these therapies approved? Both therapies showed
    efficacy for at least a subgroup of ALS patients. And if the concern
    was safety, both trials showed a strong safety profile-particularly in
    the context of a 100% fatal disease. Moreover, the denials deprived
    patients of the chance to access FDA-regulated drugs under the
    supervision of an ALS specialist. So, instead, patients are forced to
    try to replicate the formula for AMX0035 on their own and to travel
    abroad for risky stem cell procedures.
        I've been told that the FDA has claimed to members of Congress and
    their staff that they are doing everything they can and that there was
    nothing else they could do with respect to these two therapies. This is
    simply not true or, if FDA actually believes this, they have provided
    Congress a clarion call to reform how FDA regulates treatments for
    diseases like ALS.
        I am a former federal government employee. I come from a family of
    former and current federal government employees. I truly believe the
    FDA is filled with honorable, dedicated public servants. However, their
    actions here are impossible to square with their own Guidance. This is
    most clearly demonstrated by the fact that AMX0035 appears headed
    towards approvals in Canada and Europe based on the same data presented
    to FDA. FDA stands alone as an immovable obstacle.
        I implore Congress to hold hearings on these denials to bring
    transparency and accountability to a process that has left the ALS
    community devastated.
        In addition to hearings, I ask you to pass and fund 2 bills to
    ensure this does not happen again. Over the last year, the fight
    against COVID-19 showed how much regulatory flexibility FDA has when it
    wants to use it. Since FDA appears unwilling to use it to give ALS
    patients a chance to live, we have worked with members of Congress to
    reform how FDA approaches diseases like ALS.
        The first, ACT for ALS, will, among other items, make a significant
    amount of funding available to establish expanded access programs.
    Programs that will make promising therapies available to ALS patients
    now while fueling additional research into a therapy's safety and
    efficacy.
        The second, The Promising Pathways Act, will, among other things,
    allow for conditional approval of promising therapies after Phase II
    for life-threatening diseases like ALS. This would put us on par with
    Europe.
        Today, the science needed to cure ALS is moving faster than ever
    and finally producing therapies that may be able to slow or stop this
    disease. This reality must be matched by a new regulatory approach that
    speeds promising therapies to patients. As I have outlined, despite
    programs aimed to do just that which have worked in other diseases, we
    do not have that approach for ALS today. It is our moral obligation to
    change this broken approach for all those facing ALS just as we did for
    HIV and cancer.
        If we do, I will have a chance to see my daughters graduate from
    kindergarten, high school, and college.
        You have the power to make that happen.
        I thank you for having the courage to do so.
        And I look forward to working with each of you to finally defeat
    ALS.

        [This statement was submitted by Brian Wallach, Co-Founder, I AM
    ALS.]
                                     ______

        Prepared Statement of the Infectious Diseases Society of America
        On behalf of the Infectious Diseases Society of America (IDSA),
    which represents more than 12,000 physicians, scientists, public health
    practitioners and other clinicians specializing in infectious diseases
    prevention, care, research and education, I urge the Subcommittee to
    provide robust FY2022 funding for public health and biomedical research
    activities that save lives, contain health care costs and promote
    economic growth. IDSA asks the Subcommittee to provide $10 billion for
    the Centers for Disease Control and Prevention (CDC), $46.111 billion
    for the National Institutes of Health (NIH), $300 million for the
    Biomedical Advanced Research and Development Authority (BARDA) Broad
    Spectrum Antimicrobials and CARB-X programs and $200 million for the
    Strategic National Stockpile Special Reserve Fund program.
        While we must continue to direct substantial resources to tackle
    the COVID-19 pandemic, we must also address other domestic and global
    infectious diseases threats and epidemics, including those for which
    progress has stalled and/or worsened during the pandemic. For example,
    routine immunization rates have fallen, and access to care for diseases
    like HIV has been disrupted. In addition, high levels of antibiotic use
    likely exacerbated existing antibiotic resistance, deepening the need
    for antimicrobial stewardship, surveillance and new antimicrobial
    drugs. The COVID-19 pandemic has shown us all too clearly the
    fundamental importance of expanding the infectious diseases workforce,
    public health infrastructure and biomedical research enterprise
    necessary to successfully confront the panoply of infectious threats
    facing our increasingly interconnected world.
                   centers for disease control and prevention
    Antibiotic Resistance Solutions Initiative (ARSI)
        We urge $672 million in funding for the Antibiotic Resistance
    Solutions Initiative in FY2022. IDSA members see the impact that
    antimicrobial resistance (AMR) has on patients daily. Antimicrobial
    resistance is one of the greatest public health threats of our time.
    Drug-resistant infections sicken at least 2.8 million each year and
    kill at least 35,000 people annually in the United States. Antibiotic
    resistance accounts for direct healthcare costs of at least $20
    billion. If we do not act now, by 2050 antibiotic resistant infections
    are expected to be the leading cause of death in the world.
        We therefore recommend $672 million for the Antibiotic Resistance
    Solutions Initiative to achieve the goals outlined in the 2020-2025
    National Action Plan for Combating Antibiotic-Resistant Bacteria. The
    ARSI is the cornerstone of the nation's efforts to detect, prevent, and
    respond to AMR. The program is also a critical building block of CDC's
    public health infrastructure that directly supports broader agency
    activities, including COVID-19 first responders, foodborne illness
    pathogen detection, sexually transmitted infections, health care
    associated infections and global health. Increased funding would help
    expand antibiotic stewardship across the continuum of care; double
    grant awards at the state and local level; expand the Antibiotic
    Resistance Laboratory Network globally and domestically to strengthen
    the identification, tracking and containment of deadly pathogens;
    support AMR research and epicenters; and increase public and health
    care professional education and awareness activities. Since FY2016,
    funding for the initiative has improved antibiotic use, increased state
    and regional laboratory capacity to rapidly detect resistant infections
    and enhanced tracking of health care-associated infections. However,
    many state laboratories still do not monitor for and report resistance
    data on pathogens of importance and the program will be unable to
    effectively address current and newly emerging threats and prepare for
    future challenges without a significant increase in funding in FY2022.
    Increased funding is vital to achieving the plan's goals, including a
    20 percent decrease in health care-associated antibiotic-resistant
    infections and a 10 percent drop in community-acquired antibiotic-
    resistant infections by 2025.
    Advanced Molecular Detection
        Advanced Molecular Detection (AMD) strengthens CDC's epidemiologic
    and laboratory expertise to effectively detect and track pathogens,
    including how they mutate, to inform responses and improve clinical
    care of patients. AMD provides more rapid identification of pathogens
    which can positively benefit antimicrobial stewardship to improve
    patient outcomes and reduce AMR. Requested FY2022 funding of $60
    million would further enhance federal, state and local laboratory
    capabilities and spur innovation, including through further integration
    of genomics and other advanced laboratory technologies into AMR
    surveillance. Increased funding would help CDC apply the work of
    SPHERES, a national genomics consortium led by AMD that coordinates
    large-scale, rapid SARS-CoV-2 sequencing across the U.S., to bolster
    AMR surveillance, detection and response.
    National Healthcare Safety Network
        FY2022 funding of $100 million for the National Healthcare Safety
    Network (NHSN) will enable the program to meet its current and
    projected demands. Requested funding would expand data collection on
    antibiotic use and resistance in health care facilities as outlined in
    the 2020-2025 National Action Plan for Combating Antibiotic-Resistant
    Bacteria. In 2020, many additional health care facilities began
    reporting COVID-19 data to NHSN, and new funding will help expand that
    reporting to include antibiotic use and resistance data. FY2022 funding
    would help achieve the National Action Plan goals for 75 percent of
    acute care hospitals and 25 percent of critical access hospitals
    reporting to the NHSN Antibiotic Resistance Option and 100 percent of
    acute care and 50 percent of critical access hospitals reporting to the
    NHSN Antibiotic Use Option. These data help measure and drive progress
    toward optimizing antibiotic use. Additionally, increased funding would
    provide access to technical support for more than 65,000 staff at
    health care facilities who use NHSN.
    CDC Center for Global Health
        IDSA urges the Subcommittee to provide $857.8 million in FY2022
    funding, including $456.4 million for CDC's Division of Global Health
    Protection. Public health experts address more than 400 diseases and
    health threats in 60 countries, including SARS-CoV-2. An emerging
    infection in any part of the world is just a plane ride away from the
    U.S. (or any other location). As highlighted by the COVID-19 pandemic,
    increased resources for this vital CDC program are needed to improve
    global capacity to prevent, detect and respond to health threats at
    their source before international spread. As a key implementor of the
    Global Health Security Agenda, the division works to improve health
    emergency preparedness and response, enhance infectious disease
    surveillance systems, strengthen laboratory capacity, train health care
    workers and disease detectives and build and support emergency
    operations centers in countries with limited public health capacities.
    The current COVID-19 tragedy in India and Brazil underscores the
    critical importance of global public health infrastructure. The program
    also works to address AMR by providing technical assistance to 30
    countries, working to detect resistant threats; prevent and contain
    resistance pathogens; and improve antibiotic use. Other divisions in
    the CDC Center for Global Health are instrumental in providing
    technical assistance on HIV, tuberculosis (TB) and malaria and other
    parasitic diseases, and also ensuring access to essential immunization
    services for children in low- and middle-income countries. U.S.
    leadership of global health security efforts is essential, and the
    resources allocated to those efforts have been inadequate. Until all
    countries have laboratory monitoring and surveillance capacities and
    the trained staff and equipment necessary to detect and respond swiftly
    to emerging infectious threats, we all will remain vulnerable.
    Elimination of Opioid Related Infectious Diseases
        $120 billion in funding for the Opioid-Related Infectious Diseases
    program would allow CDC to address the significant and growing burden
    of the opioid epidemic by expanding surveillance for infectious
    diseases commonly associated with injection drug use, including HIV,
    viral hepatitis and infective endocarditis. CDC has found steep
    increases in multiple viral, bacterial and fungal infections due to
    injection drug use, and CDC estimates that individuals who inject drugs
    are 16 times more likely to develop an invasive Methicillin-resistant
    Staphylococcus aureus (MRSA) infection. We are very concerned about how
    the opioid crisis is driving higher rates of infectious diseases
    including hepatitis C, endocarditis, HIV, and pneumonia, as well as
    skin, soft tissue, bone, and joint infections. Support systems for
    individuals with substance use disorders are suffering disruptions due
    to the COVID-19 pandemic, which may be worsening the opioid epidemic
    and associated infectious diseases.
            assistant secretary for preparedness and response (aspr)
    Biomedical Advanced Research and Development Authority (BARDA), Broad
            Spectrum Antimicrobials and Combating Antibiotic-Resistant
            Bacteria Biopharmaceutical Accelerator (CARB-X )
        The BARDA Broad Spectrum Antimicrobials program and CARB-X leverage
    public/private partnerships to develop products that directly support
    the government-wide National Action Plan for Combating Antibiotic-
    Resistant Bacteria and have been successful in developing new FDA-
    approved antibiotics. To help achieve the plan's goals to accelerate
    basic and applied research for developing new antibiotics and other
    products, $300 million in FY2022 funding is needed. This funding will
    help prevent a situation in which we lose many modern medical advances
    that depend upon the availability of antibiotics, such as cancer
    chemotherapy, organ transplantation and other surgeries.
    Project BioShield Special Reserve Fund (SRF), Broad Spectrum
            Antimicrobials
        We recommend $200 million in funding for the Project BioShield SRF.
    The SRF is positioned to support the response to public health threats,
    including AMR. BARDA and National Institute of Allergy and Infectious
    Diseases efforts have helped companies bring new antibiotics to market,
    but those companies now struggle to stay in business and two filed for
    bankruptcy in 2019. In December 2019, SRF funds supported a contract
    for a company following approval of its antibiotic--a phase of drug
    development during which small biotech firms are particularly
    vulnerable. $200 million in funding would expand this approach to
    better support the antibiotics market.
                         national institutes of health
    National Institute of Allergy and Infectious Diseases (NIAID)
        $6.520 billion for NIAID, including $600 million for AMR research,
    would allow NIAID to address AMR while carrying out its broader role in
    supporting infectious diseases research, including emerging infectious
    diseases, HIV, TB and influenza. Increased FY2022 funding would
    strengthen investment in the biomedical research workforce, including
    training and efforts to support early-career physician-scientists and
    promote diversity, update the national clinical trials infrastructure
    to include community hospitals and enable access for underserved
    populations.
        The COVID-19 pandemic has demonstrated the need to better prepare
    our biomedical research infrastructure to respond to emerging
    infectious diseases and future emergencies, including the need to
    strengthen and diversify the ID research workforce. High educational
    debt, low research salaries, and competing work-life demands have
    driven many promising researchers from the field. The current pandemic
    has reportedly increased interest in infectious diseases as a career,
    but translating increased interest into recruitment and retention
    remains a challenge. Infectious diseases as a specialty only filled 88%
    of positions and 75% of programs in the recent match; further, 80% of
    counties in the US do not have an ID physician. Strong NIAID support
    for career development through increased FY2022 funding and other
    initiatives is critical to maintaining and improving the pipeline of
    physician scientists committed to a career in ID. NIAID should use
    increased resources to provide additional K, T, and F awards, and Early
    Investigator Awards as well as new opportunities for community-based ID
    physicians to participate in clinical trials and other research to
    enhance recruitment, training and diversity of the physician-scientist
    workforce.
        The COVID-19 pandemic has exposed systemic deficits that threaten
    our ability to combat future outbreaks and threats, such as AMR. FY2022
    funding will allow NIAID to continue to respond to the pandemic and
    prepare for future outbreaks while carrying out its broader role in
    infectious diseases research. Such efforts include research on
    antimicrobial mechanisms of resistance, therapeutics, vaccines and
    diagnostics; development of a clinical trials network to reduce
    barriers to research on emerging and difficult-to-treat infections; and
    support for training more physician scientists and clinical
    investigators to improve research capacity, for example, as outlined in
    the 2020-2025 National Action Plan to Combat Antibiotic-Resistant
    Bacteria.
                                   conclusion
        Thank you for the opportunity to submit this statement. The
    nation's ID physicians and scientists rely on strong federal
    partnerships to keep Americans healthy and urge you to support these
    efforts. Please forward any questions to Lisa Cox at
    lcox@idsociety.org.

        [This statement was submitted by Barbara D. Alexander, MD, MHS,
    FIDSA, IDSA, President, Infectious Diseases Society of America.]
                                     ______

         Prepared Statement of the Integrative Health Policy Consortium
        Thank you, Chair Murray and Ranking Member Blunt, for this
    opportunity to testify in support of programs at the Department of
    Health and Human Services under your Subcommittee's jurisdiction that
    are important to the members of the Integrative Health Policy
    Consortium (IHPC) (www.ihpc.org). Specifically, IHPC is writing to
    express its support for funding the National Center for Complementary
    and Integrative Health (NCCIH), a component of the National Institutes
    of Health (NIH), and the Federally Qualified Health Centers (FQHCs)
    program within the Health Resources and Services Administration (HRSA).
    In addition, our testimony respectfully asks the Subcommittee to
    support the inclusion of report language urging the Department of
    Health and Human Services (HHS) to implement recommendations issued by
    the HHS Pain Management Best Practices Inter-Agency Task Force.
        The Integrative Health Policy Consortium (IHPC) IHPC is a broad-
    based coalition of organizations whose mission is to eliminate barriers
    to health. IHPC includes 26 organizations representing more than
    650,000 state licensed, certified and/or nationally certified
    healthcare professionals, including medical doctors, registered nurses,
    doctors of chiropractic, naturopathic doctors, licensed acupuncturists,
    licensed massage therapists, and academic, research, clinical, and
    public education organizations. IHPC has championed the Congressional
    Integrative Health & Wellness Caucus and functions to support the
    federal agencies overseeing America's health and health research needs.
    IHPC envisions a world with no barriers to health and is focused on
    promoting a healthier world that incentivizes health creation for all
    individuals, communities, and the planet.
            national center for complementary and integrative health
        IHPC appreciates the strong support that the Chair and Ranking
    Member have given the NIH. IHPC shares your enthusiasm for the agency's
    research and research training mission and encourages the subcommittee
    to continue prioritizing NIH funding. In addition, we urge the
    Subcommittee to provide the National Center for Complementary and
    Integrative Health (NCCIH) with similar, commensurate increases. With
    this additional support, NICCH could support its ongoing mission as
    well as embark fully on a new, promising research initiative, the Whole
    Health Perspective. This initiative would promote research looking at
    the interactions between systems in the body, such as connections
    between the brain and the heart, that predispose people to disease and
    expand our understanding of integrative health and pathways to
    improving health and preventing disease.
        IHPC specially wants to draw attention to the importance of
    including all the regulated integrative health systems and professions
    in whole person research. One of the major lessons of the COVID-19
    pandemic and the importance of optimal health is the need for each of
    the major systems as well as integrative protocols to be studied in
    real world environments to determine the whole person effect of regular
    care through specific approaches such as acupuncture, naturopathic
    medicine, chiropractic, homeopathy, holistic nursing, massage therapy,
    lifestyle and functional medicine approaches, direct entry midwifery,
    and traditional healing approaches from Native American and indigenous
    communities.
        IHPC joins other organizations in asking the Subcommittee to
    provide NIH with $46.1 billion in FY 2022. This request, which is a
    $3.177 billion (7.4%) increase over the comparable FY 2021 funding
    level for the NIH, would allow for the agency's base budget to keep
    pace with the biomedical research and development price index (BRDPI)
    and allow meaningful growth of 5%. Further, such an increase would
    expand NIH's capacity to support promising science across all
    disciplines, particularly including the new Whole Health initiative
    underway at NCCIH. IHPC asks the subcommittee to provide NCCIH with at
    least a similar 7.4% funding increase in FY 2022.
                       federally qualified health centers
        Federally Qualified Health Centers (FQHCs) are community-based
    health care providers that receive funds from the HRSA Health Center
    Program to provide primary care services in underserved areas. In
    recent years, especially with the onset of the nation's opioid crisis,
    FQHCs have emerged as a platform for Integrative Whole Health
    innovation and for the delivery of non-pharmacologic pain management
    services. During the COVID-19 pandemic, select FQHCs have expanded
    their services to deliver pain management services to an increased
    number of uninsured and underinsured individuals. To advance and expand
    the FQHC mission, IHPC endorses the recommendation issued by the
    National Association of Community Health Centers to provide community
    health centers with $2.2 billion in discretionary funding in FY 2022.
    Further, we respectfully request the Subcommittee to request a report
    from HRSA in FY 2022 regarding the inclusion of regulated complementary
    and integrative health professionals and services system wide, Medicare
    and Medicaid reimbursement for services within the FQHC system and
    barriers to access and reimbursement for non-pharmacologic pain
    management services; and possible solutions to the elimination of noted
    barriers.
           hhs pain management best practices inter-agency task force
        IHPC respectfully asks that the Subcommittee support the inclusion
    of proposed report language, urging HHS to facilitate adoption of
    recommendations from The Pain Management Best Practices Inter-Agency
    Task Force and launch a public awareness campaign to educate Americans
    about the differences between acute and chronic pain and the evidence-
    based non-opioid (non-pharmacologic) treatment options that are
    available. In 2019, this congressionally established task force issued
    a ground-breaking report regarding best practices for managing acute
    and chronic pain. Of note, the report underscores the philosophical and
    cultural shift to focus on addressing chronic and acute pain by using
    complementary and integrative health including non-pharmacologic
    approaches that have been proven effective and are widely supported by
    practitioners working in all healthcare settings. These treatment
    options include acupuncture, massage therapy, physical and occupational
    therapies, chiropractic, cognitive behavioral therapy, manipulative
    therapy, yoga, tai chi, and meditation. If implemented, these
    recommendations will have profound public health and positive national
    economic impact on a significant percent of the U.S. population. The
    IHPC stands ready to assist the agency and the Congress in advancing
    this important public awareness.
        Thank you for considering our views. The IHPC looks forward to
    working with you to enact the FY 2022 Labor, Health and Human Services
    and Education Appropriations bill and to help ensure our priorities are
    addressed in the final version of this important funding legislation.

        [This statement was submitted by Margaret Erickson, PhD, RN, CNS,
    APRN, APHN-BD, Co-Chair, Integrative Health Policy Consortium.]
                                     ______

              Prepared Statement of International Foundation for
                           Gastrointestinal Disorders
             fiscal year 2022 l-hhs appropriations recommendations
    _______________________________________________________________________

      --At least $46.1 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increase for the National Institute of
                Diabetes and Digestive and Kidney Diseases (NIDDK).
      --Please provide $10 billion for the Centers for Disease Control and
            Prevention (CDC).
        --Please provide $5 million for the Chronic Disease Education and
                Awareness Program.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Subcommittee, as you work with your colleagues to develop the
    FY2022 Labor-Health and Human Services (L-HHS) appropriations bill,
    please keep in mind the needs and concerns of the functional GI and
    motility disorders community. Nearly two decades ago, I was diagnosed
    with one of these diseases, irritable bowel syndrome (IBS). As a young
    adult, I underwent extensive testing and workups over many years in a
    difficult effort to discover what was causing my symptoms and how best
    to treat them. I often relied on self-treatment as best as I could, but
    this was not sustainable. Unfortunately, I am not alone in these
    experiences. As President of IFFGD, I have heard my story echoed back
    to me by thousands of others. Patients affected by these disorders
    often face similar delays in diagnosis, frequent misdiagnosis, and
    inappropriate treatments including unnecessary and costly surgery.
    These are common concerns for our community, and they underscore the
    need for increased research, improved provider education, and greater
    public awareness.
                              about the foundation
        The International Foundation for Gastrointestinal Disorders (IFFGD)
    is a registered nonprofit education and research organization dedicated
    to informing, assisting, and supporting people affected by
    gastrointestinal (GI) disorders. IFFGD works with patients, families,
    physicians, nurses, practitioners, investigators, regulators,
    employers, and others to broaden understanding about GI disorders,
    support and encourage research, and improve digestive health in adults
    and children.
               about gastrointestinal (gi) and motility disorders
        GI and motility disorders are the most common digestive disorders
    in the general population. These disorders are classified by symptoms
    related to any combination of the following: motility disturbance,
    visceral hypersensitivity, altered mucosal and immune function, altered
    gut microbiota, and altered central nervous system (CNS) processing.
    Some examples of functional GI disorders are: dyspepsia, gastroparesis,
    irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD),
    bowel incontinence, and cyclic vomiting syndrome. The costs associated
    with these diseases range from $25-$30 billion annually; economic costs
    are also reflected in work absenteeism and lost productivity.
                   centers for disease control and prevention
        We greatly appreciate the support from the Subcommittee in creating
    the Chronic Disease Education and Awareness Program in FY2021. Patients
    with FGIMDs frequently suffer for years before receiving an accurate
    diagnosis, exposing them to unnecessary and costly tests and procedures
    including surgeries, as well as needless suffering and expense.
    Functional GI and motility disorders are among the most common
    digestive disorders in the general population. They affect an estimated
    1 in 4 people in the U.S. and account for 40% of GI problems seen by
    medical providers. A CDC program focused on surveillance, provider
    education, and public awareness would increase diagnoses and improve
    patient outcomes. We ask that the Subcommittee provide $5 million for
    the Chronic Disease Education and Awareness Program in FY2022.
                         national institutes of health
        Strengthening the nation's biomedical research enterprise through
    NIH fosters economic growth and sustains innovations that enhance the
    health and well-being of the American people. Functional GI disorders
    are prevalent in about 1 in 4 people in the U.S., accounting for 40% of
    GI problems seen by medical providers. NIDDK supports basic, clinical,
    and translational research on aspects of gut physiology regulating
    motility and supports clinical trials through the Motility and
    Functional GI Disorders Program.
        Several of NIH's crosscutting initiatives are currently advancing
    science in meaningful ways for patients with gastrointestinal
    disorders. The Stimulating Peripheral Activity to Relieve Conditions
    (SPARC) Initiative supports research on the role that nerves play in
    regulating organ function. Methods and medical devices that modulate
    these nerve signals are a potentially powerful way to treat many
    chronic conditions, including gastrointestinal and inflammatory
    disorders. The Human Microbiome Project is also unlocking important
    discoveries that will help to inform and advance emerging treatment
    options for many in the community.
                      patient perspective--jacqui's story
        I got sick after an emergency appendectomy on Thanksgiving 2010
    while I was in Army basic training. I was able to fight off the
    inevitable and did four years in the Army during which I did a tour in
    Afghanistan. When I got back, my health really started declining.
        I fought and fought and fought for an answer, but it took just over
    seven years to be diagnosed with gastroparesis. My main symptoms were
    nausea, vomiting and pain. It got so bad that I had to give up my dream
    career and was medically retired from the service.
        Because we had tried pretty much every conservative treatment, they
    told me I would just have to live with it. It got to the point where I
    was going weeks without eating and was in and out of the ER getting
    fluids, because anything that went in my stomach came back up. My hair
    thinned, so I shaved it, and I was having memory problems and
    confusion, which got so bad that my neuropsych tests came back with my
    score being in the range of dementia.
        My gastroenterologist even told me at one point that she couldn't
    do anything ``drastic'' to help me until my blood work was ``bad
    enough.''
        Thank you for the opportunity to submit our community's
    perspective, as you consider appropriations priorities for FY 2022. We
    look forward to continuing to work with you on these critical issues.

        [This statement was submitted by Ceciel T. Rooker, President and
    Executive
    Director, International Foundation for Gastrointestinal Disorders.]
                                     ______

         Prepared Statement of the Interstate Mining Compact Commission
        We are writing in regard to the fiscal year 2022 Budget for the
    Mine Safety and Health Administration (MSHA), U.S. Department of Labor.
    In particular, we urge the Subcommittee to support a full appropriation
    for state assistance grants for safety and health training of our
    Nation's miners pursuant to section 503(a) of the Mine Safety and
    Health Act of 1977 (the Act). MSHA's budget for at least the last five
    fiscal years has included an amount of not less than $10,537,000 for
    state assistance grants. We are pleased to see that President Biden's
    fiscal year 2022 budget proposes to continue funding at this level. We
    urge the Subcommittee to fund these grants at this statutorily
    authorized level for state assistance grants so that states are able to
    meet the training needs of miners and to fully and effectively carry
    out important state responsibilities under section 503(a) of the Act.
    We believe the states can more than justify the need for funding at the
    statutorily authorized level.
        The Interstate Mining Compact Commission is a multi-state
    governmental organization that represents the natural resource,
    environmental protection and mine safety and health interests of its 26
    member states. The states are represented by their Governors who serve
    as Commissioners.
        We support full funding $10,537,000 for the state assistance grants
    that enable the states to provide essential safety and health training
    for the nation's coal miners, undiminished by use of these funds for
    other purposes. Section 503 of the Act was structured to be broad in
    scope and to stand as a separate and distinct part of the overall mine
    safety and health program. In the Conference Report that accompanied
    passage of the Federal Coal Mining Health and Safety Act of 1969, the
    conference committee noted that both the House and Senate bills
    provided for ``Federal assistance to coal-producing States in
    developing and enforcing effective health and safety laws and
    regulations applicable to mines in the States and to promote Federal-
    State coordination and cooperation in improving health and safety
    conditions in the Nation's coal mines.'' (H. Conf. Report 91-761). The
    1977 Amendments to the Mine Safety and Health Act expanded these
    assistance grants to both coal and metal/non-metal mines and increased
    the authorization for annual appropriations to $10 million. The
    training of miners was only one part of the obligation envisioned by
    Congress.
        With respect to the training component of our mine safety and
    health programs, IMCC's member states are concerned that without full,
    stable funding of the State Grants Program, the federally required
    training for miners employed throughout the U.S. will suffer. Our
    experience over the past 40 years has demonstrated that the states are
    often in the best position to design and offer mine safety and health
    training in a way that insures that the goals and objectives of
    Sections 502 and 503 of the Mine Safety and Health Act are adequately
    met. We greatly appreciate Congress' recognition of this fact and this
    Subcommittee's strong support for state assistance grants, especially
    in past years when the Administration sought to eliminate or
    substantially reduce those moneys.
        We also appreciate the recognition by Congress that the
    availability of these funds to states should not be diminished by
    allowing them to be used for other purposes. We urge Congress to reject
    any attempt to diminish the funds available to states in the budget it
    adopts for fiscal year 2022 and future years. The budget that is
    adopted should include the full amount of $10,537,000 for state
    assistance grants, without any provisos or other qualifications that
    could reduce the amount of money states receive.
        Thank you for the opportunity to present our views on the proposed
    fiscal year 2022 budget for MSHA.

        [This statement was submitted by Thomas L. Clarke, Executive
    Director,
    Interstate Mining Compact Commission.]
                                     ______

          Prepared Statement of the Interstitial Cystitis Association
                summary of recommendations for fiscal year 2022
    _______________________________________________________________________

      --Provide $1.5 million for the IC Education and Awareness Program and
            the IC Epidemiology Study at the Centers for Disease Control
            and Prevention (CDC)
      --Provide $46.1 billion for the National Institutes of Health (NIH)
            and Proportional Increases Across all Institutes and Centers
      --Support NIH Research on IC, including the Multidisciplinary
            Approach to the Study of Chronic Pelvic Pain (MAPP) Research
            Network and Chronic Pain
    _______________________________________________________________________

        Thank you for the opportunity to present the views of the
    Interstitial Cystitis Association (ICA) regarding interstitial cystitis
    (IC) public awareness and research. ICA was founded in 1984 and is the
    only nonprofit organization dedicated to improving the lives of those
    affected by IC. The Association provides an important avenue for
    advocacy, research, and education. Since its founding, ICA has acted as
    a voice for those living with IC, enabling support groups and
    empowering patients. ICA advocates for the expansion of the IC
    knowledge-base and the development of new treatments. ICA also works to
    educate patients, healthcare providers, and the public at large about
    IC.
        IC is a condition that consists of recurring pelvic pain, pressure,
    or discomfort in the bladder and pelvic region. It is often associated
    with urinary frequency and urgency. This condition may also be referred
    to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and
    chronic pelvic pain (CPP). It is estimated that as many as 12 million
    Americans have IC symptoms. Approximately two-thirds of these patients
    are women, though this condition does severely impact the lives of as
    many as 4 million men. IC has been seen in children and many adults
    with IC report having experienced urinary problems during childhood.
    However, little is known about IC in children, and information on
    statistics, diagnostic tools and treatments specific to children with
    IC is limited.
        The exact cause of IC is unknown and there are few treatment
    options available. There is no diagnostic test for IC and diagnosis is
    made only after excluding other urinary/bladder conditions. It is not
    uncommon for patients to experience one or more years delay between the
    onset of symptoms and a diagnosis of IC. This is exacerbated when
    healthcare providers are not properly educated about IC.
        The effects of IC are pervasive and insidious, damaging work life,
    psychological well-being, personal relationships, and general health.
    The impact of IC on quality of life is equally as severe as rheumatoid
    arthritis and end-stage renal disease. Health-related quality of life
    in women with IC is worse than in women with endometriosis, vulvodynia,
    and overactive bladder. IC patients have significantly more sleep
    dysfunction, and higher rates of depression, anxiety, and sexual
    dysfunction.
        Some studies suggest that certain conditions occur more commonly in
    people with IC than in the general population. These conditions include
    allergies, irritable bowel syndrome, endometriosis, vulvodynia,
    fibromyalgia, and migraine headaches. Chronic fatigue syndrome, pelvic
    floor dysfunction, and Sjogren's syndrome have also been reported.
                 ic public awareness and education through cdc
        ICA recommends a specific appropriation of $1.5 million in fiscal
    year 2022 (FY2022) for the CDC IC Program. This will allow CDC to fund
    the Education and Awareness Program, per ongoing congressional intent,
    as well as the IC Epidemiology Study.
        CDC had shifted the focus of the IC program to an epidemiology
    study and away from education and awareness, but thanks to the
    Subcommittee the ICA and IC community have been able to open
    discussions with CDC to ensure a renewed focus on education and
    awareness activities. The IC community had been concerned that focusing
    solely on an epidemiology study instead of on education and awareness
    activities was detrimental to patients and their families. We have
    recently met with CDC thanks to the actions of this Subcommittee where
    we openly and effectively communicated the need for CDC to include ICA
    in any collaboration along with the epidemiology study. We know that
    CDC has not received as generous increases as NIH over the past few
    fiscal years, but it is important the CDC continue supporting both
    critical components of the IC Program. The CDC IC Education and
    Awareness Program is the only federal program dedicated to improving
    public and provider awareness of this devastating disease, reducing the
    time to diagnosis for patients, and disseminating information on pain
    management and IC treatment options. ICA urges Congress to provide
    funding for IC education and awareness in FY2022.
        The IC Education and Awareness program has utilized opportunities
    with charitable organizations to leverage funds and maximize public
    outreach. Such outreach includes public service announcements in major
    markets and the internet, as well as a billboard campaign along major
    highways across the country. The IC program has also made information
    on IC available to patients and the public though videos, booklets,
    publications, presentations, educational kits, websites, self-
    management tools, webinars, blogs, and social media communities such as
    Facebook, YouTube, and Twitter. For healthcare providers, this program
    has included the development of a continuing medical education module,
    targeted mailings, and exhibits at national medical conferences.
        The CDC IC Education and Awareness Program also provided patient
    support that empowers patients to self-advocate for their care. Many
    physicians are hesitant to treat IC patients because of the time it
    takes to treat the condition and the lack of answers available.
    Further, IC patients may try numerous potential therapies, including
    alternative and complementary medicine, before finding an approach that
    works for them. For this reason, it is especially critical for the IC
    program to provide patients with information about what they can do to
    manage this painful condition and lead a normal life. With the recent
    developments in our conversations with the CDC we are confident that we
    will continue to provide key education and awareness that will continue
    to benefit the IC community.
             ic research through the national institutes of health
        ICA recommends a funding level of $46.1 billion for NIH in FY2022.
    ICA also recommends continued support for IC research including the
    MAPP Study administered by NIDDK.
        The National Institutes of Health (NIH) maintains a robust research
    portfolio on IC with the National Institute of Diabetes and Digestive
    and Kidney Diseases (NIDDK) serving as the primary Institute for IC
    research. The NIDDK Multidisciplinary Approach to the Study of Chronic
    Pelvic Pain (MAPP) Research Network has continued to include cross-
    cutting researchers who are currently identifying different phenotypes
    of the disease. Phenotype information will allow physicians to
    prescribe treatments with more specificity. Research on chronic pain
    that is significant to the community is also supported by the National
    Institute of Neurological Disorders and Stroke (NINDS) as well as the
    National Center for Complementary and Integrative Health (NCCIH). The
    vast majority of IC patients often suffer major and multiple quality of
    life issues due to this condition. Many IC patients are unable to work
    full time because pain affects their mobility, sleep, cognition, and
    mood. These are people that simply want to lead productive lives, and
    need pain medication to do so. Due to the fact that IC is categorized
    as a non-cancer pain condition, IC patients already have a difficult
    time obtaining pain meds. IC doctors do not have time nor the
    inclination to effectively prescribe or monitor the distribution of the
    opioid class of medication. They often refer their patients to Pain
    Management Specialists, many who have never heard of IC, who often
    refuse to treat them. In addition, antidepressants and benzodiazepines
    are often used to treat both mood and sleeping disorders for IC
    patients. Additionally, the NIH investigator-initiated research
    portfolio continues to be an important mechanism for IC researchers to
    create new avenues for interdisciplinary research.
                              patient perspective
        IC is a tough disease to diagnose, and it is one of the most
    challenging things to deal with, finding a doctor that specializes in
    IC that can help diagnose and treat. I can't stress enough how
    important finding the right doctor is. IC patients need a doctor who
    understands and is willing to go along with them on this long,
    frustrating, painful and confusing road. I have found strength through
    having this that I never knew I had, strength to keep going when all
    treatments so far have failed me.
        There are a small number of treatments available for managing IC
    symptoms, but they only work on a small percentage of patients. I have
    tried those treatments and some drugs that ``might'' help. I manage my
    diet, take lots of supplements and have to see all kinds of doctors
    now. I have six! That includes holistic medicine doctors, physical
    therapists, and acupuncturist. That's along with my regular MD,
    urologist and two different gynecologists. This is what my life has
    become. The life of an IC patient. I deal with one or more symptoms of
    IC EVERY SINGLE DAY. Some days definitely better than others, but every
    single day. It affects my life in so many ways. Work, social, travel
    and my intimate relationships. I never know how I'm going to feel from
    one day to the next. Anxiety and fear included.
        Thank you for the opportunity to present the views of the
    interstitial cystitis community.

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

      Prepared Statement of the Learning and Education Academic Research
                                    Network
        The Learning and Education Academic Research Network (LEARN), a
    coalition of 38 of the nation's leading research colleges of education
    across the country, advocates for the importance of research on
    learning and development. Education research provides the bedrock of
    knowledge used by our principals, teachers, counselors and professors
    to help preK-12 students and those seeking a postsecondary education
    succeed. With the staggering learning loss being experienced by
    students due to the COVID-19 pandemic, it is critical that Congress
    provides education research with the resources to guarantee that
    educational interventions are innovative, evidence-based and effective.
    LEARN urges the Subcommittee to meet the President's fiscal year (FY)
    2022 budget request of 737.5 million for the Institute of Education
    Sciences (IES) overall with $267.9 million dedicated to Research,
    Development and Dissemination (RD&D). LEARN also requests that the
    Subcommittee provide $70 million for the National Center for Special
    Education Research (NCSER). In addition to requesting that the
    Subcommittee meet the President's FY2022 budget request of $1.94
    billion for National Institute of Child Health and Human Development
    (NICHD), LEARN requests that the Subcommittee provide $2.21 billion for
    National Institute of Mental Health (NIMH) in FY2022.
        While advocating for these increased resources for FY2022, we want
    to express our appreciation for the increases for IES that were made in
    FY2021. We would also like to thank Congress for the inclusion of $100
    million for IES in the American Rescue Plan Act; this investment marks
    Congress' awareness of the importance of education research in
    addressing the nation's most difficult educational challenges. An
    increased investment in IES for FY2022 would allow for a more robust
    development, and dissemination of valuable education research to
    innovatively address the vast array of educational challenges posed
    before, during and after the COVID-19 pandemic.
                        institute of education sciences
        The work of IES and its grantees can guide the nation's learning
    recovery so that we can exit the pandemic with a stronger, more
    equitable, educational system than we entered with. As the primary
    Federal agency charged with supporting research for education practice
    and policy, IES is essential to developing a comprehensive, reliable
    evidence base, and ensuring that teaching and learning practices are
    grounded in scientifically valid research. Unfortunately, IES is only
    able to fund one out of every 10 applications it receives due to the
    limitations in its budget, despite a far greater percentage of such
    applications being rated excellent and worth of funding.
        Without a critical examination of what works and what does not work
    to further knowledge, our education systems would be left to the same
    curriculum, instructional techniques and assessments, regardless of
    whether they spur student success. Examples of critical education
    research funded by IES include the development and adoption of a
    statewide approach to math instruction in one State that is now
    utilized in other States; the development and implementations of a
    reading curriculum now being adopted as a statewide literacy approach
    by a State legislature and improved instructional and behavioral
    practices for children with disabilities. Without continued support for
    general education research infrastructure, notable programs like these
    would not exist to address some of the nation's longest standing
    educational challenges and support the nation's most at-risk students.
        The physical closure of schools and transition to virtual learning
    due to the COVID-19 pandemic has greatly disrupted education research
    at a time when it is more critical than ever before. Although IES
    grantees have adjusted their research where possible to remote and
    hybrid instruction, this pivot has also resulted in unanticipated
    costs, delays and cancellations; these increased costs are likely to
    persist through 2022. Nevertheless, IES funded work has provided
    insightful research findings and valuable tools for educators and
    caregivers throughout the pandemic. This includes a longitudinal study
    on the impact of COVID-19 on the educational attainment of economically
    disadvantaged undergraduates and an interactive tool guide on teaching
    math to young children at home. The work of IES and its grantees have
    already begun guiding the nation towards a strong and successful
    educational recovery.
        The focus IES drives on education research is especially important
    today as our schools must ensure that efforts to reduce learning loss
    because of the COVID-19 pandemic are rooted in research and evidence-
    based practice. Given the importance of developing reliable evidence,
    LEARN is requesting that the Subcommittee meet President Biden's FY2022
    request for $737.5 million for IES overall and $267.9 million for the
    Research, Development, and Dissemination (RD&D) line item within IES.
    These resources for the RD&D line item will build upon the critical
    resources provided in the American Rescue Plan Act for IES to further
    combat the negative learning outcomes resulting from the COVID-19
    pandemic. The President's request for a 15 percent increase towards IES
    and a 35 percent increase for the RD&D line item is further evidence of
    the importance of supporting education research and evidence-based
    practices in response to the challenges of the COVID-19 pandemic.
        In addition, we recommend that funding for research in special
    education, through the National Center for Special Education Research
    (NCSER), should be increased to $70 million. NCSER is the only Federal
    agency specifically designated to develop and provide evaluations for
    programs for students with disabilities, but currently has a budget
    that has remained relatively flat since FY2014. Research funded by
    NCSER provides special educators and administrators research-based
    resources that improve educational academic outcomes for children with
    or at risk of disabilities. During a time when special education
    students have been dramatically impacted by the change in schooling due
    to COVID-19, additional funding to NCSER is necessary to support data
    and evidence-based resources to guide the continued COVID-19 response
    and recovery for these students. Funding of $70 million would allow for
    a new competition in FY2022, allowing further resources to address
    COVID-19 learning issues.
                         national institutes of health
        There are critical education research programs within the National
    Institutes of Health (NIH) that also need additional support. NICHD is
    essential to education research as it examines brain functions and the
    impact of different educational services on learning and development.
    LEARN supports an increase in NICHD funding to $1.94 billion. This
    increase will ensure that researchers can build on the knowledge
    already gained, evaluate what works best in treating developmental
    disorders and develop new research-based strategies to improve
    student's learning and development. Additionally, it will support
    NICHD's efforts to understand the effects of COVID-19 on key at-risk
    populations, including the cognitive development of children and
    adolescents.
        LEARN also supports an increase in funding for NIMH to $2.21
    billion. This increase will help further understanding of the
    behavioral, biological and environmental mechanisms necessary for
    developing interventions to reduce the burden of mental and behavioral
    disorders and optimize learning and development. The untraditional
    school year and strains of the COVID-19 pandemic has had a largely
    negative impact on the mental health of children and adolescents
    nationwide, it is important that research in this field is supported to
    address these challenges.
        LEARN believes it is critical that evidence-based research is
    implemented and applied to schools nationwide as they work to address
    the myriad of educational challenges that existed prior, and were
    exacerbated, by the COVID-19 pandemic. As the nation looks towards
    recovery, IES and NIH must be at the forefront of any effort to ensure
    that Federal resources are going towards effective programming and
    interventions. The LEARN Coalition strongly believes that key
    investments in education research through IES and NIH will drive
    improvements in teacher and student performance in the coming years and
    allow for the beginning of a successful recovery from the COVID-19
    pandemic. Thank you for your commitment to sustaining and strengthening
    the nation's education research infrastructure.
        Respectfully submitted,

        [Camilla P. Benbow, Ed.D., Co-Chair, Learning and Education
    Academic Research Network]
        [Patricia and Rodes Hart Dean of Education and Human Development of
    the
    Peabody College of Education and Human Development, Vanderbilt
    University]
        [Rick Ginsberg, Ph.D., Co-Chair, Learning and Education Academic
    Research
    Network, Dean of the School of Education, University of Kansas]
        [Glenn E. Good, Ph.D., Co-Chair, Learning and Education Academic
    Research Network, Dean of the College of Education, University of
    Florida]
                                     ______

        Prepared Statement of the Lymphatic Education & Research Network
                              key recommendations
    _______________________________________________________________________

      --Establish a National Commission on Lymphatic Disease Research at
            the NIH to identify emerging opportunities, challenges, gaps,
            structural changes, and recommendations on lymphatic disease
            research
      --Provide the National Institutes of Health (NIH) with $46.1 billion
            for FY 2022 and advance lymphatic disease research by expanding
            resources and encouraging better coordination among relevant
            institutes and centers
      --Provide the Centers for Disease Control and Prevention (CDC) with
            $10 billion for FY 2022 and enable $5 million for the Chronic
            Disease Education and Awareness Program.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt and distinguished members
    of the Subcommittee, thank you for the opportunity to submit the
    priorities of the lymphatic diseases community you as you consider FY
    2022 appropriations for the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention (CDC).
                                  about le&rn
        The Lymphatic Education & Research Network (LE&RN) is an
    internationally recognized non-profit organization founded in 1998 to
    fight lymphatic diseases and lymphedema through education, research and
    advocacy. With chapters throughout the world, LE&RN seeks to accelerate
    the prevention, treatment and cure of these diseases while bringing
    patients and medical professionals together to address the unmet needs
    surrounding lymphatic diseases, which include lymphedema and lipedema.
                    about lymphedema and lymphatic diseases
        The lymphatic system is a circulatory system that is critical to
    immune function and good health. When it is compromised and lymph flow
    is restricted, the physical impact to patients can be devastating, life
    altering, and can lead to shortened lifespan. Lymphedema (LE) is one
    such lymphatic disease. LE is a chronic, debilitating, and incurable
    swelling that can be a result of cancer treatment, inherited or genetic
    causes, and damage to the lymphatic system from surgery or an accident,
    or from parasites as in lymphatic filariasis. Stanford University
    estimates that up to 10 million Americans have lymphedema. This
    represents more Americans than those living with AIDS, Multiple
    Sclerosis, Parkinson's disease, Muscular Dystrophy and ALS--combined.
    The World Health Organization puts the global number of people with
    this disease at 250 million. There is no cure. There is no approved
    drug therapy. And there are currently only three drug studies worldwide
    seeking a treatment. Psychosocially bruised by a disease that leaves us
    deformed, we do our best to hide our lymphedema. We are currently
    isolated and alone.
        Lymphedema is an equal opportunity disease, affecting women, men
    and children alike. Many are born with congenital or hereditary
    lymphedema. Others, like our veterans, get the disease as a result of
    physical trauma, bacterial infection, or as result of exposure to burn
    pits. Lymphedema is an ignored disease. A study concluded that
    physicians are currently getting an average of only 15-30 minutes of
    study on the lymphatic system in their entire medical training. This
    leaves them ill-prepared to diagnose the disease. Misdiagnosis leads to
    improper treatment. Those who are diagnosed find it difficult to find
    certified lymphedema therapists. Few medical centers exist that are
    prepared to address lymphatic diseases. Surgeons are experimenting with
    treatment that could alter the course of the disease. However, the
    necessary basic research is not being done to inform their procedures.
    And currently, Medicare and Medicaid do not cover some of the basic
    treatment needs of these patients--such as compression garments, which
    must be worn daily by patients.
                fiscal year 2022 appropriations recommendations
        We have been hopeful with recent advancements, but more needs to be
    done. We ask that within 20 years, we will make lymphedema a truly
    treatable disease. To reach this goal will require a commitment to
    important medical research. LE&RN joins the broader medical research
    community in thanking Congress for continuing to provide the National
    Institutes of Health with proportional and sustainable funding
    increases over the past several fiscal years, and we ask you all to
    continue to prioritize these activities by providing at least a $46.1
    billion for NIH in FY 2022.
        We continue to urge the Subcommittee to work to expand and advance
    the lymphatic disease portfolio at the NIH. In late 2015, the NIH
    hosted a Lymphatic Symposium, where experts in the field identified a
    scientific roadmap that could build the research portfolio up to a
    level of at least $70 million annually over subsequent years by funding
    meritorious grants on critical topics. In an effort to further support
    and enhance emerging lymphedema and lymphatic disease research
    activities, we ask the Subcommittee to encourage further collaboration
    among relevant institutes and centers conducting research in this area.
    We are grateful to the Subcommittee for continuing to support the
    establishment of a National Commission on Lymphatic Disease Research,
    which can thoroughly examine the portfolio and make recommendations on
    how best to advance this emerging scientific area under NIH's current
    structure. We ask that you continue to impress on NIH the critical need
    for this Commission and how they can work with relevant stakeholders
    such as ourselves. Currently, the National Institutes of Health spends
    approximately $25 million annually on lymphatic research, and only $5
    million of this is dedicated to clinical lymphedema research. Experts
    state with confidence that there is no other disease affecting more
    Americans that receives so little attention. It must also be noted that
    study of the lymphatic system is poised to bring miracles for a host of
    diseases that are part of the lymphatic continuum: obesity, heart
    disease, diabetes, Rheumatoid arthritis, cancer metastasis, AIDS,
    Crohn's disease, lipedema, and a host of other diseases. Recent
    research discovered lymphatics surrounding the brain, which now has us
    studying its impact on Alzheimer's disease and multiple sclerosis. We
    appreciate the Subcommittee's continued support for the establishment
    of a National Commission on Lymphatic Diseases and ask that NIH be held
    accountable for the lack of progress on its establishment.
        LE&RN also joins the public health community in asking Congress to
    provide the Centers for Disease Control and Prevention (CDC) with $10
    billion through FY 2022 and to increase funding to increase awareness,
    education, and surveillance of lymphatic diseases. We encourage the
    Subcommittee to support $5 million for the Chronic Disease Education
    and Awareness Program in FY2022 which will allow CDC to work with
    stakeholder organizations to expand important initiatives on chronic
    diseases such as lymphedema and lymphatic diseases. Formal study of the
    lymphatic system and of lymphatic diseases is virtually nonexistent in
    the current curricula of U.S. medical schools, and misinformation
    routinely leads to misdiagnosis and under-treatment. This delay and
    misdirection of treatment results in irreparable physical and
    psychosocial harm to patients suffering from these already debilitating
    diseases. CDC can help to address this lack of public and provider
    awareness.
        Thank you for the opportunity to testify before you today. LE&RN
    looks forward to working with you all to advance medical research and
    public health activities that will improve patient outcomes for the
    members of our community suffering from these debilitating diseases.

        [This statement was submitted by William Repicci, President and
    CEO,
    Lymphatic Education & Research Network.]
                                     ______

                    Prepared Statement of the March of Dimes

        March of Dimes, the nation's leading nonprofit organization
    fighting for the health of all moms and babies, appreciates this
    opportunity to submit testimony for the record on fiscal year (FY) 2022
    appropriations for the Department of Health and Human Services (HHS).
    March of Dimes leads the fight for the health of all mothers and
    infants through our research, community services, education, and
    advocacy.
        Our organization strongly supports President Biden's historic HHS
    budget proposal for FY 2022 which includes strong increases for
    critical programs supporting families, and we recommend the following
    funding levels for programs and initiatives that are essential
    investments in maternal and child health.
        Eunice Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD): March of Dimes recommends that Congress provide no
    less than $1.7 billion for NICHD's groundbreaking biomedical research
    activities in FY 2022. Increased funding will allow NICHD to sustain
    vital research on preterm birth, maternal mortality, maternal substance
    use, prenatal substance exposure and related issues through extramural
    grants, Maternal-Fetal Medicine Units, the Neonatal Research Network
    and the intramural research program.
        Additionally, now that the Task Force on Research Specific to
    Pregnant and Lactating Women (PRGLAC) has laid the foundation for
    addressing research on safe and effective therapies for pregnant and
    lactating women in clinical trials by releasing recommendations in
    September 2018, as mandated by Congress in the 21st Century Cures Act
    (P.L. 114-255), and provided an additional implementation plan
    increased funding will allow for NICHD to more closely look at ways to
    include and integrate pregnant and lactating women in clinical trials.
    NICHD funding also supports research to address gaps in our
    understanding of the best way to treat mothers with opioid use disorder
    and the long-term impact of opioid exposure in utero. We support the
    inclusion of this dedicated funding to address the nation's preterm
    birth crisis.
        Surveillance for Emerging Threats to Mothers and Babies Initiative:
    March of Dimes recommends funding the Surveillance for Emerging Threats
    to Mothers and Babies Initiative Program (known as SET-NET) within the
    National Center for Birth Defects and Developmental Disabilities at
    Centers for Disease Control and Prevention (CDC) at $100 million. SET-
    NET was created during the Zika outbreak, which allowed CDC to create,
    a unique nationwide mother-baby linked surveillance network to monitor
    the virus' impact in real-time to inform clinical guidance, educate
    health care providers and the community, and connect families to care.
    Unfortunately, states were unable to sustain systems due to the program
    being chronically underfunded, and we were left without a national
    system to mobilize when COVID-19 struck.
        Consequently, we have an incomplete picture on how to best care for
    mothers and babies with confirmed or suspected virus infection as the
    CDC currently only supports 29 state, local, and territorial health
    departments. The increased funding will allow for CDC to address these
    knowledge gaps and expand the initiative to provide real-time clinical
    and survey data from all 50 states, territories and jurisdictions on
    the impact of COVID-19 and new public health threats.
        Perinatal Quality Collaboratives: PQCs are state or multistate
    networks working to improve the quality of obstetric care and improve
    outcomes. Currently, CDC funds 13 state-based PQCs that are
    implementing recommendations across health facility networks. However,
    many PQCs lack adequate resources to meet demands and reach their
    maximum potential. We request no less than $30 million to fully scale
    these programs in all states, an increase of $26.5 million.
        Maternal Mortality Review Committees: Under the Enhancing Reviews
    and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program,
    CDC provides funding, technical assistance, and guidance to state
    maternal mortality review committees. These multidisciplinary
    committees identify, review and characterize maternal deaths and
    prevention opportunities. Currently, CDC has made 24 awards and
    supports 25 state agencies and organizations that coordinate and manage
    MMRCs. However, more standardized data collection is needed to help
    examine all the factors contributing to severe maternal mortality,
    preventable deaths, and poor birth outcomes. To this end, we request no
    less than $30 million, an increase of $15 million, to reach all 50
    states, DC, and Puerto Rico and tribes with enhanced technical
    assistance to maximize MMRCs.
        Newborn Screening: Newborn screening is one of our nation's most
    successful public health programs. Each year, nearly every one of the
    approximately 4 million infants born in the United States is screened
    for certain genetic, metabolic, hormonal and/or functional conditions.
    The early detection afforded by newborn screening ensures that infants
    who test positive for a screened condition receive prompt treatment,
    saving or improving the lives of more than 12,000 infants each year.
        Both the Newborn Screening Quality Assurance Program at CDC and the
    Heritable Disorders program at Health Resources and Services
    Administration's (HRSA) have significantly improved the quality of
    newborn screening programs throughout the country. NSQAP works hand-in-
    hand with state laboratories by performing quality testing for more
    than 500 laboratories to ensure the accuracy of newborn screening
    tests. Where the Heritable Disorders program provides assistance to
    states to improve and expand their newborn screening programs and
    supports the work of the Advisory Committee on Heritable Disorders in
    Newborns and Children (ACHDNC), which provides recommendations to the
    HHS Secretary for conditions to be included in the Recommended Uniform
    Screening Panel (RUSP). To continue sustaining, improving, and
    enhancing these programs, March of Dimes urges funding of $28 million
    for NSQAP and $28.883 million for the Heritable Disorders program for
    FY22.
        Grants for Maternal Depression Screening and Treatment: 1 in 5
    women are affected by anxiety, depression, and other maternal mental
    health (MMH) conditions during pregnancy or the year following
    pregnancy. These illnesses are the most common complication of
    pregnancy and childbirth, impacting 800,000 women in the United States
    each year. Sadly, MMH conditions often go undiagnosed and untreated,
    increasing the risk of multigenerational long-term negative impact on
    the mother's and child's physical, emotional, and developmental health,
    increasing the risk of poor health outcomes of both the mother and
    baby. Furthermore, women of color and women who live in poverty are
    disproportionately impacted by MMH conditions, experiencing them 2-3
    times the rate as White women.
        At the current funding level, only seven states have received
    grants to provide real-time psychiatric consultation, care
    coordination, and training for front-line providers to better screen,
    assess, refer and treat pregnant and postpartum women for depression
    and other behavioral health conditions. March of Dimes urges the
    Committee to provide $10 million in FY 2022 to add five programs and
    provide technical assistance to non-grantee states.
        Maternal Mental Health Hotline: We thank the Committee for funding
    $3 million in FY21 to the new maternal mental health hotline. This
    funding will allow qualified counselors to staff a hotline 24 hours a
    day and conduct outreach efforts on maternal mental health issues.
    COVID-19 has exacerbated maternal mental health conditions at 3-4 times
    the rate prior to the pandemic and leaving these conditions untreated
    can have a long-term effects. We urge the Committee to provide $5
    million to allow for the hotline to provide text messaging services,
    culturally-appropriate support, and continue public awareness efforts.
        Conclusion: March of Dimes looks forward to working with you and
    all Members of Congress to secure the resources needed to improve our
    nation's health. Federal public health programs are essential to
    preventing preterm birth, ending preventable maternal deaths, and
    addressing the maternal mental health that impacts mother, infants and
    families.
                                     ______

                 Prepared Statement of Meals on Wheels America
        Dear Chair Murray, Ranking Member Blunt, and Members of the
    Subcommittee:
        Thank you for the opportunity to submit testimony concerning Fiscal
    Year 2022 (FY22) appropriations for the Older Americans Act (OAA)
    Nutrition Program, administered by the Department of Health and Human
    Services' (HHS) Administration for Community Living (ACL). On behalf of
    Meals on Wheels America, the nationwide network of community-based
    senior nutrition providers and the individuals they serve, we are
    grateful for your ongoing support for the program, particularly in
    response to the COVID-19 pandemic. With Congress' help in securing
    much-needed emergency relief funding for the OAA network, local senior
    nutrition programs (e.g., Meals on Wheels) continue to serve on the
    front lines of the ongoing public health crisis, delivering essential
    nutrition assistance and so much more to older Americans. Despite the
    historic emergency supplemental funding and recent investments in
    annual appropriations, senior nutrition programs continue to be
    challenged by a soaring need for services which not only preexisted
    COVID-19 but have been rendered far worse as a result of the pandemic.
    For this reason, we request a total of $1,903,506,000 for the OAA Title
    III C Nutrition Program--Congregate Nutrition Services, Home-Delivered
    Nutrition Services, and Nutrition Services Incentive Program (NSIP)--in
    FY22. As programs will continue to serve a greater number of older
    adults through the new fiscal year and costs remain high, our specific
    appropriations requests are:
      --$965,342,000 for Congregate Nutrition Services (Title III C-1)
      --$726,342,000 for Home-Delivered Nutrition Services (Title III C-2)
      --$211,822,000 for Nutrition Services Incentive Program (Title III)
        While this FY22 request is double the FY21-enacted funding levels
    for the program, it reflects the amount necessary to maintain current
    levels of service, while enabling the network to expand and adapt to
    serve more seniors. As our country strives to respond, recover and
    rebuild from the health and economic crisis, these nutrition programs
    are a lifeline for millions of older adults and the services they
    provide must flex to meet the need.
        Overseen by ACL's Administration on Aging and implemented at the
    local level through more than 5,000 community-based providers, the OAA
    Nutrition Program delivers nutritious meals, opportunities for social
    connection and safety checks to adults 60 and older--either in a group
    setting or directly in the home--and has been at the forefront of
    addressing senior hunger and isolation for nearly fifty years. Amid the
    pandemic, older adults face unprecedented demands on their physical and
    mental health, independence and financial well-being. The local
    providers that serve them are seeing a far greater demand for their
    services as operational expenses and/or overall costs to safely deliver
    meals continue to rise. Accordingly, additional federal funding and
    flexibility of use of OAA nutrition resources are needed for senior
    nutrition programs to adequately adapt and expand operations to meet
    the growing and evolving needs of the communities they serve.
        Before the coronavirus pandemic, nearly 9.7 million (13%) older
    adults ages 60 and older were threatened by hunger (i.e., marginally
    food insecure)--5.3 million (7%) of which were food insecure or very
    low food secure.\1\ Social isolation--which has been amplified amidst
    safety and social distancing measures--is yet another threat for the
    nearly 17.5 million (24%) seniors that lived alone in 2019.\2\ One in
    five older adults reported frequent feelings of loneliness prior to the
    pandemic, and many more seniors have experienced feeling lonely or lack
    of social connection since then.\3\ Most older Americans possess at
    least one trait that puts them at increased risk of experiencing food
    insecurity, malnutrition, social isolation and/or loneliness, thereby
    increasing the likelihood of experiencing myriad adverse health
    effects. Despite the wide recognition of the relationship between
    healthy aging and access to nutritious food and regular socialization,
    millions of seniors were struggling to meet these basic human needs
    pre-COVID; and these issues have only been exacerbated as a result of
    the pandemic.
    ---------------------------------------------------------------------------
        \1\ J. Ziliak & C. Gundersen, The State of Senior Hunger in America
    2018: An Annual Report, prepared for Feeding America, 2020. https://
    www.feedingamerica.org/research/senior-hunger-research/senior.
        \2\ U.S. Census Bureau, American Community Survey 2018, available
    on the Administration for Community Living Aging, Independence, and
    Disability Program Data Portal (AGID), 2020. https://agid.acl.gov/
    CustomTables/.
        \3\ AARP, Loneliness and Social Connections: A National Survey of
    Adults 45 and Older, 2018. https://www.aarp.org/research/topics/life/
    info-2018/loneliness-social-connections.htm.
    ---------------------------------------------------------------------------
        The OAA Nutrition Program is designed to reduce hunger, food
    insecurity and malnutrition, and to promote socialization and the
    overall health and well-being of older adults. Providers across the
    country have long played a pivotal role in supporting the independence
    and quality of life of the 2.4 million older adults they serve. Meals
    served by the program must also meet the dietary guidelines set by the
    OAA Nutrition Program and are often tailored to meet medical needs and
    cultural preferences. OAA services are targeted toward seniors with the
    greatest social and economic need-including those who are low-income;
    are a racial or ethnic minority; live in a rural community; have
    limited English proficiency; and/or are at risk of
    institutionalization.\4\ For many program participants, the volunteer
    or staff member who delivers meals to their homes may be the only
    individual(s) she or he sees that day.
    ---------------------------------------------------------------------------
        \4\ Administration for Community Living (ACL), State Program
    Reports 2019, available on AGID, 2021. https://agid.acl.gov/
    CustomTables/.
    ---------------------------------------------------------------------------
        The profile of home-delivered meal clients reveals the high degree
    of vulnerability among recipients, with the majority being age 75 or
    older, female, living alone, taking multiple prescription medications
    daily and/or having three or more chronic conditions. A significant
    number of those served belong to a racial and/or ethnic minority group,
    as 19% of participants are Black or African American, 7% are Hispanic
    or Latino, and 5% are Native American or Hawaiian or Pacific Islander.
    Additionally, among participants:
      --35% live at or below the poverty level;
      --25% live in rural areas;
      --15% are veterans.\5\
    ---------------------------------------------------------------------------
        \5\ Mabli et al. Evaluation of the Effect of the Older Americans
    Act Title III-C Nutrition Services Program on Participants' Food
    Security, Socialization, and Diet Quality, Mathematica Policy Research,
    report prepared for ACL, 2017. https://acl.gov/sites/default/files/
    programs/2017-07/AoA_outcomesevaluation_final.pdf.
    ---------------------------------------------------------------------------
        A third (33%) of home-delivered meal recipients report not having
    enough money to purchase food.\6\ Fortunately, the vital services
    financed by the OAA Nutrition Program enable seniors with these risk
    factors to remain safer, healthier and less isolated in their own homes
    and communities.
    ---------------------------------------------------------------------------
        \6\ ACL. National Older Americans Act Participants Survey (NPS),
    2018, available on AGID Custom Tables and NPS Data Files, 2020. https:/
    /agid.acl.gov/.
    ---------------------------------------------------------------------------
        The results of a 2015 study commissioned by Meals on Wheels America
    found that seniors who received daily home-delivered meals were more
    likely to report improvements in mental health, self-rated health and
    feelings of isolation and loneliness, as well as reduced rates of falls
    and decreased concerns about their ability to remain in their home.\7\
    Additional research has found home-delivered meal program participants
    experience less healthcare utilization and lower expenditures than the
    non-participant controls, suggesting the program's potential to reduce
    costs among patients with high-cost or complex healthcare needs.\8\
    ---------------------------------------------------------------------------
        \7\ Meals on Wheels America. More Than a Meal Pilot Research Study,
    report prepared by K. S. Thomas & D. Dosa, 2015, https://
    www.mealsonwheelsamerica.org/learn-more/research/more-than-a-meal/
    pilot-research-study.
        \8\ Berkowitz et al. Meal Delivery Programs Reduce the Use of
    Costly Health Care in Dually Eligible Medicare and Medicaid
    Beneficiaries. Health Affairs (Vol. 37, No. 4), 2018. https://doi.org/
    10.1377/hlthaff.2017.0999.
    ---------------------------------------------------------------------------
        Additionally, the OAA Nutrition Program is a true public-private
    partnership that provides critical support and resources to local
    community-based organizations. By serving seniors in their homes and
    communities, local programs generate a powerful social and economic
    return on investment for older adults and taxpayers alike. They
    leverage funds granted to states through the OAA to offer nutrition and
    social services with the help of millions of volunteers, who provide
    innumerous in-kind contributions to support daily operations. In the
    aggregate, funding from the OAA accounted for 40% of the total amount
    spent to provide over 223 million congregate and home-delivered meals
    in 2019, based on the latest available data.\9\ As public spending on
    healthcare rises each year--largely attributable to a rapidly growing
    senior population with complex health needs and disproportionate risk
    to severe illness and complications due to COVID-19--it is imperative
    that we invest in these cost-effective programs that safely promote
    health and independence and reduce costly healthcare utilization among
    many of our country's most at-risk seniors. To further underscore,
    Meals on Wheels can serve a senior for an entire year for approximately
    the equivalent cost of one day in the hospital or 10 days in a nursing
    home.
    ---------------------------------------------------------------------------
        \9\ See note 4 above.
    ---------------------------------------------------------------------------
        Prior to the pandemic, federal funding for the senior nutrition
    network was not keeping pace with increasing demand, rising costs and
    inflation, leaving a huge gap between seniors served and those in need
    of services but not receiving them. Nationally, the OAA Nutrition
    Program network served 17+ million fewer meals in 2019 than in 2005--a
    7% decline--despite the population of adults 60 and older growing 53%
    over that same period.\10\ Further illustrating the need for more
    funding, a 2015 Government Accountability Office study estimated that
    83% of low-income, food insecure seniors do not receive the congregate
    or home-delivered meals that they likely needed.\11\ Among Meals on
    Wheels America members surveyed in 2019, nearly half of all local
    programs reported maintaining an active waiting list due to
    insufficient resources, and 85% of programs surveyed saw unmet need for
    services in their communities at that time.\12\ The emergency funding
    provided through COVID-19 relief legislation not only enabled programs
    to provide services for those individuals in their communities who have
    long been eligible and underserved but also helped address a huge
    influx of older adults newly in need of nutrition services because of
    the pandemic. An increase in FY22 appropriations is needed to ensure
    that these individuals can continue to receive the nutritional and
    social support unique to the OAA Nutrition Program that helps them
    remain healthier and independent at home and out of far more costly
    institutional or healthcare settings.
    ---------------------------------------------------------------------------
        \10\ ACL. State Program Reports 2005-2019, available on AGID, 2021.
    https://agid.acl.gov/CustomTables/.
        \11\ U.S. Government Accountability Office (GAO). Older Americans
    Act: Updated Information on Unmet Need for Services, 2015. https://
    www.gao.gov/products/GAO-15-601R.
        \12\ Meals on Wheels America. More Than a Meal Comprehensive
    Network Study, research conducted by Trailblazer Research, 2019.
    www.mealsonwheelsamerica.org/learn-more/research/more-than-a-meal/
    comprehensive-network-study.
    ---------------------------------------------------------------------------
        With the onset of the pandemic in March 2020, as mentioned above,
    the Meals on Wheels network faced an unprecedented surge in demand as
    the number of older adults sheltering in place increased and congregate
    centers shifted ways of operating--including transitioning congregate
    services to fully home-delivered or to grab-and-go and curbside pick-up
    alternatives, as well as offering virtual socialization activities and
    wellness checks over the phone. Most Meals on Wheels programs overcame
    significant challenges to continue and then rapidly scale their
    operations to serve more older Americans in need. In a survey conducted
    in November 2020 on behalf of Meals on Wheels America, programs
    reported delivering an average of 100% more home-delivered meals at
    their pandemic peak than they served before.\13\ At that time, programs
    also reported serving home-delivered meals to 84% more clients on a
    weekly basis, and four out of five local programs agreed that these
    ``new clients are here to stay.''
    ---------------------------------------------------------------------------
        \13\ Meals on Wheels America. COVID-19 Impact Survey, research
    conducted by Trailblazer Research, November 2020.
    ---------------------------------------------------------------------------
        Despite the incredible response from the senior nutrition network
    to quickly scale services, barriers remain in addressing the full
    demand. According to the November 2020 survey, 88% of Meals on Wheels
    programs reported increased costs due to the necessary purchase of
    personal protective equipment (PPE) and safety supplies, meal
    production expenses and/or labor needs. Local programs reported that
    costs are expected to remain high, and nine in 10 Meals on Wheels
    programs reported unmet need for home-delivered meals in their
    community. Nearly a third of programs said they would need to, at
    minimum, double their home-delivered efforts to fill the gap in their
    community, as many reported increased numbers of seniors forced to go
    on waiting lists. More than 15 months into this public health crisis,
    local programs are continuing to deliver these life-saving services at
    high rates and have cited funding as the primary factor impacting their
    ability to serve individuals most directly affected by the pandemic.
    Without additional funding through the OAA, many nutrition providers
    will not be able to support their current client base, much less expand
    to reach more seniors who need services but are not receiving them.
        We understand the difficult decisions you face with respect to
    annual appropriations bills and other budgetary challenges as Congress
    works to mitigate the impacts of the global pandemic and recover from
    this prolonged national emergency. However, to address the current
    level of nutrition services needed in communities, increased federal
    funding through the regular appropriations cycle is critically needed
    for the next fiscal year and beyond. With approximately 12,000
    individuals turning 60 every day, the requested appropriations increase
    will help provide the levels needed for community-based nutrition
    programs to reach eligible older adults, especially as the demand for
    these essential services continues to rise.
        As the Subcommittee develops its FY22 Labor-HHS-Education
    appropriation bill, we request you provide a minimum of $1,903,506,000
    for the OAA Nutrition Program so that local community-based Meals on
    Wheels programs can ensure the health, safety and social connectedness
    of our nation's seniors, build the capacity of OAA programs and
    services, and bridge the growing gaps and unmet need for services in
    communities nationwide. Thank you for your leadership, support and
    consideration. We look forward to working together to ensure that no
    senior in America is left hungry and isolated.

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

     Prepared Statement of the Medical Library Association and Association
                     of Academic Health Sciences Libraries
        I, Mary M. Langman, Director, Information Issues and Policy,
    Medical Library Association (MLA), submit this statement on behalf of
    MLA and the Association of Academic Health Sciences Libraries (AAHSL).
    MLA is a global, nonprofit, educational organization with a membership
    of more than 400 institutions and 3,000 professionals in the health
    information field. AAHSL supports academic health sciences libraries
    and directors in advancing the patient care, research, education and
    community service missions of academic health centers through visionary
    executive leadership and expertise in health information, scholarly
    communication, and knowledge management.
        We thank the Subcommittee for the opportunity to submit testimony
    supporting appropriations for the National Library of Medicine (NLM),
    an agency of the National Institutes of Health (NIH), and recommend
    $475 million for NLM in FY22, a 3% (+$12.9 million) increase. Working
    in partnership with the NIH and other Federal agencies, NLM is the key
    link in the chain that translates biomedical research into practice,
    making the data and other results of research readily available to all
    who need it. As NLM works to achieve key objectives of its Strategic
    Plan--to accelerate data powered discovery and health, reach new users
    in new ways, and prepare a workforce for a future of data-driven
    research and health, it also supports NIH-wide efforts to answer the
    call to respond to national priorities, close the gap in health
    disparities, and capitalize on fundamental investments. NLM
    accomplishes this through effective preservation of valued scientific
    and data resources, judicious investments in extramural and intramural
    research, informed stewardship of Federal resources, and innovative
    partnerships to align priorities and leverage investments across HHS,
    the Federal government, and the biomedical research community.
        As health sciences librarians who use NLM's programs and services
    every day, we can attest that NLM resources literally save lives.
    Therefore, investing in NLM is an investment in good health.
    Leveraging NIH Investments in Biomedical Research
        NLM's budget supports information services, research, and programs
    that sustain the nation's biomedical research enterprise. In FY22 and
    beyond, NLM's budget must continue to be augmented to support
    modernization and expansion of its information resources, services,
    research, and programs which collect, organize, and develop new ways to
    make readily accessible rapidly expanding biomedical knowledge
    resources and data. NLM maximizes the return on investment in research
    conducted by the NIH and other organizations. It makes the results of
    biomedical information accessible to researchers, clinicians, business
    innovators, students, and the public, enabling such data and
    information to be used more efficiently and effectively to drive
    innovation and improve health. Rapid growth of data also necessitates
    funding that will ensure long-term sustainability of these valuable
    information resources. NLM is unique because it stimulates and supports
    innovative research in data science and information management that
    transcends specific disease areas and data types.
        NLM plays a critical role in NIH's data science and open science
    initiatives leading the development, maintenance and dissemination of
    key standards for health data interchange that are now required of
    certified electronic health records (EHRs). NLM builds, sustains, and
    augments a suite of almost 300 databases which provide information
    access to health professionals, researchers, educators, and the public.
    It supports the acquisition, organization, preservation, and
    dissemination of the world's biomedical literature. In FY 2019, NLM
    made genomic sequence data available in the cloud. NLM's Sequence Read
    Archive (SRA) is the world's largest publicly available repository of
    next-generation genome sequence data, with more than 9 million records
    comprising 25 petabytes of data. To improve access and utility of SRA
    data, NLM uploaded the public access SRA data to two commercial clouds
    that have agreements with NIH's Science and Technology Research
    Infrastructure for Discovery, Experimentation, and Sustainability
    (STRIDES) Initiative. This transition significantly expands the
    discovery potential of the data. Freed from the limitations of local
    storage and computational resources, users are empowered to compute
    across the full corpus of SRA data without having to download and store
    large volumes of data. Moving to cloud platforms also makes it possible
    to develop customized tools and methods for asking research questions
    of the data.
    Growing Demand for NLM's Information Services
        Each day, more than 6 million people use NLM websites and download
    115 terabytes of data. Thousands of researchers and businesses upload a
    total of 15 terabytes of data daily. Annually, NLM information systems
    process more than six billion human requests and eight billion
    computer-to-computer interactions. NLM's information services help
    researchers advance scientific discovery and accelerate its translation
    into new therapies; provide health practitioners with information that
    improves medical care and lowers its costs; and give the public access
    to resources and tools that promote wellness and disease prevention.
    Every day, medical librarians across the nation use NLM's services to
    assist clinicians, students, researchers, and the public in accessing
    information to save lives and improve health. Without NLM, our nation's
    medical libraries would be unable to provide quality information
    services that our nation's health professionals, educators, researchers
    and patients increasingly need.
        NLM's data repositories and online integrated services such as
    GenBank, dbGaP, Genetics Home Reference (GHR), PubMed, and PubMed
    Central (PMC) are revolutionizing medicine. GenBank is the definitive
    source of gene sequence information. Each month, 2.1 million users
    accessed consumer-level information about genetics from GHR, which
    contains more than 2,700 summaries of genetic conditions, genes, gene
    families, and chromosomes. PubMed, with more than 32 million references
    to the biomedical literature, is the world's most heavily used source
    of bibliographic information with almost 3.3 million users each day.
    NLM also launched a new PubMed platform for an improved user
    experience, including a new search algorithm with relevance rankings
    and better tools for citations. PubMed Central is NLM's digital archive
    which provides public access to the full-text versions of more than 6.8
    million biomedical journal articles, including those produced by NIH-
    funded researchers. On a typical weekday more than 3.5 million users
    download articles from PubMed Central.
        NLM continually expands biomedical information services to
    accommodate a growing volume of relevant data and information and
    enhances these services to support research and discovery. NLM ensures
    the availability of this information for future generations, making
    books, journals, technical reports, manuscripts, microfilms,
    photographs and images accessible to all Americans, irrespective of
    geography or ability to pay, and guaranteeing that citizens can make
    the best, most informed decisions about their healthcare.
    Disseminating Clinical Trial Information
        ClinicalTrials.gov, the world's largest clinical trials registry,
    now includes more than 370,000 registered studies and summary results
    in all 50 states and in 219 countries for more than 48,000 trials. More
    than 158,000 users access this vital information each day. As health
    sciences librarians who fulfill requests for information from
    clinicians, scientists, and patients, we applaud NIH and NLM for
    implementing requirements for clinical trials registration and results
    submission consistent with the FDA Amendments Act of 2007, and for
    applying them to all NIH-supported clinical trials. These efforts
    increase transparency of clinical trial results and provide patients
    and clinicians with information to guide health care decisions. They
    also ensure biomedical researchers have access to results that can
    inform future protocols and discoveries.
    Partnerships Ensuring Outreach and Engagement in Communities Across the
            Nation
        NLM's outreach programs are essential to the MLA and AAHSL
    membership and to the profession. The NLM coordinates an 8,000-member
    Network of the National Library of Medicine (NNLM), including 7
    Regional Medical Libraries that receive NLM support, 125 resource
    libraries connected to medical schools, and more than 5,000 libraries
    located primarily in hospitals and clinics. Through the NNLM, NLM
    educates medical librarians, health professionals, and the general
    public about its services and provides training in their effective use.
    The NNLM serves the public by promoting educational outreach for public
    libraries, secondary schools, senior centers and other consumer
    settings, and its outreach to underserved populations helps reduce
    health disparities.
        Since May 2018, the NNLM has partnered with the NIH All of Us
    Research Program to support community engagement efforts by United
    States public libraries and to raise awareness about the program.
    Together, NLM and NIH have built the NNLM All of Us Community
    Engagement Network (CEN). The CEN focuses on NNLM's mission to improve
    the public's access to health information and provide awareness of All
    of Us to communities that are Underrepresented in Biomedical Research
    by partnering with libraries across the United States. The CEN is
    designed to leverage the mission of the NNLM to help libraries in
    supporting the health information needs of their users.
        NLM's MedlinePlus provides consumers with trusted, reliable health
    information on 1,000 topics in English and Spanish. It attracts more
    than 1 million visitors daily. NLM continues to enhance MedlinePlus and
    disseminate authoritative information via the website, a web service,
    and social media. MedlinePlus and MedlinePlus en Espanol have been
    optimized for easier use on mobile phones and tablets. NIH MedlinePlus
    Magazine and NIH MedlinePlus Salud are available in doctors' offices
    nationwide, and NLM's MedlinePlus Connect enables clinical care
    organizations to link from their EHR systems to relevant patient
    education materials.
    Strengthening Data Science and Open Science Capacity
        NLM is a leader in data science and open science, including the
    acquisition and analysis of data for discovery and the training of
    biomedical data scientists. The library aims to strengthen its position
    as a center of excellence for health data analytics and discovery, and
    to spearhead the application of advanced data science tools to
    biological, clinical and health data. NLM is building a workforce for
    data-driven research and health by funding PhD-level research training
    in biomedical informatics and data science. The library also partners
    with NIH to ensure inclusion of data science and open science core
    skills in all NIH training programs, and is expanding training for
    librarians, information science professionals, and other research
    facilitators. NLM is participating in NIH-wide efforts to foster a
    culture that advances science and ensures the development and retention
    of a diverse, safe, and respectful workforce for data-driven research
    and health well into the future.
    Responding to the Novel Coronavirus (COVID-19)
        The health sciences library community thanks Congress for providing
    NLM with the $10 million supplemental appropriations to prevent,
    prepare for, and respond to the Coronavirus. From the beginning, NLM
    has been at the forefront of providing people with information on
    COVID-19 . Our frontline health care providers use NLM's databases to
    access the latest research datasets, literature publications, and
    scientific information about Covid-19. NLM has responded to COVID-19's
    rapidly evolving situation through its suite of tools and deep well of
    expertise in managing large and complex datasets and making them
    accessible to the public. Our frontline healthcare providers use NLM's
    databases to access the latest research datasets, literature
    publications, and scientific information about COVID-19. For example,
    NLM has been:
      --Making immediately available to the public in PubMed Central tens
            of thousands of coronavirus-related research publication and
            data contributed by major publishers
      --Contributing to the COVID-19 Open Research Dataset (CORD-19), which
            represents the most extensive machine-readable coronavirus
            literature collection available for text mining to date, with
            more than 30,000 full-text scholarly articles from PMC as of
            mid-May 2020. The Text REtrieval Conference (TREC)-COVID
            Challenge makes use of the CORD-19 dataset to help search
            engine developers evaluate and optimize their systems in
            meeting the needs of the research and healthcare communities.
      --Creating BI SARS-CoV-2 Resources, a portal of literature, gene
            sequence data, and clinical resources related to the virus that
            causes COVID-19.
      --Providing the biomedical community free and easy access to genome
            sequences from the coronavirus through the GenBank sequence
            database.
      --Providing information about US clinical trials related to COVID-19
            via ClinicalTrials.gov, which is also now making available
            information about trials listed in the World Health
            Organization's international clinical trial registry.
      --Extending standard terminologies to include terms related to COVID-
            19, including codes for laboratory tests, chemical entities,
            and indexing terms.
      --Applying machine learning techniques to research conducted at NLM
            to assist in identifying COVID-19 in X-rays and to identify and
            categorize relevant published literature.
    Supporting Biomedical Informatics Research and Health Information
            Technology Innovation
        NLM conducts and supports informatics research, training and the
    application of advanced computing and informatics to biomedical
    research and healthcare delivery. NLM's National Center for
    Biotechnology Information (NCBI) focuses on genomics and biological
    data banks, and the Lister Hill National Center for Biomedical
    Communications (LHC), is a leader in clinical information analytics and
    standards. Many of today's biomedical informatics leaders are graduates
    of NLM-funded informatics research programs at universities nationwide.
    A number of the country's exemplary electronic and personal health
    record systems benefit from findings developed with NLM grant support.
    A leader in supporting the development, maintenance, and free,
    nationwide dissemination of standard clinical terminologies, NLM
    partners with the Office of the National Coordinator for Health
    Information Technology to support the interoperability of EHRs. NLM
    also develops tools to make it easier for EHR developers and users to
    implement accepted health data standards and link to relevant patient
    education materials. In FY 2019, NLM played a critical role in the
    development, usage, and utility of a data exchange standard to improve
    flow and availability of data, the Health Level Seven International
    (HL7) Fast Healthcare Interoperability Resources (FHIR(r)). NIH is
    encouraging funded investigators to use the FHIR standard to capture,
    integrate, and exchange clinical data for research purposes and to
    enhance capabilities to share research data. NIH has also announced to
    the small business communities its special interest in supporting
    applications that use FHIR in the development of health IT products and
    services. To support these efforts, NLM is managing the development and
    testing of FHIR tools that researchers can use to increase the
    availability of high-quality, standardized research datasets and
    phenotypic information for genomic research and genomic medicine.
    Closing the Gap in Health Disparities
        The National Library of Medicine supports NIH's efforts to close
    the gap in health disparities and improve the diversity of the
    biomedical information science workforce. Their work supports our
    mission and core values to make MLA and AAHSL more diverse and
    inclusive organizations. NLM accomplishes this by:
      --Providing open access to scientific literature through PubMed and
            PubMed Central make scientific literature accessible, lading to
            biological discoveries and providing the foundation to
            developing clinical guidelines that inform health care.
            Resources include PubMed Special Query for Health Disparities
            and Minority Health Information Resources.
      --Utilizing the Network of the National Library of Medicine to
            provide equal access to biomedical information and improves the
            public's access to information. NNLM supports events including
            the recent DEI webinar series ``Nine Conversations that Matter
            to Health Sciences Librarians'' as well as NNLM Reading Clubs
            on Disability Health, LGBTQ Health, Racism and Health and
            Diversity in Medicine.
      --Funding grant programs that support research to advance health
            equity and grants to reduce health disparities research
            supplements to promote diversity in health research and
            leveraging health information technology to address minority
            health and health disparities.
      --Raising awareness and sparking conversations about the intersection
            of society and ethical considerations in biomedical research
            and technology through the annual NLM Science, Technology, and
            Society lecture series.
        We look forward to continuing this dialogue and thank you for your
    efforts to support funding of at least $475 million for NLM in FY22,
    with additional increases in future years.
                                     ______

         Prepared Statement of the METAvivor Research and Support, Inc.
                fiscal year 2021 appropriations recommendations
    _______________________________________________________________________

      --Please provide the National Institutes of Health (NIH) with an
            increase of at least a $3.2 billion for FY 2022 to bring total
            agency funding up to a minimum of $46.1 billion annually.
        --Please support establishment and adequate funding for the new
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH as proposed in the Administration's Budget Request to
                Congress to facilitate robust scientific progress on
                cancers.
      --Please continue to support additional investment for the cancer
            ``moonshot'' as outlined by the 21st Century Cures Act and
            otherwise ensure the National Cancer Institute (NCI) has
            adequate resources.
      --Please continue to emphasize the importance of federal research
            activities focused on controlling and eliminating cancer that
            has already disseminated (Metastatic Cancer) through committee
            recommendations and timely oversight of ongoing activities.
      --Please support emerging efforts to modernize the Surveillance,
            Epidemiology, and End Results Research Program (SEER) Registry
            to better capture the experience of metastatic cancer patients
            (as outlined by recommendations within the FY 2021 Senate LHHS
            Appropriations Bill).
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Subcommittee, thank you once again for considering the views of
    METAvivor and the stage IV metastatic cancer community as you work on
    FY 2022 appropriations for medical research and public health. The
    community is deeply grateful for the sustained investment in NIH, and
    emerging calls for a robust and comprehensive effort to enhance cancer
    research. Please maintain the commitment to supporting innovative
    medical research and providing adequate resources to public health
    programs moving forward, for FY 2022.
                                about metavivor
        My name is Jamil Rivers. I had a typical family before my diagnosis
    of ``de novo'' metastatic breast cancer. I was 39 years old, married,
    with three children and a full-time job. We were very active and always
    doing something. I have a big, tight-knit family and we love to travel.
    I had just changed jobs and we moved into a new house. I never missed a
    beat--and then my husband was diagnosed with stage-one colon cancer. I
    became his caregiver. It was in 2017, and everyone got sick in the
    wintertime like we always do. We had colds and were coughing, but my
    cold didn't go away. I also had this pain and this pinch, like I had
    pulled a muscle on my right side. When I went to the doctor about my
    cold and cough, they had prescribed me antibiotics. I also asked for an
    ultrasound because appendicitis runs in my family. The results showed
    that I had lesions in my liver. I had no other symptoms and no other
    pain, but further testing showed I had stage IV ``de novo'' metastatic
    breast cancer. It was the most shocking news ever.
        The breast cancer had spread to my liver, my spleen, lymph nodes,
    lungs, bones, my abdomen and my chest wall. I was devastated. I'm
    blessed with this beautiful family and my kids are really young. At the
    time they were only 5, 6 and 16 years old. Why would God bless me with
    this beautiful family and then strip me from them? I couldn't wrap my
    brain around the fact that my husband and I could both have a serious
    health issue. It just wasn't a possibility.
        ``Who is going to take care of our kids?'' That was the first thing
    I thought about in the midst of my devastation. But after that, I
    realized I had to survive for them; I have to be here for them. I
    wanted my kids to know that I did everything I could possibly do in my
    power to be here for them. I had to process my diagnosis so I could
    focus on my health. You never think this could happen to you but it
    did. It happened to me.
        I'm the type of person who, when a challenge is brought to me, I
    figure out how to execute it and get it done. I basically had to figure
    out. I empowered myself and armed myself with as much knowledge,
    information, resources and support as possible. My mission was
    survival.
        I'm my kids' mom and no one else can be. I'm the breadwinner in my
    family and everyone is also on my benefits. It was imperative that I
    keep my job and do well at my job so I could continue to take care of
    them. I started chemotherapy right away because, on paper, I was
    literally dying. The kids had to see me lose all of my hair and be
    really tired. That's when I started researching what else I could do in
    terms of integrative therapy to help me manage the side effects of the
    chemo in order to still work, be active and take care of my kids the
    same way I always had.
        Now, my husband is in recovery and after 1 year of chemotherapy, my
    tumors have shrunk to the point where they're a microscopic size so you
    can't see them on a scan... also known as ``no evidence of disease''.
    I'm still working, taking care of the kids and involved in their school
    activities. I want to soak in every waking second with my family.
        I'm not giving up anytime soon.
        Through my advocacy, I have tried to help bring more attention to
    metastatic breast cancer, the need for more research funding and
    investment towards metastatic breast cancer. I now serve as Board
    President of METAvivor and work alongside others to push this important
    work forward. I hope the lives of the more than 600,000 people with
    stage IV metastatic cancer is considered when making decisions about
    the future of cancer research and especially funding the stage IV
    metastatic cancer research. METAvivor has worked hard to fund research.
    Since 2009, we have funded over $18 million but we need more...stage IV
    metastatic cancer needs more research.
                   the facts about metastatic stage iv cancer
        Roughly 600,000 Americans die annually from cancer. Ninety percent
    of these deaths are caused by a metastasis. If we wish to lower the
    death rate, we must tackle metastasis. For more than 20 years, the
    primary focus has been on preventing cancer altogether and if that
    fails, catching it early. But aside from convincing people to stop
    smoking, forbidding smoke in common areas and removing colon polyps
    prior to malignancy, little progress has been made. For most cancers,
    it is believed there are multiple causes, few if any of which are
    known, making prevention a formidable goal. Improved equipment has
    allowed some cancers to be diagnosed as early as stage 0; however,
    stage 0 patients are also metastasizing. And although we are slowly
    adding drugs to the treatment repertoire, a treatment's effectiveness
    often runs out in 2-3 months. Thus, we empty our toolbox of drugs far
    too quickly and we, metastatic patients, die. Saving lives is an
    achievable goal but tragically is not being realized because the focus
    continues to be prevent and early detect. Those goals have been
    maximized. Backs have been turned to the metastatic community long
    enough. It is high time to include metastasis as a major focus area.
    Sarah, Oregon
        My name is Sarah Wald. I live in Eugene, Oregon. I am a professor
    at the University of Oregon and a parent. I'm also living with
    metastatic breast cancer. I was diagnosed with metastatic breast cancer
    just over two years ago. It was a denovo diagnosis. This means I was
    Stage IV at diagnosis. It was not a recurrence. I have no family
    history of breast cancer. I saw my doctor annually for breast exams and
    planned to start mammograms at forty. I had no symptoms at diagnosis. I
    felt healthy. I biked 50 miles the weekend after I found what felt like
    an immobile small grape in my breast. I called my doctor the morning
    after I found the lump and took the first available appointment. She
    got me in for a mammogram and ultrasound the day I saw her. It was
    already too late. There were breast cancer cells in my bones.
        I don't know how to explain to you what it is like to find out you
    are dying of a terminal disease in your thirties. I don't know how to
    explain to you what is like to feel healthy and be looking forward to
    the future with your family and then to be told that you will almost
    certainly be dead in the next few years. There is nothing I want more
    than to live. I want every day of life that I can have. I want every
    extra week I can spend with my family. I want to see the flowers come
    in and bloom every spring. We need money for research. I was shocked to
    find out how little money actually goes to metastatic breast cancer
    research when it is metastatic breast cancer that kills. For those of
    us living with the disease, it is a race against time to find new
    treatments that will give us those extra months and those extra days.
    New research and new treatments make a difference. For the past two
    years, my cancer has been controlled by a treatment that first received
    FDA approval in 2015. My second line of treatment will contain a drug
    that received FDA approval after my diagnosis in 2019. The research you
    fund today might be the research that lets me see another birthday,
    mine or my child's. We need to find out how to stop breast cancer from
    metastasizing and treat it when it does. I don't want anyone else to go
    through what I am enduring. Please support funding more research for
    stage IV metastatic breast cancer.

        [This statement was submitted by Jamil Rivers, Board Chair,
    METAvivor
    Research and Support, Inc.]
                                     ______

          Prepared Statement of the Michelson Center for Public Policy
        The Michelson Center for Public Policy (MCPP) thanks the
    Subcommittee for its long-standing bipartisan leadership in support of
    the National Institutes of Health (NIH). Robust support for science and
    innovation is critical if we are to advance public health, sustain U.S.
    leadership in medical research, and remain competitive in today's
    innovation economy.
        It is now estimated that the COVID-19 pandemic will cost the U.S.
    economy more than $16 trillion.\1\ The NIH's fiscal year (FY) 2021
    budget was just 0.25 percent of that. The NIH is the world's largest
    funder of medical research and the basic, clinical, and translational
    research that it funds is the very fuel that feeds the American engine
    of discovery and drives innovation in pharmaceuticals and
    biotechnology. More importantly, NIH research saves lives and improves
    wellbeing for millions worldwide. Now is the time to vaccinate the
    economy and bolster our ability to respond to the emerging public
    health threats of tomorrow by continuing to invest heavily in
    biomedical research with transformative potential. MCPP urges the
    Subcommittee to provide $100 billion for NIH in FY 2022.
    ---------------------------------------------------------------------------
        \1\ https://news.harvard.edu/gazette/story/2020/11/what-might-
    covid-cost-the-u-s-experts-eye-16-trillion/.
    ---------------------------------------------------------------------------
        MCPP is a 501(c)(4) social welfare organization that propels
    legislative change through meaningful collaboration with elected
    officials, government agencies, and civic leaders to achieve positive
    outcomes in medical research, education, equity, and animal welfare.
    The Michelson Center for Public Policy is an affiliated but separate
    organization from the Michelson Philanthropies network of foundations
    (Michelson 20MM Foundation, Michelson Found Animals Foundation, and
    Michelson Medical Research Foundation) and complements the Michelson
    Philanthropies' thought leadership and expertise with bold and
    effective advocacy.
        MCPP's founder and co-chair is physician, inventor, and
    philanthropist Gary Michelson, M.D. He is committed to using his
    platform to advocate for robust investment in biomedical research,
    disruptive innovation that can deliver more treatments and cures, and
    support for the next generation of researchers.
        Through the Michelson Medical Research Foundation, Dr. Michelson
    makes grants to support high-quality, cutting-edge medical research
    because a single breakthrough could benefit the lives and health of
    hundreds of millions. But philanthropy cannot do it alone. Truly
    transformative medical advances are seeded by robust investment in the
    NIH and these investments have exponential returns for the economy,
    jobs, tax revenues and--most importantly-humankind.
        MCPP is thankful for the strong bipartisan support that the
    Subcommittee leaders, Chairwoman Rosa DeLauro and Ranking Member Tom
    Cole, have shown in providing the NIH with six consecutive funding
    increases during this time of constrained budgets. These increases have
    helped the NIH regain ground from the years of largely flat funding in
    inflation-adjusted dollars. However, we must do more.
        The Biden Administration has proposed to fund the NIH at $51
    billion in 2022, which is a good start, but not nearly enough. This is
    precisely the right time to be bold and go bigger. For the NIH to
    invest adequately in risky research with the most promise for
    transformative advances--the very type of research that enabled the
    unprecedented COVID-19 vaccine development we saw over the past year-it
    needs twice that.
        We cannot afford to be modest in our efforts. No one deserves to
    fall ill and die, or to helplessly watch as their child, parent or
    spouse suffers because we failed to do the work right now to save them.
    We must dramatically increase the NIH's budget, so that a lack of
    funding is not the reason why patients go untreated and diseases remain
    a threat to public health.
        The COVID-19 pandemic has shown that the NIH cannot only rely on
    incremental annual increases to its base budget to meet the next public
    health challenge. A fraction of the resources put into combating the
    pandemic should have been invested in the NIH years ago. With impacts
    like $16 trillion from one pandemic, we need more than inflationary
    increases to NIH each year to keep pace and inoculate the country
    against the next public health crisis.
        Investing in the NIH is an investment in our national security. The
    investments that protect our nation's health and wellbeing should be
    protected in the same manner as investments in our national defense.
        Not only is NIH research essential to advancing health and national
    security, it also plays a key economic role. Funds provided to NIH are
    not costs, but instead generate remarkable rates of economic return and
    even greater returns on our health and wellbeing. In FY 2020, NIH
    invested $34.65 billion, or almost 80 percent of its budget, in the
    biomedical research industry across the country. This investment
    supported more than 536,338 jobs nationwide and generated nearly $91.35
    billion in economic activity across the U.S.\2\ Just one NIH-funded
    medical research program, The Human Genome Project, directly generated
    more than a trillion dollars for the US economy--a 178-fold return on
    investment--and has paid for itself many times over in industry tax
    revenues returned to the government.\3\
    ---------------------------------------------------------------------------
        \2\ NIH's funding information and economic impact data comes from
    United for Medical Research's 2021 State-By-State Update, https://
    www.unitedformedicalresearch.org/wp-content/uploads/2021/03/NIHs-Role-
    in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
        \3\ https://www.nih.gov/about-nih/what-we-do/impact-nih-research/
    our-society.
    ---------------------------------------------------------------------------
        MCPP is enthusiastic about the Biden Administration's proposal to
    establish a new Advanced Research Projects Agency for Health (ARPA-H).
    As proposed, ARPA-H could drive innovation and accelerate the
    development of innovative therapeutics, treatments, and cures for
    chronic conditions such as cancer, diabetes, and Alzheimer's Disease.
    Too often, research supported by the NIH results in incremental
    advancements and not the transformative scientific breakthroughs that
    only come from robust investment in high-risk high-reward research.
    MCPP is committed to supporting innovative ideas that can accelerate
    the pathway to cures. Standing up an entity like ARPA-H that is focused
    on high-risk high-reward research and accelerating the timeline from
    idea to clinical application is the exact thing our nation needs to
    leverage the lessons learned from the COVID-19 pandemic and apply them
    to other pressing public health challenges.
        A crucial component of ensuring that the NIH is equipped to meet
    the health challenges of the future is supporting the next generation
    of scientists. Early career researchers in the biomedical sciences face
    many struggles as they move toward independence. Lack of independent
    funding opportunities and tenure-track faculty positions place many
    early career researchers in a cycle of training positions that may
    hinder growth, innovation, and scientific independence. In addition,
    the NIH funding ecosystem is harmfully ``hypercompetitive.'' In 2020,
    only one out of every five applicants was ultimately awarded NIH
    funding, and the resulting grant was almost always less than the amount
    requested to effectively perform the research. This system especially
    disadvantages early career investigators, squandering the potential of
    scientists with groundbreaking and innovative ideas.\4\ Furthermore,
    among early career researchers, women, parents, and those from
    underrepresented backgrounds in STEM bear a disproportionate amount of
    this burden. MCPP urges the Subcommittee to build NIH's ability to
    devote more of its annual budget to programs that support early career
    researchers, with the goal of attaining ten percent of the agency's
    overall budget invested in the most promising young investigators
    conducting highly innovative research with truly transformative
    potential.
    ---------------------------------------------------------------------------
        \4\ https://nexus.od.nih.gov/all/2018/05/04/the-issue-that-keeps-
    us-awake-at-night/.
    ---------------------------------------------------------------------------
        MCPP thanks the Subcommittee for its important work dedicated to
    ensuring the health and security of the nation, and we appreciate this
    opportunity to urge the Subcommittee to continue the success of NIH by
    providing at least $100 billion in FY 2022. This is the minimum amount
    needed to transform our nation's investment in life-saving medical
    research, enhance NIH's ability to support highly innovative and
    groundbreaking research, and expand support for young investigators.
        We have a once-in-a-lifetime opportunity to pave the way for future
    medical advances to benefit humankind. Let's seize it.
                                     ______

               Prepared Statement of the Midwest Urban Strategies
        Dear Chairman Murray and Ranking Member Blunt:
        Midwest Urban Strategies (MUS) represents a coordinated effort on
    behalf of 13 Department of Labor urban workforce development boards to
    connect traditional workforce development practices with economic
    development. Our member organizations are directly involved in the
    implementation of the bipartisan Workforce Innovation and Opportunity
    Act (WIOA) of 2014, specifically promoting the successful execution by
    local workforce boards of the law to serve businesses, employers, and
    job--and career-seekers. The economic recession and recovery caused by
    COVID-19 is unlike any other period is our nation's history. MUS
    members, along with local workforce development boards across the
    country, immediately adapted to continue to provide critical supports
    and services to job seekers and businesses throughout the pandemic. Our
    methods may have changed given the circumstances, but the impact of our
    work persisted, no matter the obstacle.
        As the Senate Appropriations Committee considers the Fiscal Year
    (FY) 2022 Labor-HHS Appropriations Bill, we urge you to support further
    federal investment into WIOA and fully fund the law beyond its FY2020
    authorized levels. We strongly support the proposed funding levels in
    President Biden's FY 2022 Budget as it recognizes that appropriated
    levels have fallen short of authorized levels specifically in Title I
    accounts at the Department of Labor (Adult Employment and Training
    Services, Youth Workforce Investment Activities, and Dislocated Worker
    Employment and Training Services).
        Additional federal resources for WIOA programs lead to more job
    training, education, skills development and innovative, proven
    practices like industry-based sector partnerships, career pathways, and
    apprenticeships. MUS works collaboratively in our region and across the
    country to advance these best practices. Workers and entire industries
    have been severely disrupted as a result of COVID-19 and these
    strategies will need to be implemented seamlessly to respond. The
    established local workforce system is well-positioned to enhance
    efforts for an equitable recovery; low wage, low skill workers and
    minority populations were hit hardest by COVID-19. The federal funding
    structure, which allows these funds to be invested locally, provides
    for intentional investments to help those most in need.
        Local workforce development leaders engage directly with businesses
    to keep individuals employed and design training/education programs to
    prepare the workforce for the future. We continue to work with
    unemployed individuals to re-connect them to the workforce and identify
    and evaluate other opportunities; recent BLS data suggests nearly 41%
    of those unemployed have been unemployed for at least 27 weeks (long-
    term unemployed).\1\ Business services, especially for small and
    medium-sized enterprises, have been critical during the COVID-19
    pandemic as employers sought to maintain payrolls and find workers as
    businesses began to re-open. Increased federal appropriations are
    greatly needed to address this unprecedented health, economic, and
    social destabilization.
    ---------------------------------------------------------------------------
        \1\ https://www.bls.gov/charts/employment-situation/unemployed-27-
    weeks-or-longer-as-a-percent-of-total-unemployed.htm.
    ---------------------------------------------------------------------------
        The Fiscal Year 2022 Labor, Health and Human Services, Education,
    and Related Agencies Appropriations bill must fully fund all Titles--I,
    II, III, and IV--at a minimum to the level authorized by the Workforce
    Innovation and Opportunity Act (WIOA).
        The funding levels we are requesting in the FY2022 Labor, HHS,
    Education Appropriations Bill are listed below:
    Title I--Department of Labor
      --At least $899.987 million for Adult Employment and Training
            Services,
      --At least $963.837 million for Youth Workforce Investment
            Activities, and
      --At least $1.436 billion for Dislocated Worker Employment and
            Training Services
    Title II--Department of Education
      --$678.640 million for Adult Education
    Title III--Department of Labor
      --$692,370,000 for Wagner-Peyser (FY2021 Enacted)
    Title IV--Department of Education
      --$3,675,021,000 for Vocational Rehabilitation Services (FY2021
            Enacted)

        This training, support and business partnership is vital to our
    country's economic prosperity. For further information, please contact
    Tracey Carey.
        Sincerely.

        [This statement was submitted by Tracey Carey, Executive Director,
    Midwest Urban Strategies.]
                                     ______

         Prepared Statement of the Moore Center for the Prevention of
                               Child Sexual Abuse
        The Moore Center for the Prevention of Child Sexual Abuse at the
    Johns Hopkins Bloomberg School of Public Health (Moore Center) welcomes
    the opportunity to submit this statement for the record about the
    importance of federal investment in child sexual abuse prevention
    research. The Moore Center was founded in 2012 on the premise that
    child sexual abuse is a preventable, not inevitable public health
    problem. Our mission is to create, through rigorous science, a public
    health approach to preventing child sexual abuse. Together with many
    stakeholders in the child welfare community, the Moore Center requests
    that Congress appropriate $10 million for child sexual abuse prevention
    research at the Centers of Disease Control and Prevention's National
    Center for Injury and Violence Prevention, Division of Violence
    Prevention in FY 2022.
        Child sexual abuse and the damage it causes to children, adults,
    families, and communities too often makes headlines. Astoundingly,
    approximately 13 percent of all children will become victims of the
    crime. Child sexual abuse is associated with serious mental and
    physical health problems that shorten the lifespan and reduce its
    quality. Effects include increased risk for post-traumatic stress
    system disorder, substance use disorders (including opioid abuse), HIV,
    heart disease, and suicide. Given this, it is no surprise that our 2018
    study found that the economic burden of child sexual abuse was $9.3
    billion in 2015, and costs each victim more than $280,000 in earning
    and other losses over their lifetime.\1\
    ---------------------------------------------------------------------------
        \1\ Letourneau, Elizabeth J., et al. ``The Economic Burden of Child
    Sexual Abuse in the United States.'' Child Abuse & Neglect, vol. 79,
    2018, pp. 413-422., doi:10.1016/j.chiabu.2018.02.020.
    ---------------------------------------------------------------------------
        The COVID-19 pandemic has further underscored the need for
    effective prevention programming. The National Center for Missing and
    Exploited Children reported an almost 100 percent increase in online
    enticement reports and a 63 percent increase in CyberTipline reports
    between January and September 2020, compared to the same months in
    2019. Additionally, the International Criminal Police Organization
    reported increased consumption of child sexual exploitation and abuse
    materials among several member countries during the pandemic. In
    addition to increased online offending, data from US and UK Stop it
    Now! helplines and websites indicate a surge in requests for help by
    people concerned about their own sexual thoughts and behaviors,
    particularly stepfathers with sexual thoughts about their
    stepdaughters. These increases are likely due to steep pandemic-related
    job losses and work-from-home/learn-from-home policies that leave at-
    risk men who were previously managing their urges with too much time,
    too much access to children, and too little structure. We expect risk
    for online and intra-familial offending will remain high until pre-
    pandemic employment and in-school education levels are regained.
        The federal government rightly funds treatment and other services
    for crime victims, including victims of child sexual abuse, and funds
    criminal justice efforts to detect, prosecute and hold accountable
    those who commit child sexual abuse. Indeed, the federal government
    annual spends approximately $529,000,000 solely to incarcerate people
    with sex crimes against children in federal facilities. Yet 95 percent
    of all sex crimes are committed by people with no prior sex crime
    convictions. As important as victim and criminal justice efforts are,
    they do little if anything to prevent harm from occurring in the first
    place. An inadequate focus on preventing child sexual abuse stands in
    stark contrast to robust federal efforts that address all other forms
    of child victimization as preventable public health problems and not
    solely criminal justice programs. For decades, we have supported the
    development, validation, and dissemination of programs such as home
    visitation that effectively prevent child physical abuse and neglect,
    as well as school-based programs that effectively prevent peer-on-peer
    bullying, teen dating violence, and suicide. The lack of similar
    strategies to prevent child sexual abuse is primarily due to the
    failure to fund similar research in this space.
        In the absence of validated prevention efforts, organizations and
    individuals that work with children have had to develop and implement
    idiosyncratic and untested prevention efforts. Youth serving
    organizations, schools, religious groups, sports clubs, after-school
    programs, child care settings, hospitals, and other youth-focused
    organization have to create and recreate their untested prevention
    strategies. Indeed, most states mandate that child sexual abuse
    curricula be implemented in K-12 schools, yet few such programs have
    been tested for their effectiveness. There is no way to tell if any
    given prevention effort might be effective, ineffective, or even
    harmful to children in the absence of evaluation.
        The FY 2019 appropriations bill directed the CDC to release a
    report on the current state of child sexual abuse prevention research.
    The report, released in December 2019, outlines significant gaps in
    existing research efforts, which include the need to: improve
    surveillance systems and data collection; increase the understanding of
    risk and protective factors; and, strengthen, develop and disseminate
    evidence-based prevention policies, programs and practices.
        In FY 2020 $1 million was allocated to the CDC's Division of
    Violence Prevention, which funded two grants to study adult child
    sexual abuse perpetration prevention. The Moore Center was a recipient
    of one of these grants, which is being used to conduct research to
    validate our Help Wanted intervention, an online prevention program
    designed to provide individuals with sexual interest in younger
    children with the support and resources to maintain their commitment to
    non-offending. Virginia Commonwealth University was the recipient of
    the other grant, which will be used to evaluate Praesidium's Armatus(r)
    Learn to Protect program, a program focused on the prevention of school
    employee-perpetrated child sexual abuse, misconduct, and exploitation
    of students.
        In FY 2021 child sexual abuse prevention research received a
    $500,000 increase. In response, the CDC published a funding opportunity
    announcement for proposals to evaluate approaches on primary prevention
    of child sexual abuse perpetrated by youth or adults. The Moore Center
    was very appreciative for this increase and recognizes the difficulty
    that the budget caps created for giving programs funding increases;
    however, it is critical that additional funding is allocated in FY 2022
    to address the aforementioned research gaps identified by the CDC. We
    believe that a $10 million appropriation would allow for meaningful
    advances to be made in the successful prevention of child sexual abuse.
        We want all American children to grow up free from abuse; federal
    investment in child sexual abuse prevention research is needed to make
    this wish a reality. The foundation and philanthropic community
    currently supporting prevention research and evaluation cannot continue
    to fund it alone. We urge you to include $10 million for research on
    the primary prevention of child sexual abuse at the CDC as funding
    priority for FY 22.
        We look forward to working with the committee on efforts to protect
    our children from child sexual abuse and hope that you will consider
    the Moore Center a resource in the future. Thank you in advance for
    your time and consideration.

        [This statement was submitted by Elizabeth J. Letourneau, Ph.D.,
    Director, Moore Center for the Prevention of Child Sexual Abuse.]
                                     ______

                           Prepared Statement of NAF
        NAF is a national network of education, business, and community
    leaders who work together to ensure high school students are college,
    career, and future ready. NAF appreciates the opportunity to submit
    testimony to the Senate Labor, Health and Human Services, Education,
    and Related Agencies (LHHS) Appropriations Subcommittee regarding our
    request for Fiscal Year 2022 report language for a Work-based Learning
    Coordinators Demonstration Program funded at $5,000,000 at the
    Department of Labor's Employment and Training Administration.
        NAF's educational design promotes open enrollment in our career
    academies and allows students of all backgrounds and capabilities to
    participate. The design is replicable, sustainable, and cost-effective,
    and because it integrates within public schools, supports lasting
    systemic reform and equity nationwide. NAF transforms the learning
    environment to include STEM-infused, industry-specific curricula and
    work-based learning experiences. NAF serves more than 117,000 students
    in 34 states, Washington D.C., Puerto Rico, and the U.S. Virgin
    Islands. NAF is focused on helping to eliminate systemic, educational,
    and professional barriers faced by students of color.
        Economic upheaval from the pandemic will negatively affect the
    young people entering the workforce at a time when communities need
    talented workforce to aid in the recovery. It is even more challenging
    for students of color and from low-income communities with systemic
    inequities who will face lower earnings, less overall wealth, and
    greater economic consequences.
        Public secondary education institutions play a critical role in
    preparing youth for future success through initiatives like career and
    technical education programs, access to local colleges, and work-based
    learning opportunities with employers. As a principal public
    institution that young adults go through before becoming adults, the
    secondary education system plays a significant role in setting up the
    next generation for success in the workforce. Work-based learning
    programs ensure a connection between schools and the working world,
    whether it's preparing students to enter existing jobs, encouraging
    entrepreneurial endeavors, or serving as a foundation for career
    opportunities after post-secondary education.
        Work-based learning is the continuum of activities both in
    classroom learning and the actual workplace setting that leads students
    to gain real world experience. It also has proven economic benefits for
    Black and Latinx students and young people from families with low
    incomes. Through work-based learning, virtual and in-person, students
    can better identify their career interests and aptitudes, understand
    the education and training they need to achieve their aspirations, and
    build their professional and support networks.
        The most effective work-based learning experiences provide
    sustained and meaningful interaction between a student and employer
    partner. This would include career preparation activities such as
    internships, apprenticeships, and mentorship programs. While less
    intensive activities--such as guest speakers, mock interviews, and
    worksite tours--are important to help students with career awareness
    and exploration and to introduce employers to the concept of work-based
    learning, the more time--and resource-intensive activities like
    internships are where students gain the most insight into the working
    world and are able to hone their professional skills.
        When created with intentional student learning outcomes and
    ownership by all stakeholders, work-based learning can shape students'
    aspirational opportunities by helping them explore potential careers of
    interest; build student skills; and help level the playing field by
    exposing students to networking opportunities to build a diverse
    professional network, which research indicates is particularly
    transformative for students of color and those from low-income
    households.
        Further, 80% of jobs are filled through personal and professional
    connections. Work-based learning helps students build these
    relationships and expand their networks beyond their immediate
    communities. The relationships with adults nurtured through work-based
    learning opportunities are also shown to be long-lasting, positively
    benefiting students up to a decade later. Young people deserve an
    education that builds workforce-ready skills, helps them create social
    capital, and connects them to opportunity. This is true in ``normal''
    economic times and even more critical during a downturn.
        Engaging high school students in work-based learning experiences
    ensures these students graduate college, career, and future ready,
    which is essential, especially for students who fail to see the
    connection between high school academics and future careers. In a
    recent study, students enrolled in a NAF program in grade 9 and were
    identified as at-risk of not graduating were 5 percentage points more
    likely to graduate from high school than their non-NAF counterparts.
    NAF academy students have a 99% graduation rate.
        Educators often have the challenge of finding time to plan and
    implement work-based learning due to their lack of staffing capability
    to this particular initiative. With so many demands on school staff,
    work-based learning is seen as supplementary and not a priority.
    Administrators and teachers who have accountability testing
    requirements also push back on the amount of time this strategy
    requires outside of the classroom. These educators may lack the
    capacity to meaningfully engage employers and develop sustainable
    relationships.
        Work-based learning coordinators can bridge the divide between
    school and community employers. The coordinators support work-based
    learning programs by assisting schools and districts with strategic
    program planning, coordinating work-based learning activities, and
    building relationships with employer partners to increase access to
    internships and other career-focused activities.
        NAF encourages schools and communities to have work-based learning
    coordinators as we have seen it make a difference in the quality and
    quantity of experiences for students. NAF urges the subcommittee to
    support and advocate for the inclusion of the following report language
    in the Fiscal Year 2022 Appropriations bill.
        Research shows that participation in work-based learning during
    high school has a positive impact on students, including completing
    high school, and helps them secure higher-quality jobs, boosting equity
    and economic opportunity. To build upon Congress' request of the
    Department in Fiscal Year 2021 to encourage local secondary education
    authorities be included on local workforce development boards, the
    Committee recommends $5,000,000 in Fiscal Year 2022 for the first year
    of a five-year demonstration program to provide full-time, work-based
    learning coordinators in underserved communities with an already proven
    track record for secondary career and technical education. Work-based
    learning coordinators to conduct outreach, engagement, recruitment and
    coordination of work-based learning activities, including, but not
    limited, to paid internships or pre-apprenticeships for high school
    students, with local community employers, especially with in-demand
    industries of information technology, health sciences, and engineering.
    The work-based learning coordinators may be employed by the local
    education agency, local workforce development board or local workforce
    development agency, a group of employers, or a consortium of eligible
    entities. In making grant awards, the Committee directs the Secretary
    to ensure to require a plan for evaluations in each individual grant
    proposal, including types of work-based learning opportunities
    completed, demographics of participating students, and students' post-
    secondary career plan, as well as to conduct a national assessment of
    all grantee proposals once complete.
                                   conclusion
        Though our world is changing rapidly, and we face unprecedented
    challenges; we have an opportunity to pave the way for a stronger and
    more equitable economy. Work-based learning, including paid
    internships, is a proven, effective way to ensure high school students
    are college, career, and future ready and prepared to meet the demands
    of an evolving economy. NAF appreciates the opportunity to share its
    expertise; and thanks you for your consideration of this important
    request.
                                     ______

           Prepared Statement of the National Alliance for Caregiving
        Chair Murray and Ranking Member Blunt, and members of the
    Subcommittee, thank you for your tireless efforts during the COVID-19
    pandemic to ensure that older adults, people with disabilities, and
    their caregivers across the nation could access the supports and
    services that they needed to survive. As you know, during our historic
    collective crisis, Older Americans Act programs that provide community-
    based care and services to millions of older adults, caregivers, and
    people with disabilities each year, became part of the lifeline that
    empowered many to stay safely in their homes. Other vital federal
    programs provided critical support for caregivers, who became
    increasingly isolated during one of our nation's most challenging
    periods. Your Subcommittee's work saved lives and helped to ensure
    quality care for millions of people. We are grateful to you and your
    staff for all you have done.
        As we move into the next phase of the pandemic and recovery, we
    submit our funding requests for FY 2022 with the sincere hope that
    programs supporting family caregivers will again emerge as a priority
    for the Subcommittee. The needs of caregivers in your states and across
    the nation, including mid-career Americans who are juggling children
    and aging parents, have only become more pronounced. Many have left the
    workforce altogether because they needed more support. In the wake of
    emergency investments that responded to a historic increase in the
    needs of older adults and caregivers during the pandemic, federal
    investments cannot simply return to normal.
        We urge congressional appropriators to embrace, at a minimum, many
    of the recommendations included in the FY 2022 Biden Administration
    budget. However, for key, national caregiver support programs, we ask
    that you consider going above the Administration's request and fund
    these programs at levels that sufficiently recognize the immense
    challenges that caregivers of all ages and demographics faced during
    the global crisis. Therefore, we ask that you consider the following
    appropriations requests which fall under the Administration for
    Community Living (ACL) and the Administration on Aging (AoA):
      --$334,000,000--Older Americans Act Title III E, National Family
            Caregiver Support Program (NFSCP), including $400,000 for the
            Recognize, Assist, Include, Support, and Engage (RAISE) Family
            Caregivers Council
      --$21,600,000--Older Americans Act Title VI, Native American
            Caregiver Support Services
      --$14,200,000--Lifespan Respite Care Program
      --$5,000,000--Care Corps Community Care Corps Grants
      --$35,000,000 Alzheimer's Disease Program Initiatives (ADPI):
        In addition, we ask that you provide $20,000,000 for the BOLD
    Infrastructure for Alzheimer's Act initiatives under the Centers for
    Disease Control and Prevention. These funding requests align with those
    of national coalitions that focus on caregiving, including. the
    Leadership Council of Aging Organizations (LCAO), Leaders Engaged in
    Alzheimer's Disease (LEAD), and the Eldercare Workforce Alliance (EWA).
        I submit these requests and this testimony as the President and
    Chief Executive Officer of the National Alliance for Caregiving (NAC).
    NAC's mission is to build partnerships in research, advocacy, and
    innovation to make life better for family caregivers. Our work aims to
    support a society which values, supports, and empowers family
    caregivers to thrive at home, work, and life. As a 501(c)(3) charitable
    non-profit organization based in Washington, D.C., we represent a
    coalition of more than 60 non-profit, corporate, and academic
    organizations; nearly 40 family support researchers with expertise in
    pediatric to adult care to geriatric care; advocates who work on
    national, state, and local platforms to support caregivers across over
    30 states. In addition to our national work, NAC leads and works
    closely with peer organizations in countries such as Australia, Canada,
    Denmark, Finland, France, Hong Kong, India and Nepal, Ireland, Israel,
    Japan, New Zealand, Sweden, Taiwan, and the United Kingdom. You can
    learn more about NAC and our work at www.caregiving.org.
        Background: For the purposes of this testimony, the term
    ``caregiver'' is defined as it is in the RAISE Family Caregivers Act. A
    caregiver is ``an adult family member or other individual who has a
    significant relationship with, and who provides a broad range of
    assistance to, an individual with a chronic or other health condition,
    disability, or functional limitation.'' \1\ Many on this committee have
    been personally impacted by family caregiving. We appreciate your
    leadership and that of your colleagues in the Senate and House who have
    spoken openly, and candidly, about the realities of caregiving.\2\
    Those experiences, along with 53 million other Americans who support a
    friend or family member, form the backbone of our long-term care
    systems.
    ---------------------------------------------------------------------------
        \1\ From P.L. No: 115-119, available at https://www.congress.gov/
    bill/115th-congress/house-bill/3759. In research and in advocacy,
    ``caregiver'' may be described as: informal caregiver, care partner,
    caretaker, and related terminology. In an international context, the
    term ``carer'' is often used. It should be noted that an estimated 1.4
    million children in the U.S. are unpaid caregivers (NAC and United
    Hospital Fund, Young Caregivers in the U.S. (2005) at https://
    www.caregiving.org/data/youngcaregivers.pdf).
        \2\ See Congressional Stories of Family Caregiving (November 2017),
    https://www.caregiving.org/wp-content/uploads/2018/02/GSA-
    Congressional-Stories-of-Caregiving-briefing-paper.pdf.
    ---------------------------------------------------------------------------
        Family caregiving is a public health issue. In a nationally
    representative research study NAC conducted with AARP and released last
    year, we identified some of the common issues facing caregivers
    today.\3\ Just in the last five years, 9.5 million more people have
    taken on caregiving, and we anticipate additional caregivers because of
    the coronavirus pandemic. Compared to 2015, family caregivers have
    faced more confusing care pathways and face a ``ripple effect'' on
    their mental health, physical health, and financial health. About 1 in
    5 (18%) of caregivers feel financial strain due to caregiving.
    Caregivers often must work less, spend more money out-of-pocket, and
    save less for retirement. More people are caring for someone for up to
    five years when compared to five years ago--and these caregivers are
    more likely to care for someone with multiple care needs. Yet we know
    from economic analysis that when supported, family caregivers can
    improve health outcomes for individuals, reduce health care costs, and
    improve population health.
    ---------------------------------------------------------------------------
        \3\ National Alliance for Caregiving and AARP Public Policy
    Institute, Caregiving in the U.S. 2020 (May 2020), Caregiving in the
    U.S. 2020--NAC/AARP Research Report
    ---------------------------------------------------------------------------
        Investing in supports and services for caregivers makes sense. Even
    modest investments could add an additional $1.7 trillion to the U.S.
    GDP by 2030.\4\ New analysis from BlueCross BlueShield \5\ likewise
    anticipates that supporting caregivers can improve population health
    and reduce costs. Without support, caregivers who were also
    commercially insured beneficiaries faced worse overall health, and a
    higher prevalence of cost-driving health conditions including anxiety,
    major depression, adjustment disorder, behavioral health disorders, and
    hypertension. Given the macroeconomic impact of investing in family
    caregivers, we respectfully request that this committee prioritize the
    following FY 2022 federal investments in this essential population.
    ---------------------------------------------------------------------------
        \4\ AARP. The Economic Impact of Supporting Working Family
    Caregivers (2021), available at https://www.aarp.org/content/dam/aarp/
    research/surveys_statistics/econ/2021/longevity-economy-working-
    caregivers.doi.10.26419-2Fint.00042.006.pdf, https://doi.org/10.26419/
    int.00042.006.
        \5\ See, BlueCross BlueShield. The Impact of Caregiving on Mental
    and Physical Health (9/9/20), last accessed 5/25/21, https://
    www.bcbs.com/the-health-of-america/reports/the-impact-of-caregiving-on-
    mental-and-physical-health.
    ---------------------------------------------------------------------------
    OAA Title III E-National Family Caregiver Support Program:
        We request $334,000,000 for the Older Americans Act's (OAA) Title
    III(e), National Family Caregiver Support Program (NFCSP), which is a
    critical cornerstone to supporting the dignity and independence of
    older adults, adults with disabilities, and the friends or family who
    provide care to them. NFCSP offers an entry point for identifying
    caregiver needs and can help to address the need for caregiver
    education, respite, and support. Since 2000, the program has provided
    grants to states and territories to help older adults and people with
    disabilities stay in the home as long as possible. The NFCSP offers
    five core services including information about available services to
    caregivers; assistance to gain access to services; individual
    counseling, organizational of support groups, and caregiver education;
    respite care, to allow caregivers to take a break; and other important
    supplemental services. The NFCSP remains the only nationally
    administered program to provide supports and services to caregivers of
    older adults and people with disabilities.
        Within the National Family Caregiver Support Program, we ask you to
    continue--at a minimum--funding the important and groundbreaking work
    of the Recognize, Assist, Include, Support, and Engage (RAISE) Family
    Caregivers Council. The Administration requested $400,000 for this
    ongoing work in their FY 2022 budget request, which would allow the
    RAISE Family Caregivers Council to work toward fulfilling its mission
    to develop a national strategy to address the needs of family
    caregivers of all ages and circumstances.
    OAA Title VI C-Native American Caregiver Support Services:
        Title VI of the OAA provides grants to eligible Tribal
    organizations to promote the delivery of home and community-based
    supportive services (HCBS), including nutrition services and support
    for family and informal caregivers, to Native American, Alaskan Native,
    and Native Hawaiian elders. During the COVID-19 crisis, we witnessed
    tragic devastation among tribal elders and their families. Therefore,
    we ask you to fund vital caregiver support programs at $21,600,000,
    which would fully double the investment in these programs and continue
    important support for tribal caregiving communities still recovering
    from the ravages of the pandemic.
    Lifespan Respite Care Program:
        The Lifespan Respite Care Program, administered through the
    Administration for Community Living, provides short-term care that
    offers individuals or family members temporary relief from the daily
    routine and stress of providing care. The program strengthens family
    stability and maintains family caregiver health and well-being by
    providing often desperately needed respite to exhausted and at-risk
    caregivers. Additionally, respite care proved through this program can
    save additional federal dollars by helping to delay, or altogether
    avoid, out-of-home placements or hospitalizations. Only 14 percent of
    family caregivers report having used respite care service, despite
    nearly 38 percent feeling respite would be helpful. We urge your
    Subcommittee to adopt the President's budget request of $14,200,000 for
    this vital program.
    Community Care Corps Grants:
        Within ACL's program portfolio, we urge you to continue to fund the
    important work of the Community Care Corps Grant program at $5,000,000.
    The Community Care Corps supports innovative local models in which
    trained volunteers assist family caregivers or directly assist older
    adults or adults with disabilities in maintaining their independence.
    These volunteers provide critical non-medical support and companionship
    to supplement their other caregiving options and relieve over-burdened
    family caregivers and help meet the growing demand for services from a
    large and growing aging and disability population.
    Alzheimer's Disease Program Initiatives (ADPI) and BOLD Act
            Initiatives:
        Within both the Administration for Community Living and the Centers
    for Disease Control and Prevention, there are two important programs
    that support those caring for Alzheimer's disease and related dementias
    (ADRDs). ADPI supports HCBS for people living with ADRD and their
    caregivers through grants to states, communities, and Tribal entities.
    To support the important work of ADPI, we hope your committee will
    support a $35,000,000 FY 2022 funding request. Within CDC, the Building
    Our Largest Dementia (BOLD) Infrastructure for Alzheimer's Act
    Initiatives establish an effort within the Centers of Excellence in
    Public Health Practice dedicated to promoting Alzheimer's disease
    management and caregiving interventions. We encourage your Subcommittee
    to include $20,000,000 to support the BOLD Initiatives.
        In closing, these vital federal efforts and programs that support
    millions of family caregivers across the country have a profound impact
    on the quality of life. They can reduce caregiver depression, anxiety,
    and stress, enabling caregivers to provide care longer and thereby
    avoiding or delaying the need for costly hospital and institutional
    care. On behalf of myself, the National Alliance for Caregiving, other
    national aging and disability advocates, and countless caregivers
    across the country, I implore you and your Subcommittee to support FY
    2022 funding levels for these programs that recognize and respect the
    immense contribution of caregivers to society. Thank you again for all
    you have done and will do for older adults and individuals with
    disabilities and their caregivers.

        [This statement was submitted by C. Grace Whiting, J.D., President
    and CEO, National Alliance for Caregiving.]
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
                               executive summary
        NAEVR, which serves as the ``Friends of the National Eye
    Institute,'' is a 501(c)4 non-profit advocacy coalition comprised of 50
    organizations involved in eye and vision research, including
    ophthalmic/optometric professional societies, patient and consumer
    groups, private funding foundations, and industry. NAEVR is immensely
    grateful to Congress, especially the House and Senate Appropriations
    Subcommittees on Labor, Health and Human Services, and Education
    (LHHS), for the strong bipartisan support for National Institutes of
    Health (NIH) funding increases from Fiscal Years (FY) 2016 through
    FY2021. The $12.85 billion NIH increase in that timeframe has helped
    the agency regain ground lost after a decade of effectively flat
    budgets.
        This past investment in NIH has not only improved our understanding
    of fundamental life and health sciences but also prepared the nation to
    combat unprecedented health threats, including the COVID-19 pandemic,
    and promoted ever-evolving medical advances. To maintain this momentum
    in FY2022, NAEVR strongly supports the NIH program funding level of
    $51.95 billion as proposed by President Biden, including no less than
    $46.1 billion for NIH's base program level budget [absent proposed
    funding for the Advanced Research Projects Agency-Health (ARPA-H)], an
    increase of at least $3.177 billion or 7.4 percent (as compared to the
    Administration's proposed $45.45 billion NIH base funding level, which
    is a $2.51 billion or 5.9 percent increase), to enable NIH's base
    budget to keep pace with the Biomedical Research and Development Price
    Index (BRDPI) and allow for 5 percent growth. This increase is
    necessary to support promising science across all Institutes and
    Centers (ICs), ensure continued Innovation Account funding established
    through the 21st Century Cures Act for special initiatives, and support
    early-stage investigators.
        NAEVR also urges one-time emergency funding for federal research
    agency ``research recovery'' investment to enable NIH to mitigate the
    pandemic-related disruptions without foregoing promising new science.
    NAEVR supports the bipartisan Research Investment to Spark the Economy
    (RISE) Act (H.R. 869/S. 289) which includes $10 billion for NIH
    (although at the Subcommittee's May 26, 2021, hearing NIH Director
    Francis Collins, MD, PhD estimated that the pandemic shutdown resulted
    in a $16 billion loss to its biomedical enterprise). Though pandemic-
    related lab closures impacted all researchers, the situation was
    especially acute for early-stage investigators. NAEVR's educational
    foundation Alliance for Eye and Vision Research (AEVR) documented this
    impact in a September 2020 video discussion engaging 22 Emerging Vision
    Scientists who described the chilling effect on their research,
    collaborations, training, and overall career pathway (a journal article
    version of this discussion will be published on July 1, 2021, in JAMA
    Ophthalmology),
        NAEVR also urges Congress to fund the National Eye Institute (NEI)
    at $900 million, a $64.3 million or 7.7 percent increase over FY2021
    that reflects both biomedical inflation and growth as compared to the
    Administration's $858.4 million funding level, a $22.83 million or 2.7
    percent increase. Despite NEI's total $160 million funding increases in
    the FY2016-2020 timeframe, its enacted FY2021 budget of $835.7 million
    is just 19 percent greater than the pre-sequester FY2021 funding of
    $702 million. Averaged over those nine fiscal years, the 2.1 percent
    annual growth rate is still less than the average annual biomedical
    inflation rate of 2.7 percent, thereby eroding purchasing power. In
    fact, NEI's FY2021 purchasing power is less than that in FY2012.
        The NEI currently faces an increasing burden of vision impairment
    and eye disease due to an aging population, the disproportionate risk/
    incidence of eye disease in fast-growing minority populations, and the
    impact on vision from numerous chronic diseases (such as diabetes) and
    their treatments/therapies. Especially with the COVID-19 pandemic, the
    NEI faces additional challenges, as both the working age population and
    students have relied almost exclusively on electronic communications
    devices and e-learning platforms which can increase the rates of
    myopia, dry eye, eye strain, and other vision disorders.
        Maintaining the momentum of vision research is vital to vision
    health, as well as to overall health and quality of life. Since the US
    is the world leader in vision research and training the next generation
    of vision scientists, the health of the global vision research
    community is also at stake.
               nei-funded research saves sight and restores vision
        The past federal investment in vision research has led to major
    advances in the prevention of vision loss as well as the restoration of
    vision.
        Audacious Goals Initiative: The NEI has been at the forefront of
    regenerative medicine with its Audacious Goals Initiative (AGI), which
    launched in 2013 with the goal of restoring vision. Engaging a broad
    constituency of scientists from the vision community and numerous other
    disciplines, the AGI currently funds major research consortia that are
    developing innovative ways to image the visual system. Researchers can
    now look at individual nerve cells in the eyes of patients in an
    examination room and learn directly whether new treatments are
    successful. Another consortium is identifying biological factors that
    allow neurons to regenerate in the retina. And the AGI is gathering
    considerable momentum with current proposals to develop disease models
    that may result in clinical trials for therapies within the next
    decade.
        Retinal Diseases: The NEI has been at the forefront of research
    into retinal diseases. NEI-funded researchers helped show that a
    protein called Vascular Endothelial Growth Factor (VEGF) stimulates
    abnormal blood vessel growth that occurs in the advanced stages of the
    ``wet'' form of Age-related Macular Degeneration (AMD) and Diabetic
    Retinopathy. Food and Drug Administration (FDA)-approved anti-VEGF drug
    therapies that slow the development of blood vessels in the eye delay
    vision loss and may improve vision for patients. The NEI has funded
    comparison trials of anti-VEGF drugs to provide eye care professionals
    and patients with the information they need to choose the best
    treatment options.
        With respect to the ``dry'' form of AMD, known as geographic
    atrophy and the leading cause of vision loss among individuals age 65
    and older, in late 2019 NEI began a first-in-human clinical trial that
    tests a stem cell-based therapy from induced pluripotent stem cells
    (iPSC) to treat geographic atrophy. This trial converts a patient's own
    blood cells to iPS cells which are then programmed to become retinal
    pigment epithelial (RPE) cells, which nurture the photoreceptors
    necessary for vision and which die in geographic atrophy. Bolstering
    remaining photoreceptors, the therapy replaces dying RPE with iPSC-
    derived RPE.
        Genetics/Genomics: The NEI has been at the forefront of genetics/
    genomics and gene therapy approaches to various vision disorders--both
    common and rare. The causes of AMD and glaucoma remain elusive--
    although most cases are not inherited, genetics does play a role. While
    NEI-funded researchers have identified many genetic risk factors for
    AMD and glaucoma, further study of these genes is helping to elucidate
    the biology of these disease and holds promise for improved therapies.
        NEI-funded research has also made discoveries of dozens of rare eye
    disease genes possible, including the discovery of RPE65, which causes
    congenital blindness called Leber congenital amaurosis (LCA). As of
    late 2017, NEI's initial efforts led to a commercialized, Food and Drug
    Administration (FDA)-approved gene therapy for this condition. These
    gene-based discoveries are forming the basis of new therapies that
    treat the disease and potentially prevent it entirely.
        Front-of-Eye Research: The NEI has launched an Anterior Segment
    Initiative (ASI) in order to capitalize on research opportunities at
    the front of the eye. The ASI is addressing clinically significant,
    quality-of-life problems such as ocular pain and Dry Eye Disease (DED),
    especially in terms of pain and discomfort sensations, as well as
    disruptions in the tearing process. Using multi-disciplinary
    approaches, the ASI plans to elucidate relevant anterior segment
    innervation pathways that contribute to normal or abnormal functioning
    of the neural circuits related to the ocular surface.
      congress must robustly fund the nei as it addresses the increasing
                  burden of vision impairment and eye disease
        NEI's FY2021 enacted budget of $835.7 million is less than 0.5
    percent of the $177 billion annual cost (inclusive of direct and
    indirect costs) of vision impairment and eye disease, which was
    projected in a 2014 Prevent Blindness study to grow to $317 billion--or
    $717 billion in inflation-adjusted dollars--by year 2050. Of the $717
    billion annual cost of vision impairment by year 2050, 41 percent will
    be borne by the federal government as the Baby-Boom generation ages
    into the Medicare program. A 2013 Prevent Blindness study reported that
    direct medical costs associated with vision disorders are the fifth
    highest--only less than heart disease, cancers, emotional disorders,
    and pulmonary conditions. The U.S. is spending only $2.53 per-person,
    per-year for vision research, while the cost of treating low vision and
    blindness is at least $6,680 per-person, per-year. [http://
    costofvision.preventblindness.org/]
        A May 2021 JAMA Ophthalmology article reported that more than 7
    million people in the U.S. are living with uncorrectable vision loss,
    including more than 1 million with blindness. Of those living with
    vision loss and blindness, nearly 1 in 4 are under the age of 40, while
    20 percent of all people aged 85 and older experience permanent vision
    loss. More females than males experience permanent vision loss or
    blindness, and the Hispanic and African American populations experience
    a higher risk of vision loss. This study's research methods allowed for
    a broader analysis of populations in the U.S. (including individuals
    under age 40) than that used in previous national estimates of vision
    loss and blindness. [doi:10.1001/jamaophthalmol.2021.0527]
        In an August 2016 JAMA Ophthalmology article, AEVR reported from a
    national attitudinal survey that a majority of Americans across all
    racial and ethnic lines describe losing vision as having the greatest
    impact on their day-to-day life. Other studies have reported that
    patients with diabetes who are experiencing vision loss or going blind
    would be willing to trade years of remaining life to regain perfect
    vision, since they are concerned about their quality of life.
    [doi:10.1001/jamaophthalmol.2016.2627]
        Investing in vision health is an investment in overall health.
    NEI's breakthrough research is a cost-effective investment, since it
    leads to treatments and therapies that may delay, save, and prevent
    health expenditures. It can also increase productivity, help
    individuals to maintain their independence, and generally improve the
    quality of life--as vision loss is associated with increased
    depression/accelerated mortality.
        In summary, NAEVR supports the President's request for $51.95
    billion in NIH funding but urges the Subcommittee to appropriate no
    less than $46.1 billion for NIH's base program level and $900 million
    for the NEI. NAEVR also supports one-time emergency ``research
    recovery'' investment to mitigate the pandemic-related disruptions
    without foregoing promising new science.
        NAEVR thanks the Subcommittee for the opportunity to submit this
    written testimony, especially as it continues to grapple with the long-
    term challenges from the COVID-19 pandemic.
        For more information, visit NAEVR's Web site at
    www.eyeresearch.org.

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

     Prepared Statement of the National Alliance for Public Charter Schools
        Madam Chair and Members of the Subcommittee, I am pleased to
    present the views of the National Alliance for Public Charter Schools
    on the fiscal year (FY) 2022 appropriation for the Charter Schools
    Program (CSP), which is administered by the U.S. Department of
    Education. I thank the Subcommittee for maintaining strong support for
    the CSP, including by providing $440 million for FY 2021. The CSP plays
    a critical role in expanding educational opportunities for families and
    in improving educational outcomes nationwide. As the Subcommittee
    considers the FY 2022 Labor, Health and Human Services, Education and
    Related Agencies appropriation, we request an increase in funding for
    the CSP to at least $500 million.
        We support the Administration's proposed investments in programs
    that will benefit all public school students, including the Title I
    program and the Individuals with Disabilities Education Act. These
    increases, along with the other COVID relief funds, will help charter
    schools, like other public schools, address the many challenges they
    face after the pandemic-related shutdowns. At the same time, we were
    disappointed to see that the Administration's budget proposal called
    for flat funding of the CSP. The CSP is the only source of federal
    funding to support the growth of high-quality charter schools in the
    communities that need them most. Given charter schools' history of
    educating students with disadvantages in diverse situations, a $60
    million increase for the CSP will deliver outsized returns.
              the operation of charter schools during the pandemic
        The COVID-19 pandemic has been extremely challenging for charter
    schools, just as for all other public schools. Most had to pivot
    quickly from on-site instruction to distance learning, ensure that
    teachers had the skills and knowledge to deliver online instruction
    effectively, overcome disparities in student access to technology, and
    address many other challenges. Fortunately, charter schools are used to
    innovating and adapting to meet changing needs, and in this time of
    crisis they were able to leverage their autonomy effectively. A recent
    report released in partnership with Public Impact found that small
    charter networks and single-site charter schools (which together
    account for 65 percent of all charter schools) were more likely than
    district schools to set expectations that teachers would engage in
    real-time synchronous instruction, check in regularly with students,
    and monitor attendance. Parents have responded accordingly: an April
    2021 survey of more than 2,700 parents nationwide found that 65 percent
    believe that choices like charter schools and learning pods would be
    ``extremely or very effective'' in helping students in their state.
    Parents want more opportunities for their kids, and charter schools are
    one critical way of providing them.
            understanding charter schools and their accomplishments
        In recent years, and notwithstanding charter schools' achievements
    and significant efforts to meet the needs of students during the
    pandemic, we have seen a number of misconceptions emerge about charter
    schools. To be clear, charter schools are public schools, supported by
    taxpayers, and open to all students, without entrance requirements. The
    CSP is the only federal K-12 program that requires its recipients to be
    open enrollment. Each State decides who may authorize charter schools
    and how schools will be held accountable for meeting the goals laid out
    in their charters. And charter schools, as public schools of choice,
    are ultimately accountable to parents: if a charter school is not
    delivering for families, it will not remain open. Moreover, while
    charter schools typically have more flexibility than district schools--
    such as to set curriculum, hire teachers and staff, and adapt to meet
    the needs of their students--they are required to meet the same
    academic testing and Title I accountability requirements as other
    public schools.
        Most importantly, although there is some variety in charter school
    performance, in the main they are delivering. The 2015 Urban Charter
    School Study, from the Center for Research on Education Outcomes
    (CREDO) at Stanford University, found that students in urban charter
    schools gained an average of 40 additional days of learning per year in
    math and 18 days in reading, compared to their non-charter-school
    peers. Moreover, the study found that the longer a student attends an
    urban charter school, the greater the gains: four or more years of
    enrollment in such a school led to 108 additional learning days in math
    and 72 in reading.
        More recently, a 2020 study from the Program on Education Policy
    and Governance at Harvard University found greater academic gains for
    students in charter schools than for students in traditional public
    schools who took the reading and math assessments administered by the
    National Assessment of Educational Progress (NAEP) in fourth and eighth
    grade between 2005 and 2017. African American and low-income students
    attending charter schools were almost 6 months ahead of their peers in
    reading and math compared with students in traditional public schools
    over the 12-year span of the study. This was the first nationwide study
    to compare student achievement trends over time between sectors rather
    than effectiveness at a single point in time.
             the importance of the federal charter schools program
        First authorized in 1994 through the bipartisan efforts of
    President Bill Clinton and Congressional leaders, the CSP was
    originally created to support the start-up costs of new schools. Since
    then, the program has enjoyed strong support from Presidents and
    Members of Congress from both parties, and has expanded to address the
    changing needs of the movement.
        Since its inception, Congress has appropriated some $6.3 billion
    for the CSP. To put that number in context, it amounts to less than 2
    percent of the appropriation for ESEA Title I LEA Grants over that same
    time period. This modest investment has helped the number of charter
    schools grow from only a handful in the early 1990s to around 7,500
    schools and campuses today that serve around 3.3 million public school
    students. CSP has made many of those schools possible by supporting
    non-sustained start-up costs not covered by per-pupil funding-such as
    planning, staff training, equipment and materials, renovations,
    recruitment, and other necessary start-up activities. In addition,
    State appropriations have often not given charter schools the same
    level of per-pupil support as non-charter schools, and often have not
    addressed their facilities needs. The majority of all charter schools,
    therefore, have needed CSP grants to open.
        The CSP makes it possible for new charter schools to open to
    address changing community needs. One such school--Lumen High School in
    Spokane, WA--received a 2020 subgrant from the Washington State Charter
    Schools Association, a 2019 State Entity CSP grant recipient. Lumen is
    a dual-generational school designed to meet the layered need of teen
    parents. It offers childcare and early childhood education,
    incorporates parenting skills in the curriculum, and offers critical
    wraparound services to eliminate barriers that might keep parenting
    teens from accessing education. When the COVID-19 pandemic struck,
    Lumen's founding Executive Director was offered the chance to delay
    opening for a year but chose to put the needs of her community first
    and open in the midst of the pandemic because, as she explained, ``our
    students need school now.'' Increased CSP funding makes it possible for
    schools like Lumen to open in the communities that need them most.
        Charter school enrollment has grown rapidly, but it has not kept up
    with family demand. Surveys indicate that some 3.3 to 3.5 million
    additional students would attend a charter school if space were
    available to them. Many of those are students who currently attend
    schools identified as in need of support and improvement under Title I,
    that is, schools that are not meeting State performance targets. The
    increase we recommend would enable the creation of charter schools to
    serve more of the students and families who want them.
                            fiscal year 2022 request
        As previously noted, our request for FY 2022 is $500 million-a $60
    million increase that would be a wise investment. Within the account,
    funds should be allocated to programs with floors and ceilings so that
    the Department can shift funds according to the needs of the field from
    one year to the next. $500 million would provide sufficient funding for
    new grants to States and CMOs and thus enable those entities to support
    the creation of new charter schools. This would reduce wait lists and
    provide high-quality educational options to more families, particularly
    those in communities that have been hit hard by the pandemic and where
    the learning needs are greatest. It will also help ensure funds are
    available for states that have recently strengthened their charter
    school laws, including Iowa, Wyoming, and West Virginia.
        Finally, our request would help charter schools access appropriate
    facilities. Charter schools generally have not had the same access to
    funding sources that support the facilities needs of other public
    schools, such as municipal bonds, property tax revenues, and State
    school facilities programs. This forces schools to scrape by in
    buildings not designed for learning, use funds that should have been
    available for instruction to cover facility needs, or simply not open
    at all. The two small facilities programs included in the CSP--Credit
    Enhancement for Charter School Facilities and the State Facilities
    Incentive Grants--help fill some of this unmet need.
                                   conclusion
        The National Alliance for Public Charter Schools takes great pride
    in the growth and accomplishments of public charter schools over the
    last quarter century. Our schools' enrollments continue to climb, and
    more and more studies have found that charter schools are succeeding:
    they increase achievement and meet the other needs of a diverse and
    often historically underserved student population. This success could
    not have been achieved without the CSP. We ask that you continue that
    support and accept our recommendation for $500 million for FY 2022.

        [This statement was submitted by Nina Rees, President and CEO,
    National
    Alliance for Public Charter Schools.]
                                     ______

         Prepared Statement of the National Alliance on Mental Illness
        Chairwoman Murray, Ranking Member Blunt and Members of the
    Subcommittee, on behalf of the National Alliance on Mental Illness,
    thank you for the federal investments in mental health crisis response
    that you have supported and made possible so far. I appreciate the
    opportunity to discuss NAMI's priorities, many of which we share, as
    evidenced by the hearing this Subcommittee held last week on building a
    robust crisis response system. Without personnel who are trained to
    handle mental health emergencies, and without the infrastructure in
    place, the default response to many people in crisis is a law
    enforcement response, which often ends in trauma or tragedy. In fact,
    one in four fatal police shootings are of people with mental illness,
    with one in three being people of color. The lack of effective crisis
    response also burdens emergency departments (EDs) that are ill-equipped
    for mental health crises, despite the fact that one of every eight ED
    visits is related to a mental health or substance use disorder. But as
    you said in your statement, Madame Chairwoman, there is something we
    can do about it. Thank you for your leadership.
        NAMI is grateful that Congress passed the bipartisan National
    Suicide Hotline Designation Act of 2020, which created 988 as a three-
    digit mental health and suicide crisis line that will go live
    nationwide by July 16, 2022. This alternative to 911 gives communities
    the opportunity to transform care by developing 988 crisis response
    systems with the core elements described in SAMHSA's National
    Guidelines for Crisis Care: 1) crisis call centers, 2) mobile crisis
    teams, and 3) crisis receiving and stabilization programs. Crisis call
    center hubs, staffed by people well-trained in crisis response, can
    assist the vast majority of people calling with a behavioral health
    crisis. For those who need more, mobile crisis teams provide an in-
    person response and are able to effectively de-escalate the majority of
    behavioral health crises and connect people to follow-up services. In
    situations where needs are more acute, crisis receiving and
    stabilization services provide safe, therapeutic settings that reduce
    reliance on ED visits and can avoid the need for hospitalization.
        While there is a clear vision for successful 988 crisis response
    systems, few systems meet the standards needed to realize this vision.
    Currently, National Suicide Prevention Lifeline (Lifeline) call centers
    rely on a patchwork of inadequate funding, leaving insufficient
    capacity to meet current needs, let alone the increased demand that
    will be spurred by the adoption of 988. There is growing availability
    of mobile crisis teams, but demand still far outstrips supply,
    particularly for children and adolescents. There is a dearth of crisis
    stabilization programs nationwide, and widespread shortages of
    behavioral health professionals to staff crisis response systems.
        Robust federal investment is required to realize the promise of 988
    to deliver a mental health response to mental health crises. Some
    states are adopting 988 user fees, but those fees are minimal and will
    support only a portion of 988 crisis system costs. Medicaid rarely
    covers the full costs of the core services--and it does not cover
    services for people who are not Medicaid-eligible. Without federal
    support, communities will be unable to develop and sustain a crisis
    infrastructure that ensures a mental health response will be available
    for mental health crises.
        To help communities develop capacity for the critical first element
    of a 988 crisis system, crisis call center response, NAMI strongly
    recommends including $240 million in FY2022 for the National Suicide
    Prevention Lifeline. This recommendation is based on an initial
    analysis from Vibrant Emotional Health, the current administrator of
    the Lifeline. This will provide needed funding to expand capacity for
    988 calls, chats, and texts, including implementing technology,
    enhancing standards and training, and providing nationwide back-up for
    local call centers.
        In FY2021, this Subcommittee included an additional $35 million in
    the Mental Health Block Grant to fund a 5% set-aside for Crisis Care
    Services. While this was a valuable start and we are grateful for this
    investment that is helping states develop crisis services, especially
    mobile crisis teams, the need is substantial. That is why NAMI is
    requesting a 10% set-aside for crisis services in FY2022 to provide
    critical funds to both start up crisis services and to support the many
    costs of crisis care that are not covered by Medicaid or insurance
    plans.
        NAMI is also requesting $12.5 million for the SAMHSA Strengthening
    Community Crisis Response Systems program. When someone experiences a
    mental health crisis, they often wind up in hospital emergency
    departments (EDs) where they frequently end up waiting in hallways,
    sometimes for days, before being admitted to an inpatient or
    residential facility. This practice, referred to as ``ED boarding,'' is
    harmful to patients and strains already-burdened EDs. The $12.5 million
    we are requesting will help communities reduce the traumatic practice
    of ED boarding by providing intensive crisis services, such as crisis
    receiving and stabilization programs, and by implementing databases of
    beds at inpatient and residential behavioral health facilities that
    help reduce the wait for intensive treatment.
        These three programs, while important, are only part of realizing
    the promise of a successful crisis response system. And while some of
    the needed investments fall outside this Subcommittee's jurisdiction, I
    believe it is important to give you the full picture of what is
    required to effectively implement a comprehensive 988 crisis response
    system over the next several years.
        Whether through the annual appropriations process, broader efforts
    to upgrade our country's infrastructure, or other means, Congress must
    invest $10 billion over the next 10 years in 988 infrastructure in
    three key areas: 1) Supporting capital projects and operations, 2)
    Increasing the behavioral health workforce, and 3) Ensuring Medicare,
    Medicaid, and TRICARE coverage. I would like to give you a quick
    overview of what is needed in each area.
        First, supporting 988 capital projects and operations. To build a
    mental health crisis system that relies on well-equipped 988 call
    centers as the first point of contact, federal support of the national
    Lifeline should be supplemented by federal authorization and funding,
    based on SAMHSA's projections, to support operations at 180+ local
    Lifeline call centers across the country. This will ensure that people
    get connected to services when and where they need them.
        In addition, communities need support for capital expenses to
    expand crisis services, such as mobile crisis team vans, facilities for
    crisis receiving and stabilization and peer respite programs, and call
    center infrastructure. Congress should expand funding and broaden the
    uses of the Health Resources and Services Administration's (HRSA)
    current Capital Development Grants to include crisis system
    infrastructure.
        Second, increasing the behavioral health workforce. As the
    Subcommittee knows, behavioral health workforce shortages pose
    challenges for health systems, including crisis response. Congress can
    help by significantly expanding behavioral health workforce training
    programs, including HRSA's Behavioral Health Workforce Education and
    Training (BHWET) and Graduate Psychology Education (GPE) programs, as
    well as SAMHSA's Minority Fellowship Program (MFP). In addition, to
    help recruit and retain skilled staff, HRSA's National Health Service
    Corps Loan Repayment Program criteria must be expanded to include
    crisis call centers, mobile crisis teams, crisis receiving and
    stabilization programs, and Certified Community Behavioral Health
    Clinics.
        Third, ensuring Medicare, Medicaid, and TRICARE coverage of crisis
    services. It is also vital that Medicare, Medicaid, and TRICARE cover
    mobile crisis and crisis stabilization services. Together, these
    programs cover tens of millions of people, many of whom will experience
    mental health and suicidal crises and deserve an appropriate response.
    Peer support specialists in particular play critical roles in crisis
    services yet are not covered providers under Medicare. That must
    change. Finally, to maximize access to behavioral health crisis
    services, Congress should make permanent the current flexibilities for
    Medicare coverage of telehealth behavioral health services.
        It is NAMI's priority to ensure that an effective 988 crisis
    response system infrastructure is developed across the country and we
    are grateful for this Subcommittee's support. We recognize that it is
    also important to invest in research and a wide range of prevention,
    intervention, and recovery programs at SAMHSA, including Certified
    Community Behavioral Health Clinics, that help people get on a path of
    recovery. To that end, we urge your consideration of the Mental Health
    Liaison Group (MHLG) recommendations for FY2022 appropriations. NAMI
    also offers our strong support for the President's FY2022 proposed
    budget of $1.6 billion for the community mental health block grant and
    $1 billion to increase mental health professionals in schools.
        Thank you for this opportunity and for the leadership you have
    demonstrated in advancing mental health care. I look forward to working
    with you to put in place the infrastructure to support a 988 crisis
    response system and transforming mental health care in America.

        [This statement was submitted by Angela Kimball, National Director
    of Advocacy & Public Policy, National Alliance on Mental Illness.]
                                     ______

       Prepared Statement of the National Alliance to End Sexual Violence
        The National Alliance to End Sexual Violence (NAESV) is the voice
    in Washington for the 56 state and territorial sexual assault
    coalitions and 1500 local programs working to end sexual violence and
    support survivors. The programs included in the Violence Against Women
    Act (VAWA) are a vital part of local programs' work to support
    survivors and end sexual violence. This testimony focuses specifically
    on the Rape Prevention & Education Program (RPE), a VAWA program
    located at the Centers for Disease Control, Injury Center, and the need
    to increase funding for the program from $51.75 million to $100 million
    in FY 22 as recommended by the President's budget and include report
    language requiring the collaboration with state sexual assault
    coalitions in the program. We are grateful to the committee for the $1
    million increase for RPE in FY 21, however, increased funding is
    desperately needed.
        RPE formula grants, administered by the CDC Injury Center, provide
    essential funding to states and territories to support rape prevention
    and education programs conducted by rape crisis centers, state sexual
    assault coalitions, and other public and private nonprofit entities. In
    the past few years, demand for programs funded by RPE have skyrocketed,
    the evidence base has progressed significantly, the current
    appropriation is very nearly the authorized level, and further
    investment in the program is desperately needed. The #MeToo movement,
    the national focus on campus sexual assault, and high-profile cases of
    sexual violence in the media have increased the need for comprehensive
    community responses to sexual violence but have also increased the
    demand for prevention programs beyond providers' capacity.
        According to the National Intimate Partner and Sexual Violence
    Survey (CDC, 2015 national data):
      --21% of women and 3% of men reported completed or attempted rape
            ever in their lifetime.
      --Among victims of rape, 43% (11 million) of females and 51% (1.5
            million) of males reported it occurred for the first time
            between the ages of 11-17.
        If our children are to face a future free from sexual violence, RPE
    must be increased. The RPE program prepares everyday people to become
    heroes, getting involved in the fight against sexual violence and
    creating safer communities by engaging boys and men as partners;
    supporting multidisciplinary research collaborations; fostering cross-
    cultural approaches to prevention; and promoting healthy, non-violent
    social norms, attitudes, beliefs, policies, and practices.
    We know RPE is working.
        A 2016 study conducted in 26 Kentucky high schools over 5 years and
    published in American Journal of Preventive Medicine found that an RPE-
    funded bystander intervention program decreased not only sexual
    violence perpetration but also other forms of interpersonal violence
    and victimization.
        ``The idea that, due to the effectiveness of Green Dot, ... there
    will be many fewer young people suffering the pain and devastation of
    sexual violence: This is priceless.'' Eileen Recktenwald, Kentucky
    Association of Sexual Assault Programs
        Across the country, states and communities are engaged in cutting-
    edge prevention projects:
      --Connecticut's Women & Families Center developed a multi-session
            curriculum addressing issues of violence and injury targeting
            middle school youth.
      --Oklahoma is working with domestic violence and sexual violence
            service agencies, public and private schools, colleges and
            other community-based organizations to prevent sexual violence.
      --Alaska's Talk Now Talk Often campaign is a statewide effort
            developed in collaboration with Alaskan parents, using
            conversation cards, to help increase conversations with teens
            about the importance of having healthy relationships.
      --Kansas is looking closely at the links between sexual violence and
            chronic disease to prevent both.
      --Maryland's Gate Keepers for Kids program provides training to
            youth-serving organizations to safeguard against child sexual
            abuse.
      --Missouri is implementing ``Green Dot'' bystander education
            statewide to reduce the rates of sexual violence victimization
            and perpetration.
      --North Carolina was able to ensure sustainability of its consent-
            based curriculum by partnering with the public-school system to
            implement their sexual violence prevention curriculum in every
            8th grade class.
      --Washington is implementing innovative skill building projects that
            amplify the voices of historically marginalized communities,
            such as LGBTQ youth, teens with developmental disabilities,
            Asian American & Pacific Islander teens, & Latino parents &
            children.
    Why increase funding for RPE?
        The societal costs of sexual violence are incredibly high including
    medical & mental health care, law enforcement response, & lost
    productivity. 2017 research sets the lifetime economic burden of rape
    at $122 million per victim and also reveals a strong link between
    sexual violence and chronic disease.
        The national focus on campus and military sexual assault as well as
    high profile cases of sexual violence in the media have increased the
    need for comprehensive community responses to sexual violence but has
    also increased the demand for prevention programs beyond providers'
    capacity.
        A Missouri program reported: ``The demand for our services has
    increased about 18% both in 2014 and in 2015. Increased awareness and
    increased need (crime) are most likely contributors to this trend.
    There are limited resources available for prevention education. In
    addition, new government requirements/laws, such as with Title IX and
    PREA, have contributed to referrals to our organization. Our
    organization always works to increase support from local resources, but
    funding is extremely competitive and limited.''
        A Massachusetts program reported: ``With Title IX in the news,
    requests for prevention education have increased...We are saying no to
    many requests for education because of capacity issues. We are unable
    to build and sustain relationships with other underserved communities
    because of a lack of capacity.''
        A Nebraska program reported: ``I am hugely dismayed at the lack of
    funding for prevention...It's noble to provide direct services to
    victims of sexual violence, but if we don't provide prevention monies,
    then we are just a band-aid. It's terribly frustrating.''
    Funded involvement of state sexual assault coalitions is imperative for
            the success of RPE.
        RPE was first authorized in the original 1994 version of the
    Violence Against Women Act (VAWA) and has been reauthorized
    subsequently with each iteration of VAWA. RPE was the brainchild of
    National Alliance to End Sexual Violence (NAESV) founder, Gail Burns-
    Smith, as a coordinated federal response to the prevention of sexual
    violence. While funding goes to state health departments, the original
    intent of the RPE program was to fully involve state sexual assault
    coalitions and rape crisis centers as leaders in this work because of
    their vast experience in addressing sexual violence. Over the years,
    the level of involvement of state coalitions has varied between states
    and has ebbed and flowed. At the same time, there are states in which
    the state sexual assault coalition has never been meaningfully involved
    in RPE.
        During 2019, NAESV met with state sexual assault coalitions and
    conducted two membership surveys. While some state coalitions continue
    to have good and strong working relationships with their state health
    departments and feel positively about how RPE is being administered,
    based on our research, over half of the state sexual assault coalitions
    are dissatisfied or very dissatisfied with how RPE is being
    administered. This past year, there have been changes in some states
    that have resulted in both concerns about state approaches to RPE and
    elimination of some state sexual assault coalitions involvement in RPE-
    funded prevention work. Our research also found that:
        1. One in four coalitions expressed a concern about lack of sexual
    violence expertise in the administration of RPE at the state level.
        2. 30% of coalitions have concerns about lack of collaboration and
    leadership.
        3. Over 60% of coalitions thought there was too little involvement
    of community based sexual assault programs in the work of RPE.
        NAESV has concluded, with the complete consensus of state sexual
    assault coalitions, that enough states are having a problem to warrant
    a legislative solution. Communities deserve the best, most well-
    informed prevention efforts especially in this era where demand and
    interest in sexual violence prevention is so high. We know, with the
    funded involvement of state sexual assault coalitions and increased
    funding, RPE can be an even more powerful tool in ending sexual
    violence. The field looked to other successful national formula grants
    designed to address violence against women as a guide in developing a
    legislative proposal. The STOP and Sexual Assault Services (SASP)
    Programs at the Department of Justice Office on Violence Against Women
    (OVW), designed to provide a criminal justice and survivor services
    response respectively, both include language to require meaningful
    collaboration as well as funding to state sexual assault coalitions. We
    suggest following the success of these grant programs to also ensure
    the meaningful, funded involvement of state sexual assault coalitions
    in the prevention of sexual violence.
        We recommend the following report language:
        ``The Committee believes significant involvement of state sexual
            assault coalitions and underserved communities is critical to
            ensure rape prevention education dollars are spent on the most
            impactful programs. So in granting funds to states, the
            Director of the National Center for Injury Prevention and
            Control shall set forth procedures designed to ensure
            meaningful involvement of the State or territorial sexual
            assault coalitions and representatives from underserved
            communities in the application for and implementation of
            funding.''
        Funding History: In the 2013 reauthorization of Violence Against
    Women Act, Congress cut authorization for RPE from $80 to $50 million.
    In FY 17, the program was funded at $44.4 million, a $5 million
    increase from FY 16. In FY 18 & FY 10, RPE was funded in the omnibus at
    $49.4 million. In FY 20, RPE was funded at $50.75 million. In FY 21,
    RPE was funded at $51.75 million.
        Please increase funding for RPE to $100 million and include report
    language requiring the funded collaboration of state sexual assault
    coalitions in the RPE program.
        Please feel free to contact me with any additional questions at
    terri@endsexualviolence.org.

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

         Prepared Statement of the National Alopecia Areata Foundation
     the foundation's fiscal year 2022 l-hhs appropriations recommendations
    _______________________________________________________________________

      --At least $46.1 billion for the National Institutes of Health (NIH).
        --Proportional funding increases for National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS),
                National Institute of Allergy and Infectious Diseases
                (NIAID) and the National Center for Advancing Translational
                Science (NCATS)
      --Please provide $10 billion for the Centers for Disease Control and
            Prevention (CDC).
        --Please provide $5 million for the Chronic Disease Education and
                Awareness Program.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt and distinguished members
    of the Subcommittee, thank you for your time and your consideration of
    the priorities of the alopecia areata community as you work to craft
    the FY2022 L-HHS Appropriations Bill.
                             about alopecia areata
        Alopecia areata is a prevalent autoimmune skin disease resulting in
    the loss of hair on the scalp and elsewhere on the body. It usually
    starts with one or more small, round, smooth patches on the scalp and
    can progress to total scalp hair loss (alopecia totalis) or complete
    body hair loss (alopecia universalis).
        Alopecia areata affects approximately 2.1 percent of the
    population, including more than 6.9 million people in the United States
    alone. The disease disproportionately strikes children and onset often
    occurs at an early age. This common skin disease is highly
    unpredictable and cyclical. Hair can grow back in or fall out again at
    any time, and the disease course is different for each person. In
    recent years, scientific advancements have been made, but there remains
    no cure or indicated treatment options.
        The true impact of alopecia areata is more easily understood
    anecdotally than empirically. Affected individuals often experience
    significant psychological and social challenges in addition to the
    biological impact of the disease. Depression, anxiety, and suicidal
    ideation are health issues that can accompany alopecia areata. The
    knowledge that medical interventions are extremely limited and of minor
    effectiveness in this area further exacerbates the emotional stresses
    patients typically experience.
                              about the foundation
        NAAF, headquartered in San Rafael, California, supports research to
    find a cure or acceptable treatment for alopecia areata, supports those
    with the disease, and educates the public about alopecia areata. NAAF
    is governed by a volunteer Board of Directors and a prestigious
    Scientific Advisory Council. Founded in 1981, NAAF is widely regarded
    as the largest, most influential, and most representative foundation
    associated with alopecia areata. NAAF is connected to patients through
    local support groups and also holds an important, well-attended annual
    conference that reaches many children and families.
        NAAF initiated the Alopecia Areata Treatment Development Program
    (TDP) dedicated to advancing research and identifying innovative
    treatment options. TDP builds on advances in immunological and genetic
    research and is making use of the Alopecia Areata Clinical Trials
    Registry which was established in 2000 with funding support from the
    National Institute of Arthritis and Musculoskeletal and Skin Diseases;
    NAAF took over financial and administrative responsibility for the
    Registry in 2012 and continues to add patients to it. NAAF is engaging
    scientists in active review of both basic and applied science in a
    variety of ways, including the November 2012 Alopecia Areata Research
    Summit featuring presentations from the Food and Drug Administration
    (FDA) and NIAMS.
        NAAF is also supporting legislation to provide coverage for cranial
    prosthetics under Medicare. This bill will grant increased access to
    cranial prosthetics and therapies for patients with alopecia areata and
    other forms of medical hair loss. Many patients living with medical
    hair loss suffer from a variety of diseases, including cancer. With no
    known cause or cure, alopecia areata is an autoimmune skin disease
    affecting approximately 6.9 million Americans, many of whom are
    children.
                         national institutes of health
        NIH hosts a modest alopecia areata research portfolio, and the
    Foundation works closely with NIH to advance critical activities. NIH
    projects, in coordination with the Foundation, have the potential to
    identify biomarkers and develop therapeutic targets. In fact,
    researchers at Columbia University Medical Center (CUMC) have
    identified the immune cells responsible for destroying hair follicles
    in people with alopecia areata and have tested an FDA-approved drug
    that eliminated these immune cells and restored hair growth in a small
    number of patients. This huge breakthrough has led to NIAMS providing a
    research grant to the researchers at Columbia to continue this work. In
    this regard, please provide NIH with meaningful funding increases to
    facilitate growth in the alopecia areata research portfolio.
                              patient perspective
        ``There is a chance you could lose all your hair.'' That was the
    last thing anyone ever wants to hear. I will never forget standing in
    the shower in November 2015 with my hands full of hair and in complete
    disbelief. Was this really happening to me? I felt as though my
    identity was being ripped away from me as every strand of hair fell out
    of my head. My hair was my identity. Who would I be without it? How was
    I going to live like this for the rest of my life?
        I lost all of my hair on my entire body including eyebrows and
    eyelashes within four weeks and I was diagnosed with the autoimmune
    disease called alopecia areata. For the next year, I did everything in
    my power to grow my hair back from every topical cream to medicines
    that compromised my immune system to weekly steroid injections into my
    scalp. This was the worst pain I had ever experienced in my life but I
    would do anything to grow my hair back.
        Nothing was working. I had to stop as my mind, body, and soul
    couldn't take it anymore.
        I don't know what was worse, the treatments or the stares I would
    receive out in public as everyone thought I was going through treatment
    for cancer. I wanted to blend in with society so badly, but wigs were
    so expensive. I refused to look at myself in the mirror because I hated
    the reflection. I wore a hat everywhere I went even to bed until the
    lights were turned off to take it off and I wouldn't take any pictures,
    especially during the holidays because I was ashamed of my appearance.
    I wanted my life back so I could be a good mom to my daughters and just
    enjoy life. Alopecia areata is not just cosmetic, it takes an emotional
    toll as it caused severe anxiety and depression that I continue to deal
    with years later. I was very fortunate to have the unconditional
    support of my parents who helped me to purchase wigs so I could feel
    somewhat normal again; however, there are too many people with alopecia
    areata who do not have the luxury of support that I was blessed with.
    Your support would impact people's lives immensely.
        Thank you for the opportunity to testify before you today. NAAF
    looks forward to working with you all to advance medical research and
    public health activities that will improve patient outcomes for the
    members of our community suffering from alopecia.

        [This statement was submitted by Jeanne Rappoport, Acting Chief
    Executive
    Officer, National Alopecia Areata.] Foundation.]
                                     ______

              Prepared Statement of the National Association for
                       State Community Services Programs
        As Board President of the National Association for State Community
    Services Programs (NASCSP), I am pleased to submit testimony in support
    of the Department of Health and Human Services' (HHS) Community
    Services Block Grant (CSBG). We are seeking a Fiscal Year 2022
    appropriation level of $800 million for CSBG and an increase in client
    eligibility to 200% of the Federal Poverty Level. The current 200%
    eligibility established under the Coronavirus Aid, Relief, and Economic
    Security (CARES) Act will expire at the end of Fiscal Year 2021,
    creating a steep drop-off of services for many vulnerable families
    during a critical time of recovery. These funding and eligibility
    levels will empower States and local communities with the resources
    they need to lead the fight against poverty through innovative,
    effective, and locally tailored anti-poverty programs that help
    individuals, families, and communities achieve economic security.
        NASCSP is the member organization representing the State CSBG
    Directors in all 50 states, the District of Columbia, and three U.S.
    territories on issues related to CSBG and economic opportunity. NASCSP
    provides training and technical assistance to empower State Offices in
    implementing program management best practices and in developing
    evidence-based policy. The State Offices represented by our
    organization would like to thank the members of this committee for
    their support of CSBG over the years, particularly for the supplemental
    funding through the CARES Act and the increase to CSBG in the FY 2021
    Labor-HHS Bill.
        CSBG is a model example of a successful Federal-State-Local
    partnership, a fact I can personally attest to having worked for more
    than 15 years in the Arkansas State CSBG office. I worked closely with
    the local Community Action Agencies and with federal OCS and ACF staff.
    The CSBG network leverages federal and non-federal funds to support a
    range of essential services and activities that improve the lives and
    communities of Americans. These activities are incredibly important to
    vulnerable individuals and families, especially during times of crisis.
    CSBG is in every state and county, from the most urban counties to the
    most rural ones, where CSBG furthers the critical goals of economic
    security, social mobility, and racial justice. I will highlight three
    main points in my testimony:
        1. The structure of CSBG empowers States and local communities to
    take the lead on poverty, giving States wide discretion to tailor
    funding to their unique economic and social conditions.
        2. CSBG creates impact in communities across the country by
    leveraging additional private, local, state, and federal investments to
    fight poverty, serving as the national human services infrastructure by
    weaving together and coordinating private and public antipoverty
    efforts.
        3. The robust local, state, and federal accountability measures of
    the CSBG Performance Management Framework are uniquely comprehensive
    when compared to other federal programs, preventing service duplication
    and fostering continuous improvement.
    Structure
        Proponents of state and local anti-poverty efforts often highlight
    their ability to tailor services, asserting that state and local
    leaders are best equipped to tackle the challenges facing their
    communities. CSBG is a block grant administered and managed by states,
    who administer and distribute funds to a nationwide network of more
    than 1,000 local CSBG Eligible Entities, also known as Community Action
    Agencies or CAAs. The CSBG network forms the bedrock of the human
    services infrastructure that uplifts urban, rural, and suburban
    communities across the United States. In some rural counties, the CAA
    is the only human services organization addressing poverty and
    uplifting low-income families in the community.
        State offices distribute funds to Community Action Agencies, who
    utilize CSBG funds to address their specific local needs, often in one
    or more of these core domains: employment, education and cognitive
    development, income, infrastructure and asset building, housing, health
    and social behavioral development, and civic engagement and community
    involvement. The CSBG Act requires that these services are shaped by a
    community needs assessment performed at least every three years,
    ensuring programs are tailored and responsive to unique community
    needs, rather than a one-size-fits-all solution. The needs assessment
    prevents service duplication and incorporates community feedback in the
    strategic planning process.
        Furthermore, the CSBG Act requires at least one-third of a
    Community Action Agency's board to be composed of people with low-
    incomes or their representatives, ensuring that local needs and
    viewpoints are accurately reflected in organizational priorities. In
    addition to low-income representation, Community Action boards are also
    comprised of local elected officials or their representatives and
    community stakeholders including local businesses, other assistance
    organizations, professional groups, and community organizations. This
    unique tripartite structure assures the needs of a community are
    identified and met with the available resources necessary to maximize
    outcomes and impact. The tripartite structure of Community Action
    boards calls on all sectors of society to join in the shared fight
    against poverty.
        State Offices are charged with providing the oversight and support
    necessary for effective administration of CSBG at the local and state
    levels. States provide training and technical assistance to build the
    capacity of local CAAs; ensure compliance with federal and state
    requirements; and serve as important partners in the development of
    statewide linkages and coordination to combat state causes and
    conditions of poverty. The structure of CSBG empowers states and locals
    to work collaboratively, maximizing impact for America's communities.
    Impact
        CSBG is a positive federal investment in a national system to
    address poverty that produces concrete results. Federal CSBG dollars
    are used to build, coordinate, support, and strengthen anti-poverty
    infrastructure across our communities. In Fiscal Year 2018,\1\ for
    every $1 of CSBG, CAAs leveraged $8.27 from non-federal sources.
    Leveraging funds allowed CAAs to expand highly successful and impactful
    programs. Including all federal sources, non-federal sources, and
    volunteer hours valued at the federal minimum wage, the CSBG Network
    leveraged $21.97 of non-CSBG dollars per $1 of CSBG. Without CSBG, many
    rural communities across America would not be able to implement
    critical programs that address poverty for low-income families and
    their communities. The CSBG network served more than 10.2 million
    people with low incomes in Fiscal Year 2018. A robust appropriation
    will expand impact and foster innovation within the network Below is a
    snapshot of some quantitative impacts of CSBG:
    ---------------------------------------------------------------------------
        \1\ FY 2018 data is the latest publicly available from the Office
    of Community Services (OCS) within the Department of Health and Human
    Services (HHS).
    ---------------------------------------------------------------------------
      --915,230 households improved their energy efficiency and/or energy
            burden in their homes.
      --594,718 low-income seniors (65+) achieved or maintained an
            independent living situation.
      --253,422 children and youth who are achieving at a basic grade level
            (academic, social and other school success skills.
      --78,713 adults who improved their education levels.
      --55,684 unemployed adults who obtained employment up to a living
            wage.
      --18,090 unemployed adults who obtained employment with a living wage
            or higher.
        Looking beyond the data, we see that the CSBG Network is delivering
    innovative, comprehensive, and effective programs across the country
    that uplift individuals, families, and their communities:
      --Disaster Response and Recovery in Oregon: In September of 2020,
            Oregon residents in Douglas and Josephine counties already
            experiencing a surge in COVID-19 cases were faced with the
            additional threat of unprecedented wildfires. Evacuating
            families struggled to find adequate shelter and consistent
            access to food as the fires raged across multiple impacted
            counties. Already familiar with serving local low-income
            communities, the United Community Action Network (UCAN)
            immediately began providing disaster relief. UCAN partnered
            with FEMA, local public health departments, and emergency
            response centers to help homeless or unsheltered individuals
            and families find safety. Unable to cook while evacuating,
            families utilizing food assistance relied on expensive prepared
            meals which quickly drained their resources. Despite the
            extreme circumstances, UCAN continued to provide food, hygiene
            products, and social services wherever space was available,
            including parking lots and outside gas stations. While the
            wildfires stoked confusion and separated families, UCAN
            connected those who were displaced and supplied cellphones so
            those affected could contact loved ones. UCAN was instrumental
            in organizing the emergency response, providing critical
            resources, and reconnecting those separated by disaster.
      --Vaccination Coordination & Education in Wisconsin: In coordination
            with Wisconsin's Vaccination Task Force, the Wisconsin
            Department of Children and Families and the Wisconsin Community
            Action Program Association (WISCAP) are training case managers
            to help Wisconsin residents to navigate the COVID-19
            vaccination process. Trainings cover vaccine scheduling through
            the 2-1-1 Wisconsin phone service, a framework for discussing
            vaccine confidence, and a review of wrap-around services
            available to compliment vaccination. Through this coordination,
            Wisconsin is leveraging the 2-1-1 service as a referral source
            for hyper-local, trusted community member-driven vaccination
            education. Wisconsin's CSBG network also applied for a COVID-19
            Outreach Grant to better assist BIPOC and rural, low-income
            people with vaccine hesitance or barriers to access like
            transportation. This coordinated effort helped all programs
            leverage vaccine rollout funding to create a broader reach
            within local communities, increase access to vaccines, and
            ultimately save lives.
      --Flexible & Bundled Services in Michigan: Michigan's Bureau of
            Community Action and Economic Opportunity (BCAEO) began
            organized discussions around new services as soon as the CARES
            Act was first introduced. Working regionally with local CAAs as
            well as with Governor Whitmer's taskforce, BCAEO developed
            contracts and procedures to expand services as soon as CARES
            funding was available. Expanding their nutrition programs,
            local agencies created online grocery stores so families with
            medical, religious, or cultural dietary restrictions could
            choose foods for delivery. CAAs also delivered quarantine-
            boxes, packages of food and hygiene supplies that allowed
            residents to shelter in place before making long-term
            preparations. Agencies partnered with struggling local farmers
            to provide fresh produce while also fully retaining their staff
            during lockdowns by moving them to food warehouse & delivery
            positions. At the same time, Michigan CAAs utilized
            supplemental funding to provide more than 2,200 people with
            internet-connected devices to access remote education,
            employment opportunities, telehealth, and other critical online
            resources.
    Accountability
        CSBG is bolstered by a Performance Management Framework to ensure
    accountability at all levels of the network. This federally established
    Performance Management Framework includes state and federal
    accountability measures, organizational standards for Community Action
    Agencies, and a Results Oriented Management and Accountability (ROMA)
    system. Under the Performance Management Framework, CSBG state offices
    gather and document outcomes for the CSBG Annual Report. Within this
    reporting mechanism, National Performance Indicators are used across
    the network to track and manage progress, empowering CAAs have the data
    they need to improve services and innovate delivery. The ROMA system
    engages local communities to strengthen their impact and achieve robust
    results through continuous learning, improvement, and innovation.
    Furthermore, CSBG State Offices monitor local agency performance and
    adherence to organizational standards, providing training and technical
    assistance to ensure continuously high-quality delivery of programs and
    services.
        In closing, we ask the committee to fund CSBG at no less than $800
    million for FY 2022 and to increase client eligibility to 200% of the
    Federal Poverty Level, ensuring that this nationwide network with a
    nearly 60-year record of success continues to positively impact the
    lives of vulnerable Americans. The structure of CSBG empowers States
    and local agencies to address poverty in their communities, while
    prioritizing the voices of people with low incomes in determining
    solutions. CSBG is committed to the comprehensive accountability
    mechanisms of the Performance Management Framework, ensuring effective
    and responsible stewardship of funds at the Federal, State, and local
    level. CSBG is producing tangible results, serving millions of
    vulnerable Americans each year and empowering communities, families,
    and individuals to achieve economic security, social mobility, and
    racial justice. NASCSP looks forward to working with Committee members
    to ensure CSBG continues to help families achieve these outcomes,
    strengthening our communities and providing our most vulnerable
    neighbors with security, dignity, and justice. Thank you.
        Respectfully submitted.

        [This statement was submitted by Beverly Buchanan, Board President,
    National Association for State Community Services Programs.]
                                     ______

         Prepared Statement of the National Association of Councils on
                           Developmental Disabilities
        The National Association of Councils on Developmental Disabilities
    (NACDD), a national membership organization for the State Councils on
    Developmental Disabilities (DD Councils), appreciates the opportunity
    to present this testimony. NACDD respectfully requests $89 million, the
    level included in the President's FY22 budget request, for the DD
    Councils within the Administration for Community Living (ACL) in the
    Labor-HHS-Education appropriations bill for Fiscal Year (FY) 2022. We
    also respectfully request that the following report language be
    included in the Fiscal Year 2022 Labor, Health and Human Services,
    Education Appropriations bill:
        Technical Assistance.--The Committee provides not less than
            $700,000 for technical assistance and training for the State
            Councils on Developmental Disabilities. Such technical
            assistance should be provided by an organization with
            longstanding experience providing technical assistance to the
            national network of state developmental disabilities councils
            or similar Developmental Assistance and Bill of Rights Act
            national programs. In addition, the agreement encourages ACL to
            consult with the appropriate Developmental Disabilities Act
            stakeholders prior to announcing opportunities for new
            technical assistance projects and to notify the Committees
            prior to releasing new funding opportunity announcements,
            grants, or contract awards with technical assistance funding.
        Funding for the DD Councils has obtained broad bicameral support
    from members of Congress. This funding request also has broad support
    from the disability community. The Consortium for Citizens with
    Disabilities, the largest coalition of national organizations working
    together to advocate for people with disabilities, submitted a support
    letter to this committee dated April 26, 2021.
        Authorized by the Developmental Disabilities Assistance and Bill of
    Rights Act (DD Act), DD Councils work collaboratively with the
    University Centers for Excellence in Developmental Disabilities, and
    the Protection and Advocacy program for Developmental Disabilities, to
    ``assure that individuals with developmental disabilities and their
    families participate in the design of and have access to needed
    community services, individualized supports, and other forms of
    assistance that promote self-determination, independence, productivity,
    and integration and inclusion in all facets of community life, through
    culturally competent programs.'' \1\ Appointed by Governors, and
    consisting of at least 60 percent of people with DD and their families,
    DD Councils assess problems or gaps in the I/DD system and design
    innovative solutions that make real changes to social systems such as
    employment, transportation, education, healthcare, housing and more, to
    fully integrate people with I/DD into society.
    ---------------------------------------------------------------------------
        \1\ 42 U.S.C. 15001(b).
    ---------------------------------------------------------------------------
        The request for an increase in funding for FY2022 is informed by
    the tragedy and lessons learned from last year's COVID-19 pandemic and
    the spotlight it placed on circumstances of everyday living for people
    living with intellectual or developmental disabilities (I/DD) that
    present obstacles. For decades since the passage of the DD Act and
    later the Americans with Disabilities Act, the whispered concerns about
    the dangers of living with I/DD in isolation and stripped of critical
    supports were realized when the pandemic hit. Several studies showed a
    link between having an I/DD and a greater risk of contracting and dying
    from COVID-19, with one study finding having an intellectual disability
    was the strongest independent risk factor for presenting with a Covid-
    19 diagnosis and the strongest independent risk factor other than age
    for Covid-19 mortality. The Centers for Disease Control and Prevention
    identified social factors which increased the risk of COVID-19
    transmission including: relying on direct support workers and families,
    difficulties understanding information and preventative measures, and
    difficulty communicating symptoms of the illness. The circumstances of
    simply living with I/DD means that people are struggling to simply
    live, not only during pandemics but every day of their lives. For
    example, it is true that relying on direct support workers and families
    is an obstacle to surviving COVID, but it is also an obstacle to
    obtaining employment, accessing transportation, and most activities
    people without disabilities take for granted.
        The DD Councils support innovative programs to promote self-
    determination and create systemic pathways to independent living to
    keep people with I/DD safe during public health emergencies and to help
    them live their fullest lives in the community long after the pandemic.
    DD Councils direct resources through partnerships with local non-
    profits, businesses, and state and local governments, to overcome
    obstacles to community living for people with I/DD. States and
    territories rely on DD Councils to turn fragmented approaches into
    innovative and cost-effective strategies to increase the percentage of
    individuals with I/DD who become independent, self-sufficient and
    integrated into the community. Examples of DD Council projects include:
    partnerships to increase competitive and integrated employment,
    campaigns promoting access to qualified direct support workers,
    programs for successfully transitioning to independent living, advocacy
    for access to affordable housing, training to build leadership and
    advocacy skills, and more. DD Council members also provide a critical
    and unique role in educating state and local policymakers by directly
    participating in the design of state and local government-funded
    supports and services affecting their lives.
        DD Councils promote community living in the states through narrowly
    tailored, state-specific initiatives for emerging issues. Every DD
    Council pivoted during COVID-19 to meet immediate and critical needs.
    For example, in response to the hardship that COVID-19 has placed on
    people's ability to stay connected and engaged, the Washington State
    Developmental Disability Council invested in grants including:
    providing laptops and prepaid data cards for internet access for those
    without technology; promoting healthy living during COVID; and
    combating social isolation. At the same time, their longer-term plans
    were implemented. For example, as part of their five-year plan, the
    Missouri Developmental Disabilities Council identified affordable and
    accessible housing is an essential need for people with I/DD. The
    council supported community initiatives that resulted in persons with
    developmental disabilities having opportunities for housing including
    the Missouri Inclusive Housing Development Corporation (MoHousing).
        Thank you for consideration of our request.
                                     ______

               Prepared Statement of the National Association of
                            Drug Court Professionals
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, I am honored to have the opportunity to submit my
    testimony on behalf of this nation's nearly 4,000 treatment court
    programs and the 150,000 people the programs will connect to lifesaving
    addiction and mental health treatment this year alone. Given the
    overlapping crises of substance use and the COVID-19 pandemic, I am
    requesting that Congress provide funding of $105 million for the Drug
    Treatment Court Program at the Department of Health and Human Services,
    Substance Abuse and Mental Health Services Administration for fiscal
    year 2022.
        I serve as a superior court judge in Lewis County, Washington,
    where, for the entirety of my tenure as judge, I have presided over our
    county's treatment court programs, including drug courts. I have never
    participated in a more effective approach to promoting public health
    while also remaining steadfast to the promise of the justice system to
    protect public safety. Strong empirical evidence shows time after time
    that treatment courts not only reduce crime, but also save lives and
    families by connecting participants to evidence-based treatment
    services and recovery support.
        Participants like Brant. Before coming to our program, he spent
    much of his life cycling in and out of the justice system because of an
    addiction that began in his early twenties. By the time he came to our
    program, he had been to jail seven times, with more on the horizon
    unless something changed. Our treatment court program provided the
    accountability and treatment that Brant needed to change.
        In our program, Brant, like the rest of our participants, was
    assessed and given an individualized treatment plan designed by
    substance use treatment professionals using evidence-based methods,
    including medication-assisted treatment where appropriate. Together, in
    concert with the multidisciplinary treatment court team who ensured
    Brant received the services and accountability he needed to succeed, we
    set a goal of recovery for him, not another costly and ineffective
    stint behind bars.
        Today, Brant is not only living that goal, he's doing what he can
    to help others achieve the same. He works for an organization that
    conducts outreach to vulnerable populations with substance use
    disorders and helps them get their lives back on track, with a special
    focus on homeless veterans. He also serves as the president of the
    nonprofit organization that helps support the Lewis County Drug Court,
    ensuring the lifesaving work of our program continues well into the
    future.
        I have worked in treatment courts since 2004, when I helped launch
    Lewis County's adult drug court as chief criminal deputy in the
    prosecutor's office. Subsequently, as the chief criminal deputy of
    neighboring Thurston County, I supervised our adult drug court, mental
    health court, and veterans court units. Since then, I have watched many
    of the most helpless individuals in our justice system overcome their
    substance use or mental health disorder, regained their lives, and
    became productive citizens. Most go on to raise families, begin growing
    careers, and help others in the similar difficult positions they once
    found themselves in. Without hesitation, I credit the treatment court
    model for the health and safety of these individuals.
        Lewis County is a rural, relatively quiet part of southwestern
    Washington. But we are not immune from the grips of the twin crises
    currently gripping the nation from coast to coast: the substance use
    epidemic and the ongoing effects of COVID-19, including isolation and
    economic devastation. Treatment courts, such as adult drug courts,
    veterans treatment courts, family treatment courts, and others, offer a
    public health and public safety response to these crises by expanding
    and enhancing substance use treatment capacity to serve more
    individuals in their communities.
        With overwhelming empirical evidence showing their effectiveness,
    it is easy to see that treatment court programs across the country
    merit continued funding. The Government Accountability Office finds the
    drug court model reduces crime by up to 58%. Further, the Multi-Site
    Adult Drug Court Evaluation conducted by the Department of Justice
    confirmed drug treatment courts significantly reduce both drug use and
    crime, as well as finding a cost savings averaging $6,000 for every
    individual served. Additional benefits include improved employment,
    housing, financial stability, and reduced foster care placements.
        Brant is not alone in his success. Treatment courts in this country
    have connected 1.5 million people who have lifesaving mental health and
    substance use disorders with treatment options best suited to them.
    Together, the court team offers the tools to overcome substance use
    disorder and past trauma to create meaningful, healthy relationships.
        Continued support from the Drug Treatment Court Program at the
    Department of Health and Human Services ensures the nearly 4,000
    treatment courts in the United States today provide critical treatment
    services to save lives and reunite families. But we know there are many
    more who still need this opportunity. I strongly urge this committee to
    recommend funding of $105 million to the Drug Treatment Court Program
    in fiscal year 2022, so treatment courts in Washington and beyond can
    continue providing lifesaving substance use treatment services.

        [This statement was submitted by Hon. Andrew Toynbee, Judge,
    Superior Court of Lewis County, Washington, Chehalis, Washington.]
                                     ______

               Prepared Statement of the National Association of
                         Emergency Medical Technicians
        Thank you, Chairwoman Murray, Ranking Member Blunt, and
    distinguished members of the Subcommittee. My name is Bruce Evans, and
    I am the President of the National Association of Emergency Medical
    Technicians (NAEMT). I am also a fire chief leading a fire-based EMS
    organization in a super rural area of Southwest Colorado--12,000
    residents in 264 square miles.
        Founded in 1975 and over 70,000 members strong, NAEMT represents
    our nation's frontline EMS practitioners, who provide critical,
    lifesaving services to communities nationwide, especially in rural,
    frontier, and other hard-to-reach areas. On behalf of our organization,
    thank you for your ongoing support of EMS professionals. NAEMT would
    like to offer our views on the Subcommittee's FY 2022 bill. At the
    outset, we write to ask the subcommittee to provide robust funding for
    the SIREN Rural EMS Equipment and Training Assistance (REMSTEA) program
    within the Department of Health and Human Services' (HHS) Substance
    Abuse and Mental Health Services Administration (SAMHSA).
        This testimony is submitted just a few weeks after the 46th Annual
    EMS Week, which occurred from May 16--May 22, 2021. The goal of EMS
    Week is to thank paramedics, EMTs, and the entire EMS workforce for
    their services and sacrifices. However, EMS professionals do not just
    want a pat on the back--like the rest of our members, I am writing to
    continue to raise public awareness about the critical funding shortfall
    of EMS in the communities we serve. This urgent request aligns with the
    spirit of EMS Week.
        Passed in the 2018 Farm Bill, the SIREN/REMSTEA grant program
    supports rural public and nonprofit EMS agencies in their efforts to
    complete their mandate to provide critical emergency medical care to
    all of the residents in the communities they serve. The grants help
    rural EMS agencies train and retain staff and purchase equipment, among
    filling other needs. Community demands keep growing: each year, fire
    departments and EMS agencies respond to more than 20 million calls for
    emergency services. While the COVID-19 pandemic exacerbated the plight
    of these agencies, EMS practitioners and agencies were facing severe
    challenges before the virus' outbreak. This can be attributed, in part,
    to greater distances between health care facilities and low
    reimbursement rates. The most pressing impact is the decline of
    available medical care in rural communities, which has heightened the
    need for already-stretched EMS agencies to perform these lifesaving
    services. Again, this foreboding and bleak landscape existed even
    before the onset of the pandemic, which has strained the social safety
    net that EMS professionals provide.
        COVID-19 made an already growing problem much worse. In FY2020 and
    FY2021, your Committee provided $5 million and $5.5 million for SIREN
    grants, respectively. However, the program requires a substantial
    increase in funds to make sure our personnel have the equipment and
    training they need. Social distancing and ``stay-at-home'' protocols
    because of the pandemic complicated income streams for these agencies.
    Many rural EMS agencies rely heavily on community fundraising efforts,
    such as bingo, raffles, and community barbeques. At the same time,
    support from localities whose tax revenue base has dramatically
    declined, further hindering EMS agencies' ability to fill their
    coffers. Beyond smaller revenue streams, costs have gone up, especially
    as EMS agencies have been paying higher prices for personal protection
    equipment (PPE) throughout the pandemic.
        Rural EMS organizations, like mine in Colorado, have
    disproportionately suffered from shrinking revenue streams and
    increased demand before the pandemic and now, especially as it relates
    to synthetic opioid overdoses, which have skyrocketed and do not seem
    to be slowing down. Ambulance crews that support the most far-flung
    areas of our country are running out of money and personnel. Because of
    the especially demanding work that rural EMS organizations shoulder,
    they are struggling to stay afloat at a much higher rate than their
    more urban counterparts. This challenge is not limited to one region of
    the country; rather, rural EMS organizations across the board are more
    likely to shut their doors, leaving their residents without reliable
    access to local ambulance service. Ultimately, without the support this
    grant program provides, many more local EMS operations will likely have
    to close their doors.
        The result is, unfortunately, predictable: increasing workforce
    shortages as EMS personnel become increasingly burnt out, face
    shrinking compensation, and are constantly exposed to unpredictable and
    dangerous environments. In short, more money is needed to bring more
    people aboard to ensure that our professionals are provided a safe,
    healthy, and respectful work environment, and that their EMS agency can
    effectively serve their communities. The enhanced funding for the
    SIREN/REMSTEA program will go to good use, especially as our country
    and economy recover from the economic and health care crisis brought on
    by the pandemic.
        Beyond the demonstrated need, EMS personnel made good use of the
    funds allocated under the FY2020 and FY2021 spending bills. For FY2020,
    SAMHSA awarded REMSTEA grants ranging from $92,000 to $200,000 to
    approximately 27 EMS agencies across the country for recruitment and
    training purposes. In December 2020, SAMHSA announced the potential to
    grant awards to another 27 rural EMS applicants. Rural EMS agencies are
    in dire need for additional support--we can assure you that our
    organization's members will not leave money allocated by Congress on
    the table.
        On behalf of our 70,000 members who live and work in every state
    across our country, thank you again for supporting our brave men and
    women who provide important roles in the health care ecosystem. SIREN/
    REMSTEA grants will certainly help them do their jobs to their fullest
    ability.

        [This statement was submitted by Bruce Evans, MPA, NRP, CFO, SPO,
    President, National Association of Emergency Medical Technicians.]
                                     ______

               Prepared Statement of the National Association of
                     Nutrition and Aging Services Programs
        Our ask for FY 2022 is for a minimum total of $1.9 billion for the
    three Older Americans Act (OAA) Title III-C Nutrition Programs, divided
    approximately as follows:
      --Congregate Nutrition Services (Title III C-1)--$965 million
      --Home-Delivered Nutrition Services (Title III C-2)--$726 million
      --Nutrition Services Incentive Program (NSIP) (Title III)--$211
            million
        We can more than justify the need for this funding level. It is
    important to understand the reality of how the pandemic impacted these
    programs. The OAA nutrition programs endured a wholescale conversion of
    the operations because of the COVID-19 pandemic. Before the pandemic,
    according to the Administration for Community Living's AGID database,
    more than twice as many older adults were served in the congregate
    program as in the home-delivered nutrition program. The pandemic caused
    the transition of almost all congregate program participants to the
    home-delivered nutrition program.
        This conversion resulted in programs encountering immediate
    increases in costs for food, transportation and personnel, since many
    relied on older volunteers who were unable to continue their work.
    Price increases have been particularly felt in those transportation
    costs, including gasoline prices. Programs went from serving hundreds
    of participants per day in one location to getting meals to hundreds of
    individual locations. Gasoline prices have shown a 49.6 percent
    increase over the last year, including a 9.1 percent increase between
    just April and May.
        Further, in addition to providing additional funding during the
    pandemic, Congress also has approved some needed flexibilities to allow
    these programs to seamlessly convert. The most impactful of these was
    an updated definition of ``homebound,'' allowing any older adult forced
    to shelter in place to be eligible for a home-delivered meal,
    overriding any previous state restrictions. This has led to tremendous
    increases in demand. In fact, a survey conducted by Meals on Wheels
    America showed an average of 95 percent increase in demand in the early
    months of the pandemic, including 80 percent of surveyed programs
    reporting doubling of requests for home-delivered meals. While demand
    has stabilized to some extent, it remains at a national average of a 60
    percent increase over pre-pandemic levels. Local programs also reported
    that operating costs will likely remain high for the foreseeable
    future, and nine in 10 home-delivered meals programs reported continued
    unmet need for home-delivered meals in their community. Nearly a third
    of these programs said they would need to nearly double or more than
    double their home-delivered efforts in the future to serve this unmet
    need.
        This is perhaps the greatest justification for this funding. We do
    not want to see older adults crashing into and falling over this
    ``cliff'' of funding running out while the need for service continues.
    We do not want to have our dedicated personnel in the field be forced
    to remove older adults in need from their programs, knowing what the
    health consequences would be.
        This funding request is premised on the fact that while the
    pandemic may be easing, it is not over by any means. Without question,
    the emergency funding provided to this nutrition network has been used.
    These funds we request will absolutely also be used.
        It should also be noted that nutrition programs were creative and
    innovative in their use of emergency funds, establishing partnerships
    with restaurants, food delivery services, drop-ship services and the
    like in order to stretch their funding as far as it would go. But
    public-private partnerships do involve resources from both sides.
    Supporting our funding request for FY 2022 will allow these innovations
    and partnerships to continue and expand.
        Another justification for this funding request must be what it can
    do to help alleviate the three evils of hunger, food insecurity, and
    malnutrition in older adults. We have documented information on major
    increases in food insecurity during the pandemic. We were also acutely
    aware that even before the pandemic, one in two older adults were at
    risk of or were already malnourished. The provision of a daily meal to
    an older adult in a homebound setting can often be the main source of
    their nutrition for that given day. Said another way, if you remove
    that meal, that older adult simply may not eat at all.
        A continued investment in the OAA nutrition programs allows us an
    important intervention for those older adults who are socially
    isolated. Funding provided during the pandemic went well beyond just
    providing a meal. Our nutrition network responded by developing
    critically important programs to maintain contact with older adults who
    suddenly found themselves not being able to have their normal daily
    socialization at their congregate program. They provided telephone
    reassurance calls as well as higher-tech approaches to maintaining
    contact such as virtual book clubs, exercise classes, and nutrition
    education. These services, like the food provided, need to be continued
    in the year ahead.
        We were also especially pleased that the American Rescue Plan Act
    included funding to allow the aging network to assist in the effort to
    get older adults vaccinated. At the time FY 2022 begins, we will be
    entering flu and pneumonia season. We need to ensure that we continue
    to provide the aging network with resources to aid older adults in
    getting the vaccines they need to prevent these illnesses.
        In addition, we are all striving for the day when congregate
    nutrition sites, senior centers and adult day centers that provide
    meals can reopen. Of course, this can only be done with proper regard
    for health and safety rules and ordinances. NANASP and our colleagues
    at the National Council on Aging are surveying our members to find out
    what costs facilities will incur both to open and remain open. The
    results are concerning--many programs are reporting $15,000 in costs or
    more per facility--and these expected costs go outside of most budgets.
    We hope that this funding can be significant and flexible enough to
    allow some to be used to facilitate reopening and/or that funding for
    these facilities be included in any major infrastructure bill Congress
    may produce with the President.
        Finally, we implore this Subcommittee to think about what has
    unfolded in the past year with respect to different funding sources.
    Aging network programs must report their spending of regular FY 2021
    funding as well as four streams of emergency funding and expected FY
    2022 funding. We strongly request that you communicate through this
    legislation that while accurate reporting is necessary and important,
    steps should be taken by the Administration to ensure that the
    reporting process is as simplified as possible to ensure that programs
    are not spending much of their limited staff hours and resources on
    this onerous task.
        Next year, this wonderful Older Americans Act nutrition program
    will celebrate its 50th anniversary. Without question, its 49th year
    has likely been its toughest. Yet the fact that the OAA nutrition
    program went seamlessly through an unexpected full-scale conversion
    speaks volumes about the dedication of nutrition service providers, who
    deserve our sincere thanks. They pivoted and persevered despite their
    personal struggles and fears about the virus. While not technically
    first responders, they were first to respond to one critical need for
    older adults--nutrition. In short, they always have the best interest
    of the older adults they serve front and center, as has this
    Subcommittee. We ask for you to keep this interest in mind again in
    this incredibly challenging time so we can be prepared for the final
    phases of the pandemic and all the related downstream issues there may
    be.
        In closing, in the words of a program director from a recently-
    published New York Times article on OAA nutrition programs:

        ``[Program administrators] worry that if Congress doesn't sustain
            this higher level of appropriations, the relief money will be
            spent and waiting lists will reappear.
        `There's going to be a cliff,' Mary Beals-Luedtka [director of the
            area agency on aging serving northern Arizona] said. `What's
            going to happen next time? I don't want to have to call people
            and say, `We're done with you now.' These are our
            grandparents.' ''
                                     ______

               Prepared Statement of the National Association of
                          Secondary School Principals
        The National Association of Secondary School Principals (NASSP)
    appreciates the opportunity to submit the following testimony for the
    record to the Senate Appropriations Subcommittee on Labor, Health and
    Human Services, Education, and Related Agencies. As the premier
    national organization and voice for middle level and high school
    principals, assistant principals, and other school leaders, NASSP seeks
    to transform education through school leadership, recognizing that the
    fulfillment of each student's potential relies on great leaders in
    every school committed to the success of each student.
        As you develop the fiscal year (FY) 2022 appropriations bill for
    the U.S. Departments of Labor, Health and Human Services, Education,
    and Related Agencies, NASSP encourages you to help every American
    student achieve success and be ready for college, career, and life by
    prioritizing funding for Supporting Effective Instruction State Grants,
    the School Leader Recruitment and Support program, the Literacy for
    All, Results for the Nation (LEARN) program, and Student Support and
    Academic Enrichment grants.
        NASSP urges the subcommittee to allocate $3.00 billion for the
    Supporting Effective Instruction State Grants program, Title II, Part A
    (Title II-A) of the Every Student Succeeds Act (ESSA). This program
    provides states and school districts with formula funding that ensures
    that educators, principals, and school leaders receive the professional
    learning and leadership skills needed to support every student.
        Research continues to show that Title II-A's investments in
    educators pays significant dividends in terms of improving educational
    practice and increasing student achievement. School districts use Title
    II-A funding to implement ESSA's rigorous definition of professional
    development that embodies the important transition from scattershot,
    one-off professional development workshops and sessions to
    collaborative, ongoing, job-embedded professional learning such as
    coaching, mentoring, and professional learning communities (PLCs).
    Research supports the positive effect of the kinds of professional
    development defined in ESSA. For example, key studies show that
    coaching helps teachers improve their practice faster. A 2018 meta-
    analysis, which examined 60 rigorous studies of coaching, found large
    positive effects of coaching on teachers' instructional practices.
    Across 43 studies, researchers found that coaching accelerates the
    growth that typically occurs as one moves from novice to veteran
    status. Additionally, multiple researchers have documented that
    teachers who collaborate in PLCs to continuously improve their practice
    and their students' learning experiences have a measurable positive
    impact in schools. A 2009 study that took place in New York City
    documented student achievement gains across grade levels when teachers
    engaged in purposeful, content-focused interactions.
        Title II-A's support for principal and school leader professional
    learning is also critical, as research shows a strong correlation
    between high-quality principals and student achievement and teacher
    retention. A March 2021 Wallace Foundation paper stated that a review
    of two decades of evidence--including six quantitative, longitudinal
    studies involving 22,000 principals--found that ``principals have large
    effects on student learning, comparable even to the effects of
    individual teachers. A separate 2016 review of 18 studies meeting
    ESSA's Tiers I-III evidence standards concluded that ``school
    leadership can be a powerful driver of improved education outcomes.''
    This research buttresses earlier studies that concluded that principals
    are second only to teachers as the most important school-level
    determinant of student achievement. Other research suggests that
    schools led by high-quality principals have lower teacher turnover
    rates.
        While the federal government's investment in Title II-A has proven
    to be much needed and welcome, the COVID-19 pandemic laid bare the need
    for higher levels of support for our nation's educators. A significant
    increase to $3.00 billion for Title II-A will provide schools and
    districts with crucial funds to address new and existing challenges
    induced or exacerbated by the pandemic. A larger investment in Title
    II-A will help accelerate student learning, curb teacher and principal
    shortages by recruiting new individuals into the educator workforce,
    provide supports to keep educators in the profession, keep class sizes
    low, and provide mental health and wellness support to our nation's
    educators as they reenter classrooms full time for the upcoming school
    year.
        NASSP urges the subcommittee to support our nation's school leaders
    through renewed funding for the School Leader Recruitment and Support
    Program (SLRSP). Authorized under ESSA and funded at $14.5 million in
    FY 2017, SLRSP is the only federal program specifically focused on
    investing in evidence-based, locally-driven strategies to strengthen
    school leadership in high-need schools. Unfortunately, this program has
    received no funding in the last several fiscal years. Recently though,
    President Joe Biden released his FY 2022 budget, where he called for
    the program to receive $30 million, a number that NASSP requests this
    committee support.
        SLRSP empowers states and school districts, individually or in
    partnership with nonprofits or institutions of higher education, to
    accelerate the recruitment, preparation, support, and retention of
    dynamic school leaders who have a measurable, positive effect on
    student achievement in high-need schools. Through this program,
    aspiring principals gain access to high-quality preparation programs,
    sitting principals receive critical professional development supports,
    and thousands of teachers--along with hundreds of thousands of
    students--have the opportunity to work and learn in schools where
    school leaders have the tools to help them maximize their potential.
    Funding SLRSP at $30 million will allow proven programs to train more
    principals to lead during this critical time, provide additional
    support to current principals, and ultimately lead to better support
    for teachers and students.
        As we continue working with states, districts, and schools on how
    best to serve students and teachers as schools begin close out the
    current school year and look toward the next, it is important we
    recognize that investments in school leadership are critical to
    addressing learning loss and meeting students' social and emotional
    learning needs. Additionally, investments in leadership are extremely
    cost effective when you consider that investing in one principal is
    actually an investment in the 25 teachers and 500 students they, on
    average, support. A recent report from The Wallace Foundation states,
    ``Principals really matter. Indeed, it is difficult to envision an
    investment with a higher ceiling on its potential return than a
    successful effort to improve principal leadership.''
        While investments in school leadership will have a significant
    impact on addressing lost instructional time for students, additional
    investments in critical programs will also be necessary to help student
    achievement. That is why NASSP also calls for the subcommittee to
    provide $500 million for the LEARN program, which builds on the success
    of the Striving Readers Comprehensive Literacy (SRCL) program.
        Research has already started to highlight the pandemic's impact on
    students' literacy skills. McKinsey & Company found that students
    taking formative assessments in 2020 learned only 87% of the reading
    that grade-level peers would typically have learned by the fall.
    Students lost the equivalent of one-and-a-half months of learning in
    reading on average, but in schools that predominantly serve students of
    color, the learning loss was especially acute. The LEARN program builds
    on the success of the SRCL program where states implementing
    comprehensive literacy plans have seen significant improvements in
    English language arts achievement in districts and schools serving
    disadvantaged students.
        Eleven states (Georgia, Kansas, Kentucky, Louisiana, Maryland,
    Minnesota, Montana, North Dakota, New Mexico, Ohio, and Oklahoma), the
    Bureau of Indian Education, and four territories received SRCL grants
    in 2017, and an additional 13 states (Alaska, Arkansas, California,
    Georgia, Hawaii, Kentucky, Louisiana, Minnesota, New Mexico, Ohio,
    Rhode Island, and South Dakota) received grants in 2019 under the now-
    named Comprehensive Literacy State Development program. With these
    grants, states are able to support high-quality professional
    development for teachers, principals, and specialized instructional
    support personnel to improve literacy instruction for struggling
    readers and writers, including English-language learners and students
    with disabilities.
        The literacy skills our students need today are much more complex
    than they were 50 years ago. Creating a globally competent workforce
    depends on students using their reading and writing skills to develop
    important abilities in areas such as math, science, technology, and
    manufacturing. Yet despite the fundamental importance of reading and
    writing, only 35% of fourth-grade students and 34% of eighth-grade
    students performed at or above the proficient level in the reading
    assessment of the National Assessment of Educational Progress--the
    Nation's Report Card.
        Of the more than 523,000 students who leave U.S. high schools each
    year without a diploma, many have low literacy skills. Research clearly
    demonstrates that a high-quality, literacy-rich environment beginning
    in early childhood is one of the most important factors in determining
    school readiness and success, high school graduation, college access
    and success, and workforce readiness.
        A strong federal commitment to literacy is imperative. LEARN
    supports states in a comprehensive, systemic approach to strengthen
    evidenced-based literacy and early literacy instruction for children
    from early learning through high school and supports district capacity
    to accelerate reading and writing achievement for all students.
        Lastly, NASSP urges the subcommittee to allocate $2.00 billion for
    the Student Support and Academic Enrichment (SSAE) grant program
    authorized by Title IV-A of ESSA for FY 2022. This would be a $780
    million increase over the FY 2021 enacted level. Title IV-A is a
    flexible grant that supports state and district efforts to: 1) support
    safe and healthy students by providing comprehensive mental and
    behavioral health services and implementing violence prevention
    programs, trauma informed care, school safety trainings, and other
    evidenced-based initiatives; 2) increase student access to a well-
    rounded education, such as STEM, computer science and accelerated
    learning courses, career and technical education, physical education,
    music, the arts, foreign languages, college and career counseling,
    effective school library programs, and social and emotional learning;
    and 3) provide students with access to technology and digital learning
    materials and educators with professional development and coaching
    opportunities necessary to effectively use those resources.
        Over the last four fiscal years, on a bipartisan basis, Congress
    has provided a $4 billion investment for Title IV-A, which has allowed
    districts to meaningfully invest in programs that provide direct
    educational services and equitable supports to students. Its
    flexibility has allowed districts to provide funding for critical
    programs that support educators, school leaders, and students. As
    district leaders continue to leverage the flexibility of the SSAE
    grants, they are eager to plan for the continuance and/or expansion of
    existing programs and services, and to create new programs.
        To address unprecedented interruptions to learning caused by COVID-
    19, we call on Congress now to go beyond what was authorized in ESSA by
    providing $2 billion for the SSAE block grant. This will allow
    additional school districts, especially in rural areas, to make
    investments in not just one, but all three areas that this grant
    supports. Right now--more than ever--districts need the continued
    investments in the Title IV-A program. This pandemic has made clear
    that districts face a wide range of unique challenges, whether it's
    ensuring all children have access to technology for remote or blended
    learning or the ability to provide mental health supports from afar. As
    school systems prepare for the return to classrooms next school year,
    they will need the flexibility of Title IV-A funds to provide social
    and emotional learning programs, engaging well-rounded classes like
    music and physical education, and active learning opportunities enabled
    through technology.
        NASSP thanks you again for the opportunity to share these thoughts
    and information with you, and also thanks you for your continued work
    to support our nation's students and educators. To discuss this
    testimony further or if you have any questions, please contact NASSP's
    senior director of federal engagement and outreach, Zach Scott, at
    scottz@nassp.org.
                                     ______

               Prepared Statement of the National Association of
                        State Head Injury Administrators
        On behalf of the National Association of State Head Injury
    Administrators (NASHIA), thank you for the opportunity to submit
    testimony regarding the fiscal year 2022 appropriations for federal
    programs that impact approximately 2.87 million Americans who are
    treated annually in emergency department visits and hospitals for a
    traumatic brain injury (CDC, 2014). To address their needs, NASHIA is
    requesting increased funding for programs authorized by the Traumatic
    Brain Injury (TBI) Program Reauthorization Act of 2018 and administered
    by the U.S. Department of Health and Human Services' (HHS)
    Administration for Community Living (ACL) and the Centers for Disease
    Control and Prevention's National Center for Injury Prevention and
    Control (NCIPC). We also support additional funding for the ACL's
    National Institute on Disability, Independent Living, and
    Rehabilitation Research (NIDILRR) program authorized by the Workforce
    Innovation and Opportunity Act (WIOA) of 2014, and which funds TBI
    Model Systems and TBI research. NASHIA is requesting:
      --$12 million additional funding for the ACL TBI State Partnership
            Grant Program to provide funding to all states, territories and
            District of Columbia;
      --$6 million additional funding for the ACL TBI Protection & Advocacy
            Grant Program to increase the amount of the awards; and
      --$5M additional funding for the CDC's NCIPC to establish and oversee
            a National Concussion Surveillance System as authorized by the
            TBI Program Reauthorization Act of 2018.
        NASHIA is also requesting a funding increase of $6.6 million to
    expand the NIDILRR TBI research capacity through the TBI Model Systems
    (TBIMS):
      --To increase the number of TBIMS from 16 to 18 ($1 million each),
            while increasing per center support by $200,000;
      --$1 million to expand TBIMIS collaborative research projects from 1
            to 3; and
      --$100,000 to increase funding for the National Data and Statistical
            Center in order to gain information for valuable research.
        Each year, a substantial number of Americans are injured due to
    motor vehicle crashes, falls, military-related injuries, violence,
    industrial injuries, sports-related injuries and other injuries that
    cause cognitive, emotional, physical, sensory and health-related
    problems resulting in unemployment and loss income; homelessness;
    incarceration; and institutional and nursing home placement due to lack
    of community alternatives. While recent trends have noted the
    increasing number of Americans with TBI-related disabilities among
    older adults due to falls, the COVID-19 pandemic is raising alarms
    regarding those who are infected who may experience hypoxia due to the
    deprivation of oxygen, resulting in brain damage that may necessitate
    the need for rehabilitation to regain functioning and ongoing supports
    should functioning not be restored. In addition, the increased risk of
    domestic and intimate partner violence during the time of the ``stay at
    home'' orders put people at risk for sustaining a brain injury from the
    abuser hitting the head, slamming the head against the wall or from
    near strangulation. As we emerge from the pandemic, the impact on both
    those at risk for a brain injury and for those with a brain injury will
    certainly become more apparent.
        This year has been especially challenging for individuals with
    brain injury and their families. States have reported that brain injury
    program participants have cancelled services due to the fear and
    anxiety that COVID-19 has caused them. At the same time, providers have
    experienced loss of income as the result of not being able to perform
    contractual duties due to the restrictions. As a result, states have
    witnessed increased anxiety and self-isolation among individuals with
    brain injury. Thus, the federal funding requested is critical to assist
    states with issues that emanate from the pandemic, as well as to
    address the increased number of brain injuries due to an aging
    population and other factors.
             administration for community living--tbi act programs
        The ACL TBI State Partnership Grant Program is the only program
    that assists states in building and expanding service capacity to
    address the complex needs associated with brain injury that generally
    require the coordination of multiple systems (e.g., medical,
    rehabilitation, education, vocational, behavioral health, Medicaid) and
    payers (e.g., insurance, Workers' Comp, state and federal programs).
    Twenty seven states are ending their grant activities. We are
    requesting additional funding so that all states, territories and
    District of Columbia may receive funding to address gaps in services
    within their states.
        These grants also help to carry out the ACL priorities to increase
    direct services, including home and community-based services;
    accelerating COVID-19 recovery; supporting caregivers; and advancing
    equity.
              acl tbi state protection & advocacy (patbi) program
        The ACL Federal Protection and Advocacy TBI (PATBI) program is a
    formula grant that provides $4 million total in funding for the 57 P&As
    in the United States, its territories and the Native American
    Protection and Advocacy Project in order to provide: (1) information,
    referrals, and advice; (2) Individual and family advocacy; (3) legal
    representation; and (4) specific assistance in self-advocacy. The
    requested amount will increase the amount awarded to state and PATBI
    grantees.
     centers for disease control and prevention--national center on injury
                             prevention and control
        CDC's National Injury Center initiated a pilot study as a first
    step in implementing a national surveillance system to determine the
    extent of mild brain injury or concussions in this country. Most
    individuals with a concussion are treated in an emergency department or
    physician's office and may not be reported in other data systems that
    capture the number of Americans who are hospitalized with moderate to
    severe TBI. Subsequently, Congress included $5 million authorization to
    implement the National Concussion Surveillance System within the TBI
    Program Reauthorization Act of 2018.
        Last year, the Government Accountability Office (GAO) issued a
    Report to Congress that found that data on the overall prevalence of
    brain injuries resulting from intimate partner violence are limited and
    that such data is needed to better understand the problem to ensure
    that resources are targeted appropriately to address these issues. In
    2013, the Institute of Medicine (IOM) and the National Research Council
    released an extensive report on sports-related concussions in children
    and teens and also examined sports-related concussions among military
    dependents, as well as concussions in military personnel ages 18 to 21
    that result from sports and physical training at military service
    academies or during recruit training. The report noted that limited
    data is available and recommended that CDC oversee a national
    surveillance system to accurately determine the incidence of sports-
    related concussions.
        We strongly support funding to implement a national surveillance
    system to help states, federal and national partners with needed data
    to address prevention, identification, and treatment for concussions.
        acl's national institute on disability, independent living, and
                       rehabilitation research (nidilrr)
        NIDILRR supports innovative projects and research in the delivery,
    demonstration, and evaluation of medical, rehabilitation, vocational,
    and other services designed to meet the needs of individuals with TBI
    through TBI Model Systems grants. Each TBI Model System contributes to
    the TBI Model Systems National Data and Statistical Center (TBINDSC),
    participates in independent and collaborative research, and provides
    valuable information and resources. This research is critical to help
    TBI providers to better deliver services that result in good outcomes.
        In closing, NASHIA, as a nonprofit organization, works on behalf of
    states to promote partnerships and build systems to meet the needs of
    individuals with TBI with the goal of all states having resources to
    assist individuals with TBI to return to home, community, work and
    school after sustaining a brain injury. Federal funding is critical to
    help states in that endeavor, including data and research to support an
    effective delivery system. We urge you to consider increasing funding
    for the ACL TBI Program (state and protection & advocacy grant
    programs), for the ACL NIDILRR program to expand TBI research, for CDC
    to establish a National Concussion Surveillance system.
        Thank you for your continued support. Should you wish additional
    information, please do not hesitate to contact: Susan L. Vaughn,
    Director of Public Policy at svaughn@nashia.org, or Becky Corby, NASHIA
    Government Relations at rcorby@ridgepolicygroup.com.
                                     ______

    Prepared Statement of the National Association of State Long-Term Care
                               Ombudsman Programs
        Chairman Murray and Ranking Member Blunt, I present this testimony
    on behalf of the nearly 74,000 residents in Washington State's long-
    term care facilities and in collaboration with the National Association
    of State Long-Term Care Ombudsman Programs (NASOP). Thank you for your
    past support of State Long-Term Care Ombudsman Programs (SLTCOPs) and
    the at-risk individuals that they serve, particularly in the CARES Act.
    As you know, our work to serve the residents of long-term care
    facilities under the terrible cloud of the COVID-19 pandemic has been
    extremely challenging. We are emerging from this period facing many
    crises in facilities across the nation, but we are determined to
    protect the rights of residents, resolve their complaints and service
    problems, and work with facilities to improve the quality of care, the
    roles in which we ombudsmen have been entrusted.
        I submit this statement and the funding recommendations for the
    Fiscal Year 2022 for SLTCOPs administered through the Administration
    for Community Living, Department of Health and Human Services, to
    include:
      --$65 million to support our work with residents of assisted living,
            board and care, and similar community-based long-term care
            settings as these are less regulated and residents often need
            greater advocacy;
      --$70 million for our current core obligation to respond to
            tremendous need, ensuring residents have regular and timely
            access to our program; and
      --$20 million under the Elder Justice Act for training and services
            to address increasing abuse, neglect, and exploitation,
            including related to staff that are part of the opioid crisis.
        Let me explain why our program is requesting this funding. I will
    start by letting you know why we ombudsmen are so passionate about our
    work. Our mission is to protect the health, safety, welfare, and rights
    of our nation's older adults and individuals with disabilities living
    in nursing homes and assisted living facilities. We protect the
    residents' rights to be treated as individuals with autonomy, choice,
    independence, and access to quality health care. We believe that in a
    just society, all people would have their needs met. LTC Ombudsmen are
    paid professionals who recruit, train, and oversee teams of local
    volunteers who want to give back to their communities. The advocacy we
    provide is the first line of protection for thousands of elders living
    in licensed long-term care facilities. Increased consistent funding is
    needed for the SLTCOP to support the critical role ombudsmen play in
    the care infrastructure, specifically the long-term care and community-
    based care infrastructure funded in part by Medicaid and Medicare.
        Two years ago, volunteers in Washington donated approximately
    32,860 hours of their time and skill to resolve complaints made to the
    program with a success rate of nearly 90 percent. We save the state
    resources by resolving complaints at the lowest level keeping them out
    of the expensive regulatory and legal systems. However, like our sister
    programs across the nation, we are not able to keep up with consumer
    needs and growing costs. One of the key areas of need right now is the
    direct result of the covid-19 pandemic. The advocacy and protections
    our programs provide are necessary to address the trauma and impact
    that residents, family members, and staff have experienced during the
    pandemic. Many ombudsman programs, due to the risks, have lost paid
    staff and volunteers who need to be replaced.
        The pandemic put all ombudsmen on high alert. The Washington State
    LTCOP responded swiftly to the needs of residents and their families by
    adapting our methods, and developing ways to reach into facilities that
    were in ``lockdown''. We distributed nearly 70,000 post cards and notes
    to long-term care residents and their families informing them about the
    program, and Residents Rights. Through private donors and a grant from
    Washington State, we delivered approximately 800 Amazon Fire Tablets to
    adult family homes to help residents ``stay connected'' with their
    family, friends, and communities. We advocated on behalf of residents
    and their families through participation in multiple stakeholder
    meetings, educating and informing journalists, providing testimony, and
    working with our state legislature to pass meaningful legislation
    (HB1218). The State LTCOP created a mental health and spiritual
    counselor referral list to address the loss and grief, and the trauma
    experienced by long-term care residents. We organized a new resident-
    only advisory council to the State LTC Ombuds, giving voice to the
    thousands of long-term care residents who were voiceless during the
    pandemic. These are just a few examples of the work conducted during
    the COVID-19 crisis which is not yet over.
        To alleviate the effects of diminished budgets and expanding long-
    term care populations, we respectfully request the following funding to
    support all SLTCOPs.
        First, we request $65,000,000 to support SLTCOP work with residents
    of assisted living, board and care, and similar community-based long-
    term care settings. While the mandate to serve residents in assisted
    living facilities was added to our mission Act, there have been no
    appropriations for this function. Assisted living and similar
    businesses have boomed, but SLTCOP funding has not increased to meet
    the demand and respond to the industry boom. We rarely are able to get
    to the growing number of assisted living facilities, which depending on
    the state are called board and care and other names. Nationally, for
    example, while assisted living beds have grown to more than 57,000 in
    the years 2013 to 2018, we have about 2,000 fewer volunteers and only
    71 more paid ombudsmen over that five-year period.
        Home and Community based service options continue to grow in
    number, but there is no expansion in ombuds services. Increases in
    long-term care residents is a key factor and challenge to providing our
    cost saving advocacy services. Washington State has demonstrated
    leadership by reducing Medicaid costs, while excelling in consumer
    options outside of expensive nursing homes. Assisted living residents
    have complex medical needs, very much like the nursing home residents
    of 20 years ago. Growth in the number of assisted living facilities, in
    conjunction with complex needs of consumers and diminished funding
    threaten the health and wellbeing of people in our care. These
    challenges hinder our ability to meet program requirements to provide
    regular and timely access to all residents wanting long-term care
    ombudsman services. Current funding levels preclude SLTCOPs from
    quickly responding to complaints and monitoring facilities. Without our
    eyes and ears in these buildings, residents are at risk of abuse,
    neglect, and serious financial exploitation, and any number of
    violations of their rights.
        Our second request is for $70,000.000, which is needed to provide
    core program funding for the program under Title VII of the Older
    Americans Act. These funds must be allocated to all fifty states. In
    addition to improving the quality of life and care for our family
    members and neighbors in long-term care, our work saves Medicare and
    Medicaid funds by avoiding costs associated with poor quality care,
    unnecessary hospitalizations and expensive procedures and treatments.
    Furthermore, nationally in 2019, more than 5,947 volunteers donated
    their time. Ombudsman staff and volunteers investigated 198,502
    complaints made by residents, relatives, friends, and volunteers.
    Ombudsmen were able to resolve or partially resolve 71.5 percent--or an
    ombudsman resolved nearly three out of every four complaints
    investigated.
        In 2018, Washington State had 3,818 long-term care facilities with
    approximately 71,000 residents. Our state program includes me, and two
    other full-time staff, which has not changed much since 1989.
    Thankfully, we have great partnerships with other not-for-profits to
    operate local ombudsman programs, extending our reach into the most
    isolated of nursing home residents in our rural communities. These
    partners include seven Area Agency on Aging entities and three
    Community Action Programs and in total, we employ 17.51 full-time
    staff. Two national studies about the effectiveness of the LTC
    Ombudsman Program (the Institute of Medicine, and the Bader Report)
    have recommended that best practice be to employ one full-time paid
    ombudsman for every 2,000 long-term care residents or licensed beds.
    Washington State falls short of that goal at having only 49 percent of
    the needed paid staff.
        Although we have a great team of paid and volunteer ombudsmen, our
    program suffered a significant loss of volunteers during the pandemic.
    We weren't able to cover every facility before the pandemic and things
    are worse now. Nearly half of the facilities in our state never receive
    routine visits by an ombuds, and visitations are the hallmark activity
    of the Program--vital to building trust and effectiveness. We are so
    busy responding to complaints that we are not able to conduct regular
    outreach or build presence in all facilities. We are overwhelmed with
    complaints about involuntary, and unlawful discharges, also known as,
    ``resident dumping'' which is harmful to residents, and costly. Long-
    term care providers recognize the value and benefit of the LTC
    Ombudsman program trainings, and consultation services, which often
    address problems before they escalate.
        Third, we request $20,000,000 to support the work of SLTCOPs under
    the Elder Justice Act (EJC). This appropriation would allow states to
    hire and train staff and recruit more volunteers to prevent abuse,
    neglect, and exploitation of residents and investigate complaints.
    However, the funds have been authorized since 2010, to date no EJC
    funds have been appropriated for SLTCOPs, except for $4 million in the
    Coronavirus Response and Relief Supplemental Appropriations Act of
    2021. Currently, federal Older Americans Act funding comprises about a
    third of the total funding required to maintain the Washington Long-
    Term Care Ombudsman Program, at its current level, with the majority of
    funding coming from our State General Funds.
        Demand for our services is growing. The number of complex and very
    troubling cases that ombudsmen investigate has been steadily
    increasing. As more residents are vaccinated and facilities ``re-open''
    ombudsmen are returning to in-person visits. What we see is concerning
    and disturbing when it comes to poorer staffing levels and the impacts
    of social isolation. In addition, there continues to be a disturbing
    increase in the frequency and severity of citations for egregious
    regulatory violations by long-term care providers that put residents in
    immediate jeopardy of harm. Ombudsmen are needed now more than ever in
    nursing homes, assisted living, and similar care facilities.
        In order to improve advocacy and services available to residents,
    our office and NASOP respectfully request the aforementioned funding
    levels. Just think how much more we could accomplish if we had the
    resources to meet the demand.
        We appreciate that the Leadership Council of Aging Organizations
    has written in support of these requests.
        Thank you for your ongoing support.

        [This statement was submitted by Patricia L. Hunter, MSW,
    Washington State Long-Term Care Ombudsman.]
                                     ______

         Prepared Statement of the National College Attainment Network
        Dear Chair Murray and Ranking Member Blunt,
        Thank you for your continued leadership in past funding cycles to
    reinforce investments in the federal programs that support students in
    their pursuit of higher education. Today, we write to respectfully
    request that federal student aid funding be a high priority for the
    Subcommittee. Without the statutory discretionary spending caps for
    Fiscal Year 2022, we hope that total discretionary funding can rise to
    provide strong support for our nation's higher education system and
    students.
        With this goal in mind for FY22, NCAN recommends these specific
    funding levels for the U.S. Department of Education programs:
      --NCAN recommends the requisite funding in FY22 so that the maximum
            Pell Grant award can be increased to $12,990, double the
            current maximum award.
      --Supplementary Educational Opportunity Grant funding of $1.061
            billion.
      --Federal Work-Study funding of $1.48 billion.
      --TRIO program funding of $1.316 billion.
      --GEAR UP funding of $435 million.
      --$200 million increase in administrative funding for federal student
            aid management.
        Additionally, we request that the Corporation for National and
    Community Service receive $1.21 billion in funding for FY22--and that
    the AmeriCorps program, that allows some college access programs to
    provide near-peer mentors for their students, receive $501 million in
    funding.
        The National College Attainment Network (NCAN), founded in 1995,
    represents more than 600 members across the country that all work
    toward NCAN's mission to build, strengthen, and empower communities and
    stakeholders to close equity gaps in postsecondary attainment for all
    students. Collectively, we are committed to college access and success
    so that all students, especially those underrepresented in
    postsecondary education, can achieve their educational dreams. NCAN's
    members span a broad range of the education, nonprofit, government, and
    civic sectors, including national and community-based nonprofit
    organizations, federally funded TRIO and GEAR UP programs, school
    districts, colleges and universities, foundations, and corporations.
        Drawing on the expertise of our hundreds of organizational members
    in every U.S. state, NCAN is dedicated to improving the quality and
    quantity of support that underrepresented students receive to apply to,
    enter, and succeed in postsecondary education. Students of color,
    students from low-income backgrounds, and those who are the first in
    their family to attend college experience disproportionately lower
    rates of postsecondary success. For example, a low-income student is
    29% less likely to enroll in postsecondary education directly after
    high school than a high-income student. Ultimately, only 35% of low-
    income high school students obtain a postsecondary credential by age
    26, compared to 72% of high-income students.
        The federal investments that would most bolster the goal of closing
    attainment gaps include the following:
                             pell grant investments
        NCAN recommends that the maximum Pell Grant award be increased to
    $12,990, double the current maximum award. The Pell Grant has served as
    the cornerstone of financial aid for students from low-income
    backgrounds pursuing higher education since its creation in 1972. This
    need-based grant provides crucial support for around 7 million students
    each year, or about one-third of undergraduates. Without this need-
    based grant funding, an even smaller portion of students from low-
    income backgrounds would be able to access higher education. Congress
    has recognized the importance of the Pell Grant over the past five
    years by investing in annual increases of, on average, about $140 to
    the maximum award.
        Given that the previously required automatic inflationary increases
    have expired, these annual investments by Congress have been essential
    for the nation's students who do not have the means to pay for college
    from falling farther behind in their pursuit of higher education. Even
    with these investments, the purchasing power of the Pell Grant for a
    four-year college degree from a public institution is holding at a
    historic low of 29% of the cost of attendance. At its peak in 1975-76,
    the maximum Pell Grant award covered more than three-fourths of the
    average cost of attendance--tuition, fees, and living expenses--for a
    four-year public university.
        To address the long-term purchasing power of the Pell Grant, and to
    have the Pell Grant be increased so that it covers at least half of the
    cost of a four-year public higher education, the maximum award should
    be doubled.
        In President Biden's budget for FY22, the administration has
    requested that Congress consider a Pell Grant increase of $1,875,
    through discretionary and mandatory funding, to bring the maximum award
    to $8,370 for the 2022-23 award year. If Congress adopted the
    President's request, raising the maximum Pell Grant to $8,370, its
    purchasing power would significantly increase to 36%. NCAN applauds
    this historic investment, referred to in the budget as a ``down payment
    on the President's commitment to doubling the grant in future years.''
    NCAN encourages Congress to consider a plan for future increases that
    would achieve a doubling of the Pell Grant, such as is outlined in the
    bicameral Pell Grant Preservation and Expansion Act of 2021--which
    would achieve this goal, over a five-year timeframe.
        To reach this goal, NCAN requests the requisite funding in FY22 so
    that the maximum individual Pell Grant award can be increased to
    $12,990, double the current maximum award.
                              fafsa simplification
        In President Biden's budget for FY22, the administration requests a
    $200 million increase in administrative funding for federal student aid
    management. These funds are necessary to help with the implementation
    of the FAFSA Simplification Act and FUTURE Act--two laws that will
    achieve the goal of simplifying the Free Application for Federal
    Student Aid (FAFSA) process, a top priority for NCAN. With the Office
    of Federal Student Aid announcing a phased implementation plan for
    FAFSA simplification, to take full effect one year later than
    originally anticipated, NCAN supports this funding request to ensure
    that the timeline is not further delayed. The urgency for students to
    access need-based aid has only grown since passage of the legislation.
                                campus-based aid
        As low-income students piece together resources from a variety of
    sources to support their postsecondary education pursuits, every dollar
    and type of aid is significant. For most low-income students, the
    Supplemental Educational Opportunity Grant (SEOG) and Federal Work-
    Study help to fill unmet need in their financial aid packages.
        The SEOG program should be increased for FY22 so that institutions
    of higher education to support a greater percentage of the country's
    lowest-income students. For FY22, NCAN respectfully requests that
    Congress fund the SEOG program at a total of $1.061 billion.
        Sixty-four percent of today's students work while enrolled in
    school. The Federal Work-Study (FWS) program allows students to work in
    a flexible environment, learn important skills, and minimize the amount
    of time they spend commuting between work and campus. For FY22, NCAN
    respectfully requests that Congress increase the FWS program budget for
    a total of $1.48 billion.
        Federally Funded College Access Programs--TRIO and GEAR UP
        Annually, approximately 1.8 million high school seniors are defined
    as students from low-income backgrounds. A variety of programs are
    needed to meet all their needs as they pursue their options for
    education beyond high school. The NCAN community serves approximately 2
    million students annually from middle school through college
    graduation. To reach all the students needing services nationwide, our
    members build important partnerships both with TRIO and GEAR UP
    programs. NCAN respectfully requests that Congress continue its
    investment in federally funded college access programs at the amounts
    requested by their communities: $1.316 billion for TRIO and $435
    million for GEAR UP.
             corporation for national and community service (cncs)
        For every dollar spent on national service, the country sees a
    return on investment that is almost fourfold. Service also plays an
    important role in the college access movement. Many of NCAN's largest
    members can maximize their impact on underrepresented students by
    participating in the AmeriCorps public-private partnership. Continuing
    support for CNCS, and specifically the AmeriCorps program, will enable
    additional volunteers to work with low-income students, students of
    color, and students who are first in their family to attend college.
    NCAN respectfully requests of that the Corporation for National and
    Community Service and the AmeriCorps program receive $1.21 billion and
    $501 million, respectively, for FY22.
        Thank you for this opportunity to provide our funding priorities
    for the fiscal year 2022. Through continued supports--both financial
    and programmatic--our country can work together to close gaps in
    attainment, where a low-income student is about half as likely to
    complete a postsecondary degree or credential as a high-income student.
    Thank you for your support of this important goal.
        Sincerely.

        [This statement was submitted by Kim Cook, Executive Director,
    National College Attainment Network.]
                                     ______

           Prepared Statement of the National Council for Diversity
                           in the Health Professions
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to submit this
    statement for the record on behalf of the National Council for
    Diversity in the Health Professions (NCDHP). I am Dr. Wanda Lipscomb
    and I serve as President of the NCDHP and Director of the Center of
    Excellence for Culture Diversity in Medical Education at Michigan State
    University. NCDHP was established in 2006 and is composed of
    institutions that are either currently or formerly distinguished as a
    ``Center of Excellence'' through the Health Resources and Services
    Administration's (HRSA)'s Centers of Excellence (COE) program or are a
    current or former recipient of the Health Careers Opportunities Program
    (HCOP) grant, now known as the National HCOP Academies program. Every
    member institution within the council is committed to advancing
    pipeline programs and programmatic activity that leads to diversity in
    the health professions.
        The National Council for Diversity in Health Professions (NCDHP) is
    comprised of institutions with Centers of Excellence (COE) and Health
    Careers Opportunity Program (HCOP) grants funded by the Health
    Resources and Services Administration under the Title VII Health
    Professions Training Programs. COE/HCOP grantees are in health
    professions education and other institutions which excel in the
    development of educational pipeline programs for individuals from
    minority and disadvantaged backgrounds, and in the improvement of the
    quality of health care delivery to medically underserved communities. I
    am proud to put forth the following recommendations for the fiscal year
    (FY) 2022 appropriations process:
        Minority health professional development is a cost-effective and
    long-term mechanism of improving health care and decreasing health
    disparities in minority and underserved communities. 50-80% of Under-
    Represented Minority (URM) physicians and other health professionals
    practice in shortage areas serving minority patients. Minority health
    professionals possess the cultural, experiential and linguistic skills
    needed to provide cost-effective health care to minority communities.
    Minority students identified, recruited, supported, admitted, and
    trained in the health professions in this decade will provide services
    into the 2060s and 2070s.
                hrsa centers of excellence (coe) recommendation
        COE award recipients serve as innovative resource and education
    centers to recruit, train, retain and graduate URM students and faculty
    at health professions schools. Programs improve information resources,
    clinical education, curricula, and cultural competence as they relate
    to minority health issues and social determinants of health. These
    award recipients also focus on facilitating faculty and student
    research on health issues particularly affecting URM groups. The goal
    of the program is to effectively deliver health care to underserved
    communities.
        NCDHP recommends $47.42 million for the COE program in Fiscal Year
    2022
         hrsa health career opportunities program (hcop) recommendation
        HCOP provides opportunities for colleges and community-based health
    professions training and promotes the recruitment of qualified students
    and non-traditional students like veterans from disadvantaged
    backgrounds into health and allied health professions programs. As a
    major federal pipeline program into the health professions, HCOP
    improves the acceptance, retention and matriculation rates of
    participating students by implementing tailored enrichment programs
    designed to address their academic and social needs.
        The NCDHP recommends $47.95 million for the HCOP program in Fiscal
    Year 2022.
     funding justification and appropriations history for hrsa's hcop and
                                  coe programs
        --The Association of American Medical Colleges projects that in the
                U.S. there will be a shortage of nearly 120,000 primary
                care physicians by the year 2030. Looming workforce
                shortages exist not only in medicine, but also in
                dentistry, public health, physician assistants and other
                health professions. If not adequately addressed, our nation
                will continue to fall short in addressing the needs of
                medically underserved communities as most recently exposed
                by the COVID-19 pandemic.
        --We are seeking to restore COE and HCOP funding to FY 2005 levels.
                For FY 2006 the COE appropriation was cut by 65% from $33M
                to only $12M. Similarly HCOP was cut by 89% to only $4M.
                Adjusting for inflation COEs $33M in 2005 dollars would be
                $45M in 2021 dollars. HCOPs $35M in 2005 would now be $47M.
        --The number of COE grantees dropped from 34 (in 2005) to 19 (in
                2020), and the number of HCOP grantees dropped from 74 (in
                2005) to 22 (in 2020). These programs have not fully
                recovered. Presently there is not enough funding in either
                program to support a new competition-only to maintain
                existing programs. A significant increase is needed in COE
                and HCOP to increase the number of Latino, Black, American
                Indian and disadvantaged students recruited, admitted and
                graduated as culturally competent physicians and other
                health professionals who have a high likelihood of
                practicing in underserved minority communities. For
                example, with increased funding, COE could launch an
                initiative to increase the number of post-baccalaureate
                slots and programs that enroll previously rejected
                applicants in one-year programs, with 90% being accepted to
                medical school, of which >95% will graduate as physicians.
        As you begin the FY 2022 process, NCDHP asks that you further
    prioritize Title VII health professions training programs. Chairwoman
    DeLauro, Ranking Member Cole, please allow me to express my
    appreciation to you and the members of this subcommittee. With your
    continued help and support, NCDHP member institutions are keeping
    course to overcome health workforce and health disparities. Thank you
    for your time and consideration of these requests. We look forward to
    working with the Subcommittee to prioritize the health professions
    programs in FY 2022 and the future.

        [This statement was submitted by Wanda Lipscomb, PH.D., President,
    National Council for Diversity in the Health Professions.]
                                     ______

             Prepared Statement of the National Eczema Association
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --Please provide the National Institutes of Health (NIH) with at
            least $46.1 billion to expand and advance critical research
            activities, and provide individual NIH institutes and centers,
            such as the National Institute of Allergy and Infectious
            Diseases (NIAID) and the National Institute of Arthritis and
            Musculoskeletal and Skin Diseases (NIAMS) with proportional
            funding increases.
        --While NIH has received notable funding over recent years, funding
                for the eczema portfolio has stayed relatively flat and
                additional resources are needed.
      --Please provide the Centers for Disease Control and Prevention (CDC)
            with at least $10 billion to facilitate timely public health
            efforts on a variety of conditions, including skin disease.
            Additionally, please provide individual CDC centers, such as
            the National Center for Chronic Disease Prevention and Health
            Promotion (NCCDPHP) with proportional funding increases.
        --Please provide $5 million for the new Chronic Disease Education
                and Awareness Program at CDC.
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of the
    National Eczema Association and the over 31 million eczema patients of
    all ages across the country. Chairwoman Murray, Ranking Blunt, and
    distinguished members of the subcommittee, thank you for the ongoing
    investment in medical research that has facilitated breakthroughs and
    scientific progress for the eczema community. As you and your
    colleagues work on appropriations for FY 2022, please continue this
    investment in medical research and similarly provide robust funding for
    public health programs. Thank you for your time and for your
    consideration of these requests.
                  about the national eczema association (nea)
        NEA is the driving force for an eczema community fueled by
    knowledge, strengthened through collective action and propelled by the
    promise for a better future.
        Reflecting back and looking ahead led us to appreciate how central
    the concept of ``community'' has become to NEA's identity and its
    existence, as is now captured in our aforementioned mission statement.
    We also recognize that what we mean by the term ``eczema community''
    has expanded over the years to reflect a multitude of personal and
    professional interests committed to making life better for those who
    live with eczema. Many people seek out NEA to connect with others who
    understand and share the experience of living with eczema. Each
    individual's unique perspective, based on their own experience, is a
    source of strength and vibrancy for the diversity of our community.
    Through our dedicated advocates, we will share some of those stories
    and perspectives with you today.
                                  about eczema
        Eczema is the name for a group of conditions that cause the skin to
    become itchy, inflamed and red in lighter skin tones or brown, purple,
    gray or ashen in darker skin tones. Eczema is very common in both
    children and adults and affects all races and ethnicities. In fact,
    more than 31 million Americans have some form of eczema- with up to 40%
    of affected individuals experiencing more severe disease symptoms and
    chronic disease burden.
        Eczema is not contagious. You cannot ``catch it'' from someone
    else. While the exact cause of eczema is unknown, researchers do know
    that people who develop eczema do so because of a combination of genes
    and environmental triggers.
        When an irritant or an allergen from outside or inside the body
    ``switches on'' the immune system, it produces inflammation. It is this
    inflammation that causes the symptoms common to most types of eczema.
        There are seven different types of eczema:
      --Atopic dermatitis
      --Contact dermatitis
      --Neurodermatitis
      --Dyshidrotic eczema
      --Nummular eczema
      --Seborrheic dermatitis
      --Stasis dermatitis
        It is possible to have more than one type of eczema on your body at
    the same time. Each form of eczema has its own set of triggers and
    treatment requirements, which is why it is so important to consult with
    a healthcare provider who is knowledgeable in treating eczema. Many
    healthcare providers can be involved in the diagnosis and treatment of
    eczema including primary care providers, pediatricians, dermatologists,
    and allergists. Recent years of scientific progress have led to the
    emergence of new therapies, but much more work needs to be done in
    research and public health to improve care for patients and address
    areas of continued unmet treatment and quality of life needs.
            recent advancements and emerging research opportunities
        NEA's research priorities, including grants that we fund on an
    annual basis, focus on improving health outcomes for the community and
    translating breakthroughs in basic science to diagnostic tools,
    innovative therapies, and improved healthcare information:
      --Cutting-Edge Basic & Translational Science- Innovative
            investigations of targets, pathways or technologies that will
            advance understanding of the pathophysiology or natural history
            of eczema, and potentially lead to novel or enhanced
            therapeutic/preventative areas of exploration or application.
      --Eczema Heterogeneity: Novel Insights- Projects aimed at advancing
            understanding of the underlying factors contributing to the
            diversity of eczema clinical presentation, treatment response
            and comorbidities.
      --Innovations in Clinical Practice & Care-Studies addressing
            approaches to facilitate optimal identification and treatment
            of eczema and associated comorbidities in all health care
            settings to enhance patient-reported and patient-centric
            outcomes.
      --Understanding & Alleviating Disease Burden-Insightful proposals
            that identify, quantify or aim to reduce aspects of eczema
            burden that negatively affect patient or family/caregiver
            quality of life (including lifestyle, academic/occupational, or
            economic impacts) based on patient population, treatment
            approach, etc.
      --Eczema Prevention-Novel investigations into the potential risk
            factors and strategies of primary eczema prevention at all
            ages.
        Our research efforts overlap with NIH-supported research
    activities, which currently total a modest-but-meaningful $35 million
    annually.
                                patient stories
        People with eczema and their loved ones are the true experts, which
    is why we call upon our community regularly to share their stories.
        Lindsay is one of our Illinois advocates. She was diagnosed at six
    years old with eczema. Now, in her 40s, she wants to ensure that
    policymakers understand that eczema is more than just a rash. While
    getting access to a biologic has been a challenge (to the point where
    she had to miss doses), the medicine has changed the way eczema
    presents on her skin. It still gets angry and red, but it no longer
    weeps. It will just dry up and flake off. Her body is about 75% clear
    on a good day, but she can still get bad flares primarily on her face
    and neck.
        Andrea is one of our Connecticut advocates. She has had eczema for
    15 years and her youngest child was diagnosed with eczema on the back
    of her knees two years ago. She advocates that all patients should have
    access to specialty care because to help heal eczema you need the right
    support and right care to know the underlying cause.
        Traciee is one of our Oregon advocates. She advocates on behalf of
    herself and all the eczema warriors and their families. She feels
    strongly that patients should have access to quality healthcare and
    that fellow eczema warriors should not have to suffer in silence with
    an uncontrollable itch. The solution is that treatment decisions should
    be made by the provider who has received extensive training in this
    disease.

        [This statement was submitted by Michele Guadalupe, MPH, Associate
    Director, Advocacy and Access.]
                                     ______

       Prepared Statement of the National Family Planning & Reproductive
                               Health Association
        Dear Chairwoman Murray and Ranking Member Blunt:
        As President & CEO of the National Family Planning & Reproductive
    Health Association (NFPRHA), I thank you for this opportunity to
    provide testimony in support of a fiscal year (FY) 2022 appropriation
    of $737 million for the Title X family planning program (Office of
    Population Affairs, funded within the Health Resources and Services
    Administration account). We are grateful for Chairwoman Murray's
    longtime leadership in advocating for family planning and urge you to
    take this substantial step forward in this year's bill.
        NFPRHA is a non-partisan, non-profit membership association whose
    mission is to advance and elevate the importance of family planning in
    the nation's health care system; NFPRHA membership includes close to
    1,000 members that operate or fund more than 3,500 health centers that
    deliver high-quality family planning education and preventive care to
    millions of people every year in the United States. These members cover
    the broad spectrum of publicly funded family planning providers,
    including state and local health departments, hospitals, family
    planning councils, federally qualified health centers, Planned
    Parenthood affiliates, and other private non-profit agencies. NFPRHA
    represents three-quarters of all current Title X grantees as well as
    the majority of grantees that withdrew from the program in 2019 rather
    than comply with the Trump administration's program rule.
        Title X is the nation's only federal program dedicated to providing
    family planning services for people with low incomes across the United
    States. In 2018, prior to the implementation of the Trump
    administration's devastating regulations, nearly 4,000 health centers
    in the network served nearly 4 million patients.\1\ Title X-funded
    health centers are lifelines for their communities, providing high-
    quality reproductive and sexual health care, including cancer
    screenings, testing and treatment for sexually transmitted infections,
    HIV/AIDS education and testing, contraceptive services and supplies,
    pregnancy testing, and other vital health care services. These centers
    disproportionately serve people from communities that face systemic
    barriers to accessing quality health care, including people with low
    incomes, people who are uninsured or underinsured, people of color,
    people who live and work in rural areas, LGBTQ people, and young
    people. In fact, 60% of women who received contraceptive services from
    a Title X-funded health center in 2016 had no other source of medical
    care in the prior year,\2\ and almost two-thirds of patients at these
    sites have incomes at or below the federal poverty level.\3\
    ---------------------------------------------------------------------------
        \1\ Christina Fowler et al, ``Family Planning Annual Report: 2018
    National Summary,'' RTI International (August 2019). https://
    www.hhs.gov/opa/sites/default/files/title-x-fpar-2018-national-
    summary.pdf.
        \2\ Meghan Kavanaugh, ``Use of Health Insurance Among Clients
    Seeking Contraceptive Services at Title X-Funded Facilities in 2016,''
    Guttmacher Institute (June 2018). https://www.guttmacher.org/journals/
    psrh/2018/06/use-health-insuranceamong-clients-seeking-contraceptive-
    services-title-x.
        \3\ Christina Fowler et al, ``Family Planning Annual Report: 2019
    National Summary,'' RTI International (September 2020). https://
    opa.hhs.gov/sites/default/files/2020-09/title-x-fpar-2019-national-
    summary.pdf.
    ---------------------------------------------------------------------------
        Unfortunately, the current funding level is woefully below what is
    required to meet the family planning and sexual health needs of people
    living with low incomes. Title X has been cut or flat-funded every year
    for the past decade, and the program's FY2021 allocation is just $286.5
    million, the same allocation the program has received for seven fiscal
    years, and significantly below the allocation from a decade ago. Other
    important public health programs, such as the Title V Maternal-Child
    Health Block Grant and the Ryan White HIV/AIDS Program, have seen
    significant increases in the same period, and people who rely on
    publicly funded family planning care deserve that same investment in
    their health care needs. The current allocation is also well below the
    $737 million estimate that researchers from the Centers for Disease
    Control and Prevention, the Office of Population Affairs (OPA), and the
    George Washington University determined in 2016 would be needed
    annually just to provide family planning care to low-income women
    without insurance.\4\ We urge you to take a substantial step forward
    for family planning access and appropriate that $737 million for the
    program in FY2022.
    ---------------------------------------------------------------------------
        \4\ Euna August, et al, ``Projecting the Unmet Need and Costs for
    Contraception Services After the Affordable Care Act,'' American
    Journal of Public Health (February 2016): 334-341.
    ---------------------------------------------------------------------------
        This funding increase is particularly vital given the harms the
    Trump administration inflicted on the program, the providers funded by
    it, and, most importantly, the people who seek family planning and
    sexual health care. On July 15, 2019, that administration's regulations
    for Title X went into effect, and the impact was felt almost
    immediately: by fall 2019, approximately 1,000 health centers across 33
    states had withdrawn from the program. In 2018, those health centers
    had provided 1.6 million patients with high-quality Title X-supported
    family planning and sexual health services.\5\ In September 2020, OPA
    released the first federal data showing the impact of the rule, and the
    results were devastating: relative to 2018, Title X-funded health
    centers provided family planning services to 844,083 fewer patients in
    2019, a staggering 21% decrease, and that was after just five months of
    having the rule in effect. In addition, fourteen states lost more than
    one-third of their patient volume. This drastic decrease translated to
    hundreds of thousands of fewer contraceptive services provided, more
    than 1 million fewer STD tests administered, and more than 250,000
    fewer life-saving breast and cervical cancer screenings performed with
    Title X funds.\6\ The numbers for 2020--no doubt exacerbated by the
    impact of COVID-19 on health care access--are even worse, with
    preliminary data showing that only 1.5 million people were able to
    receive Title X-supported services in 2020, a drop of 60% from just two
    years earlier.\7\ Six states--Hawaii, Maine, Oregon, Utah, Vermont, and
    the chairwoman's home state of Washington--have had no Title X-funded
    services for almost two years.
    ---------------------------------------------------------------------------
        \5\ Mia Zolna Sean Finn, and Jennifer Frost, ``Estimating the
    impact of changes in the Title X network on patient capacity,''
    Guttmacher Institute (February 2020). https://www.guttmacher.org/
    article/2020/02/estimating-impact-changes-title-x-network-patient-
    capacity.
        \6\ Christina Fowler et al, ``Family Planning Annual Report: 2019
    National Summary,'' RTI International (September 2020). https://
    opa.hhs.gov/sites/default/files/2020-09/title-x-fpar-2019-national-
    summary.pdf.
        \7\ Ensuring Access to Equitable, Affordable, Client-Centered,
    Quality Family Planning Services, 86 Federal Register 19812 (proposed
    April 15, 2021) (to be codified at 42 CFR 59).
    ---------------------------------------------------------------------------
        Compounding these harms, a 2020 study shows that COVID-19 has led
    many women to want to delay or prevent pregnancy while it has
    simultaneously made it more difficult for people to access family
    planning and sexual health care, including contraception. Women of
    color and women with low incomes are more likely to report both
    findings.\8\ The confluence of the Trump administration's rule and a
    global pandemic means that a significant influx of funds is desperately
    needed to begin to rebuild the network and restore Title X services to
    communities across the country as quickly as possible.
    ---------------------------------------------------------------------------
        \8\ Lindberg LD et al, ``Early Impacts of the COVID-19 Pandemic:
    Findings from the 2020 Guttmacher Survey of Reproductive Health
    Experiences,'' Guttmacher Institute (June 2020). https://
    www.guttmacher.org/report/early-impacts-covid-19-pandemic-findings-
    2020-guttmacher-survey-reproductive-health.
    ---------------------------------------------------------------------------
        These funds will be particularly significant given the Biden
    administration's commitment to restore the Title X program's commitment
    to high-quality, client-centered, evidence-based care by fall 2021.\9\
    That process is moving quickly: on April 15, HHS published a notice of
    proposed rulemaking, and comments were due on May 17.\10\ NFPRHA
    continues to urge HHS to complete the rulemaking process as quickly as
    possible and to subsequently make funds available to communities that
    have been without services as soon as the new rule is in effect.
    ---------------------------------------------------------------------------
        \9\ Office of Population Affairs, ``Title X Statutes, Regulations,
    and Legislative Mandates,'' US Department of Health and Human Services
    (March 2021). https://opa.hhs.gov/grant-programs/title-x-service-
    grants/title-x-statutes-regulations-and-legislative-mandates.
        \10\ Ensuring Access to Equitable, Affordable, Client-Centered,
    Quality Family Planning Services, 86 Federal Register 19812 (proposed
    April 15, 2021) (to be codified at 42 CFR 59).
    ---------------------------------------------------------------------------
        We thank you for your consideration of this request.
        Sincerely.

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

            Prepared Statement of the National Institutes of Health
        Good morning, Chairwoman Murray, Ranking Member Blunt, and
    distinguished Members of the Subcommittee. I am Francis S. Collins,
    M.D., Ph.D., and I have served as the Director of the National
    Institutes of Health (NIH) since 2009. It is an honor to appear before
    you today.
        First, I want to thank this Subcommittee for your commitment to
    NIH, which allowed the biomedical research enterprise to respond
    quickly to the greatest public health crisis in our generation over the
    past year. We mounted vigorous research efforts to understand the viral
    biology and pathogenesis of the coronavirus disease 2019 (COVID-19),
    develop vaccines in record time, support and commercialize diagnostics
    at the point of care, and test therapeutics for both outpatient and
    inpatient settings. This work is far from finished.
        The President's Discretionary Request proposes budget authority of
    $51 billion for NIH in fiscal year (FY) 2022. The Biden Administration
    places great emphasis on research and development in general. At NIH in
    particular, the Request proposes to build on the successes of pandemic
    era research and to put the research enterprise to work on some of our
    Nation's most persistent and perplexing health challenges, including
    cancer, Alzheimer's disease, opioid use disorder, health disparities,
    maternal mortality, HIV/AIDS, gun violence, climate change, and other
    areas with major implications for our Nation's health.
        First and foremost, the President's Request proposes $6.5 billion
    to establish the Advanced Research Projects Agency for Health--ARPA-H
    to drive transformational innovation in health research and speed
    application and implementation of health breakthroughs. ARPA-H will
    tackle bold challenges requiring large scale, cross-sector
    coordination, employing a non-traditional and nimble approach to high
    risk research, modeled after DARPA in the Department of Defense. To
    achieve this, ARPA-H will invest in emergent opportunities by
    conducting advanced systematic horizon scans of academic and industry
    efforts, leveraging novel public-private partnerships, recruiting
    visionary program managers, and using directive approaches that provide
    quick funding decisions to support projects that are results-driven and
    time-limited. Potential areas of transformative research driven by
    ARPA-H include: the use of the mRNA vaccines to teach the immune system
    to recognize any of the 50 common genetic mutations that drive cancer;
    development of a universal vaccine that protects against the 10 most
    common infectious diseases in a single shot; development of wearable
    sensors to measure blood pressure accurately 24/7; and leveraging of
    artificial intelligence technology to advance care for individual
    patients and improve detection of early predictors of disease.
        ARPA-H represents the kind of transformative idea for biomedical
    research that only comes along once in a long while. Our confidence
    that NIH is ready has been greatly advanced by our experience in
    addressing the COVID-19 pandemic--developing vaccines in record time,
    establishing an unprecedented public-private partnership on
    therapeutics that has made it possible to test more than a dozen
    possible therapeutics in rigorous trials, and building a venture
    capital model for assessing SARS-CoV-2 diagnostic technologies that has
    yielded millions of daily tests in just months.
        But while we begin to imagine a life after COVID-19, we must
    acknowledge that there are COVID-related impacts that we have yet to
    understand and address, including the full impact of the pandemic on
    children. Children were largely spared from COVID-19 but for some
    children, exposure to the COVID-19 virus led to Multisystem
    Inflammatory Syndrome in Children (MIS-C), a severe and sometimes fatal
    inflammation of organs and tissues. The Eunice Kennedy Shriver National
    Institute of Child Health and Human Development (NICHD) is leading a
    multi-institute initiative known as the Collaboration to Assess Risk
    and Identify loNG-term outcomes for Children with COVID (CARING for
    Children with COVID), which will assess both short-term and long-term
    effects of MIS-C and other severe illness related to COVID-19 in
    children, including cardiovascular and neurodevelopmental
    complications.
        For many Americans, this pandemic and its related socioeconomic
    effects have had an overwhelming impact on their mental health. Prior
    research on disasters and epidemics has shown that in the immediate
    wake of a traumatic experience, large numbers of affected people report
    distress, including new or worsening symptoms of depression, anxiety,
    and insomnia. To aid in mental health recovery from the COVID-19
    pandemic, NIH will continue to focus on research in this area. This
    will be done, in part, by utilizing participants in existing cohort
    studies, who will be surveyed on the effect of the pandemic and various
    mitigation measures on their physical and mental health.
        The COVID-19 pandemic has brought into sharp focus the dramatic
    health disparities that exist across the American population. In
    addition, the Nation has been shaken by the killing of George Floyd and
    other attacks on people of color, forcing a recognition that our
    country is still suffering the consequences of centuries of racism. NIH
    will continue to address these disparities, specifically through
    research managed by the National Institute on Minority Health and
    Health Disparities (NIMHD), the National Heart, Lung, and Blood
    Institute (NHLBI), the National Institute of Nursing Research (NINR)
    and the Fogarty International Center (Fogarty).
        NIMHD looks to better understand the human biological and
    behavioral mechanisms and pathways that affect disparity populations,
    better understand the long-term effects of disasters on health care
    systems caring for populations with health disparities and research
    focusing on the societal-level mechanisms and pathways that influence
    disease risk, resilience, morbidity and mortality. NINR and Fogarty
    both look to better understand and reduce rural health disparities in
    low-income counties in the southern United States, support nursing
    science focused on racial, ethnic, and socioeconomic health
    disparities, with the goal of closing the gap in health inequities and
    increase health disparity research in low and middle income countries.
        In addition to the core health disparities research, the
    President's Request puts an additional specific focus on maternal
    morbidity and mortality (MMM), which disproportionately affect specific
    racial and ethnic minority populations. Black and American Indian/
    Alaska Native individuals are two to four times more likely to die from
    pregnancy-related or pregnancy-associated causes compared to white
    individuals. Furthermore, Black, Hispanic and Latina Americans, Asian,
    Pacific Islander, and American Indian/Alaska Native individuals all
    have higher incidence of severe maternal morbidity (SMM) compared to
    white individuals. The Implementing a Maternal Health and Pregnancy
    Outcomes Vision for Everyone (IMPROVE) initiative supports research on
    how to mitigate preventable MMM, decrease SMM, and promote health
    equity in maternal health in the United States.
        As the climate continues to change, the risks to human health will
    grow, exacerbating existing health threats and creating new public
    health challenges. Major scientific assessments document a wide range
    of human health outcomes associated with climate change. While all
    Americans will be affected by climate change, underserved populations
    are disproportionately vulnerable. These populations of concern include
    children, the elderly, outdoor workers, and those living in
    disadvantaged communities. NIH is poised to lead new research efforts
    to investigate the impact of climate on human health, with the goal to
    understand all aspects of health-related climate vulnerability.
    Therefore, the President's Request includes a $100 million increase for
    research on the human health impacts of climate change.
        The FY 2022 President's Discretionary Request makes a major
    additional investment to address the opioid crisis. The crisis of
    opioid misuse, addiction, and overdose in the United States is a
    rapidly evolving and urgent public health emergency that has been
    exacerbated by the coronavirus pandemic. Since the declaration of a
    public health emergency for COVID, illicit fentanyl use and heroin use
    have increased, and overdoses in May 2020 were 42 percent higher than
    in May 2019.
        The use of opioids together with stimulants, such as
    methamphetamine, is increasing; and deaths attributed to using these
    combinations are likewise increasing. Taking note of these trends, FY
    2021 appropriation language expanded allowable use of Helping to End
    Addiction Long-term (HEAL) funds to include research related to
    stimulant misuse and addiction. Identifying how opioids and stimulants
    interact in combination to produce increased toxicity will enhance our
    ability to develop medications to prevent and treat comorbid opioid and
    stimulant use disorders and overdoses associated with this combination
    of drugs.
        Finally, I'd like to take a moment to thank this Subcommittee for
    its recognition over the last two years that America's continuing
    leadership in biomedical research requires infrastructure and
    facilities that are conducive to cutting-edge research. With your
    support, we will break ground in the near future on a new Surgical,
    Radiological, and Laboratory Medicine division of our Clinical Center,
    which will replace severely outdated and deteriorating operating suites
    and lab space with state-of-the-art facilities. NIH continuously works
    to ensure that the buildings and infrastructure on its campuses are
    safe and reliable and that these real property assets evolve in support
    of science--but NIH's backlog of maintenance and repair is now nearly
    $2.5 billion. The President's FY 2022 Discretionary Request includes
    $250 million to make progress on reducing this backlog and requests
    flexibility for Institutes and Centers to fund construction, repair,
    and improvement projects.
        COVID-19 compelled us to perform a stress test on biomedical
    research enterprise. The enterprise performed nobly. We found what
    worked, and also identified barriers we hadn't fully appreciated
    before, and invented new ways around them. The President's FY 2022
    Discretionary Request is a roadmap for how to build on the successes of
    research, address our gaps, and apply our insights to the most
    important problems we face as a nation. With your support, the future
    is filled with opportunity. My colleagues and I look forward to
    answering your questions.

        [This statement was submitted by Francis S. Collins, M.D., Ph.D.,
    Director,
    National Institutes of Health.]
                                     ______

              Prepared Statement of the National Kidney Foundation
        The National Kidney Foundation (NKF) is pleased to submit testimony
    to highlight the significant burden that chronic kidney disease (CKD),
    including irreversible kidney failure, places on patients, families,
    and our nation's health care system. We urge the subcommittee to
    increase funding for programs and activities as a bold step to help
    transform CKD awareness, prevention, detection, and management.
    Specifically, NKF requests $15 million for CKD activities at the
    Centers for Disease Control and Prevention and a substantive increase,
    commensurate with or exceeding the increase for NIH as a whole, for the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK) for kidney research activities. We also urge greater
    collaboration between NIDDK and other Institutes studying related
    comorbidities and conditions, such as hypertension, cardiovascular
    disease, immunology, disparities, and genomics.
                                   about ckd
        CKD impacts an estimated 37 million American adults and was the
    nation's 8th leading cause of death in 2020. Although it can be
    detected through simple blood and urine tests, an estimated 90% of CKD
    patients are undiagnosed, often until advanced stages when it is too
    late for interventions to slow disease progression. Alarmingly, some
    patients are not diagnosed until they have progressed to irreversible
    kidney failure (end stage kidney failure, or ESKD) and undergo urgent
    start dialysis. More than 750,000 Americans have irreversible kidney
    failure, requiring kidney dialysis at least 3 times per week at a
    dialysis center; daily home dialysis, or a kidney transplant to
    survive. Medicare spends $130 billion on the care of people with a CKD
    diagnosis. Individuals with kidney failure represent 1% of Medicare
    beneficiaries but comprise 7% of Medicare fee-for-service expenditures.
    The need for a substantially increased federal commitment to address
    the societal and economic burdens of CKD is undeniable.
        CKD is a disease multiplier, with many patients experiencing
    cardiovascular disease, bone disease, cognitive challenges, depression,
    and increased hospitalization. CKD also is an independent risk
    predictor for heart attack and stroke. Early-stage intervention can
    improve outcomes and lower costs, yet fewer than half of patients with
    high blood pressure or diabetes (which together are responsible for
    three-fourths of all cases of ESKD) receive CKD testing. To improve
    awareness, early identification, and early-stage intervention, NKF
    calls on Congress to invest in kidney health programs throughout HHS.
                                  disparities
        CKD is characterized by racial, ethnic, and socioeconomic
    disparities. Blacks or African Americans, Hispanics, Asian Americans
    and Pacific Islanders, and Native Americans or Alaska Natives are at
    higher risk for CKD and ESKD. A common reason is the disproportionate
    incidence of chronic comorbidities such as diabetes and hypertension in
    many of these groups. While Blacks or African Americans make up 13
    percent of the U.S. population, they account for 35 percent of
    Americans with kidney failure, and are almost four times more likely
    than Whites to progress to kidney failure. Hispanic Americans are 1.3
    times more likely than Whites to have kidney failure. Blacks or African
    Americans and Hispanics experience more rapid decline of kidney
    function than Whites and are less likely to have had a visit with a
    nephrologist prior to starting dialysis. Disparities are present in
    kidney transplant as well. Blacks have less access to the kidney wait
    list and experience a longer wait once listed. As of May 6, 2021, Black
    patients were 31.5% of the kidney wait list candidates, but in 2020
    they received only 27% of kidney transplants. Hispanics represent 21%
    of the wait list and received 18.4% of kidney transplants.
                                    covid-19
        COVID-19 has amplified the CKD and ESKD disparities discussed
    above, as kidney patients (including transplant recipients) are at risk
    for severe COVID-19 infection and mortality. In October 2020, COVID-19
    hospitalizations were 2,194 per 100,000 Medicare ESKD beneficiaries,
    compared to 320 per 100,000 Medicare aged beneficiaries. In data
    reported by CDC, from February 1-August 31, 2020, a comparison of
    observed and predicted monthly deaths among ESKD patients showed an
    estimated 8.7-12.9 excess deaths per 1,000 ESKD patients, or a total of
    6,953-10,316 excess deaths. The increased vulnerability is due to a
    series of factors, including compromised immune systems, multiple
    comorbidities, and exposure through the in-center dialysis care
    environment that necessitates close contact with others. Transplant
    recipients in particular face higher COVID-19 mortality risk. In
    addition, patients experiencing severe COVID-19 are at an increased
    risk of developing acute kidney injury (AKI), often requiring the need
    for acute dialysis and sometimes resulting in CKD or irreversible
    kidney failure.
                       kidney public awareness initiative
        A key aspect of the Department of Health and Human Services's 2019
    Advancing American Kidney Health (AAKH) Initiative is increased
    awareness of CKD among the public and health care practitioners to
    improve early detection, provide early intervention and improve
    outcomes. Early intervention can slow the CKD progression and, in some
    instances, prevent kidney failure, reduce the impact of comorbidities,
    and reduce hospitalizations and readmissions. A sustained Kidney Public
    Awareness Initiative under the guidance of CDC will educate at-risk
    individuals to enhance awareness of the causes, consequences, and
    comorbidities of kidney disease, and educate clinical professionals on
    early detection and opportunities for intervention.
                     cdc chronic kidney disease initiative
        The CDC Chronic Kidney Disease Initiative comprehensive public
    health strategy was created at the urging of Congress and NKF 15 years
    ago. Annual funding has fluctuated between $1.6 million and $2.6
    million. This funding level has supported activities including the
    development of a web site for patients, surveillance and epidemiology
    activities, and assistance to the National Center for Health Statistics
    for CKD data collection. However, a more robust effort is needed to
    increase awareness and reduce incidence of CKD. The National Kidney
    Foundation requests additional funds to establish a CKD screening
    program to detect people at high risk and examine the benefits
    screening this population; determine changes in provider behavior and
    care, and monitor patients' health outcomes. Additional funding would
    also expand capacity for national CKD prevalence surveillance to allow
    for repeated laboratory measures in the National Health and Nutrition
    Examination Survey (NHANES). Current national estimates of CKD
    prevalence using NHANES rely on single measurements of both serum
    creatinine and urinary albumin, preventing researchers from estimating
    CKD persistence. NKF requests $15 million to the CDC for these enhanced
    activities.
                                   nih niddk
        Despite the high prevalence of CKD and its impact on patients and
    Medicare, NIH funding for kidney disease research is only about $700
    million annually. NIH invests only $18 per CKD patient, a fraction of
    what it spends on other major diseases. Fiscal Year 2021 funding for
    NIDDK increased by less than 1%, the smallest percentage increase of
    any disease Institute under NIH. From FY 2015-2020, NIH monetary
    support for kidney research increased at half the rate of NIH funding
    increases overall. America's scientists are at the cusp of many
    potential breakthroughs in improving our understanding of CKD,
    including genetic kidney disease. Further advances can lead to new
    therapies to delay and treat kidney diseases, which has the potential
    to provide cost savings to the government like that of no other chronic
    disease.
        In December 2020, NKF established Research Roundtables comprised of
    nephrology leaders from prominent academic institutions, the
    pharmaceutical industry, and key bodies with expertise in the multiple
    areas of pre-clinical and clinical research, including pediatric
    nephrology, genetics, epidemiology, drug development, public health,
    and health equity. In addition, kidney disease patients as well as
    family members of children with kidney disease and living kidney donors
    were recruited to share patient priorities and viewpoints on research
    needs.
        The Roundtables were charged with identifying pre-clinical and
    clinical areas of research in which additional funding could help
    bridge existing deficits in kidney disease treatments and reduce kidney
    disease incidence, reduce health disparities, and lower healthcare
    costs. Their final recommendations are expected in June 2021, which NKF
    will share with policy makers.
        As the first step towards expanding kidney research opportunities,
    NKF requests a substantive funding increase for NIDDK in FY 2022 that
    is at least commensurate with if not exceeding the percentage increase
    to NIH as a whole. We also request additional support from other
    Institutes on kidney activities. Opportunities include NHLBI support
    for cardiorenal syndromes in CKD patients; NIAID initiatives to study
    CKD effects on the immune system; and NCI activities to study decreased
    kidney function in cancer patients. Thank you for your consideration of
    the National Kidney Foundation's requests for Fiscal Year 2022.

        [This statement was submitted by Sharon Pearce, Senior Vice
    President,
    Government Relations.]
                                     ______

      Prepared Statement of the National Marrow Donor Program/Be The Match
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee, my name is Kristin Akin from Chesterfield, Missouri. On
    behalf of the patients, family members, donors, couriers, volunteers,
    and staff of the National Marrow Donor Program (NMDP)/Be The Match, I
    want to express my most sincere gratitude to the members of the
    Committee for your work last year, continuing the full funding of the
    C.W. Bill Young Cell Transplantation Program (Program) within the
    Health Resources and Services Administration (HRSA), Health Care
    Systems account. In Fiscal Year 2022, we respectfully request that the
    subcommittee increase funding for the Program to the amount of
    $56,000,000 to eliminate financial and socioeconomic barriers that
    reduce access to cellular therapies for thousands of primarily
    traditionally underserved patients.
        By establishing a national bone marrow donor registry in the mid-
    1980s, Congress promised patients with blood cancers, like leukemia and
    lymphoma, that they would have a way to find a life-saving donor match.
    While bone marrow transplant started as a cure for a single disease, we
    now provide cures for over 70 diseases, everything from cancers, blood
    disorders, immune deficiencies and Sickle Cell. In 2019, the Program
    completed its milestone 100,000th transplant between a matched,
    unrelated donor and a patient. This has been a true public/private
    partnership for more than 30 years and it is obvious that the funding
    is saving lives.
        My son, Andrew Preston Akin, was born on June 5, 2007. At ten weeks
    old, what initially started as severe jaundice quickly landed us in the
    Pediatric Intensive Care Unit (PICU) at our local hospital. After
    months of tests, on September 7, 2007, our world was officially turned
    upside down when we were informed that Andrew had a rare immune
    deficiency called Hemophagocytic Lymphohistiocytosis (HLH), and the
    only cure was a bone marrow transplant.
        Our then six-month-old son underwent his first bone marrow
    transplant in an effort to save his life. He was started on the
    standard protocol for HLH (HLH 2004) and initially responded very
    positively. But, suddenly, his HLH came roaring back and not only did
    we have to move up his transplant, we used umbilical cord cells, as
    there was not a suitable bone marrow match on the registry at the time.
    Grateful and optimistic that this was the end of HLH and the beginning
    of a new and healthy Andrew, we were devastated to learn that two
    months after his transplant, it did not work, and he would need another
    one.
        In the meantime, we continued with steroids, chemotherapy and a
    host of other drugs, all the while keeping him in a bubble away from
    any germs. The search began again to find Andrew the best possible
    unrelated, matched bone marrow donor. Excited that marrow was going to
    be the answer to our prayer, Andrew underwent his second bone marrow
    transplant right before his first birthday. Sadly, almost a year to the
    day of his diagnosis, we learned that again, for various reasons, his
    transplant was not a success.
        Through this process, we learned several things about Andrew's
    disease: the cause of his HLH was among the newest genetic mutations--
    X-Linked Lymphoproliferative Disorder #2 (XLP-2). Because it is X-
    linked, the doctors immediately tested me and our other son Matthew. On
    my 34th birthday, I received among the worst news in my life: not only
    was I the carrier, but my healthy 4-year old son also carried the
    mutation, meaning it was only a matter of time before he, too, would
    get HLH.
        After countless discussions with the team of experts, we weighed
    the pros and cons of taking Matthew into transplant while he was
    healthy or waiting until the disease struck.
        We did another preliminary search on the bone marrow registry and
    found one perfect match. Not knowing if that match would be there down
    the road, we made the extremely difficult decision to transplant
    Matthew prophylactically.
        At the same time, we prepared Andrew for his third bone marrow
    transplant in less than two years.
        We were fighting for the lives of our two sons.
        Andrew, only 27 months old, developed severe pulmonary
    complications that ultimately took his life on September 5, 2009, in
    the PICU.
        Matthew was just two weeks post-transplant, we thought life could
    not get any worse, but somehow, eight short months later, it did. Our
    first-born son, Matthew Austin Akin passed away in the same PICU on May
    1, 2010. He was only 5 and a half years old.
        My husband and I have experienced every parent's worst nightmare,
    twice, but we both agreed we would not allow our son's deaths to be the
    last thing people remembered about them. It's why my husband and I
    started the Matthew and Andrew Akin Foundation in their memory: to
    raise awareness and critical funds for HLH, NMDP, and the American Red
    Cross, and to advocate for other parents and children.
        However, I would be remiss if I did not share that a very large
    part of what drives us to continue to help others is the fact that we
    were blessed with the opportunity to be parents again, twice, through
    adoption. William and Christopher are the reason we have love in our
    hearts and can fight for the memory of their brothers Matthew and
    Andrew.
        While Matthew and Andrew ultimately lost their lives due to disease
    complications, NMDP was our line of hope that we held onto from day one
    when learned that a successful bone marrow transplant was the only
    cure. With each transplant my boys received, we were reminded of the
    kindness of strangers, the feeling of indebtedness to NMDP and Congress
    for establishing the registry and the power of a worldwide network. It
    has been and will continue to be my honor to volunteer my time with
    NMDP.
        The C.W. Bill Young Cell Transplantation Program, authorized by
    Congress, has been funded by the Committee and fulfills three important
    missions. The first is the nation's registry, which includes more than
    39 million selfless volunteers worldwide, like my sons' donors, who
    stand ready to be a life-saving bone marrow donor. It also includes
    more than 806,000 cord blood units through Be The Match and
    international partnerships, 106,000 of which are in the National Cord
    Blood Inventory, which is also funded by your Committee. When we
    couldn't find a matching donor for Andrew right away, a cord blood
    transplant was our only hope for his first transplant.
        While Matthew and Andrew were able to proceed to transplant thanks
    to their selfless matching donors, there are still many patients who
    cannot find a match on the registry. This is why the funding you
    provided in Fiscal Year 2021, and which we are asking for in Fiscal
    Year 2022, is so critically important. From the moment doctors search
    the registry for a donor, to the safe delivery of the life-saving cells
    to the bedsides of patients for transplant--NMDP is there every step of
    the way. NMDP ensures that the global network, technology, and
    logistical support are in place to facilitate a transplant.
        The Program's second mission is to support patients and families
    through its Office of Patient Advocacy. NMDP works tirelessly to
    improve the lives of patients and provide one-on-one support to these
    individuals and their families. They offer the resources and guidance
    patients need throughout the transplant process--from deciding if
    transplant is right for them to adjust to life after transplant.
        Finally, the Stem Cell Therapeutic Outcomes Database is a third
    program component that helps doctors significantly impact/improve
    survival for blood cancer and other diseases while also improving the
    quality of life for thousands of transplant patients. NMDP is
    relentless in its search to find answers that will lead to better donor
    matching, more timely transplants, and treatment of even more blood
    diseases through transplant.
        Thank you for the opportunity to share my story and most
    importantly thank you for learning a little bit about my beautiful sons
    Matthew and Andrew. Your longstanding support for this Program is the
    hope that people hold onto after receiving their life-threatening
    diagnosis. On behalf of those who are alive today, those who are
    currently searching the national registry for their potentially life-
    saving donor, and for those who will need to look to the Program for
    help in the future, I urge you to fund the C.W. Bill Young Cell
    Transplantation Program at $56 million to immediately provide access to
    therapy at the point of diagnosis for all patients.
        Our bold request this year builds upon the full funding you
    provided in Fiscal Year 2021 to clear a pathway for more patients,
    especially those from minority and rural communities, to be able to
    access transplant services. More than any other Committee in Congress,
    the programs you support save lives every day. The increase we are
    asking for this year will immediately increase the number of patients
    who enter the pipeline to receive a bone marrow transplant for a
    lifesaving cure.

        [This statement was submitted by Kristin Akin on behalf of National
    Marrow Donor Program/Be The Match.]
                                     ______

         Prepared Statement of the National Multiple Sclerosis Society
        Madam Chairwoman and Members of the Subcommittee, the National
    Multiple Sclerosis Society (Society) thanks you for this opportunity to
    provide testimony regarding fiscal year 2022 (FY22) funding for the
    federal agencies under the jurisdiction of the Labor, Health and Human
    Services, Education and Related Agencies (LHHS) subcommittee. Nearly
    one million people who live with multiple sclerosis (MS) rely on these
    agencies and as the U.S. recovers from the COVID-19 pandemic, the
    federal agencies and programs under the jurisdiction of this Committee
    are more important than ever.
        The Society is supportive of the President's FY22 proposed budget
    request. We believe this request would support the ability of people
    with MS to receive the coverage and services they need and fund
    critical research toward a cure for MS. We urge the Subcommittee to
    provide the following funding in Fiscal Year 2022 (FY22):
      --$500 million for the Agency for Healthcare Research and Quality
            (AHRQ)
      --$10 billion for the Centers for Disease Control and Prevention
            (CDC) inclusive of $5 million for the National Neurological
            Conditions Surveillance Program authorized in the 21st Century
            Cures Act;
      --$14.2 million for the Lifespan Respite Care Program;
      --Robust support for Medicare and Medicaid and protection of
            Medicaid's current financing structure; and
      --At least $46.1 billion for the National Institute of Health (NIH),
      --Fully fund the Patient Centered Outcomes Research Institute
            (PCORI); and
      --At least $13.5 billion for the Social Security Administration's
            administrative budget.
        MS is an unpredictable, often disabling disease of the central
    nervous system that interrupts the flow of information within the
    brain, and between the brain and body. Symptoms range from numbness and
    tingling to blindness and paralysis. The progress, severity, and
    specific symptoms of MS in any one person cannot yet be predicted. The
    Society is a fundamental partner to the federal agencies under the LHHS
    jurisdiction, and is focused on curing MS while ensuring that people
    affected by the disease have what they need to live their best lives.
                   agency for healthcare research and quality
        AHRQ is a small agency that is revolutionizing the healthcare
    system based on health care costs and quality. It provides evidence-
    based reports for health care providers to use in making health care
    safer, higher quality, more accessible, equitable, and affordable.
    These reports are vital to patients and the health care community,
    which needs high-quality science and evidence-based
        information to aid in consultations on treatment decisions. The
    Society recommends Congress provide $500 million for AHRQ in FY22.
                   centers for disease control and prevention
        CDC is tasked with protecting public health and safety through the
    control and prevention of disease, injury, and disability. COVID-19
    demonstrated how years of consistent underfunding impacted the Agency's
    ability to fulfill its mission. Part of that mission that is often
    overlooked involves data collection for diseases and conditions. The
    21st Century Cures Act authorized the creation of the National
    Neurological Conditions Surveillance System (NNCSS) at CDC, and
    Congress has funded it since 2018. Although COVID-19 has delayed its
    efforts, CDC has set up pilot projects in MS and Parkinson's disease to
    determine the best method to collected incidence and prevalence data.
    These methods would then be expanded to use in other neurologic areas.
    Having strong and reliable prevalence data is critical to protecting
    the public health and funding new and novel research to treat
    neurologic conditions. The Society recommends that Congress increase
    funding for the CDC to $10 billion in FY22, inclusive of the $5 million
    for the NNCSS.
                    centers for medicare & medicaid services
        Approximately 25-30 percent of the MS population relies on Medicare
    as their primary insurer. Many of these individuals are under the age
    of 65 and are eligible for Medicare due to disability. The Society
    urges Congress to ensure appropriate reimbursement levels for Medicare
    providers. These reimbursement levels allow Medicare beneficiaries to
    maintain affordable access to prescription drugs, diagnostics, durable
    medical equipment, medically necessary speech, physical and
    occupational therapy services, and allows the program to update
    coverage determinations to keep pace with advances in care.
        Up to 15 percent of people with MS are thought to qualify for
    Medicaid benefits for all or part of their health and/or long-term care
    needs. The Society urges Congress to ensure robust funding for Medicaid
    that allows for its enrollees to access benefits that are affordable
    and adequate to their needs. Additionally, we advise Congress to oppose
    proposals to cap or block grant the program or that impose unreasonable
    utilization review practices that can result in disruptions in MS care,
    putting patients at risk of disease exacerbations and irreversible
    disability. Ensuing that lower income individuals have access to health
    coverage and care is vital to the continued health and economic
    recovery of the country and we oppose any policy shift that would limit
    or cut services for people with MS.
                         lifespan respite care program
        The Lifespan Respite Care Program provides competitive grants to
    states to establish or enhance statewide lifespan respite programs that
    better coordinate and increase access to quality respite care.
    Approximately one quarter of individuals living with MS require long-
    term care services at some point during their lifetime. Often, a family
    member steps into the role of primary caregiver. Family caregivers
    allow the person living with MS to remain home for as long as possible
    and avoid premature admission to costlier institutional facilities but
    can also become overwhelming. Respite offers professional short-term
    help to give caregivers a break from the stress of providing care and
    has been shown to provide family caregivers the relief necessary to
    maintain their own health and bolster family stability. Many existing
    respite care programs have age eligibility requirements, but the
    Lifespan Respite Care Program serves families regardless of special
    need or age. MS is typically diagnosed between the ages of 20 and 50,
    and Lifespan Respite programs are often the only open door to needed
    respite services. For these reasons, the Society asks that Congress
    provide $14.2 million for the Lifespan Respite Care Program in FY22.
                         national institutes of health
        The importance of the NIH cannot be overstated. It is the nation's
    premiere biomedical research institution and drives innovation while
    supporting jobs in all 50 states. The NIH is a fundamental partner in
    the Society's mission to cure MS while empowering people affected by
    the disease to live their best lives. To date, the Society has invested
    over $1 billion in MS research; but we rely on Congress to provide
    consistent and sustained investments to the NIH to cultivate an
    environment that is optimal for scientific discovery and innovation. As
    evident by the NIH funding that paved the way to the development of the
    mRNA COVID-19 vaccines, NIH continues to provide the basic research
    necessary to facilitate the development of novel therapies. In fact,
    the NIH has provided the basic research that has led to every MS
    treatment that is available today. The Society urges Congress to
    provide at least $46.1 billion for the NIH in FY22. This funding level
    would allow for meaningful growth of 5% in the NIH base budget, and we
    urge the Agency to continue its efforts to diversify its workforce and
    grantees and to support the careers of early-career investigators.
                  patient-centered outcomes research institute
        PCORI serves a vital role in ensuring that the public and private
    health care sectors have valid and trustworthy data on health outcomes,
    clinical effectiveness, and appropriateness of different medical
    treatments by both conducting research and evaluating existing studies.
    Its research addresses the need for real-world evidence and patient-
    focused outcomes data that will improve healthcare quality and help
    shift healthcare payment models toward value-based care. To date, PCORI
    has invested over $69 million in comparative effectiveness studies in
    MS. These studies will provide important evidence for the best ways to
    address questions surrounding what care approaches work best for whom
    in various care settings and can inform conversations about value that
    truly considers the patient perspective. This information is important
    to aid in shared decision-making conversations between people with MS
    and their healthcare providers in consultations on treatment decisions.
    To complete this important work, we urge Congress to fully fund PCORI
    in FY22.
                      social security administration (ssa)
        Due to the unpredictable nature and sometimes disabling impairments
    caused by the disease, SSA recognizes MS as a chronic illness or
    ``impairment'' that can cause disability severe enough to prevent an
    individual from working. During such periods, people living with MS are
    entitled to and rely on Social Security Disability Insurance (SSDI) or
    Supplemental Security Income (SSI) benefits to survive. The National MS
    Society urges Congress to provide robust funding of at least $13.5
    billion for the Social Security Administration's administrative budget
    in FY22.
        The Society thanks the Committee for the opportunity to provide
    written testimony on our recommendations for the base funding for
    federal agencies programs under the jurisdiction of the FY22 LHHS
    appropriations bill. The above agencies are of vital importance to
    people affected by MS and all Americans. Please do not hesitate to
    contact the Society with any questions that you may have, and we look
    forward to continuing to work with the Committee to help move us closer
    to a world free of MS.

        [This statement was submitted by Leslie Ritter, Associate Vice
    President, Federal Government Relations, National Multiple Sclerosis
    Society.]
                                     ______

             Prepared Statement of the National Pancreas Foundation
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --The Foundation joins the broader research community in requesting
            $46.1 billion in discretionary funding for the National
            Institutes of Health (NIH), an increase of $3.2 billion over FY
            2021. Further, please provide proportional increases for the
            National Cancer Institute (NCI), the National Institute of
            Diabetes and Digestive and Kidney Diseases (NIDDK), and other
            NIH Institutes and Centers.
        --Please support adequate funding to establish the new Advanced
                Research Projects Agency for Health (ARPA-H) at NIH as
                proposed in the Administration's Budget Request to Congress
                to facilitate robust and tangible scientific progress on a
                variety of conditions, particularly cancers.
      --The Foundation joins the broader public health community in
            requesting $10 billion in overall funding for the Centers for
            Disease Control and Prevention (CDC) to reinvigorate meaningful
            professional education, public awareness, and public health
            activities.
        --Please provide the new CDC Chronic Disease Education and
                Awareness Program with $5 million, an increase of $3.5
                million over FY 2021, to further advance and expand timely
                public health efforts with community stakeholders.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished Members
    of the Subcommittee, thank you for the opportunity to submit testimony
    on behalf of the National Pancreas Foundation (NPF) and the patient
    community that we serve. We deeply appreciate the investments in the
    National Institutes of Health (NIH) that have occurred over the past
    five fiscal years and the research advancements that additional
    resources have facilitated, most notably in potential treatments for
    pancreatitis. Moreover, we thank you for establishing the new Chronic
    Disease Education & Awareness Program at CDC with an initial investment
    of $1.5 million in FY 2021. The COVID-19 pandemic has highlighted the
    importance of robust investment in public health and with an infusion
    of much-needed resources for CDC for FY 2022, please also enhance this
    important new initiative. Thank you again.
                              about the foundation
        The National Pancreas Foundation is a patient-driven, non-profit
    organization that provides hope for those suffering from pancreatitis
    and pancreatic cancer by funding cutting edge research, advocating for
    new and better therapies, and providing support and education for
    patients, caregivers, and health care professionals.
                           conditions of the pancreas
        Pancreatitis can be acute or chronic. It is characterized by
    inflammation of the pancreas, and chronic pancreatitis does not heal or
    improve-it gets worse over time and leads to permanent damage. Chronic
    pancreatitis eventually impairs a patient's ability to digest food and
    make pancreatic hormones. Chronic pancreatitis can strike at any age,
    but often develops in patients between the ages of 30 and 40, and is
    more common in men than women. The annual incidence rate is 5-12 per
    100,000 and the prevalence is 50 per 100,000. Pancreatitis can be
    managed with proper information and healthy practices.
        Pancreatic cancer is currently the third leading cause of cancer
    deaths in the United States. One of the major challenges associated
    with pancreatic cancer is that the condition often goes undetected for
    a long period of time because signs and symptoms seldom occur until
    advanced stages. By the time symptoms occur, cancer cells are likely to
    have spread (metastasized) to other parts of the body, often preventing
    surgical removal of tumors. Research indicates an emerging link between
    pancreatitis and the onset of pancreatic cancer.
                    nih research: progress and opportunities
        NIDDK has been a leader on pancreatitis research while NCI has
    facilitated key breakthroughs for pancreatic cancer. More work needs to
    be done though as translation and clinical research are necessary to
    ensure innovative treatment options and diagnostic tools can be
    deployed to the benefit of affected patients.
        In this regard, NIDDK recently hosted an effort with the community
    to capitalize on progress for pancreatitis and ensure promising ideas
    move into the FDA pipeline for review. The need remains great as
    pancreatitis patients currently have extremely limited treatment
    options despite the severity of the illness. The advancements in the
    pancreatitis research portfolio have now led to treatment review
    activities at FDA and a critical Patient-Focused Drug Development
    Initiative meeting with the community.
        Moreover, the Cancer Moonshot has been extremely meaningful for
    scientific efforts focused on pancreatic cancer. Similar to
    pancreatitis though, treatment options remain extremely limited despite
    the severity of the disease. In fact, due to improvements in other
    areas and an overall lack of progress in outcomes, pancreatic cancer is
    now the third leading cause of cancer deaths in America. While the
    details in the budget request remain sparse our hope is the new ARPA-H
    initiative will greatly enhance cancer research activities at NIH.
        Over recent years, key Committee Recommendations have been included
    that have moved the pancreas and pancreatitis research portfolios
    forward, and it is our hope that the Subcommittee will continue to
    demonstrate an interest in this area during the FY 2022 process.
               cdc chronic disease education & awareness program
        Thank you again for establishing the CDC Chronic Disease Education
    & Awareness Program in FY 2021 and providing an initial investment of
    $1.5 million. For many years, CDC has lacked public health initiatives
    in a variety of conditions where simple interventions can save lives
    and lower healthcare costs. Conditions of the pancreas are no exception
    and access to simple health information can prevent the progress of
    many conditions and in some cases lower the rate of pancreatic cancer.
    Many patient organizations are seeking timely collaborations with CDC
    that can directly impact patients and improve public health using this
    new mechanism. It is important that this emerging program receives
    annual funding increases to ensure it can grow and facilitate new
    projects. While CDC has the ability to fund meritorious proposals,
    there will be no shortage of opportunities and the current investment
    of $1.5 million will only go so far. Please increase funding for this
    program to $5 million for FY 2022.
    Adam Barbosa--Rhode Island
        I am a 21 year-old resident of Rhode Island. I had my first
    pancreatic episode at age 15. It wasn't until after my third attack,
    and many medical tests later, that the Drs. told me I had two genetic
    mutations (SPINK1 & CFTR) and a physical anomoly (pancreas divisum)
    that were causing my attacks. I was officially diagnosed with chronic
    pancreatitis. Since my first attack, my condition went on a downward
    spiral. I went from a 3-day hospital stay every 5-6 months to a 7-day
    stay every 2 months, then eventually every 2 weeks. At that point, my
    case was so severe that the only option I had was to have the TPIAT
    surgery at the University of Minnesota. The surgery lasted 14 hours,
    required the removal of 4 organs [pancreas and spleen included], and
    left me with post-operative cognitive dysfunction. A condition that has
    crippled my college studies and hope for a ``normal'' future. Also,
    without a pancreas, I became an instant Type-1 diabetic. I now have to
    count carbs, dose myself with insulin and slug down a fistful of pills
    [pancreatic enzymes] before anything I eat/drink . I suffer with
    significant digestive issues and have lost 40 lbs. since surgery. Every
    day is an intense physical, mental, and emotional struggle. I suffer
    from depression, anxiety and panic attacks. Things I have come to find
    patients with a chronic illness have to deal with on a daily basis.
    There is no real ``Recovery'' from this surgery. My life is simply an
    agonizing waiting game for medical advancements.
    Jenny Jones--Illinois
        I am 36 and live in Chicago, Illinois. I was 9 or 10 years old when
    I experienced my first pancreatitis attack; my pediatrician at the time
    ran blood work and immediately said I would need a liver transplant.
    She also recommended we get a second opinion and see a GI pediatrician
    specialist at another local hospital. After a full battery of tests,
    the physician came to the conclusion that I probably had chronic
    pancreatitis. I am glad that we went for the second opinion. I battled
    this disease throughout my life, but it ceased after my ERCP from the
    ages of 17-24. But, when I was 24 the pancreatitis had returned and by
    then my sister was also diagnosed with pancreatitis. Life was ever more
    challenging, the pain intolerable, and I could not imagine living
    another 5-10 years this way. At this point, I had already become a Type
    2 diabetic along with dealing with CP. In 2019, I had my 13-hour Total
    Pancreatectomy Auto Islet Cell Transplant at the University of Chicago
    Medicine on the South Side of Chicago where they removed my pancreas
    and transferred any working islets from the pancreas into my liver,
    removed half my stomach, small intestine, and duodenum. I am almost
    one-year post op and although I am now Type 3C diabetic, I am glad I
    choose to have the surgery. I am totally insulin-dependent and rely on
    an insulin pump as my islets have not awakened yet. My life post-op has
    been very challenging and I still deal with a measure of pain, and
    digestive issues. Despite all the surgeries and debilitating illnesses
    I have learned to become an advocate for others dealing with any
    chronic debilitating illness.
    Cecilia Petricone--Connecticut
        My story with pancreatitis started at the age of 12-years-old. Just
    a few weeks before I was supposed to start middle school I suddenly
    woke up with excruciating abdominal pain. After the first
    hospitalization, I started seeing lots of doctors including pancreatic
    specialists, my official diagnosis became Idiopathic Recurrent Acute
    Pancreatitis. During the first couple of years, I had genetic testing
    done which showed I have a SPINK1 mutation, which made me more prone to
    pancreatitis.
        Doctors spent years trying to manage my symptoms. We tried changes
    to my diet, getting more rest, staying extra hydrated, taking
    precautions when I got onto airplanes, going on an anti-anxiety and
    getting multiple pancreatic stents--nothing worked. In fact, my
    condition worsened! My freshman year at Boston College was when things
    really escalated. My yearly hospitalizations had become 2-3 a year and
    my diagnosis transitioned from acute pancreatitis to chronic. My
    sophomore year of college I made a visit to the ER, unaware that it was
    the beginning of back-to-back pancreatitis attacks that left me living
    in a hospital for the majority of time between October 2017 and
    February 2018. I left school, finishing the fall semester partially
    from a hospital bed 3 months later than my classmates. I lost a
    significant amount of weight, was malnourished, and began losing my
    hair.
        That was until March, when my pancreatic specialist recommended I
    consider getting a Total Pancreatectomy and Islet Auto Transplant
    (TPIAT). In April of 2018, I had the surgery. Fast forward three years
    later, I am in no pain and realize I am one of the lucky ones as having
    the TPIAT does not guarantee a life of being pain-free. I have Type 3C
    diabetes which I monitor and manage on a daily basis. While I am pain-
    free, there are mental and emotional hurdles that come with medical
    experiences as all-encompassing as this. I am deeply grateful to be
    healthy and to no longer suffer from pancreatitis and I believe that
    mental health is an incredibly important component of medical issues
    that needs to be addressed.
    Jane Holt--Rhode Island
        My name is Jane Holt and I am a patient with chronic pancreatitis
    from Rhode Island. My journey began in early January, 1988. I was at
    home, asleep, with my husband and four young children. I woke up in the
    middle of the night in excruciating pain. It felt as though my insides
    were exploding. I knew immediately there was something terribly wrong
    and I needed to go to the hospital. Ten days later my gall bladder was
    removed, after the surgery, I told the surgeon that the original pain
    was still there. I was able to get an appointment with a
    gastroenterologist at BI Deaconess Hospital in Boston in October, 1988.
    After doing a medical history and blood work my doctor said he thought
    I had pancreatitis. I had an ERCP that confirmed this diagnosis.
    Finally, a cause for the pain and it only took several months instead
    of years for some patients. In November I had major surgery on my
    pancreas to open the ducts to my pancreas and the journey continued.
        Since then, I've had a few ERCPs, many MRCPs, CAT scans,
    Ultrasound, and thousands and thousands of blood tests. I have
    travelled to Mayo Clinic, Lahey Clinic, George Washington Hospital for
    second opinions. My doctor has brought my records to many medical
    meetings for input from other physicians. Over the last 32 years I have
    done everything I can to try and fix this disease or at least find out
    more about it. For most patients treatment hasn't changed. The only
    treatment for patients is hospitalization and I would be hospitalized 3
    or 4 times a year, sometimes for as long as a month. It is now even
    getting harder to get the one thing that can help, pain medication. We
    can't ignore patients like me. We have to do something to make a
    difference for all of our patients.

        [This statement was submitted by David Bakelman, Chief Executive
    Officer,
    National Pancreas Foundation.]
                                     ______

              Prepared Statement of the National Respite Coalition
        Mr. Chairman, I am Jill Kagan, Chair, National Respite Coalition
    (NRC), a network of state respite coalitions, providers, caregivers,
    and national, state and local organizations. We are requesting $14.2
    million in the FY 2022 Labor, HHS, and Education Appropriations bill
    for the Lifespan Respite Care Program administered by the
    Administration for Community Living, Department of Health and Human
    Services. The request is consistent with the Administration's request
    to double funding for the program and will allow all States to receive
    a Lifespan Respite Grant to help family caregivers, regardless of care
    recipient's age or disability, access affordable respite. Additional
    funding will help states improve respite quality; expand the respite
    workforce; and use person and family-centered approaches that provide
    family caregivers tailored information on how to find, use and pay for
    respite services.
        The pandemic cast a harsh light on the lack of supports for the
    nation's family caregivers. When congregate and group settings became
    too risky for older adults and people with disabilities, the importance
    of family caregivers to providing care at home was greatly amplified.
    At the same time, the availability of services, such as respite, became
    harder to access. The Lifespan Respite network responded with flexible
    respite and support options for family caregivers. During this
    challenging time, this may have been the only support they received.
        Respite Care Saves Money and Benefits Families. Now, more
    importantly than ever, delaying a nursing home placement for
    individuals with Alzheimer's or avoiding hospitalization for children
    with autism can save Medicaid billions of dollars. Researchers at the
    University of Pennsylvania studied records of 28,000 children with
    autism enrolled in Medicaid and concluded that for every $1,000 states
    spent on respite, there was an 8% drop in the odds of hospitalization
    (Mandell, et al., 2012). Respite may help delay or avoid facility-based
    placements (Gresham, 2018; Avison, et al., 2018), improve maternal
    employment (Caldwell, 2007), strengthen marriages (Harper, 2013), and
    reduce caregiver depression, stress and burden linked to caregiver
    health (Broady and Aggar, 2017; Lopez-Hartmann, et al., 2012; Zarit, et
    al., 2014).
        With at least two-thirds (66%) of family caregivers in the
    workforce (Mantos, 2015), U.S. businesses lose from $17.1 to $33.6
    billion per year in lost productivity of employed caregivers (MetLife
    Mature Market Institute, 2006). Higher absenteeism among working
    caregivers costs the U.S. economy an estimated $25.2 billion annually
    (Witters, 2011). The University of NE Medical Center conducted a survey
    of caregivers receiving respite through the NE Lifespan Respite Program
    and found that 36% of family caregivers reported not having enough
    money at the end of the month to make ends meet, but families overall
    reported a better financial situation when receiving respite (Johnson,
    J., et al., 2018).
        Who Needs Respite? About 53 million unpaid family caregivers of
    adults provide care worth $470 billion annually (National Alliance for
    Caregiving and AARP, 2020; Reinhard, SC, et al., 2019). Eighty percent
    of those needing long-term services and supports (LTSS) are living at
    home. Two-thirds of older people with disabilities receiving LTSS at
    home receive care exclusively from family caregivers (Congressional
    Budget Office, 2013).
        Concerns about providing care for a growing aging population are
    paramount. However, caregiving is a lifespan issue. The majority (54%)
    of family caregivers care for someone between the ages of 18 and 75
    (NAC and AARP, 2020). In addition, nearly 14 million children with
    special health care needs require specialized care from parents and
    guardians (Child and Adolescent Health Measurement Initiative, 2021).
    Families caring for children with special health care needs provide
    nearly $36 billion worth of care annually (Romley, et al., 2016).
        National, State and local surveys have shown respite to be among
    the most frequently requested services by family caregivers (Anderson,
    L, et al., 2018; Maryland Caregivers Support Coordinating Council,
    2015). Yet, 86% of family caregivers of adults did not receive respite
    services at all in 2019 (NAC and AARP, 2020). Nearly half of family
    caregivers of adults (44%) identified in the National Study of
    Caregiving were providing substantial help with health care tasks, yet,
    fewer than 17% used respite (Wolff, 2016). The percentage is similar
    for parents of children with disabilities. The Elizabeth Dole
    Foundation continues to recommend that respite should be more widely
    available to military and Veteran caregivers.
        Respite Barriers and the Effect on Family Caregivers. While most
    families want to care for family members at home, research shows that
    family caregivers are at risk for emotional, mental, and physical
    health problems (American Psychological Association, 2012; Spillman,
    J., et al., 2014). When caregivers lack effective coping styles or are
    depressed, care recipients may be at risk for falling, developing
    preventable secondary health conditions or limitations in functional
    abilities. The risk of care recipient abuse increases when caregivers
    are depressed or in poor health (American Psychological Association,
    nd). Parents of children with special health care needs report poorer
    general health, more physical health problems, worse sleep, and
    increased depressive symptoms compared to parents of typically
    developing children (McBean, A, et al., 2013).
        Respite, that has been shown to ease family caregiver stress, is
    too often out of reach or completely unavailable. In a survey of more
    than 3000 caregivers of individuals with intellectual and developmental
    disabilities (ID/DD), nine in ten reported that they were stressed.
    Nearly half (49%) reported that finding time to meet their personal
    needs was a major problem. Yet, more than half of the caregivers of
    individuals with ID or Autism Spectrum Disorder reported that it was
    difficult or very difficult to find respite care (Anderson, L., et al.,
    2018). Respite may not exist at all for those with Alzheimer's, ALS,
    MS, spinal cord or traumatic brain injuries, or children with serious
    emotional conditions.
        Barriers to accessing respite include fragmented and narrowly
    targeted services, cost, and the lack of information about respite or
    how to find or choose a provider. Moreover, a critically short supply
    of well-trained respite providers or meaningful service options may
    prohibit a family from making use of a service they so desperately
    need.
        Lifespan Respite Care Program Helps. The Lifespan Respite Care
    Program, designed to address these barriers to respite quality,
    affordability and accessibility, is a competitive grant program to
    states administered by ACL in the Administration on Aging. The premise
    behind the program is both care relief and cost effectiveness. Lifespan
    Respite provides funding to states to expand and enhance local respite
    services across the country, coordinate services to reduce duplication
    and fragmentation, and improve respite access and quality.
        Since 2009, 37 states and DC have received Lifespan Respite grants.
    The program received $4.1 million in FY 18 and FY 19, and $6.1 million
    in FY 2020. We are grateful for the increase to $7.1 million in FY
    2021; however, the program received no emergency Congressional
    supplemental funding during the pandemic, despite the elevated need.
    With these funds, States are required to establish statewide
    coordinated Lifespan Respite care systems to serve families regardless
    of age or special need; provide planned and emergency respite care;
    train and recruit respite workers and volunteers; and assist caregivers
    in accessing respite. Lifespan Respite helps states maximize use of
    limited resources and deliver services more efficiently to those most
    in need. Increasing funding could allow funding for all states and help
    current grantees complete their ground-breaking work in serving the
    unserved, and ensuring sustainability by integrating services into
    statewide No Wrong Door systems for long-term services and supports.
        During the current pandemic, when family caregiver social isolation
    is escalating, grantees and their primary partners continue to provide
    respite safely in states where they are permitted to do so. They are
    the frontline workers who may be the only outside contact and support
    these families are receiving. If they cannot provide in-person respite,
    the network has expanded support services to include regular phone call
    check ins, delivery of care packages, online support groups, virtual
    training and other educational services via Facebook and other social
    media outlets.
        How is Lifespan Respite Program Making a Difference? Key
    accomplishments of State Lifespan Respite grantees are highlighted in a
    new ARCH National Respite Network report, In Support of Caregivers
    [archrespite.org/key-accomplishments]. State Lifespan Respite programs
    are engaged in the following innovative activities:
      --AL, AR, AZ, CO, DE, MD, MT, ND, NE, NV, NC, OK, RI, SC, TN, VA, WA,
            and WI, administer successful self-directed respite vouchers
            for underserved populations, such as individuals with
            Alzheimer's disease, traumatic brain injury, MS or ALS, adults
            with intellectual or developmental disabilities (I/DD), rural
            caregivers, or those on waiting lists for services. When
            families were willing and states allowed it, these programs
            continued to operate with enhance flexibilities during the
            pandemic.
      --AL's respite voucher program found a substantial decrease in the
            percentage of caregivers reporting how often they felt
            overwhelmed with daily routines after receiving respite.
            Caregivers in NE's Lifespan Respite program reported
            significant decreases in stress levels, fewer physical and
            emotional health issues, and reductions in anger and anxiety.
      --Innovative and sustainable respite services, funded in AL, CO, MA,
            NC, and NY through mini-grants to community-based agencies,
            also have documented benefits to family caregivers.
      --AL, MD, ND and NE offer emergency respite and AL, AR, CO, NE, NY,
            PA, RI, SC and TN implemented new volunteer or faith-based
            respite services.
      --Respite provider recruitment and training are priorities in NE, NY,
            SC, SD, VA, and WI.
        State agency partnerships are changing the landscape. Lifespan
    Respite WA, housed in Aging & Long-Term Support Administration,
    partnered with WA's Children with Special Health Care Needs Program,
    Tribal entities and the state's Traumatic Brain Injury program to
    provide respite vouchers to families across ages and disabilities. The
    OK Lifespan Respite program partnered with the state's Transit
    Administration to develop mobile respite in isolated rural areas.
    States, including NC, NY and NV, are building ``no wrong door systems''
    in partnership with Aging and Disability Resource Centers to improve
    respite access. States are developing long-term sustainability plans,
    but without continued federal support, many grantees will be cut off
    before these initiatives achieve their full impact.
        During the pandemic, social isolation and severe mental health
    issues among family caregivers intensified. The CDC found that ``unpaid
    adult caregivers reported having experienced disproportionately worse
    mental health outcomes, increased substance use, and elevated suicidal
    ideation.'' The Lifespan Respite network responded with flexible and
    innovative respite options. For countless caregivers, respite became
    their only lifeline to supports, services, and vital human connection.
    OK, ND, NV, WA, VA, and WI were some of the states that introduced
    flexibility to their respite voucher programs to encourage use, such as
    expanded eligibility and timeframes, increased flexibility in who could
    provide respite to include other family members in the home, and
    increased voucher amounts. Other Lifespan Respite grantees met the
    needs of family caregivers through new and creative approaches:
        Alabama: Alabama Lifespan Respite, in order to increase targeted
    support to caregivers during the pandemic, offered Care Chats (one-on-
    one support by phone or video conferencing) with their social worker
    staff, monthly support groups, and caregiver mental health education
    opportunities to help increase overall caregiver wellness. Alabama
    Lifespan Respite also introduced a Caregiver Wellness Initiative that
    increases Emergency Respite reimbursement funds and designates funds
    specifically for mental health counseling to caregivers currently
    enrolled with their reimbursement (voucher) program. The intended
    impacts of the Caregiver Wellness Initiative include decreases in
    caregiver stress, anxiety, fatigue, and burnout after receiving
    Emergency Respite and/or mental health counseling.
        Tennessee: The TN Respite Coalition awarded mini-grants for
    caregiver-selected items, such as personal protective equipment,
    tablets enabling internet access to online support groups, home
    exercise equipment, and movie or magazine subscriptions. Expanding
    ideas of traditional respite services, the Tennessee Respite Voucher
    Program provided respite in innovative ways that allowed for safe
    social distancing but maintained caregiver-provider contact that kept
    caregivers socially connected during times of increased stress and
    isolation.
        No other federal program has respite as its sole focus, helps
    ensure respite quality or choice, and supports respite start-up,
    training or coordination. We urge you to include $14.2 million in the
    FY 2022 Labor, HHS, and Education appropriations bill. Families will be
    able to keep loved ones at home safely and ensure their own well-being,
    saving Medicaid and other federal programs billions of dollars.
        For more information, please contact Jill Kagan, National Respite
    Coalition at jkagan@archrespite.org. Complete references available on
    request.

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

      Prepared Statement of the National Technical Institute for the Deaf
        Mr. Chairman and Members of the Committee:
        I respectfully submit the FY 2022 budget request for NTID, one of
    nine colleges of RIT, in Rochester, New York. Created by Congress by
    Public Law 89-36 in 1965, NTID provides a university-level technical
    and professional education for students who are deaf and hard of
    hearing, leading to successful careers in high-demand fields for a sub-
    population of individuals historically facing high rates of
    unemployment and under-employment. NTID students study at the
    associate, baccalaureate, master's and doctoral levels as part of a
    university (RIT) that includes more than 17,000 hearing students. NTID
    also provides baccalaureate and graduate-level education for hearing
    students in professions serving deaf and hard-of-hearing individuals.
                                 budget request
        On behalf of NTID, for FY 2022 I would like to request $89,700,000
    for Operations. NTID has worked hard to manage its resources carefully
    and responsibly. NTID actively seeks alternative sources of public and
    private support, with approximately 24% of NTID's Operations budget
    coming from non-federal funds, up from 9% in 1970. Since FY 2006, NTID
    raised more than $26 million in support from individuals and
    organizations.
        NTID's FY 2022 request of $89,700,000 includes $3,400,000 for
    establishing a national hub of innovation for deaf scientists in
    Rochester, New York. The ``Hub'' will be a collaborative partnership
    with the University of Rochester and Rochester Regional Health that
    will enhance the access of deaf and hard-of-hearing persons to career
    opportunities as scientists, biomedical researchers and health
    professionals. Hub programs will include a summer research program, a
    pre-career training pipeline for deaf and hard-of-hearing scientists,
    mentoring programs, a postdoc-to-faculty program, and guidance for
    biomedical research institutions and medical schools on best practices
    for training deaf and hard-of-hearing scientists and health
    professionals. The coronavirus has also demonstrated the national need
    for timely, accurate and official information in ASL about pandemics
    and health care concerns--a service the Hub could provide.
        NTID's FY 2022 request also includes an additional $2,000,000 to
    expand the NTID Regional STEM Center (NRSC) partnership, which serves
    deaf and hard-of-hearing students in 12 southeastern states by
    promoting training and postsecondary participation in STEM fields,
    providing professional development for teachers, and developing
    partnerships with business and industry to promote employment
    opportunities. Via the NRSC, deaf and hard-of-hearing middle school
    students are introduced to STEM programs and careers that will help
    inform their academic and career decisions. Deaf and hard-of-hearing
    high school students can take NTID STEM dual-credit courses and
    participate in career exploration and college preparation programs that
    will help them transition from high school to college. In FY 2020, up
    to 2,023 educators, 1,685 students, 590 employers, 379 interpreters,
    241 parents, and 190 vocational rehabilitation staff enrolled in NRSC
    programs (some may have enrolled in multiple programs).
        NTID's FY 2022 operations request also provides $700,000 to
    establish a Computer Science and Cybersecurity Training Center for deaf
    and hard-of-hearing students based at RIT's new Global Cybersecurity
    Institute (GCI), a 52,000-square-feet facility providing students,
    researchers and industry professionals with the most advanced
    technology tools and education offerings to help further digital
    security across the world. The Cybersecurity Training Center would
    allow NTID to build on its new partnership with the GCI, which is
    currently offering a boot camp to deaf and hard-of-hearing students
    that results in an RIT GCI Cybersecurity Bootcamp Certificate and
    preparation for industry-standard certifications, including CompTIA
    Security+ and Cybersecurity First Responder. Finally, the requested
    increase in operations will also provide $2,100,000 for NTID to manage
    inflationary costs.
                                   enrollment
        Truly a national program, NTID has enrolled students from all 50
    states. In Fall 2020 (FY 2021), NTID's enrollment was 1,101 students.
    NTID also serves students nationwide through Project Fast Forward, a
    project that builds a pathway for deaf and hard-of-hearing students to
    transition from high school to college in selected STEM disciplines by
    allowing deaf and hard-of-hearing high school students to take dual-
    credit courses, earning RIT/NTID college credit while they are still in
    high school. In FY 2021, 185 deaf and hard-of-hearing high school
    students enrolled in dual-credit courses at partner high schools.
                             ntid academic programs
        NTID offers high quality, career-focused associate degree programs
    preparing students for specific well-paying technical careers. NTID
    also provides transfer associate degree programs to better serve our
    student population seeking bachelor's, master's, and doctoral degrees.
    These transfer programs provide seamless transition to baccalaureate
    and graduate studies in the other colleges of RIT.
        A cooperative education (co-op) component is an integral part of
    academic programming at NTID and prepares students for success in the
    job market. A co-op assignment gives students the opportunity to
    experience a real-life job situation and focus their career choice.
    Students develop technical skills and enhance vital personal skills
    such as teamwork and communication, which will make them better
    candidates for full-time employment after graduation. Last year, 181
    students participated in 10-week co-op experiences that augment their
    academic studies, refine their social skills, and prepare them for the
    competitive working world.
                            student accomplishments
        NTID deaf and hard-of-hearing students persist and graduate at
    rates higher than or on par with national persistence and graduation
    rates for all students at two-year and four-year colleges. For NTID
    deaf and hard-of-hearing graduates, over the past five years, an
    average of 95% have found jobs commensurate with their education level.
    Of our FY 2019 graduates (the most recent class for which numbers are
    available), 95% were employed one year later, with 77% employed in
    business and industry, 16% in education and non-profits, and 7% in
    government.
        Graduation from NTID has a demonstrably positive effect on
    students' earnings over a lifetime, and results in a notable reduction
    in dependence on Supplemental Security Income (SSI) and Social Security
    Disability Insurance (SSDI). In FY 2012, NTID, the Social Security
    Administration (SSA), and Cornell University examined earnings and
    federal program participation data for more than 16,000 deaf and hard-
    of-hearing individuals who applied to NTID over our entire history. The
    study showed that NTID graduates, over their lifetimes, are employed at
    a higher rate and earn more (therefore paying more in taxes) than
    students who withdraw from NTID or attend other universities. NTID
    graduates also participate at a lower rate in SSI programs than
    students who withdrew from NTID.
        Using SSA data, at age 50, 78% of NTID deaf and hard-of-hearing
    graduates with bachelor degrees and 73% with associate degrees report
    earnings, compared to 58% of NTID deaf and hard-of-hearing students who
    withdrew from NTID and 69% of deaf and hard-of-hearing graduates from
    other universities. Equally important is the demonstrated impact of an
    NTID education on graduates' earnings. At age 50, $58,000 is the median
    salary for NTID deaf and hard-of-hearing graduates with bachelor
    degrees and $41,000 for those with associate degrees, compared to
    $34,000 for deaf and hard-of-hearing students who withdrew from NTID
    and $21,000 for deaf and hard-of-hearing graduates from other
    universities.
        An NTID education also translates into reduced dependency on
    federal transfer programs, such as SSI and SSDI. At age 40, less than
    2% of NTID deaf and hard-of-hearing associate and bachelor degree
    graduates participated in the SSI program compared to 8% of deaf and
    hard-of-hearing students who withdrew from NTID. Similarly, at age 50,
    only 18% of NTID deaf and hard-of-hearing bachelor degree graduates and
    28% of associate degree graduates participated in the SSDI program,
    compared to 35% of deaf and hard-of-hearing students who withdrew from
    NTID.
                                access services
        Access services include sign language interpreting, real-time
    captioning, classroom notetaking services, captioned classroom video
    materials, and assistive listening services. NTID provides an access
    services system to meet the needs of a large number of deaf and hard-
    of-hearing students enrolled in baccalaureate and graduate degree
    programs in RIT's other colleges as well as students enrolled in NTID
    programs who take courses in the other colleges of RIT. Access services
    also are provided for events and activities throughout the RIT
    community. Historically, NTID has followed a direct instruction model
    for its associate-level classes, with limited need for sign language
    interpreters, captionists, or other access services. However, the
    demand for access services has grown recently as associate-level
    students request communication based on their preferences.
        During FY 2020, 118,240 hours of interpreting and 21,856 hours of
    real-time captioning were provided to students.
                                    summary
        NTID's FY 2022 funding request ensures that we continue our mission
    to prepare deaf and hard-of-hearing people to excel in the workplace
    and expand our outreach to better prepare deaf and hard-of-hearing
    students to excel in college. NTID students persist and graduate at
    rates higher than or on par with national rates for all students. NTID
    graduates have higher salaries, pay more taxes, and are less reliant on
    federal SSI programs. NTID's employment rate is 95% over the past five
    years. Therefore, I ask that you please consider funding our FY 2022
    request of $89,700,000 for Operations.
        We are hopeful that the members of the Committee will agree that
    NTID, with its long history of successful stewardship of federal funds
    and an outstanding educational record of service to people who are deaf
    and hard of hearing, remains deserving of your support and confidence.
    Likewise, we will continue to demonstrate to Congress and the American
    people that NTID is a proven economic investment in the future of young
    deaf and hard-of-hearing citizens. Quite simply, NTID is a federal
    program that works.

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

         Prepared Statement of the National Viral Hepatitis Roundtable
        Dear Chairwoman Murray, Ranking Member Blunt, and members of the
    subcommittee,
        I am writing on behalf of the National Viral Hepatitis Roundtable
    (NVHR), a coalition of patients, health care providers, community-based
    organizations, and public health partners fighting for an equitable
    world free of viral hepatitis. We are respectfully requesting an
    increase in funding to CDC's Division of Viral Hepatitis (DVH), to no
    less than $134 million in FY 2022 from its current level of $39.5
    million for FY 2021.
        According to data released by the CDC last month, cases of acute
    hepatitis A increased by a staggering 1300% between 2015 and 2019,
    representing outbreaks of person-to-person transmission of this
    vaccine-preventable infection linked to substance use and homelessness.
    While reported rates of new hepatitis B infections generally remained
    stable over this period, the overwhelming majority occurred among
    unvaccinated adults between the ages of 30 and 59, with a substantial
    number of cases linked to injection drug use. Over this time period,
    acute hepatitis C cases surged by 63%, with estimated new infections
    now exceeding annual rates of new HIV infections in the United States.
    Specifically, CDC estimates 57,500 new hepatitis C infections for 2019,
    while noting that the true number could be as high as 196,000.
        The tragedy of our viral hepatitis response is that these cases
    reflect failures in prevention, exacerbations in health disparities,
    and gaps in our public health system. We have strong tools--including
    vaccination for hepatitis A and B, alongside syringe services programs
    and medication-assisted treatment for opioid use disorder for hepatitis
    C--proven effective and well-established in preventing new infections,
    when implemented comprehensively and at scale. Chronic hepatitis B is
    treatable and chronic hepatitis C is curable, and indeed CDC's
    surveillance data and 2021 National Viral Hepatitis Progress Report
    show promising momentum in decreasing mortality from hepatitis B and
    hepatitis C, including among communities burdened with substantial
    racial/ethnic health disparities (Asian and Pacific Islander
    communities for hepatitis B, and American Indian/Alaskan Native persons
    and African Americans for hepatitis C).
        The Department of Health and Human Services released a new National
    Viral Hepatitis Strategic Plan at the beginning of 2021, committing the
    nation to eliminate viral hepatitis as a public health threat by 2030
    and outlining a comprehensive and credible set of strategies and
    priorities to achieve this goal. However, we cannot meet this challenge
    without reckoning with the persistent underfunding of viral hepatitis
    within the CDC budget, a chronic shortfall that cascades down to states
    and local communities struggling to keep pace with shifting trends and
    increased new cases as a downstream consequence of the broader opioid
    and stimulant health crisis. CDC's Division of Viral Hepatitis plays an
    essential role in leading our public health efforts towards viral
    hepatitis elimination, but can only fulfill that promise with adequate
    resources. We strongly urge the subcommittee to strengthen our public
    health infrastructure by investing at least $134 million in CDC's
    Division of Viral Hepatitis for FY 2022.
        In tandem with this investment, we respectfully request that the
    subcommittee increases CDC's funding for eliminating opioid-related
    infectious diseases to $120 million in FY 2022, to accelerate urgent
    efforts to support building out programmatic infrastructure--
    particularly syringe services programs (SSPs)--capable of prevention
    and linkage to care for not only HIV and viral hepatitis but other
    infectious diseases such as endocarditis which disproportionately
    affect people who inject drugs. These programs continue to serve on the
    frontlines of both the COVID-19 pandemic and the overdose epidemic,
    uniquely effective at engaging a highly vulnerable and marginalized
    population that other systems--including health care--struggle to
    engage, serve, and retain in a timely and effective manner. In keeping
    with the vital importance of resourcing these programs, we similarly
    urge the subcommittee to remove restrictions on the use of federal
    funds to purchase sterile syringes in order to maximize the impact and
    benefits of these programs.
        In conclusion, we thank the subcommittee for their commitment to
    public health and attention to viral hepatitis, and would be eager to
    respond to questions or provide additional information and context to
    support your work.

        [This statement was submitted by Daniel Raymond, Director of
    Policy, National Viral Hepatitis Roundtable.]
                                     ______

            Prepared Statement of the NephCure Kidney International
                 summary of recommendations for fiscal year 2022
    _______________________________________________________________________

      --Provide $46.1 billion for the National Institutes of Health (NIH)
      --Provide a proportional increase for the National Institute of
            Diabetes and Digestive and Kidney Diseases (NIDDK) and the
            National Institute on Minority Health and Health Disparities
            (NIMHD) and support the expansion of the FSGS/NS research
            portfolio at NIDDK and NIMHD by funding more research into
            primary glomerular disease.
      --Provide $10 billion for the Centers for Disease Control and
            Prevention (CDC) and $5 million for the Chronic Disease
            Education and Awareness Program.
    _______________________________________________________________________

        Chairwoman Murray and Ranking Member Blunt, thank you for the
    opportunity to present the views of NephCure Kidney International
    regarding research on focal segmental glomerulosclerosis (FSGS) and
    nephrotic syndrome (NS). NephCure is the only non-profit organization
    exclusively devoted to finding a cure and supporting patients with FSGS
    and the NS disease group. Driven by a panel of respected medical
    experts and a dedicated band of patients and families, NephCure works
    tirelessly to support kidney disease research and awareness.
        NS is a collection of signs and symptoms caused by diseases that
    attack the kidney's filtering system. These diseases include FSGS,
    Minimal Change Disease and Membranous Nephropathy and others. When
    affected, the kidney filters leak protein from the blood into the urine
    and often cause kidney failure, which requires dialysis or kidney
    transplantation. According to a Harvard University report, 73,000
    people in the United States have lost their kidneys as a result of
    FSGS. Unfortunately, the causes of FSGS and other 'filter related'
    diseases are poorly understood.
        FSGS is the second leading cause of NS and is especially difficult
    to treat. There is no known cure for FSGS and current treatments are
    difficult for patients to endure. These treatments include the use of
    steroids and other dangerous substances which lower the immune system
    and contribute to severe bacterial infections, high blood pressure and
    other problems in patients, particularly child patients. In addition,
    children with NS often experience growth retardation and heart disease.
    Finally, NS that is caused by FSGS, MCD or MN is idiopathic and can
    often reoccur, even after a kidney transplant.
        FSGS disproportionately affects minority populations and is five
    times more prevalent in the African American community. In a
    groundbreaking study funded by NIH, researchers found that FSGS is
    associated with two aggressive APOL1 gene variants. 75% of Black
    Americans with FSGS possess this gene. These variants developed as an
    evolutionary response to African sleeping sickness and are common in
    the African American patient population with FSGS/NS. Researchers
    continue to study the pathogenesis of these variants.
        FSGS has a large social impact in the United States. FSGS leads to
    end-stage renal disease (ESRD) which is one of the most costly chronic
    diseases to manage. In 2008, the Medicare program alone spent $26.8
    billion, 7.9% of its entire budget, on ESRD. In 2005, FSGS accounted
    for 12% of ESRD cases in the U.S., at an annual cost of $3 billion. It
    is estimated that there are currently approximately 20,000 Americans
    living with ESRD due to FSGS.
        Research on FSGS and other forms of NS could achieve tremendous
    savings in federal health care costs and reduce health status
    disparities.
                       encourage fsgs/ns research at nih
        There is no known cause or cure for FSGS and scientists tell us
    that much more research needs to be done on the basic science behind
    FSGS/NS. More research could lead to fewer patients undergoing ESRD and
    tremendous savings in health care costs in the United States. NephCure
    works closely with NIH and has partnered with NIH on two large studies
    that will advance the pace of clinical research and support precision
    medicine. These studies are the Nephrotic Syndrome Study Network
    (NEPTUNE) and the Cure Glomerulonephropathy Network (CureGN).
        With collaboration from other Institutes and Centers, ORDR
    established the Rare Disease Clinical Research Network. This network
    provided an opportunity for NephCure Kidney International, the
    University of Michigan, and other university research health centers to
    come together to form the NEPTUNE. Now in its second 5-year funding
    cycle, NEPTUNE has recruited over 450 NS research participants, and has
    supported pilot and ancillary studies utilizing the NEPTUNE data
    resources. NephCure urges the subcommittee to continue its support for
    RDCRN and NEPTUNE, which has tremendous potential to facilitate
    advancements in NS and FSGS research.
        NIDDK houses the Cure GN, a multicenter five-year cohort study of
    glomerular disease patients. Participants will be followed
    longitudinally to better understand the causes of disease, response to
    therapy, and disease progression, with the ultimate objective to cure
    glomerulonephropathy. NephCure recommends that the subcommittee
    continues to support the work that the CureGN initiative has
    accomplished towards further understanding rare forms of kidney
    diseases. It is estimated that annually there are 20 new cases of ESRD
    per million African Americans due to FSGS, and 5 new cases per million
    Caucasians. This disparity is largely due to variants of the APOL1
    gene. Unfortunately, the incidence of FSGS is rising and there are no
    known strategies to prevent or treat kidney disease in individuals with
    the APOL1 genotype. NIMHD began supporting research on the APOL1 gene
    in FY13. Due to the disproportionate burden of FSGS on minority
    populations, it remains appropriate for NIMHD to continue to advance
    this research. NephCure asks the subcommittee to recognize the work
    that NIMHD and NIDDK are doing to address the connection between the
    APOL1 gene and the onset of FSGS and encourage NIMHD to work with
    community stakeholders to identify areas of collaboration.
        As a result of the important research done through NIH we have been
    able to work with FDA to establish new endpoints for clinical trial
    leading to more trials than ever before. This has led to the creation
    of the Kidney Health Gateway Clinical that will connect patients with
    breakthrough clinical trials and access top Nephrotic Syndrome doctors
    all in one place. These crucial trials will hopefully lead to more
    treatment options for our patients.
        CHRONIC DISEASE EDUCATION AND AWARENESS
        We thank the Subcommittee for the creation of the Chronic Disease
    Education and Awareness Program in FY2021 and encourage continued
    support by providing $5 million for this critical program in FY2022.
        Patient Perspective
        Meet 13-year-old Macy! She was diagnosed with Nephrotic Syndrome
    and later FSGS when she was three. Her 10-year journey with kidney
    disease has been long and hard. Macy did not respond to treatments for
    her kidney disease and within two years of diagnosis, her native
    kidneys were damaged beyond repair and she was in kidney failure and on
    dialysis. At the age of five, she received a living donor kidney
    transplant, but her disease, FSGS came back and attacked her new to her
    kidney. It took a full year of aggressive treatments to get Macy's FSGS
    into remission post-transplant. For the past 10 years, Macy has taken
    18 to 26 medications a day. Those medications and her kidney disease
    have led to multiple co-morbidities. She is currently followed by 7
    specialties, has endured 30+ surgeries & been hospitalized over 100
    times. Macy participates in the Beads of Courage program in which she
    earns different beads for each procedure, appointment etc. The strand
    of beads you see in this photo are just the beads she earned in 2018!
    Those black beads are for pokes (lab draws, IV's, Shots) and Macy
    earned over 400 last year. As you can see kidney disease is tough!
    Although Macy continues to struggle with kidney disease and will need
    another transplant sooner than later, she doesn't let that stop her
    from living life! Macy loves dancing and musical theater, art, and
    hanging out with her dog Bentley!
        Thank you for the opportunity to present the views of the FSGS/NS
    community.

        [This statement was submitted by Irving Smokler, PH.D., Board
    Chairman, Acting President and Founder, NephCure Kidney International.]
                                     ______

              Prepared Statement of the Neurofibromatosis Network
        Thank you for the opportunity to submit testimony to the
    Subcommittee on the importance of funding for the National Institutes
    of Health (NIH), and specifically for continued research on
    Neurofibromatosis (NF), a genetic disorder closely linked to many
    common diseases widespread among the American population. My name is
    Kim Bischoff and I am the Executive Director of the Neurofibromatosis
    (NF) Network, a national organization of NF advocacy groups. We
    respectfully request that you include the following report language on
    NF research at the National Institutes of Health within the Office of
    the Director account in the Fiscal Year 2022 Labor, Health and Human
    Services, Education Appropriations bill.
        Neurofibromatosis [NF].--The Committee supports efforts to increase
    funding and resources for NF research and treatment at multiple
    Institutes, including NCI, NINDS, NIDCD, NHLBI, NICHD, NIMH, NCATS, and
    NEI. Children and adults with NF are at elevated risk for the
    development of many forms of cancer, as well as deafness, blindness,
    developmental delays and autism; the Committee encourages NCI to
    increase its NF research portfolio in fundamental laboratory science,
    patient-directed research, and clinical trials focused on NF-associated
    benign and malignant cancers. The Committee also encourages NCI to
    support clinical and preclinical trials consortia. Because NF can cause
    blindness, pain, and hearing loss, the Committee urges NINDS to
    continue to aggressively fund fundamental basic science research on NF
    relevant to restoring normal nerve function. Based on emerging findings
    from numerous researchers worldwide demonstrating that children with NF
    are at significant risk for autism, learning disabilities, motor
    delays, and attention deficits, the Committee encourages NINDS, NIMH,
    and NICHD to increase their investments in laboratory-based and
    patient-directed research investigations in these areas. Since NF2
    accounts for approximately 5 percent of genetic forms of deafness, the
    Committee encourages NIDCD to expand its investment in NF2-related
    research. NFl can cause vision loss due to optic gliomas. The Committee
    encourages NEI to expand its investment in NF1-focused research on
    optic gliomas and vision restoration.
        On behalf of the Neurofibromatosis (NF) Network, I speak on behalf
    of the over 100,000 Americans who suffer from NF as well as the
    millions of Americans who suffer from diseases and conditions linked to
    NF such as cancer, brain tumors, heart disease, memory loss, and
    learning disabilities. Thanks in large part to this Subcommittee's
    strong support, scientists have made enormous progress since the
    discovery of the NF1 gene in 1990 resulting in clinical trials now
    being undertaken at NIH with broad implications for the general
    population.
        NF is a genetic disorder involving the uncontrolled growth of
    tumors along the nervous system which can result in terrible
    disfigurement, deformity, deafness, pain, blindness, brain tumors,
    cancer, and even death. In addition, approximately one-half of children
    with NF suffer from learning disabilities. NF is the most common
    neurological disorder caused by a single gene and is more common than
    Cystic Fibrosis, hereditary Muscular Dystrophy, Huntington's disease
    and Tay Sachs combined. There are three types of NF: NF1, which is more
    common, NF2, which initially involves tumors causing deafness and
    balance problems, and Schwannomatosis, the hallmark of which is severe
    pain. While not all NF patients suffer from the most severe symptoms,
    all NF patients and their families live with the uncertainty of not
    knowing whether they will be seriously affected because NF is a highly
    variable and progressive disease.
        Researchers have determined that NF is closely linked to heart
    disease, learning disabilities, memory loss, cancer, brain tumors, and
    other disorders including deafness, blindness and orthopedic disorders,
    primarily because NF regulates important pathways common to these
    disorders such as the RAS, cAMP and PAK pathways. Research on NF
    therefore stands to benefit millions of Americans.
    Learning Disabilities/Behavioral and Brain Function
        Learning disabilities affect one-half of people with NF1. They
    range from mild to severe and can impact the quality of life for those
    with NF1. In recent years, research has revealed common threads between
    NF1 learning disabilities, autism, and other related disabilities. New
    drug interventions for learning disabilities are being developed and
    will be beneficial to the general population. Research being done in
    this area includes working to identify drugs that target Cyclic AMP, so
    they can be paired with existing drugs targeting RAS. Identification of
    new drug combinations may benefit people with multiple types of
    learning disabilities.
    Bone Repair
        At least a quarter of children with NF1 have abnormal bone growth
    in any part of the skeleton. In the legs, the long bones are weak,
    prone to fracture and unable to heal properly; this can require
    amputation at a young age. Adults with NF1 also have low bone mineral
    density, placing them at risk of skeletal weakness and injury. Research
    currently being done to understand bone biology and repair will pave
    the way for new strategies to enhancing bone health and facilitating
    repair.
    Pain Management
        Severe pain is a central feature of Schwannomatosis, and
    significantly impacts quality of life. Understanding what causes pain,
    and how it could be treated, has been a fast-moving area of NF research
    over the past few years. Pain management is a challenging area of
    research and new approaches are highly sought after.
    Nerve Regeneration
        NF often requires surgical removal of nerve tumors, which can lead
    to nerve paralysis and loss of function. Understanding the changes that
    occur in a nerve after surgery, and how it might be regenerated and
    functionally restored, will have significant quality of life value for
    affected individuals. Light-based therapy is being tested to dissect
    nerves in surgery of tumor removal. If successful it could have
    applications for treating nerve damage and scarring after injury,
    thereby aiding repair and functional restoration.
    Cancer
        NF can cause a variety of tumors to grow, which includes tumors in
    the brain, spinal cord and nerves. NF affects the RAS pathway which is
    implicated in 70% of all human cancers. Some of these tumor types are
    benign and some are malignant, hard to treat and often fatal. Previous
    studies have found a high incidence of intracranial glioblastomas and
    malignant peripheral nerve sheath tumors (MPNSTs), as well as a six-
    fold incidents of breast cancer compared to the general population. One
    of these tumor types, malignant peripheral nerve sheath tumor (MPNST),
    is a very aggressive, hard to treat and often fatal cancer. MPNSTs are
    fast growing, and because the cells change as the tumor grows, they
    often become resistant to individual drugs. Clinical trials are
    underway to identify a drug treatment that can be widely used in MPNSTs
    and other hard-to-treat tumors.
        The enormous promise of NF research, and its potential to benefit
    over 175 million Americans who suffer from diseases and conditions
    linked to NF, has gained increased recognition from Congress and the
    NIH. This is evidenced by the fact that numerous institutes are
    currently supporting NF research, and NIH's total NF research portfolio
    has increased from $3 million in FY1990 to an estimated $36 million in
    FY2021. Given the potential offered by NF research for progress against
    a range of diseases, we are hopeful that the NIH will continue to build
    on the successes of this program by funding this promising research and
    thereby continuing the enormous return on the taxpayers' investment.
        We appreciate the Subcommittee's strong support for the National
    Institutes of Health and will continue to work with you to ensure that
    opportunities for major advances in NF research at the NIH are
    aggressively pursued. Thank you.

        [This statement was submitted by Kim Bischoff, Executive Director,
    Neurofibromatosis Network.]
                                     ______

     Prepared Statement of the Northwest Portland Area Indian Health Board
        Greetings Chair Murray, Ranking Member Blunt, and Members of the
    Subcommittee, for the opportunity to share the Northwest Portland Area
    Indian Health Board's funding priorities for the Department of Health
    and Human Services (HHS) in FY 2022. My name is Nickolaus Lewis, and I
    serve as Council on the Lummi Indian Business Council, and as Chair of
    the Northwest Portland Area Indian Health Board (NPAIHB or Board). I
    thank the Subcommittee for the opportunity to provide testimony on FY
    2022 HHS appropriations.
        The NPAIHB is a tribal organization, established in 1972, under the
    Indian Self-Determination and Education Assistance Act (ISDEAA), P.L.
    93-638 that advocates on behalf of the 43 federally-recognized Indian
    Tribes in Idaho, Oregon, and Washington on specific health care issues.
    The Board's mission is to eliminate health disparities and improve the
    quality of life of American Indian and Alaska Native (AI/AN) people by
    supporting Northwest Tribes in the delivery of culturally appropriate,
    high quality health programs and services. ``Wellness for the seventh
    generation'' is the Board's vision. In order to achieve this vision,
    NPAIHB delegates respectfully ask that this Subcommittee consider
    tribal sovereignty, traditional knowledge, and culture in all policy
    initiatives and funding opportunities.
        Last year, COVID-19 dramatically impacted Northwest Tribes. We are
    grateful for the diligent work of our Congressional representatives in
    ensuring that Tribal Nations were provided with resources, including
    vaccines, to battle this pandemic. We know that working together
    improved our ability take care of our people despite the long standing
    systemic and funding shortfalls to the Indian health care system. As we
    emerge from the pandemic, I make recommendations that will help rebuild
    and repair the foundational necessities for the Indian health care
    system.
                              hhs and its agencies
        This Committee must honor tribal sovereignty and trust and treaty
    obligations as to HHS funding to Tribal Nations. For FY 2022, we ask
    this Committee to make the legislative changes needed across all HHS
    agencies to move away from grants and allocate funding to tribes
    through Indian Self-Determination and Education Assistance Act (ISDEAA)
    compacts and contracts. We also request Tribal set-asides and direct
    funding to tribes--not through state block grants.
        We also request that this Committee consider the important role
    that Tribal Epidemiology Centers play in the Indian health system and
    support funding to TECs. TECs should be funded across HHS agencies to
    provide support to tribes in their area for any type of data or
    evaluation component, surveillance support and/or training and
    technical assistance. TECs know the tribes in their area and should be
    given the opportunity to support tribes in their roles as public health
    authorities.
           substance abuse and mental health services administration
        Tribal Opioid Response. Through Tribal Opioid Response (TOR)
    funding, NPAIHB coordinated a TOR consortium of 28 Northwest Tribes.
    Our tribes have developed innovative opioid programs with positive
    outcomes reflecting the resilience in our area. For example, the Lummi
    Nation brought on success coaches (peers) for those using or in
    recovery and 18 of the 28 TOR consortium tribes have made medication-
    assisted treatment (MAT) available. However, a funding increase is
    needed for a more robust opioid response in tribal communities. In FY
    2022, we request an increase in TOR funding to $75 million; and an
    increase in the Tribal MAT funding to $20 million.
        Other Grant Programs. Thank you for the increases to the AI/AN Zero
    Suicide Initiative funding, and Tribal Behavioral Health Grants in FY
    2021. For FY 2022, we request the following amounts for Tribal Specific
    Programs: fund the Tribal Behavioral Health Grant program at least $50
    million--$25 million for mental health and $25 million for substance
    use disorder; fund the Garrett Lee Smith Suicide Prevention Tribal Set
    Aside at $3.5 million; fund Zero Suicide Initiative at $3 million; and
    fund the National Child Traumatic Stress Initiative Tribal Set Aside at
    $1.5 million.
        Designated Resources for Youth Behavioral Health Programs. In order
    to comprehensively address the need for whole person mental health and
    substance use disorder services for AI/AN youth, there must be
    dedicated funding streams for culturally-centered prevention,
    intervention, treatment, aftercare and transitional living support.
    Funding for Youth Residential Treatment Centers that provide aftercare
    and transitional living for both substance use disorder and mental
    health are a priority for Portland Area Tribes and current facilities
    in the area do not meet demand. For FY 2022, we request $25 million in
    funding for youth-specific outpatient and inpatient mental health and
    substance use programs.
                            office of the secretary
        Minority HIV/AIDS Fund. The Minority HIV/AIDS Fund is a significant
    funding source for communities of color that have not traditionally
    been supported by mainstream opportunities, and includes important
    funding to IHS for HIV and hepatitis C (HCV) prevention, treatment,
    outreach and education. Tribes in the Portland Area appreciated the
    $1.5 million MHAF Tribal set-aside in FY 2021. For FY 2022, we request
    that funding for Minority HIV/AIDS Fund be increased to $80 million
    with a $15 million Tribal set-aside. This is a step toward addressing
    the impact that HIV has in Indian Country.
                centers for disease control and prevention (cdc)
        Public Health Infrastructure & Environmental Impacts. COVID-19 has
    demonstrated the under-investment made by the federal government in
    public health and medical care infrastructure in the Indian, Tribal,
    and Urban (I/T/U) health system. The I/T/U system is underfunded, and
    lacks capacity to respond effectively to public health emergencies like
    COVID-19. We can no longer allow population density as the primary
    consideration in the allocation of emergency preparedness resources. In
    FY 2022, we request at least $1 billion for a Tribal Public Health
    Emergency Fund established through the Secretary of HHS that tribes can
    access directly for tribally-declared public health emergencies.
        Include Tribes in HIV/HCV Funding Opportunities. HIV/HCV prevention
    and education generally flows to states via block grants. This leaves
    many tribes with limited or no resources and forces tribes to compete
    with states for funding. For FY 2022, we recommend that the Committee
    set-aside at least $25 million for HIV and HCV prevention for Tribal
    communities.
        Fund Good Health and Wellness in Indian Country (GHWIC). The GHWIC
    initiative supports AI/AN communities in the implementation of holistic
    and culturally adapted approaches to reduce and prevent chronic disease
    through policy, system and environment changes. With COVID-19, tribal
    communities are more focused than ever on the importance of traditional
    foods and the nutritional and healing qualities of these food in a time
    of crisis. Additional funding is needed to address food access issues,
    food insecurity, and support traditional food and local food system
    initiatives beyond COVID-19. NPAIHB recommends that the Committee
    allocate at least $32 million in FY 2022 to the Good Health and
    Wellness in Indian Country.
                centers for medicare and medicaid services (cms)
        Medicaid Legislative Initiative. HHS must work with Congress to
    pass legislation that creates the authority for states to extend
    Medicaid eligibility to all AI/AN people with household incomes up to
    138% of the federal poverty level; authorizes Indian Health Care
    Providers (IHCP) in all states to receive Medicaid reimbursement for
    health care services delivered to AI/AN people under IHCIA; extends
    100% FMAP to states for Medicaid services furnished by urban Indian
    providers permanently; excludes Indian-specific Medicaid provisions in
    federal law from state waiver authority; and removes the limitation on
    billing by IHCP for services provided outside the four walls of a
    tribal clinic.
        Medicare Telehealth Reimbursement. Medicare telehealth expansion is
    set to expire at the end of the current public health emergency.
    Telehealth provided a way to care for our people during the pandemic
    and should be made permanent to increase access. We request that this
    Committee support legislation to make Medicare telehealth flexibilities
    permanent at the OMB encounter rate at I/T/U facilities, expand
    telephone-only telehealth visits, direct physician supervision of non-
    physician providers be provided remotely via telephone, and expand
    ``originating site'' locations from which telehealth services can be
    received, and support inclusion of multiple platforms including
    FaceTime, Zoom, and Skype.
        Dental Health Aide Therapists Reimbursement. In Washington, tribes
    have faced barriers to get the state plan amendment in Washington
    approved to include dental health aide therapists (DHATs) working in
    tribal health programs in the Medicaid program. The state and the
    Swinomish Indian Tribal Community have petitioned the Ninth Circuit
    Court of Appeals to hear an appeal on the rejection of the Washington
    State Plan Amendment. Medicaid reimbursement for DHATs is critical to
    supporting and expanding dental services in tribal communities. We
    trust that this matter is resolved soon so tribal health programs in
    Washington can be reimbursed at the OMB encounter rate for these
    critical services.
              health resources and services administration (hrsa)
        Provider Relief Fund Uninsured Program. The COVID-19 relief
    legislation packages exclude Indian Health Care Providers from
    receiving reimbursement from the Provider Relief Fund Uninsured
    Programs for uninsured American Indian/Alaska Native people. This
    exclusion is inconsistent with national Indian policy to elevate the
    health status of AI/AN people by making all resources available to the
    Indian health system. We request that the Subcommittee support the
    following legislative language to address this issue:
    SEC. XXX. CLARIFICATION REGARDING INDIANS AND UNINSURED INDIVIDUALS.
        Subsection (ss) of section 1902 of the Social Security Act (42
    U.S.C. 1396a), as added by section 6004(a)(3)(C) of the Families First
    Coronavirus Response Act, is amended--(ss) in paragraph (2), by
    inserting ``(except Indians (as defined in section 4 of the Indian
    Health Care Improvement Act (25 U.S.C. 1603)) who receive health
    services funded by the Indian Health Service, shall not be treated as
    enrolled in a Federal health care program for purposes of this
    paragraph)'' before the period at the end.
        Provider Shortages and Needs. The Broken Promises Report, National
    Tribal Behavioral Health Agenda, National Tribal Budget Formulation
    Workgroup Recommendations for 2021, and the IHS Strategic Plan all
    detail how culturally responsive care is critical for the health and
    well-being of AI/AN people. There are significant vacancy rates and
    challenges in filling vacancies at I/T/U facilities. Some of these
    challenges include: the rural location of tribal facilities, lower
    salaries, lack of incentives, and insufficient housing for providers.
        For these reasons, we strongly recommend that the Committee support
    funding for HRSA, as follows:
      --Increase Tribal Set-Aside for Loan Forgiveness Program. Increase
            tribal set-asides for loan forgiveness and include mid-level
            health care professionals such as Community Health Aide Program
            providers in the program.
      --Support Community Health Aide Program Expansion. As IHS is
            expanding the CHAP program in the lower 48, HRSA must create
            new funding opportunities that support national CHAP expansion.
            We recommend $60 million to support CHAP education programs and
            other implementation activities.
                         national institutes of health
        The Native American Research Centers for Health (NARCH) national
    program has catalyzed multiple tribal-academic partnerships that have
    resulted in many successful research projects and training
    opportunities for AI/AN people interested in science and health of AI/
    AN people. The NPAIHB's NARCH programs have supported and developed
    countless Native researchers through this program. We request that
    NARCH be a congressionally mandated funding priority as it supports
    tribal health research with the development of tribal health leaders to
    design and implement research that is responsive to tribal needs. In FY
    2022, we recommend increased funding for the NARCH program to $20
    million and request that 30% of the funding be directed to enhance AI/
    AN workforce development in parity with priorities of NIH institutes
    and centers.
        Thank you for this opportunity to provide recommendations to the
    Committee on FY 2022 funding for HHS. We invite you to visit Portland
    Area Tribes to learn more about the communities, utilization of HHS
    funding, and health care needs in our Area. We look forward to working
    with the Subcommittee on our requests.\1\
    ---------------------------------------------------------------------------
        \1\ For more information, please contact Candice Jimenez,
    cjimenez@npaihb.org.
    ---------------------------------------------------------------------------
                                     ______

             Prepared Statement of the Nursing Community Coalition
        As the nation continues to address COVID-19, we recognize how
    crucial federal investments for the nursing workforce and the nursing
    pipeline are to our patients and the health of our nation. Given these
    realities, the Nursing Community Coalition (NCC) respectfully requests
    that Congress continues robust and bold investment in nursing
    workforce, education, and research in Fiscal Year (FY) 2022 by
    supporting at least $530 million for the Nursing Workforce Development
    programs (authorized under Title VIII of the Public Health Service Act
    [42 U.S.C. 296 et seq.] and administered by HRSA), a doubling of Title
    VIII funding, and at least $199.755 million for the National Institute
    of Nursing Research (NINR), which aligns with the President's FY 2022
    budget and is one of the 27 Institutes and Centers within NIH.
        The Nursing Community Coalition is comprised of 63 national nursing
    organizations who work together to advance health care issues that
    impact education, research, practice, and regulation. Collectively, the
    NCC represents Registered Nurses (RNs), Advanced Practice Registered
    Nurses (APRNs),\1\ nurse leaders, students, faculty, and researchers,
    as well as other nurses with advanced degrees. With more than four
    million nurses throughout the country, the NCC is committed to
    advancing the health of our nation through the nursing lens.\2\ The
    nursing workforce is involved at every point of care, which is
    exemplified by nurses' heroic work during the COVID-19 pandemic.
    Together, we reiterate the bold request for increased funding for Title
    VIII Nursing Workforce Development programs and NINR, especially during
    these unprecedented times.
    ---------------------------------------------------------------------------
        \1\ APRNs include certified nurse-midwives (CNMs), certified
    registered nurse anesthetists (CRNAs), clinical nurse specialists
    (CNSs) and nurse practitioners (NPs).
        \2\ National Council of State Boards of Nursing. (2021). Active RN
    Licenses: A profile of nursing licensure in the U.S. as of February 9,
    2021. Retrieved from: https://www.ncsbn.org/6161.htm.
    ---------------------------------------------------------------------------
    Providing Care to All Americans Through the Nursing Lens
        As we continue to confront today's health care challenges and plan
    for tomorrow, increased federal resources for our nation's current and
    future nurses are even more imperative. Title VIII programs are
    instrumental in bolstering and sustaining the nation's diverse nursing
    pipeline by addressing all aspects of nursing workforce demand. In
    fact, the Bureau of Labor Statistics projected that by 2029 demand for
    RNs would increase 7%, illustrating an employment change of 221,900
    nurses.\3\ Further, the demand for most APRNs is expected to grow by
    45%.\4\ This is just one example on why continued and elevated
    investments in Title VIII Nursing Workforce Development Programs in FY
    2022 is essential and will help nurses and nursing students have the
    resources to tackle our nation's health care needs, remain on the
    frontlines of the COVID-19 pandemic, assist with the distribution and
    administration of the vaccine, and be prepared for the public health
    challenges of the future.
    ---------------------------------------------------------------------------
        \3\ U.S. Bureau of Labor Statistics. (20). Occupational Outlook
    Handbook-Registered Nurses. Retrieved from: https://www.bls.gov/ooh/
    healthcare/registered-nurses.htm.
        \4\ U.S. Bureau of Labor Statistics. (2021). Occupational Outlook
    Handbook-Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners.
    Retrieved from: https://www.bls.gov/ooh/healthcare/nurse-anesthetists-
    nurse-midwives-and-nurse-practitioners.htm.
    ---------------------------------------------------------------------------
        Funding for Title VIII is essential, but especially crucial during
    public health emergencies as these programs connect patients with high-
    quality nursing care in community health centers, hospitals, long-term
    care facilities, local and state health departments, schools,
    workplaces, and patients' homes. A prime example of this is the Title
    VIII Advanced Nursing Education (ANE) programs. ANE programs support
    APRN students and nurses to practice on the frontlines and in rural and
    underserved areas throughout the country. In Academic Year 2019-2020,
    ANE programs supported more than 8,200 students.\5\ Of these students
    directly supported by the Advanced Nursing Education Workforce (ANEW)
    program, 75 percent had clinical training sites in primary care
    settings, while 73 percent of Nurse Anesthetist Trainee (NAT)
    recipients were trained in medically underserved areas.\6\
    ---------------------------------------------------------------------------
        \5\ Department of Health and Human Services Fiscal Year 2022 Health
    Resources and Services Administration Justification of Estimates for
    Appropriations Committees. Pages 153-158. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2022.pdf.
        \6\ Department of Health and Human Services Fiscal Year 2022 Health
    Resources and Services Administration Justification of Estimates for
    Appropriations Committees. Pages 153-155. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2022.pdf.
    ---------------------------------------------------------------------------
        Together, Title VIII Nursing Workforce Development programs serve a
    vital need and help to ensure that we have a robust nursing workforce
    that is prepared to respond to public health threats and ensure the
    health and safety of all Americans. The Nursing Community Coalition
    respectfully requests at least $530 million for the Title VIII Nursing
    Workforce Development programs in FY 2022.
    Improving Patient Care Through Scientific Research and Innovation
        For more than thirty years, scientific endeavors funded at the
    National Institute of Nursing Research (NINR) have been essential to
    advancing the health of individuals, families, and communities.
    Rigorous inquiry and research are indispensable when responding to the
    ever-changing healthcare landscape and healthcare emergencies, such as
    COVID-19. From precision genomics to palliative care and wellness
    research to patient self-management, NINR has been at the forefront of
    evidence driven research to improve care.\7\ It is imperative that we
    continue to support this necessary scientific research, which is why
    the Nursing Community Coalition respectfully requests at least $199.755
    million for the NINR in FY 2022.
    ---------------------------------------------------------------------------
        \7\ National Institutes of Health, National Institute of Nursing
    Research. The NINR Strategic Plan: Advancing Science, Improving Lives.
    Pages 4, 10 Retrieved from https://www.ninr.nih.gov/sites/
    www.ninr.nih.gov/files/NINR_StratPlan2016_reduced.pdf.
    ---------------------------------------------------------------------------
        Now, more than ever, it is vital that we have the resources to meet
    today's public health challenges, such as COVID-19. Investing in Title
    VIII Nursing Workforce Development programs and NINR are essential to
    meeting that need. By providing bold funding for Title VIII and NINR,
    Congress can continue to reinforce and strengthen the foundational care
    nurses provide daily in communities across the country. Thank you for
    your support of these crucial programs.

    60 Members of the Nursing Community Coalition Submitting this Testimony

        Academy of Medical-Surgical Nurses
        American Academy of Ambulatory Care Nursing
        Academy of Neonatal Nursing
        American Academy of Nursing
        American Association of Colleges of Nursing
        American Association of Critical-Care Nurses
        American Association of Heart Failure Nurses
        American Association of Neuroscience Nurses
        American Association of Nurse Anesthetists
        American Association of Nurse Practitioners
        American Association of Post-Acute Care Nursing
        American College of Nurse-Midwives
        American Nephrology Nurses Association
        American Nurses Association
        American Nursing Informatics Association
        American Organization for Nursing Leadership
        American Pediatric Surgical Nurses Association, Inc.
        American Public Health Association, Public Health Nursing Section
        American Psychiatric Nurses Association
        American Society for Pain Management Nursing
        American Society of PeriAnesthesia Nurses
        Association for Radiologic and Imaging Nursing
        Association of Community Health Nursing Educators
        Association of Nurses in AIDS Care
        Association of Pediatric Hematology/Oncology Nurses
        Association of periOperative Registered Nurses
        Association of Public Health Nurses
        Association of Rehabilitation Nurses
        Association of Veterans Affairs Nurse Anesthetists
        Association of Women's Health, Obstetric and Neonatal Nurses
        Chi Eta Phi Sorority, Incorporated
        Commissioned Officers Association of the U.S. Public Health Service
        Dermatology Nurses' Association
        Emergency Nurses Association
        Friends of the National Institute of Nursing Research
        Gerontological Advanced Practice Nurses Association
        Hospice and Palliative Nurses Association
        Infusion Nurses Society
        International Association of Forensic Nurses
        International Society of Psychiatric-Mental Health Nurses
        National Association of Clinical Nurse Specialists
        National Association of Hispanic Nurses
        National Association of Neonatal Nurse Practitioners
        National Association of Neonatal Nurses
        National Association of Nurse Practitioners in Women's Health
        National Association of Pediatric Nurse Practitioners
        National Association of School Nurses
        National Black Nurses Association
        National Council of State Boards of Nursing
        National League for Nursing
        National Nurse-Led Care Consortium
        National Organization of Nurse Practitioner Faculties
        Nurses Organization of Veterans Affairs
        Oncology Nursing Society
        Organization for Associate Degree Nursing
        Pediatric Endocrinology Nursing Society
        Preventive Cardiovascular Nurses Association
        Society of Pediatric Nurses
        Society of Urologic Nurses and Associates
        Wound, Ostomy, and Continence Nurses Society

        [This statement was submitted by Rachel Stevenson, Executive
    Director, Nursing Community Coalition.]
                                     ______

         Prepared Statement of the Nutrition & Medical Foods Coalition
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --NMFC joins the research and patient advocacy community in
            requesting $46.1 billion in discretionary funding for the
            National Institutes of Health (NIH), an increase of $3.2
            billion over FY 2021.
        --Further, NMFC requests proportionate increases for all NIH
                Institutes and Centers, including the Office of the
                Director (which now houses the Office of Nutrition
                Research), to reflect the vast array of applications for
                medical foods and nutrition to address a variety of health
                conditions through ongoing scientific inquiry and
                advancement.
      --The Coalition joins the broader public health community in
            requesting $10 billion in overall funding for the Centers for
            Disease Control and Prevention (CDC) to reinvigorate meaningful
            professional education, public awareness, and public health
            activities.
      --The community encourages ongoing outreach through the annual
            appropriations process to address systemic (and often
            arbitrary) barriers that obstruct proper patient access to
            medical foods including directing HHS and FDA to administer
            public health programs and regulations where medical foods are
            classified as prescription medical products intended for the
            dietary management of unmet needs.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished Members
    of the Subcommittee: thank you for the opportunity to submit testimony
    on behalf of the Nutrition and Medical Foods Coalition (NMFC). We
    strongly support emerging efforts to modernize the medical foods
    category and enhance patient access, such as establishing the Office of
    Nutrition Research within the Office of the NIH Director, and the 2018
    National Academies workshop on distinct nutritional requirements. As
    you work with your colleagues on appropriations for FY 2022, please
    continue to invest in medical research and public health programs to
    improve coverage and access for patients in need of medical foods.
    Medical foods provide important clinical product alternatives when
    drugs are not effective or well tolerated. Consistent with the
    establishment of the medical foods regulatory category in the Orphan
    Drug Act amendments of 1988, increasing medical research and expanding
    the reimbursement of medical food products from the hospital-only
    environment to retail pharmacies through Medicare, Medicaid, TRICARE,
    and medical insurance for federal employees, would enable the use of
    medical foods to address unmet medical needs and support scientific
    innovation providing clinical options to physicians as they work to
    manage national public health issues such as the Opioid Crisis, genetic
    disorders, and the increasing incidences of chronic diseases and
    conditions associated with aging like depression, osteoarthritis, IBS,
    and Alzheimer's. This could, in-turn, manage disease progression and
    lower national healthcare costs. Thank you for your time and please
    consider the Coalition a resource.
                              about the coalition
        NMFC is a collaborative, multi-stakeholder effort to promote and
    advance proper use of safe and effective medical foods. Medical foods
    occupy a unique niche in healthcare and are used to manage many rare
    and chronic conditions for patients with unmet medical needs. NMFC is
    committed to educating policymakers and the general public about the
    role of medical foods in the healthcare ecosystem, while advancing an
    agenda focused on increasing medical research, improving regulation and
    oversight, and increasing access through appropriate insurance coverage
    and reimbursement.
        The Coalition actively supports legislative efforts to address
    coverage and access, such as the Patient Access to Medical Foods Act
    (H.R. 56), Medical Nutrition Equity Act, and similar legislation. In
    this regard, NMFC calls on legislators to ensure that any updates to
    medical foods coverage:
      --Maintains the integrity of the current (aforementioned) definition
            for the category.
      --Does not arbitrarily carve out specific patient communities for
            coverage while leaving other communities (including patients
            without digestive or metabolic disorders) behind.
      --Provides comprehensive coverage and adequate access to facilitate
            reasonable outpatient access to medical foods so there is
            health insurance pharmacy reimbursement in addition to
            historical access that exists through hospitals.
        Moving forward, federal medical research and public health programs
    can play a key role in informing coverage and access updates while
    educating patients and providers about innovative (often cost-
    effective) healthcare options.
                              about medical foods
        As defined by the Orphan Drug Act of 1988, a medical food is, ``a
    food which is formulated to be consumed or administered enterally under
    the supervision of a physician, and which is intended for the specific
    dietary management of a disease or condition for which distinctive
    nutritional requirements, based on recognized scientific principles,
    are established by medical evaluation.''
        Currently, patients in need of medical foods face significant
    coverage and access barriers often stemming from a lack of awareness of
    these products and their unique role in the healthcare system.
    Reimbursement access is grounded in federal and private insurance
    pharmacy benefit plans often categorically denying coverage of medical
    foods through pharmacies as a policy matter while they generally
    reimburse under medical benefits in hospitals. This often results in
    patients being denied access to nutritional therapies which are
    necessary alternatives to drugs that are ineffective or not well
    tolerated. The Food and Drug Administration (FDA) regularly intervenes
    to provide guidance on medical foods, including through a recent
    episode where products were mislabeled as Over-The-Counter on massive
    level, but these interventions are inconsistent at best and often do
    not resolve underlying coverage issues.
               perspective of cindy steinberg, us pain foundation
        One example of important innovation in medical foods is in the area
    of chronic pain, a highly prevalent yet challenging condition to treat.
    The CDC has reported that 19.6 million Americans live with high-impact
    chronic pain resulting from a multitude of serious diseases, conditions
    and injuries that affects their ability to function on a daily basis.
    Indeed, chronic pain is the number one cause of disability in the US
    and globally.
        There are few truly effective treatment options and most of these
    come with difficult side effects, safety concerns or other risks.
    Opioids do help some with severe pain but carry significant risks when
    diverted to those with substance abuse disorder. Non-steroidal anti-
    inflammatory (NSAIDs) medications are widely prescribed but, due to
    risks of heart attack, stroke and gastrointestinal bleeding are
    contraindicated for many, especially those with multiple chronic
    conditions. Acetaminophen has limitations due to insufficient pain
    relief and liver damage at doses high enough to alleviate serious pain
    for some. Moreover, federal agencies and the broader stakeholder
    community have been actively working over recent years to identify non-
    opioid options for pain management.
        Medical foods have been found to fill a need for pain relief for
    individuals with certain chronic conditions such as osteoarthritis.
    Medical foods are generally safe products that can address conditions
    such as pain without causing other side effects. Distinct from both
    drugs and supplements, medical foods must be used under the supervision
    of a medical professional. Lack of awareness about medical foods as an
    emerging, cost-effective treatment option for certain pain conditions
    amongst healthcare providers and insurers have limited their use.
    Improving research and coverage for medical foods would offer patients
    another option, particularly those with multiple chronic conditions and
    unmet medical needs.
    Recommendation:
        Please include timely committee recommendations on medical foods
    research at NIH, like the example below, to sustain progress in this
    area. Please also work with your colleagues to engage HHS in a
    productive dialogue and otherwise seek out opportunities to improve
    coverage and access for patients in need of reliable access to medical
    foods. Thank you for your time and for your consideration of our
    request.
                          recommended report language
                         national institutes of health
                             office of the director
        Office of Nutrition Research [ONR].--The Committee applauds NIH for
    recent efforts to move the Office of Nutrition Research to the Office
    of the Director in recognition of the fact that scientific progress in
    nutrition and medical foods now has applications to a variety of health
    topics and conditions beyond diet and metabolism. NIH is encouraged to
    continue to advance cross-cutting research through ONR, including
    timely applications for a variety of conditions, such as innovative
    strategies and alternative therapeutic products for pain management.

        [This statement was submitted by P. Keith Daigle, Acting Director,
    Nutrition & Medical Foods Coalition.]
                                     ______

                 Prepared Statement of One Voice Against Cancer
        One Voice Against Cancer (OVAC) is a broad coalition of public
    interest groups representing millions of cancer patients, researchers,
    providers, survivors, and their families, delivering a unified message
    to Congress and the White House on the need for increased funding for
    cancer research and prevention priorities.
        2021 is the 50th Anniversary of the National Cancer Act and it
    provides a unique opportunity to renew the country's commitment and
    bring new urgency to the fight against cancer. Although we have made
    much progress against cancer in the past half-century, more funding is
    needed to meet the overwhelming demand for research grants at the
    National Cancer Institute (NCI), address cancer health disparities, and
    mitigate the impacts of COVID-19 on cancer research, clinical trials,
    and patient screenings and treatment. For fiscal year (FY) 2022, we are
    asking that Congress fund the National Institutes of Health (NIH) at
    $46.111 billion, including $7.6 billion for the NCI. We are also asking
    that the Centers for Disease Control and Prevention's (CDC) Division of
    Cancer Prevention and Control (DCPC) receive $559 million.
        There is much to celebrate in the fight against the hundreds of
    diseases we call ``cancer.'' The cancer death rate rose during most of
    the 20th century, but federal investments in cancer research and
    prevention have resulted in a continuous decline in the cancer death
    rate since its peak in 1991. From 1991 to 2018, the cancer death rate
    fell 31 percent. However, cancer is still the second most common cause
    of death in men and women in the U.S. In 2021, almost 1.9 million new
    cancer cases will be diagnosed, and more than 600,000 people will die
    from cancer. Approximately $183 billion was spent in the U.S. on cancer
    related health care in 2015, and this amount is projected to grow to
    $246 billion by 2030-an increase of 34 percent.
        Cancer is a disease that affects everyone, but it doesn't affect
    everyone equally. A close look at cancer incidence and mortality
    statistics reveals that certain groups, such as African Americans,
    Asian Americans, Hispanics/Latinos, Native Americans, Alaska Natives,
    Native Hawaiians/Pacific Islanders, and rural populations are more
    likely than the general population to suffer from cancer and its
    associated effects, including premature death. For instance, the death
    rate for Black men with prostate cancer is more than double that of men
    in every other population. Black women have a 40 percent higher breast
    cancer death rate than white women, even though their diagnosis rates
    are slightly lower.
        There are still some cancers for which survival rates are dismally
    low with few, if any, effective treatments. In 2021, approximately 44
    percent of patients will be diagnosed with a cancer that has a five-
    year survival rate below 50 percent. Research is critical so we can
    develop additional treatments and tools to ensure more Americans
    survive a cancer diagnosis.
        Additionally, the NCI reports that we may see a rise in cancer
    mortality rates for the first time in almost 30 years because of the
    impacts from COVID-19. The COVID-19 pandemic has led to reduced access
    to care for cancer patients, including delays in cancer screening,
    diagnosis, and treatment. These delays will likely lead to a rise in
    late-stage diagnoses and cancer deaths in the years to come.
        For the last 50 years, every major medical breakthrough in cancer
    can be traced back to the NIH and NCI. We know that investment in
    research at the NIH and NCI leads to lives saved. Additionally, more
    than 80 percent of federal funding for the NIH and NCI is spent on
    biomedical research projects at research facilities across the country.
    In FY 2020, the NIH provided over $34.6 billion in extramural research
    to scientists in all 50 states and the District of Columbia. NIH
    research funding also supported more than 536,000 jobs and more than
    $91 billion in economic activity last year.
    COVID-19 and Cancer Research and Clinical Trials:
        The Committee should be aware of the ongoing impact of COVID-19 on
    the cancer research ecosystem, including clinical trials. Thousands of
    researchers working on new discoveries that may one day alter the way
    we treat cancer had their projects disrupted, leading to increased
    costs and in some cases, having to restart research projects, losing
    data and productivity in the process.
        COVID-19 has had serious consequences for cancer clinical trials,
    which play a pivotal role in advancing cancer care and treatment. The
    results of clinical trials and the broader drug development process can
    take years to realize, meaning that without aggressive measures to
    mitigate the impact, the full effect of these disruptions on
    therapeutic innovation in cancer care is likely to be felt for years to
    come. Not only are cancer clinical trials critical in the over-all
    research and progress against the disease, for individual cancer
    patients, clinical trials often provide the best, and sometimes only,
    treatment option available.
        We therefore urge Congress to provide the NIH with at least $10
    billion to restore the research ecosystem so we can continue to make
    progress in the fight against cancer and other diseases. We hope that
    members of the Subcommittee can work with their colleagues to ensure
    this issue is addressed outside the usual appropriations process.
    ARPA-H:
        We understand that President Biden has called for the creation of
    an Advanced Research Projects Agency-Health (ARPA-H) as a key component
    to ``drive transformational innovation in health research'' to deliver
    cures for cancer and other diseases. Based upon available information,
    the initiative is likely to have twin focus areas: transformation of
    research and speeding application and implementation of breakthroughs
    in health care, where the current model has failed to deliver medical
    advancements. The President has spoken about the initiative and has
    included a $6.5 billion proposal in the his FY2022 budget, but few
    other details have emerged.
        We in the cancer community are excited by a new initiative that
    focuses separate and additional resources on the development of new
    diagnostics, treatments, and even cures for cancer. However, we also
    know that clinical advances for patients have to be built on a broad
    foundation of basic scientific understanding.
        Therefore, OVAC recommends that funding for ARPA-H remain separate
    from the established research enterprise and that Congress works to
    ensure that base funding for cancer research at the NCI is increased at
    a sustained, appropriate rate that ensures the pace of discovery is
    maintained.
    OVAC Priorities for Fiscal Year 2022:
        The NCI is currently experiencing a demand for research funding
    that is far beyond that of any other Institute or Center (IC). Between
    FY 2013 and FY 2019, the most recent year for which data are available,
    the number of Research Project Grant (R01) applications to NCI rose by
    50.6 percent. For all other ICs during that time, the number of R01
    applications rose by just 5.6 percent.
        As a result of this extraordinary demand from the scientific
    community, the RPG success rate at NCI dropped from 13.7 percent in FY
    2013 to 11.6 percent in FY 2019. This is a situation unique to NCI, at
    a time when cancer researchers are making historic advances in new
    treatments and therapies. The overall success rate for NIH during that
    same period rose from 16.8 percent to 21.2 percent.
        Thanks to bipartisan, bicameral leadership, Congress has increased
    funding for NIH by $12.9 billion over the past six years. We are
    especially grateful that Congress has highlighted the need for
    dedicated funding to address the precipitous decline in the success
    rate for R01 applications at NCI. Significant, sustained funding
    increases for NCI are essential to raising the R01 success rate and
    ensuring progress in the fight against cancer continues.
        Therefore, OVAC recommends at least $46.111 billion for NIH in FY
    2022, a $3.177 billion increase over the comparable FY 2021 funding
    level, which would allow the NIH's base budget to keep pace with the
    biomedical research and development price index and provide meaningful
    growth of 5 percent. For NCI, we recommend $7.609 billion, the amount
    proposed by NCI in its FY 2022 professional judgment budget.
        Preventing cancer is also critically important. About half of the
    over 600,000 cancer deaths that will occur this year could be averted
    through the application of existing cancer control interventions. The
    CDC's DCPC provides key resources to states and communities to prevent
    cancer by ensuring that at-risk, low-income communities have access to
    vital cancer prevention programs.
        COVID-19's impact on screening and the early-detection of cancer
    will exacerbate current barriers to cancer prevention and early
    detection strategies, potentially increasing disparities in overall
    cancer outcomes. Additionally, addressing the backlog of cancer
    screenings for those without adequate health coverage will place a new
    burden on existing cancer screening programs, which have long been
    underfunded. CDC's programs help ensure that Americans have options for
    cancer screening regardless of income or insurance status. Increased
    investment in the equitable application of existing cancer control
    interventions as spearheaded by CDC's DCPC will accelerate progress in
    the fight against cancer. For this reason, OVAC recommends $559 million
    overall for DCPC, an increase of $173.1 million over the FY 2021 level.
        Once again, thank you for your continued leadership on funding
    issues important in the fight against cancer. Funding for cancer
    research and prevention, survivorship, and must continue to be top
    budget priorities in order to increase the pace of progress in the
    fight against cancer.
        Below please find an overview of OVAC's program level requests in
    the Labor-HHS bill:

        National Institutes of Health (NIH)--$46.111 billion, including:
      --National Cancer Institute (NCI): $7.609 billion
      --National Institute on Minority Health and Health Disparities
            (NIMHD): $419.8 million
      --National Institute on Nursing Research (NINR): $187.9 million

        Centers for Disease Control and Prevention (CDC) Cancer Programs--
    $559 million, including:
      --National Comprehensive Cancer Control Program: $50 million
      --National Program of Cancer Registries: $70 million
      --National Breast and Cervical Cancer Early Detection Program: $275
            million
      --Colorectal Cancer Control Program: $70 million
      --National Skin Cancer Prevention Education Program: $5 million
      --Prostate Cancer Awareness Campaign: $35 million
      --Ovarian Cancer Control Initiative: $13 million
      --Gynecologic Cancer and Education and Awareness (Johanna's Law): $15
            million
      --Cancer Survivorship Resource Center: $900,000

        Health Resources and Services Administration (HRSA)
      --Title VIII Nursing Programs: $270 million
                                     ______

               Prepared Statement of the Pandemic Action Network
        On behalf of the Pandemic Action Network--a network of over 100
    organizations that work together to drive collective action to help
    bring an end to COVID-19 and ensure the world is prepared for the next
    pandemic--I am pleased to offer testimony for Fiscal Year 2022 Labor,
    Health, and Human Services Appropriations.
        To ensure the United States heeds the lessons learned from COVID-19
    and helps ensure the world sustainably prioritizes and invests in
    pandemic preparedness, we respectfully urge you to increase funding to
    the U.S. Centers for Disease Control and Prevention (CDC) overall and
    bolster its critical role in promoting global health security; support
    permanent, dedicated funding for the Biological Advanced Research and
    Development Authority's (BARDA) work in emerging infectious diseases;
    and ensure the U.S. government contributes to global R&D efforts by
    strengthening the Coalition for Preparedness Innovations (CEPI).
    Specifically, Pandemic Action Network calls on the Committee to
    prioritize the following investments for FY22:
      --No less than $456.4m for CDC's Center for Global Health Division of
            Global Public Health Protection and $226m for the Global
            Immunization Division;
      --No less than $10m for CDC's Global Water, Sanitation & Hygiene
            program;
      --No less than $735m for CDC's Center for Emerging Zoonotic and
            Infectious Diseases;
      --No less than $300m in CDC's Infectious Disease Rapid Response Fund
      --No less than $300m for BARDA's work on Emerging Infectious Diseases
      --No less than $200 million support US investment in and partnership
            with the Coalition for Epidemic Preparedness Innovation (CEPI),
            in collaboration with BARDA
        The COVID-19 pandemic has laid bare the grave health and socio-
    economic consequences of repeated failures to prioritize and invest in
    health security and pandemic preparedness both at home and abroad. The
    pandemic has already cost over 580,000 lives in the United States and
    3.4 million around the world. The International Monetary Fund projects
    it will cost the global economy at least $22 trillion. While
    vaccination efforts have begun to dramatically reduce COVID-19
    transmission in the U.S., the pandemic continues to spread globally as
    a majority of the world's population still lacks access to vaccines and
    other lifesaving tools and new variants of the virus continue to
    emerge. Until the virus is controlled around the world, Americans will
    not be safe and our domestic recovery will continue to stall.
        The COVID-19 pandemic was an avoidable disaster. Partners in our
    network and infectious disease experts had been warning for decades of
    the threat of a fast-moving respiratory virus pandemic. Yet a
    persistent culture of panic and neglect, has prevented forward-looking
    and long-term investments in global health security. U.S. leadership
    and international cooperation is essential both to end this pandemic
    and to prepare for the next one. CDC, BARDA, and other agencies across
    the Department of Health and Human Services have a critical role to
    play to keep both Americans and the world safe--but they must be
    appropriately, and sustainably, resourced. The Pandemic Action Network
    urges this committee and Congress to break this dangerous cycle once
    and for all and commit to increased--and sustained--investments in
    pandemic preparedness in Fiscal Year 2022 and beyond.
    CDC:
        The CDC comprises an essential piece of the U.S. and global health
    security architecture--by serving as the steward of U.S. public health
    and by partnering with countries to build and maintain their capacities
    to detect, prevent, and respond to emerging disease threats.
        The Division of Global Public Health Protection (DGHP) works to
    protect Americans from dangerous health threats around the world and
    has been vital in the global fight against COVID-19. Graduates of its
    Field Epidemiology Training Program, a program to train disease
    detectives around the world, have been supporting COVID-19 responses in
    their countries through disease detection and rapid response, as well
    as data analysis, contact tracing, and community outreach. DGHP's
    Global Rapid Response Team has deployed more than 500 deployments for a
    total of nearly 16,000 person-days, to assist with COVID-19 emergency
    response at home and abroad. In a world where pandemic threats are
    growing in frequency, this critical work needs to be resourced and
    upscaled.
        Many other divisions and programs within CDC are also critical to
    fighting deadly outbreaks and strengthening global health security,
    including the Global Immunization Division of the Center for Global
    Health, the Global Water, Sanitation & Hygiene program, the Center for
    Emerging Zoonotic and Infectious Diseases, and the Infectious Disease
    Rapid Response Fund. All have been routinely underfunded relative to
    their vital roles in protecting American and global health and deserve
    funding commensurate with their increasing demand and value.
    BARDA:
        BARDA has been playing an important and unmatched role in
    accelerating the development of medical countermeasures for emerging
    infectious diseases, including for Ebola, Zika, and pandemic influenza.
    The authority partners with industry on late-stage research and
    development, bridging the ``valley of death'' between clinical research
    and product development to translate basic science into urgently needed
    medical tools and technologies--where few entities operate.
        Yet BARDA's work to combat COVID-19 and advance innovations for
    other emerging and neglected infectious diseases has largely been
    financed through emergency supplemental funding. This means that only
    when a disease crisis strikes does BARDA get the go-ahead and funding
    to advance countermeasures. Decades of research in health R&D laid the
    groundwork for the accelerated COVID-19 vaccine development--and
    humanity was lucky that we could build on progress in SARS and mRNA
    platforms. Emergency, surge funding is not a viable solution for
    pandemic prevention or preparedness: in many cases it is not even a
    solution for pandemic response. Annual, targeted funding for emerging
    infectious disease R&D will enable BARDA to work proactively to counter
    infectious disease threats so that we are prepared, and not caught flat
    footed when the next dangerous outbreak happens.
    CEPI:
        This Committee should also prioritize BARDA's partnership with
    CEPI, which has played a critical role in the COVID-19 response.
    Scientific partnership, collaboration, and resource sharing between
    BARDA and CEPI is critical to leverage their respective strengths and
    resources, and to promote the development of infectious diseases tools
    that can be rapidly deployed in a diverse array of settings. The U.S.
    should be a leading partner in supporting CEPI's new five-year plan of
    action with an annual appropriation of at least $200 million.
        Just as the U.S. military is routinely resourced and prepared to
    fight a current war while getting ready for the next one, so too should
    Congress ensure that our civilian health infrastructure is equipped to
    fight this pandemic and prepare for the next one. We should commit the
    funds necessary to deploy a robust global response to the evolving
    COVID-19 pandemic while simultaneously make strong, sustainable, and
    ultimately cost-effective investments in future pandemic preparedness
    and prevention--lest we risk repeating the cycle of panic and neglect
    that spawned this protracted global emergency. Additional and sustained
    investments in CDC, BARDA, and CEPI are vital to America's health and
    security and warrant Congress's strong and unwavering support.
                                     ______

                           Prepared Statement of PATH
        This testimony is submitted by Jenny Blair on behalf of PATH, an
    international nonprofit organization that drives transformative
    innovation to save lives and improve health in low- and middle-income
    countries. PATH is appreciative of the opportunity afforded by
    Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies to submit written testimony regarding fiscal year (FY)
    2022 funding for global health programs within the US Department of
    Health and Human Services (HHS). PATH acknowledges and appreciates the
    strong leadership the Committee has shown in supporting HHS' work in
    this area--especially given the current pandemic--and we recommend that
    support continue. Therefore, we respectfully request that this
    Subcommittee provide no less than the FY21 enacted level of $593
    million to the Center for Global Heath (CGH) at the Center for Disease
    Control and Prevention (CDC) to sustain programming and replenish funds
    that have been diverted for the COVID-19 response that were intended
    for global immunization, malaria, global health security, and research
    and development (R&D). Within CGH, we specifically support increases
    for CDC's Division of Global Health Protection, which should be
    increased from $203.2 million to at least $456.4 million to bolster
    capacity to prevent, detect, and rapidly respond to emerging diseases--
    including the current COVID-19 pandemic--in low- and middle-income
    countries. We also support an additional $300 million for the
    Infectious Disease Rapid Response Fund, $30 million for CGH's Division
    of Parasitic Diseases and Malaria, and $271.1 million for the Global
    Immunization Division--of which $211.2 million should allocated to
    polio eradication and $60 million for measles. This funding allows CDC
    to save lives, reduce disease, prevent and detect future pandemics, and
    improve health around the world.
    The Vital Role of HHS in Global Health and Security
        PATH applauds Congressional appropriators for the global health
    funding that has been provided in four supplementals--the Coronavirus
    Preparedness and Response Supplemental, the CARES Act, the Coronavirus
    Response and Relief Supplemental Appropriations Act of 2021, and the
    American Rescue Plan Act of 2021--over the last year. COVID-19 has
    reached every country in the world, crippling economies, overwhelming
    health care systems, filling hospitals, dwindling supplies, and
    emptying public spaces. While we are beginning to see the end of the
    pandemic here in the United States, countries such as India and Brazil
    are still heavily impacted. With the potential for emergence of
    vaccine-evading strains, COVID-19 will continue to threaten global
    health security as long as it is uncontrolled anywhere in the world.
        Investments that help contain diseases at the source are some of
    the most effective and important the US government can make. US
    investments through the CDC have been used to train epidemiologists,
    engage affected communities, improve disease detection and tracking
    systems, build Emergency Operations Centers (EOCs), and upgrade
    laboratories. Such efforts have allowed partner countries to greatly
    shorten their response times to outbreaks and epidemics--for example,
    enabling Cameroon to shorten its response timeline from 8 weeks to 24
    hours. Many of the US's partner countries have deployed these systems
    for their COVID-19 response.
        The ongoing threat that COVID-19 and other infectious diseases pose
    to the health, economic security, and national security of the United
    States demands dedicated and steady funding for global health security.
    We must invest not only to end the current pandemic, but also to ensure
    that we are better prepared for the next one.
    Protecting the US Through Leadership in Global Health Research and
            Development
        The ongoing COVID-19 pandemic is a clear call for investment in
    America's capacity to rapidly develop and deploy new technologies that
    can prevent, detect, and treat emerging global health threats. The US
    leads the world in R&D for tools that solve some of humanity's most
    pressing health problems. The annual G-Finder report from Policy Cures
    Research estimates that in 2018, the US contributed $1.718 billion
    through the National Institutes of Health (NIH) and $30 million through
    CDC toward the development of global health products.
        In the current pandemic, support through NIH and the Biomedical
    Advanced Research and Development Authority (BARDA) helped speed the
    development and manufacturing of vaccines to prevent COVID-19,
    including through partnerships Janssen Research & Development, part of
    Johnson & Johnson, as well as Moderna. Under Operation Warp Speed,
    BARDA pivoted existing programs for pandemic influenza and other
    threats to accelerate the development of new vaccines, therapeutics,
    and diagnostic tests.
        However, as a nation we have failed to sustain investment in a
    suite of technologies that will help us respond to the disease threats
    most likely to impact Americans and populations around the globe. For
    example, development of a promising SARS vaccine was halted in 2016 due
    to lack of funding--only to be re-started after the spread of COVID-19.
    Congress must ensure that the US is making sustained smart investments
    for just-in-case development and just-in-time delivery of the tools we
    will need for the most likely threats to human health.
        Today more than ever, the US is at the forefront of global health
    innovation because of long-term investment in NIH, CDC, and BARDA. To
    accelerate progress toward lifesaving tools for a range of health
    threats, we call for: maintaining robust funding for NIH and
    particularly for the National Institute of Allergy and Infectious
    Diseases (NIAID) and the Fogarty International Center; providing
    funding to match CDC's increased responsibilities in global health and
    security for the Center for Global Health and the National Center for
    Emerging Zoonotic and Infectious Diseases; and supporting BARDA's work
    in emerging infectious diseases.
        As a complement to continued investment in BARDA and NIH, the US
    should invest in the Coalition for Epidemic Preparedness Innovations
    (CEPI) which is working to advance at least twelve COVID-19 vaccine
    candidates. Investment in CEPI would allow the US to leverage funding
    from other global donors and ensure the US can influence the impact and
    outcome of CEPI's efforts. A US contribution to CEPI would leverage the
    contributions of other donors to increase overall pandemic preparedness
    and response effectiveness, including the potential to help increase
    the effectiveness of vaccines already being used in the United States.
        Successful implementation of these components requires urgent
    coordination across agencies and strategic investments. Congress should
    monitor progress on investments in emerging technologies and medical
    countermeasures, as well as the integration of R&D into federal
    planning including facilitating policies and incentives across
    interagency R&D efforts.
    Immunization Programs During COVID-19 and Beyond
        HHS is also achieving complementary global health and security
    goals through investment in immunization, with most vaccine delivery
    activities overseen by CDC's Global Immunization Division. Vaccines are
    among the most high-impact and cost-effective tools available today to
    combat infectious disease threats; many vaccine-preventable diseases
    were once global pandemics much like COVID-19. This pandemic is a stark
    reminder of how fast an outbreak can spread without a vaccine to
    protect us. Thanks to immunization, outbreaks of childhood diseases
    such as polio, measles, diphtheria, and pertussis are preventable, and
    communities are protected from some of the most infectious and lethal
    pathogens.
        Immunization programs prevent an estimated 2.5 million deaths each
    year among children under the age of five worldwide; these programs
    also bolster local health systems and enable better disease detection.
    However, the COVID-19 pandemic has severely disrupted global
    immunization programs and continues to threaten achievement of critical
    global goals, such as polio eradication. Of the 129 countries able to
    report routine immunization data at the outset of the pandemic last
    year, over half reported moderate to total disruption of immunization
    services. Of the 26 countries that were forced to suspend measles
    immunization campaigns due to the pandemic, 18 reported measles
    outbreaks by July of last year, according to data available in November
    2020. Suspended campaigns put 94 million people at risk of missing
    measles vaccinations in 2020. The Global Measles and Rubella Laboratory
    Network (M&RI), for example, has been repurposed to provide laboratory
    space, equipment, staff, and reagents for COVID-19 diagnostic testing,
    and measles immunization staff supported by M&RI are being called on to
    support COVID-19 responses in many vulnerable countries. These same
    systems and infrastructure will be essential to ensuring COVID-19
    vaccines are distributed equitably.
        Even before the COVID-19 pandemic, vaccines for measles, polio, and
    other diseases were out of reach, on an annual basis, for 20 million
    children under the age of one. Worldwide, more than 10 million children
    below the age of one do not receive any vaccines at all, many of whom
    live in countries with weak health systems. Given these difficulties,
    the disruption to immunization programs caused by COVID-19 could leave
    pathways open to disastrous outbreaks in 2020 and future years and will
    increase imported cases of measles and other vaccine preventable
    diseases into the US. As health care continues to be disrupted
    globally, maintaining strong US support for global vaccination
    efforts--including key goals such as polio eradication, which we are on
    the brink of achieving--is critical to preventing needless deaths.
    Fighting to Eliminate Malaria
        The CDC plays a critical role in the fight against malaria, as co-
    implementer of the President's Malaria Initiative (PMI)--alongside the
    US Agency for International Development--as well as through its
    Parasitic Diseases and Malaria program. These programs provide crucial
    technical assistance, with a focus on monitoring, evaluation, and
    surveillance, as well as operational and implementation research,
    including serving as an evaluation partner in the large-scale pilot
    implementation of the RTS,S malaria vaccine in Kenya (one of three
    African countries involved). Malaria prevention and treatment programs
    have prevented more than seven million deaths globally since 2000.
    Sustained US commitment made this progress possible.
        The World Health Organization estimates that nearly half the
    world's population lives in areas at risk of malaria-there were an
    estimated 229 million cases and 409,000 deaths from the disease in 2019
    alone. Disruptions of essential health services due to the COVID-19
    pandemic are having a catastrophic impact on the most vulnerable
    communities worldwide, threatening our progress against malaria.
    According to the Global Fund, in Africa malaria diagnosis and treatment
    has fallen roughly 15 percent during the pandemic and more than 20
    percent of facilities have reported stockouts of medicines for treating
    children under five. In Asia, diagnosis and treatment has fallen almost
    60 percent due to COVID-19, and 37 percent of facilities have reported
    COVID-19 infections amongst their health workers.
        To reduce the pressure that COVID-19 is exerting on health systems,
    it is critical that we continue to deliver malaria interventions at the
    community level. As PMI has expanded, CDC's mandate has grown, but its
    budget for malaria has remained stagnant. In FY 2022, Congress should
    fully fund PMI and increase funding for the CDC Division of Parasitic
    Diseases and Malaria (DPDM) program from $26 million to $30 million, to
    better track, treat, and test for malaria, and to ensure these services
    continue in the midst of a global health crisis.
    An Investment in Health, at Home and Around the World
        With strong funding for global health programs within HHS, the
    department will be able to improve access to proven health
    interventions in the communities where they are needed most, as well as
    respond to the ongoing threat of COVID-19. By fully funding global
    health and BARDA accounts, the US can prevent the further spread of
    disease, protect the health of Americans, and minimize the impact of
    COVID-19 on vulnerable populations worldwide.

        [This statement was submitted by Jenny Blair, Manager, US & Global
    Policy and Advocacy, PATH.]
                                     ______

                  Prepared Statement of Patient Services, Inc.
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

    PSI joins the broader patient advocacy community in requesting:
      --$46.1 billion in discretionary funding for the National Institutes
            of Health (NIH), an increase of $3.2 billion over FY 2021.
        --Please provide proportional funding increases for the various NIH
                Institutes and Centers to expand and advance condition-
                specific research portfolios.
      --$10 billion in overall funding for the Centers for Disease Control
            and Prevention (CDC) to bolster public health activities.
        --Please provide the new CDC Chronic Disease Education and
                Awareness Program with $5 million, an increase of $3.5
                million over FY 2021, to further advance and expand timely
                public health efforts with community stakeholders.
      --$9.2 billion for the Health Resources and Services Administration
            (HRSA) and $500 million for the Agency for Healthcare Research
            and Quality (AHRQ).
      --PSI joins the broader patient advocacy community in requesting that
            the subcommittee continue to use the annual appropriations
            process, spending bills, and corresponding committee reports,
            to advance efforts that improve coverage and access for
            patients in need, including restoring equitable access to third
            party assistance offered by reputable charities.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished member
    of the Subcommittee, thank you for your leadership on health funding
    and patient care issues. I am Gwen Cooper, and I look forward to
    working with you as the CEO of PSI. We share a goal of improving the
    lives of patients and families impacted by rare, chronic, and life-
    threatening illness. In this regard, thank you for your ongoing efforts
    to invest in medical research, public health, and patient care
    programs. For FY 2022, please maintain this investment while continuing
    to utilize the appropriations process to highlight systemic issues and
    resolve contemporary coverage and access issues facing patients.
                                   about psi
        PSI is a national nonprofit charitable assistance program with over
    30 years' experience assisting patients in obtaining healthcare
    coverage and needed care and therapies. Founded by a patient for
    patients, we know the challenges of chronic illness. We help pay for
    medications, health insurance premiums and copays, navigate health
    insurance plans, provide free legal services, and walk alongside
    patients and their families through every step of their healthcare
    journey. Over the last ten years, we have had the privilege of
    providing over $800 million in financial assistance to help people
    obtain the healthcare they so desperately need. In 2020 alone, nearly
    15,000 patients from every state across the nation benefitted from $56
    million in financial assistance from PSI. We are honored to do the
    important work of breaking down barriers to healthcare access and
    payment options so that patients with rare and chronic diseases can
    focus on living their best lives.
                          about charitable assistance
        Patient assistance charities, like PSI, primarily raise private
    donations to provide health insurance premium assistance; pharmacy and
    treatment costs, as well as travel, nursing and ancillary services. Our
    programs help patients who are uninsured and underinsured in the
    commercial market, and beneficiaries of public insurance coverage like
    Medicare, Medicaid and TRICARE. PSI bridges the gaps in health coverage
    for families by providing premium assistance for:
      --Medicare beneficiaries for Medicare Part D plans,Medicare Advantage
            plans and Medigap Plans.
      --Patients during the 24-month waiting period for Medicare when
            qualified for Social Security Disability.
      --Patients who no longer qualify for the Medicaid program because of
            age or income.
      --Those who lose employer sponsored coverage through COBRA plans and
            plans through the Marketplace. In 2020, over 16M Americans lost
            their employer sponsored healthcare. PSI helped patients secure
            new plans for coverage life-saving treatments.
        When a patient turns to PSI, they often already have a doctor, and
    health plan, and a course of therapy. PSI simply assists them with the
    costs to maintain coverage and access, based on financial need and
    other factors. For patients with life-threatening conditions, who wish
    to continue working while managing their conditions, and those who do
    not qualify for disability or need-based federal programs, maintaining
    access to life-sustaining care is absolutely critical and few reliable
    options exist without compassionate charitable assistance. Most
    patients with rare and chronic diseases do not automatically quality
    for disability, nor do they want to. They wish to continue living their
    most productive lives through continued access to treatments required
    to manage their illness.
       contemporary examples of ``backdoors'' to pre-existing condition
                                 discrimination
    Third Party Payer
        Center for Medicare and Medicaid Services (CMS) has discouraged
    insurers from accepting payments from third party payers, including
    organizations like PSI and other nonprofit patient assistance programs
    (PAPs). This results in severe economic hardships for patients.
        In November of 2013, CMS published a Frequently Asked Questions
    (FAQ) document which discouraged health insurers from accepting
    payments from third party payors on behalf of enrolled individuals.
    This FAQ document was CMS' response to reported concerns, by insurers,
    that accepting payments from someone other than the insured could skew
    the insurance risk pool and create an unlevel field in the Exchanges.
        A subsequent 2014 CMS FAQ document clarified that CMS had not
    intended to discourage insurers from accepting third party premium and
    cost-sharing payments from state and federal government programs,
    Indian tribes, tribal organizations, and urban Indian organizations.
        However, insurers were still discouraged from accepting third party
    payments from any other organizations, including PAPs and other
    charitable organizations, such as churches. This creates significant
    barriers to care for many patients who deal with recurring costs and
    chronic illnesses.
    Copay Accumulators
        CMS endorsed another tactic used by insurers to limit care for the
    most ill (and, thus, most expensive) patients--the copayment
    accumulator. A copay accumulator--or accumulator adjustment program--is
    a strategy insurance companies and Pharmacy benefit Managers (PBMs) use
    that stop manufacturer copay assistance coupons from counting towards a
    patient's deductible and out-of-pocket maximum spending. This is like
    saying a manufacturer's coupon would not lower your total grocery bill
    when you use the coupon at the grocery store. These coupons help lower
    the cost of medications in these scenarios: they can't afford the high
    cost of the medication; they have a high deductible plan and cannot t
    afford the copayment, and/or they qualify for PAP assistance but their
    insurer will not accept the payment due to the CMS rule.
        Because CMS has endorsed the copay accumulator mechanism, patients
    often never reach their out-of-pocket maximum spending, putting other
    treatment for their diseases in jeopardy.
    Specialty Claim Carve-Out or Alternative Funding Model
        This prescription drug procurement model improperly uses for-profit
    drug manufacturers' free assistance programs to the detriment of
    patients who are forced to continually switch drugs because
    manufacturer assistance programs are time limited; diseases are not.
    Additionally, any costs for filling the prescriptions or are not
    counted toward the patient's out-of-pocket costs.
                                   conclusion
        Over previous years, appropriators have asked HHS and CMS to
    explain the rationale and justifications for taking various coverage
    and access actions. It would be meaningful to have the new
    administration's perspective on these issues. The community would
    welcome the opportunity to share their experiences and collaboratively
    discuss challenges and opportunities with policymakers. In addition to
    including timely committee recommendations, please consider questions
    for the record and similar options to facilitate a productive
    discussion with the administration on enhancing coverage and access
    while Congress works on potential legislative solutions, as well. Thank
    you again and please consider PSI a resource for future conversations.

        [This statement was submitted by Gwen Cooper, Chief Executive
    Officer, Patient Services, Inc.]
                                     ______

               Prepared Statement of the Pediatric Policy Council
        I write on behalf of the Pediatric Policy Council (PPC), a public
    policy collaborative of the Academic Pediatric Association, the
    American Pediatric Society, the Association of Medical School Pediatric
    Department Chairs, and the Society for Pediatric Research. We urge the
    subcommittee to provide robust investments in pediatric research and
    training to support the health and well-being of children, as outlined
    below. We are grateful for the investments Congress has made in these
    areas in recent years, as evidenced in particular through enhanced
    support for the National Institutes of Health (NIH) and other key
    pediatric research priorities, and hope you will support sustained
    increases in pediatric research and training priorities to enable the
    next generation of scientific discoveries to benefit child health.
    Fiscal Year (FY) 2022 Funding Priorities:
      --National Institutes of Health: $46.1 billion
      --Eunice Kennedy Shriver National Institute of Child Health and Human
            Development: $1.7 billion
      --Pediatric Subspecialty Loan Repayment Program: $50 million
      --Gun Violence Prevention Research: $50 million split evenly between
            NIH and CDC
      --Agency for Healthcare Research and Quality: $500 million
      --Children's Hospital Graduate Medical Education: $485 million
    National Institutes of Health (NIH):
        Biomedical research is key to improving child health and well-being
    through new cures for pediatric conditions and a deeper understanding
    of children's unique biology. Research funded by the NIH has made
    significant strides toward treating and preventing chronic diseases,
    many of which have their roots in childhood. This work has led to new
    therapies, vaccines, and diagnostic tests that have improved the lives
    of millions of people worldwide. Pediatric research has yielded
    groundbreaking treatments for deadly chronic diseases, saved the lives
    of premature babies, and even cured some common childhood cancers. NIH
    funding also helps fund the development of physician scientists through
    loan repayment and research training awards. The COVID-19 pandemic has
    only further underscored the importance of the federal investment in
    biomedical research, which was crucial in developing the scientific
    knowledge and infrastructure to rapidly study the novel coronavirus in
    children and adults and to develop needed medical interventions like
    immunizations that will be key to ending the pandemic.
        We urge a funding level for NIH of no less than $46.1 billion in FY
    2022, a $3.2 billion increase over the agency's FY 2021 level. Within
    the overall FY 2022 funding for the NIH, we request $1.7 billion for
    the Eunice Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD)--the single largest funder of pediatric research
    within the NIH and a key leader in coordinating and advancing a
    pediatric research agenda NIH-wide. This amounts to a proportionate
    increase for NICHD of $117 million over FY 2021.
    Pediatric Subspecialty Loan Repayment Program (PSLRP):
        Across the country, there are significant shortages of pediatric
    subspecialists--pediatricians who pursue additional training to care
    for the most medically complex children--which lead to long travel
    distances and long appointment wait times for families. There is also a
    disparity in the geographic distribution of pediatric subspecialists,
    resulting in many children in underserved rural and urban areas not
    receiving timely health care. Shortages of pediatric subspecialists may
    also slow the development of the next generation of treatments and
    cures for young people, since many pediatric researchers are trained as
    subspecialists and dedicate their careers to research on complex health
    needs like Type 1 diabetes and autism spectrum disorder.
        PSLRP is designed to address these shortages by providing
    qualifying child health professionals with up to $35,000 in loan
    repayment annually in exchange for practicing in an underserved area
    for at least two years, which would help address high medical school
    debt that serves as a barrier to pursuing training in a pediatric
    subspecialty. Congress reauthorized this program last year in the
    Coronavirus Aid, Relief, and Economic Security (CARES) Act in
    recognition of the need to support child access to pediatric medical
    and mental health care amid the COVID-19 pandemic. We urge you to begin
    addressing these shortages by providing $50 million in initial funding
    for PSLRP in FY 2022.
    Gun Violence Prevention Research:
        Gun violence is a public health crisis for citizens of all ages,
    genders, races, ethnicities, and socio-economic backgrounds--and this
    includes for children and youth. Firearms are now the leading cause of
    death for those 1-24 years old in the United States. Suicide accounts
    for 40% of these deaths. In the last decade, an increasing number of
    teenagers and young adults have died by suicide using a gun, which
    results in death more than 90 percent of the time. Funding to better
    elucidate risk and protective factors for gun violence in children and
    youth and their families is critical to decrease gun deaths and
    injuries. For the first time in 25 years, Congress provided a welcomed
    investment in this research in FY 2020 and again in FY 2021 at the NIH
    and the Centers for Disease Control and Prevention (CDC). After the
    absence of research funding for almost 3 generations of young
    investigators, additional funding is needed to rebuild the public
    health research infrastructure needed for gun violence. We therefore
    urge you to provide $50 million in funding for gun violence prevention
    research split evenly between the NIH and the CDC, a doubling of
    current funding in line with President Biden's FY 2022 budget request.
    Agency for Healthcare Research and Quality (AHRQ):
        The Agency for Healthcare Research and Quality (AHRQ) funds
    research into health care as it is practiced to improve care in the
    clinic and support quality improvement. For instance, AHRQ research has
    helped reduce unnecessary blood cultures in critically ill children and
    led to important insights about the health and economic benefits of
    increased physical activity in children. AHRQ has also played an
    important role in the development and evaluation of the Pediatric
    Quality Measures Program (PQMP), which is helping to improve quality of
    care for the 37.6 million children enrolled in Medicaid and the
    Children's Health Insurance Program. We urge you to provide $500
    million in funding for AHRQ in FY 2022.
    Children's Hospital Graduate Medical Education (CHGME):
        The ability to produce top quality pediatric research is dependent
    on the availability of trained pediatrician scientists who choose to
    pursue a career in research. Many factors influence a physician's
    choice to pursue research, but a stable pipeline of trained clinicians
    is a critical prerequisite. Freestanding children's hospitals train
    half of all pediatricians and pediatric subspecialists despite
    representing less than one percent of hospitals. CHGME is necessary to
    maintain the number of pediatric residents and fellows in the United
    States and has allowed participating children's hospitals to improve
    their training experience for residents and fellows. A strong
    investment in pediatric training through freestanding children's
    hospitals is essential to ensuring that future pediatrician scientists
    are trained and have the opportunity to pursue pediatric research. We
    urge you to provide $485 million in funding for CHGME in FY 2022.

                                     ______

                     Prepared Statement of Peel Ann D. deg.
                       Prepared Statement of Ann D. Peel
        Madam Chairwoman,
        Amyloidosis is a rare and usually fatal disease. There is no known
    cure for amyloidosis, an abnormal folding protein disease that can
    destroy various major organs. The causes of the disease remain elusive.
    I ask that you include language in the Committee's report for fiscal
    year 2022 directing the National Institutes of Health (NIH), Office of
    the Director, Multi-Institute Research Issues to expand its research
    efforts into amyloidosis. I also ask the Committee to direct NIH to
    inform Congress on the steps taken to increase the understanding of the
    causes of amyloidosis and the measures taken to improve the diagnosis
    and treatment of this devastating group of diseases. The vaccines
    developed to combat COVID-19 illustrate the importance of the research
    necessary to overcome diseases. Only through more research can deaths
    from amyloidosis be prevented.
        Over the years, your Committee has been instrumental in moving
    forward to finding the causes and a cure for amyloidosis. Efforts made
    by NIH and Amyloidosis Centers around the country are resulting in many
    more people being diagnosed and treated for amyloidosis than a decade
    ago.
        I have endured two stem cell transplants in order to fight the
    deadly disease amyloidosis and have been one of the lucky ones to
    survive the disease for 18 years. This was due to the intensive, life-
    saving treatment that I have received through the Amyloidosis Center at
    Boston University School of Medicine and Boston Medical Center. I
    continue to participate in a clinical trial that looks for ways to
    diagnose and treat amyloidosis.
        One of the major concerns is that current methods of treatment are
    risky and unsuitable for many patients. Even with successful initial
    treatment, amyloidosis remains a threat, since it can recur years
    later.
        Due to research, there are new forms of treatment that are options
    for me and patients with recurring amyloidosis. These new treatment
    options were not available 18 years ago. They provide evidence that
    funding through Health and Human Services can make a difference.
        I ask for your support in helping me turn what has been my life-
    threatening experience into hope for others.
                              what is amyloidosis?
        I have been treated for primary amyloidosis, which is
    immunoglobulin light chain (AL) amyloidosis. This type of amyloidosis
    occurs when cells in the bone marrow produce an abnormal amyloidogenic
    protein and these form amyloid fibrils that are deposited in major
    organs, such as the heart, kidney and liver. These misfolded proteins
    clog the organs until they are no longer able to function-sometimes at
    a very rapid pace.
        In addition to AL amyloidosis, a blood or bone marrow disorder,
    there are also cases of inherited or familial amyloidosis and secondary
    or reactive amyloidosis. Familial amyloidosis may be present in a
    significant number of African Americans.
        All three types of amyloidosis, left undiagnosed or untreated, are
    fatal. There is no explanation for how or why amyloidosis develops and
    there is no known reliable cure. Thousands of people die because they
    were diagnosed too late to obtain effective treatment. Thousands of
    others die never knowing they had amyloidosis. The small numbers of
    those with amyloidosis who are able to obtain treatment face challenges
    that can include high dose chemotherapy and stem cell replacement or
    organ transplantation.
        Amyloidosis can cause heart, kidney, or liver dysfunction and
    failure and severe neurological problems. Left untreated, the average
    survival is just months from the time of diagnosis.
        Researchers have not been able to determine the root cause of the
    disease or an effective low-risk treatment. Amyloidosis can literally
    kill people before they even know that they have the disease.
        Older Americans are susceptible to heart disease due to amyloid
    formed from the non-mutated form of the same protein. Another type of
    amyloidosis, secondary or reactive amyloidosis, occurs in patients with
    chronic infections or inflammatory diseases.
        All of these types of amyloidosis, left undiagnosed or untreated,
    are fatal.
                          how is amyloidosis treated?
        Boston University School of Medicine and other centers for
    amyloidosis treatment have found that high dose intravenous
    chemotherapy followed by stem cell replacement, or rescue, is an
    effective treatment in selected patients with AL amyloidosis. Abnormal
    bone marrow cells are killed through high dose chemotherapy and the
    patient's own extracted blood stem cells are replaced in order to
    improve the recovery process. The high dose chemotherapy and stem cell
    rescue and other new drugs have increased the remission rate and long-
    term survival dramatically. However, this treatment can also be life
    threatening and more research needs to be done to provide less risky
    forms of treatment.
        Timely diagnosis and treatment are of great importance. Early
    treatment is the key to success.
        More needs to be done in this area to alert health professionals to
    identify this disease.
                             research and diagnosis
        Researchers are moving forward with limited funding to develop
    targeted treatments that will specifically attack the amyloid proteins.
    Additional funding for research and equipment is needed to accomplish
    this task. Only through more research is there hope of further
    increasing the survival rate and finding treatments to help more
    patients.
        Amyloidosis is vastly under-diagnosed. Thousands of people die
    because they were not diagnosed or diagnosed too late. More needs to be
    done to alert health professionals to identify this disease. Although I
    was diagnosed at a very early stage of the disease, many people are
    diagnosed after the point that they are physically able to undertake
    treatment.
        I believe there are many more cases of amyloidosis than are known,
    as the disease can escape diagnosis and patients die of ``heart
    failure,'' ``liver failure,'' etc. In reality, some of these people had
    amyloidosis. Perhaps amyloidosis is not as rare a disease as we think.
        Through the leadership of this Committee and the further
    involvement of the U.S. Government, several positive developments have
    occurred. Research supported by the National Institute of Neurologic
    Disorders and Stroke at NIH and the Office of Orphan Products
    Development at the Food and Drug Administration led to successful
    repurposing of a generic drug that markedly slows progression of
    familial amyloidosis.
        Basic and clinical research at the Boston University Amyloidosis
    Center has increased: models of light chain (AL) amyloid disease have
    been developed; serum chaperone proteins that cause amyloid precursor
    protein misfolding are being identified; imaging techniques for the
    diagnosis of amyloid disease are being investigated; and new clinical
    trials for primary and familial amyloidosis are underway. Federal
    funding for research, equipment and treatment has been an important
    element in progress to date. Further funding is essential to speed the
    pace of discovery for basic and clinical research.
        Madam Chairwoman, the United States Congress and the Executive
    branch working together are key to finding a cure for and alerting
    people to this terrible disease.
        I want to use my experience with this rare disease to help save the
    lives of others. With your support more can be done to help me achieve
    my dream.
                                     ______

           Prepared Statement of the Personalized Medicine Coalition
        Chairwoman Murray, Ranking Member Blunt and distinguished members
    of the subcommittee, the Personalized Medicine Coalition (PMC)
    appreciates the opportunity to submit testimony on the National
    Institutes of Health (NIH) fiscal year (FY) 2022 appropriations and the
    importance of the agency's research to personalized medicine. PMC is a
    nonprofit education and advocacy organization comprised of more than
    220 institutions from across the health care spectrum who support this
    growing field. The tragically uneven effects of the COVID-19 pandemic
    have underlined the importance of developing more targeted health care
    interventions just as groundbreaking technologies are giving us an
    unprecedented ability to understand the biological and environmental
    factors that drive disease and influence patients' responses to various
    treatments. As the subcommittee begins work on the FY 2022 Labor,
    Health and Human Services, Education and Related Agencies
    appropriations bill, we strongly support the President's proposed
    increase in funding for NIH to $51 billion, and we request the agency
    receive no less than $46.1 billion for NIH's base program level budget,
    $3.2 billion above the comparable FY 2021 funding level.
        Personalized medicine, also called precision or individualized
    medicine, is an evolving field in which physicians use diagnostic tests
    to determine which medical treatments will work best for each patient
    or use medical interventions to alter molecular mechanisms that impact
    health. By combining data from diagnostic tests with an individual's
    medical history, circumstances and values, health care providers can
    develop targeted treatment and prevention plans with their patients.
    Personalized medicine promises to detect the onset of disease, pre-empt
    its progression, and improve the quality, accessibility, and
    affordability of health care.\1\ By increasing government spending on
    science at this pivotal moment, Congress can help advance a new era of
    personalized medicine that promises a brighter future for patients and
    health systems.
    ---------------------------------------------------------------------------
        \1\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
    Corporate/file/PMC_The_
    Personalized_Medicine_Report_Opportunity_Challenges_and_the_Future.pdf.
    ---------------------------------------------------------------------------
                  i. the role of nih in personalized medicine
        Continued research on the genetic and biological underpinnings of
    disease has made it possible to develop new personalized medicine
    treatments for cancers as well as rare, common, and infectious
    diseases. This research has informed the development of more than 286
    personalized treatments \2\ and over 166,703 genetic testing products
    \3\ available for patients in 2020. Foundational advances in genetic
    and genomic technologies have also paved the way for scientists' rapid
    response to COVID-19. The rapid progress we have seen, from mRNA
    vaccine development, diagnostic testing, and variant sequencing, to
    beginning to understand how human genomic variation influences
    infectivity, disease severity, vaccine efficacy, and treatment
    response, relies on years of personalized medicine research,\4,5\--as
    well as years of diligent funding from Congress to support this
    research.
    ---------------------------------------------------------------------------
        \2\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
    Corporate/file/PMC_The_
    Personalized_Medicine_Report_Opportunity_Challenges_and_the_Future.pdf.
        \3\ https://doi.org/10.1002/ajmg.c.31881.
        \4\ https://doi.org/10.1016/j.cell.2021.01.015.
        \5\ https://doi.org/10.1038/s41586-020-2817-4.
    ---------------------------------------------------------------------------
        The widely variable effects of COVID-19 have only highlighted the
    need for personalized medicine to move further and faster. A $3.2
    billion increase would allow for NIH's base budget to keep pace with
    biomedical inflation and allow meaningful growth of 5 percent. This
    request also includes the full $496 million NIH is scheduled to receive
    in FY 2022 from the Innovation Account established in the 21st Century
    Cures Act (Cures Act).
       ii. sustaining basic and translational research for personalized
                                    medicine
        NIH is leading scientific discovery for personalized medicine,
    which begins with basic research that generates fundamental knowledge
    about the molecular basis of a disease and with translational research
    aimed at applying that knowledge to develop a treatment or cure. Many
    institutes and centers at the NIH are supporting research informing the
    development of personalized medicines, including the National Human
    Genome Research Institute (NHGRI), the National Cancer Institute (NCI),
    the National Institute on Aging (NIA), the National Heart, Lung and
    Blood Institute (NHLBI), and the National Center for Advancing
    Translational Sciences (NCATS). An increase for NIH in FY 2022 would
    protect its foundational role in the identification and development of
    treatments, technologies, and tools for personalized medicine.
        The future of cancer care, for example, is expected to be
    profoundly influenced by personalized medicine approaches for detecting
    and treating early- and late-stage cancers. In 2020, for example, FDA
    approved the first comprehensive pan-tumor liquid biopsy test for
    patients with advanced cancer that allows physicians to detect
    actionable biomarkers in patients' blood through next-generation
    sequencing.\6\ As soon as next year, NCI aims to launch large national
    trials for similar tests that are being developed to detect multiple
    early-stage cancers in patients' blood.\7\ These tests would provide
    less invasive testing options that can detect cancers at early stages
    when treatment may be more effective and less costly.
    ---------------------------------------------------------------------------
        \6\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
    Corporate/file/PM_at_FDA_
    The_Scope_Significance_of_Progress_in_2020.pdf.
        \7\ https://www.precisiononcologynews.com/policy-legislation/nci-
    director-sharpless-outlines-ideas-aggressively-lower-cancer-deaths.
    ---------------------------------------------------------------------------
        Basic and translational research also offers opportunities for
    personalized medicine beyond oncology, especially for rare diseases.
    Although individually rare, rare diseases collectively affect an
    estimated 25 to 30 million Americans. With advances in genomics, the
    molecular causes of 6,500 rare diseases have been identified--but only
    about 5 percent have an FDA-approved treatment, and in 2019, the
    estimated economic cost of only 379 rare diseases reached nearly $1
    trillion in the U.S.\8\ Over the past decade, NIH has helped shift the
    scientific approach to researching rare diseases from one disease at a
    time to many diseases. Pooling patients, data, experiences, and
    resources promises to lead to more successful clinical trials sooner
    for rare disease patients who presently have few or no treatment
    options.
    ---------------------------------------------------------------------------
        \8\ https://everylifefoundation.org/burden-study/.
    ---------------------------------------------------------------------------
        There are others living with highly prevalent diseases where
    personalized medicine can offer patients better treatments or a cure.
    The Alzheimer's Association estimates that 6.2 million Americans are
    living with Alzheimer's disease, for example.\9\ Despite increasing
    numbers of Alzheimer's diagnoses and FDA's recent approval of the first
    new Alzheimer's drug in decades, researchers are still studying the
    genetic underpinnings of Alzheimer's disease to more fully understand
    its complexity. To shorten the time between the discovery of potential
    drug targets and the development of new drugs, the Accelerating
    Medicines Partnership for Alzheimer's disease led by NIH has identified
    over 500 drug targets, and in 2020 launched a second iteration of the
    partnership to enable a personalized medicine approach to researching
    new treatments.\10\
    ---------------------------------------------------------------------------
        \9\ https://www.alz.org/media/Documents/alzheimers-facts-and-
    figures.pdf.
        \10\ https://www.nih.gov/research-training/accelerating-medicines-
    partnership-amp/alzheimers-disease.
    ---------------------------------------------------------------------------
        Still, ensuring that the scientific breakthroughs in personalized
    medicine are impactful to all patients will require the inclusive and
    equitable representation of patients with diverse characteristics and
    health needs in research. Improving research policies and incorporating
    diverse perspectives into solving complex scientific problems, such as
    through NIH's UNITE initiative and NHGRI's action agenda for a diverse
    genomics workforce, will play a key role in addressing these
    disparities, in addition to research on improving minority health and
    understanding factors contributing to health disparities.
                iii. accelerating personalized medicine research
        Increasing the NIH's base budget will also ensure that the agency
    has the resources necessary to advance the longstanding aspects of its
    mission without de-prioritizing supplemental initiatives in
    personalized medicine provided for by Congress in the Cures Act.
        The first initiative, the All of Us\TM\ Research Program, was
    launched in 2018 to begin collecting genetic and health information
    from one million volunteers as part of a decades-long research project.
    As of May 2021, over 382,000 individuals consented to participate and
    over 279,000 have fully enrolled.\11\ More than 80 percent of those
    individuals are from groups historically underrepresented in
    research,\12\ such as seniors, women, Hispanics and Latinos, African
    Americans, Asian Americans and members of the LGBTQ community. Last
    year, program officials met their targets to start returning individual
    genetic results to participants and inviting researchers to begin using
    the data collected.\13\ The program also began analyzing data from its
    diverse participant cohort to look for patterns explaining individuals'
    different responses to COVID-19.\14\ In the future, pooling health care
    data across large datasets will play a key role in advancing research
    for personalized medicine approaches to care.
    ---------------------------------------------------------------------------
        \11\ https://www.joinallofus.org/newsletters/2021/may.
        \12\ https://doi.org/10.1016/j.cell.2021.01.015.
        \13\ https://www.joinallofus.org/newsletters/2020/december.
        \14\ https://www.nih.gov/news-events/news-releases/all-us-research-
    program-launches-covid-19-research-initiatives.
    ---------------------------------------------------------------------------
        The second initiative, the Beau Biden Cancer Moonshot, aims to
    transform the way cancer research is conducted by fostering
    collaboration and data sharing. Moonshot currently supports over 240
    new research projects, \15\ including the Partnership for Accelerating
    Cancer Therapies (PACT). Through PACT, the NIH is collaborating with 12
    pharmaceutical companies, the Foundation for NIH, and FDA to identify,
    develop, and validate biomarkers to advance the discovery of new
    immunotherapy treatments. Over the past decade, personalized treatments
    harnessing the immune system have driven declines in mortality for lung
    cancer and melanoma.
    ---------------------------------------------------------------------------
        \15\ https://doi.org/10.1016/j.ccell.2021.04.015.
    ---------------------------------------------------------------------------
                                 iv. conclusion
        PMC appreciates the opportunity to highlight the NIH's importance
    to the continued success of personalized medicine. As the subcommittee
    considers the President's proposal, we encourage the subcommittee to
    support at least a $3.2 billion increase for existing centers and
    programs, in addition to funding Congress may provide for targeted
    initiatives such as establishing the President's proposed Advanced
    Research Projects Agency for Health (ARPA-H). PMC believes that
    diligently funding basic and translational research at the NIH is key
    to bringing us closer to a future in which every patient benefits from
    an individualized approach to health care.

        [This statement was submitted by Cynthia A. Bens, Senior Vice
    President, Public Policy, Personalized Medicine Coalition.]
                                     ______

              Prepared Statement of the Physical Activity Alliance
        Members of the subcommittee, thank you for the opportunity to
    testify today. My name is Mark Fenton. I am an adjunct associate
    professor at Tuft University and a nationally recognized public health,
    planning, and transportation consultant. I am representing the Physical
    Activity Alliance, the nation's broadest coalition dedicated to
    promoting physical activity for health. As such, I'm pleased to testify
    today on specific opportunities to improve Americans' health in the
    fiscal year (FY) 2022 Labor, Health and Human Services, Education and
    Related Agencies appropriations bill that address funding for the
    Centers for Disease Control and Prevention. I respectfully request you
    work over the next three years to triple the budget of the Centers for
    Disease Control and Prevention (CDC) National Center for Chronic
    Disease Prevention and Health Promotion (NCCDPHP) to $3.75 billion,
    including in this next budget at least $125 million for the Division of
    Nutrition, Physical Activity and Obesity (DNPAO), and $10 million for
    Active People Healthy Nation (APHN), an initiative to help 27 million
    Americans become more physically active by 2027.
        The Active People Healthy Nation support would build on the
    increased capacity of the public health infrastructure from a 50-state
    DNPAO program funding commitment. The 50-state program, including the
    District of Columbia, would allow for each state to have resources for
    staff who are experts in:
      --Promoting physical activity through community and state changes to
            increase safe and convenient access to physical activity,
            especially for those populations most at risk of physical
            inactivity, through activities such as master planning, access
            to parks, safe routes to school, and improvements for
            physically active (walking and bicycling) routes to everyday
            destinations.
      --Promoting nutrition security especially for the youngest and most
            vulnerable populations
      --Obesity prevention and management with linkages to health care
            systems
      --Communication and policy
      --Evaluation, quality improvement and accountability
      --Equitable and inclusive community engagement
        The specific resources for Active People Heathy Nation would allow
    states, municipalities and, local communities to leverage the expertise
    of the 50-state program to specifically address the populations who are
    the most disproportionately affected by risk of chronic diseases
    (including obesity, diabetes, cancer and heart disease) due to their
    lack of safe and convenient access to physical activity. This could
    include but is certainly not limited to:
      --Implementing social support systems and networks to promote walking
            for older populations.
      --Implementing low-cost ``quick builds'' to improve street designs to
            encourage safe walking and biking at the local level in
            specific neighborhoods where health disparities are the
            greatest.
      --Convening local groups to develop action plans for promoting safe
            and convenient access to local parks and other key
            destinations.
      --Promoting safe routes to schools with design changes (e.g., high
            visibility crosswalks, traffic calming near schools) to
            increase safety and to reduce hesitancy from parents.
      --Taking steps to prioritize safety over speed in local and state
            policies and practices.
        As a consultant to communities across the country, I have seen the
    positive impact of these funds in communities, especially for those
    that are historically under-resourced. The pandemic has demonstrated
    that chronic diseases and infectious diseases are inextricably linked
    and inequity can be exacerbated. Addressing chronic diseases, their
    associated risk factors, as well as mental health and well-being are
    essential for improving our population health and productivity. And
    physical activity to improve cardiorespiratory fitness are integral
    interventions. Being physically active is one of the most important
    lifestyle behaviors people can engage in to maintain their physical
    health, improve their mental health, and optimize well-being.\1\
    ---------------------------------------------------------------------------
        \1\ US Department of Health and Human Services. Physical Activity
    Guidelines for Americans, 2nd edition. 2018.
    ---------------------------------------------------------------------------
      --Studies show that physical activity is associated with strong
            immune response, better outcomes from community-acquired
            infectious disease, reduced mortality and increased vaccine
            potency.\2,3,4,5\
    ---------------------------------------------------------------------------
        \2\ Nieman DC, Wentz LM. The compelling link between physical
    activity and the body's defense system. J Sport Heal Sci. Published
    online 2019. doi:10.1016/j.jshs.2018.09.009.
        \3\ Hamer M, Kivimaki M, Gale CR, David Batty G. Lifestyle risk
    factors, inflammatory mechanisms, and COVID-19 hospitalization: A
    community-based cohort study of 387,109 adults in UK. Brain Behav
    Immun. Pblished online 2020.
        \4\ Dixit S. Can moderate intensity aerobic exercise be an
    effective and valuable therapy in preventing and controlling the
    pandemic of COVID-19? Med Hypotheses. Published online 2020.
        \5\ Perico, L., Benigni, A., Casiraghi, F., Ng, LFP., Renia, L.,
    Remuzzi, G. Immuity, endothelial injury and complement-induced
    coagulopathy in COVID-19. Nature Reviews Nephrology. October 2020.
    ---------------------------------------------------------------------------
      --Physical activity also contributes to social connectedness,\6\
            quality of life,\7\ and environmental sustainability.\8,9\
    ---------------------------------------------------------------------------
        \6\ Wray, A., Martin, G., Ostermeier, E., Medeiros, A., Little, M.,
    Reilly, K., Gilliland, J. Physical activity and social connectedness
    interventions in outdoor spaces among children and youth: a rapid
    review. Health Promotion and Chronic Disease Prevention in Canada.
    Research Policy and Practice. April 2020; 40(4): 1-12.
        \7\ Posadzki, P., Pieper, D., Bajpai, R., Makaruk, H., Kongsen, N.,
    Lena Neuhaus, A., Semwal, M., Exercise/physical activity and health
    outcomes: an overview of Cochrane systematic reviews. BMC Public
    Health. November 2020. https://bmcpublichealth.biomedcentral.com/
    articles/10.1186/s12889-020-09855-3.
        \8\ Global Advocacy Council for Physical Activity International
    Society for Physical Activity and Health. The Toronto Charter for
    Physical Activity: A Global Call for Action. J Phys Act Health. 2010;7
    Suppl 3:S370-85.
        \9\ Safe routes to school: Steps to a greener future. How walking
    and bicycling to school reduce carbon emissions and air pollutants.
    Accessed online November 2020 at https://www.saferoutespartnership.org/
    sites/default/files/pdf/SRTS_GHG_lo_res.pdf.
    ---------------------------------------------------------------------------
      --Regular physical activity is both health-promoting and important
            for treatment and prevention of diseases such as cardiovascular
            disease and cancer that are the leading causes of death in the
            U.S., with numerous benefits that contribute to a disability-
            free lifespan.\10\
    ---------------------------------------------------------------------------
        \10\ Wen CP and Wu X. Stressing harms of physical inactivity to
    promote exercise. Lancet. 2012;380:192-3.
    ---------------------------------------------------------------------------
      --There are racial, ethnic and socioeconomic status (SES) disparities
            that exist with regard to physical activity, access to
            recreational spaces and physical activity-related programs.
            These disparities differ with respect to occupation,
            transportation, community infrastructure, and
            leisure.\11,12,13\
    ---------------------------------------------------------------------------
        \11\ Thornton, C.M., Conway, T.L., Cain, K.L., Gavand, K.A.,
    Saelens, B.E., Frank, L.D., Geremia, C.M., Glanz, K., King, A.C., and
    Sallis, J.F. Disparities in pedestrian streetscape environments by
    income and race/ethnicity. SSM-Population Health, 2016; 2, 206-216.
        \12\ Engelberg, J.K., Conway, T.L., Geremia, C., Cain, K.L.,
    Saelens, B.E., Glanz, K., Frank, L.D., and Sallis, J.F. Socioeconomic
    and race/ethnic disparities in observed park quality. BMC Public
    Health, 2016;16:395.
        \13\ Jones, SA., Moore, LV., Moore, K., Zagorski, M., Brines, SJ.,
    Diez Roux, A., Evenson, KR. Disparities in physical activity resource
    availability in six US regions. Prev Med. 2015; 78:17-22.
    ---------------------------------------------------------------------------
      --Low physical activity and fitness pose immediate and long-term
            threats to our nation's safety and security. Currently, 71
            percent of Americans ages 17-24 fail to meet core eligibility
            requirements for entrance into the military, creating a serious
            recruiting deficit.\14\ Among those who do meet basic
            requirements for service, musculoskeletal injuries associated
            with low fitness levels cost the Department of Defense hundreds
            of millions of dollars,\15\ and have been identified as the
            most significant medical impediment to military readiness.\16\
    ---------------------------------------------------------------------------
        \14\ U.S. Department of Defense, Joint Advertising Market Research
    and Studies. (2016). The target population for military recruitment:
    youth eligible to enlist without a waiver. https://
    dacowits.defense.gov/Portals/48/Documents/General%20Documents/
    RFI%20Docs/Sept2016/JAMRS%20RFI%2014. pdf?ver=2016-09-09-164855-510.
        \15\ Bulzacchelli M, Sulsky S, Zhu L, Brandt S, Barenberg A. The
    cost of basic combat training injuries in the U.S. Army: injury-related
    medical care and risk factors. In: Military Performance Division, U.S.
    Army Research Institute of Environmental Medicine. Edited by Natick MA,
    March 2017.
        \16\ Hauret KG, Jones BH, Bullock SH, Canham-Chervak M, Canada S.
    Musculoskeletal injuries description of an under-recognized injury
    problem among military personnel. AmJ Prev Med. Jan 2010;
    38(1)(suppl):S61-S70.
    ---------------------------------------------------------------------------
        Streets and downtowns that are designed to safely accommodate the
    physically active modes (walking, biking, and transit) along with motor
    vehicles are more economically robust,\17\ have more resilient real
    estate values,\18\ and are increasingly appealing to businesses because
    of enhanced employee recruitment and retention.\19\
    ---------------------------------------------------------------------------
        \17\ Liu JH, Wei S, Understanding Economic and Business Impacts of
    Street Improvements for Bicycle and Pedestrian Mobility: A Multi-City,
    Multi-Approach Exploration. Nat'l Inst. for Transportaion &
    Communities, NITC-RR-1031-1161, April 2020.
        \18\ Bokhari S, How Much is a Point of Walkscore Worth? https://
    www.redfin.com/news/how-much-is-a-point-of-walk-score-worth/. Aug 2016,
    update Oct. 2020.
        \19\ Andersen M, Hall ML, Protected Bike Lanes Mean Business,
    Alliance for Biking and Walking, 2016, https://
    www.peoplepoweredmovement.org/site/images/uploads/Protected_Bike_Lanes
    _Mean_Business.pdf.
    ---------------------------------------------------------------------------
        Physical activity is integral to population health and well-being,
    educational achievement, effective health care delivery, emergency
    preparedness, and military readiness, and will be critical to our
    nation's recovery from the pandemic. If we can help more Americans to
    be physically active, we will save lives, contribute to lower vehicle
    emissions and health care costs, reduce racial, ethnic, gender, and
    socioeconomic health disparities, improve mental well-being, and make
    American employers and the U.S. overall much more productive and
    successful.
        I thank you for the opportunity to offer my perspective today, and
    for your continued leadership.
                                     ______

                    Prepared Statement of Planned Parenthood
        Dear Chairwoman Murray and Ranking Member Blunt,
        Planned Parenthood is the nation's leading reproductive health care
    provider and advocate and a trusted, nonprofit source of primary and
    preventive care for women, men, and young people in communities across
    the U.S as well as the nation's largest provider of sex education. As
    experts in sexual and reproductive health care, we reach 2.4 million
    people in our health centers, 1.1 million people through educational
    programs, and see 198 million visits to our website every year. People
    come to Planned Parenthood for the accurate information and critical
    resources they need to stay healthy and reach their life goals. For
    many of our patients, Planned Parenthood is their only source of care--
    making our health centers an irreplaceable part of this country's
    health care system. Backed by more than 17 million supporters, Planned
    Parenthood Action Fund works every day to defend access to health care
    and advance reproductive rights at home and abroad. Through our
    international arm, Planned Parenthood Global, we provide financial and
    technical support to nearly 100 innovative partners in nine countries
    in Africa and Latin America for service delivery and advocacy to expand
    access to reproductive health care and empower people to lead healthier
    lives.
        Longstanding progress towards addressing sexual and reproductive
    health both here in the United States and around the world has been
    undermined and is threatened to erode further--both deliberately and as
    a result of unprecedented challenges, most notably the COVID-19
    pandemic. The Biden-Harris administration has taken welcome early
    actions to reverse the Trump-Pence administration's ideological and
    harmful policies--including the global gag rule and Title X domestic
    gag rule--and prioritize sexual and reproductive health and rights, but
    more action is needed from both the administration and congress to
    ground policies in science and equity and expand access to health care,
    including sexual and reproductive health, for millions, particularly
    for those who most often struggle to overcome the systemic barriers to
    care. Meanwhile the pandemic has exacerbated existing inequities in
    health care systems and created a growing need for timely services,
    including those to help with the growing number of households that have
    identified a need for affordable family planning and increasing rates
    of sexually-transmitted infections (STIs).
        Through these extraordinary challenges, Planned Parenthood health
    centers continue to expand services and innovate new and better ways to
    deliver health care and information--through telehealth and in health
    centers across the country. We are breaking down structural barriers to
    accessing reproductive health care by making it more timely, relevant
    and equitable for all people.
        However, there remain significant and unacceptable inequities in
    health outcomes that are the result of longstanding systems of
    oppression that deeply impact traditionally marginalized communities,
    including persons of color, those with low-incomes, those who identify
    as LGBTQ, and those who live at the intersection of structural racism,
    inequality, sexism, classism, xenophobia, and other systemic barriers
    to health care and other resources are among those most severely
    impacted. The ongoing COVID-19 pandemic has underscored the inequities
    in access to health care worldwide, both within and between countries,
    and is further exacerbating gender-based violence and the financial
    barriers to seeking care that is needed, including sexual and
    reproductive health services.
        On behalf of Planned Parenthood Federation of America, I
    respectfully request that while assembling legislation to provide
    appropriations for fiscal year 2022 (FY22) you provide increased
    funding for key sexual and reproductive health funding priorities while
    also ending harmful and discriminatory policies that undermine access
    to care, including by:
        1. Building Back the Title X Family Planning Program
        2. Increasing Funding for STI Prevention
        3. Increasing Funding for the Teen Pregnancy Prevention Program and
    the CDC's Division of Adolescent School Health, and Eliminate Harmful
    and Ineffective Abstinence-Only-Until-Marriage Programs
        4. Eliminating Harmful Policy Riders that Limit Access to Abortion
    1. Building Back the Title X Family Planning Program
        Title X is the nation's only federal program dedicated to providing
    affordable birth control and other reproductive health care to people
    with low incomes. Despite mass outcry from the public health community
    and American people, in August 2019 the Trump administration began
    enforcing a rule that made significant changes to Title X. The gag
    rule--a harmful regulation that prohibits Title X providers from giving
    their patients full and accurate information--dismantles the program
    and blocks people struggling to get by from getting free or low-cost
    birth control, STI services, cancer screenings, and other essential
    health care. The gag rule slashed the Title X network's patient
    capacity nearly in half, creating unacceptable barriers to affordable
    care. The gag rule resulted in family planning providers in 33 states
    leaving the program and at least 1.5 million people, many of whom are
    low-income, losing access to Title X-funded care at the site they had
    used in 2018. More than 1,000 sites (roughly 25 percent) have left the
    Title X network; six states (HI, ME, OR, UT, VT, and WA) currently have
    no Title X-funded services.
        In the meantime the COVID-19 pandemic has further exacerbated the
    county's sexual and reproductive health care needs. In spring 2020, 33
    percent of women faced delays or were unable to get contraception or
    other care because of the COVID-19 pandemic, while 34 percent wanted to
    get pregnant later or wanted fewer children because of the pandemic.
    Women belonging to groups already experiencing systemic health and
    social inequalities--such as Black and Latina women, queer women, and
    low income women--reported the greatest change in fertility preference
    and barriers to access.
        In April 2021, the Biden administration issued a notice of proposed
    rulemaking and we applaud their proposal to rescind the gag rule and
    make several modifications aimed at ``strengthen[ing] the program and
    ensur[ing] access to equitable, affordable, client-centered, quality
    family planning services for all clients, especially for low-income
    clients.'' \1\ However, an increase in annual funding will be necessary
    to help rebuild the Title X network and provide much-needed care to
    qualifying participants.
    ---------------------------------------------------------------------------
        \1\ https://www.hhs.gov/about/news/2021/04/14/fact-sheet-notice-of-
    proposed-rulemaking-ensuring-access-to-equitable-affordable-client-
    centered.html.
    ---------------------------------------------------------------------------
        The best analysis (conducted prior to the pandemic and without
    adjusting for inflation) estimates that the Title X program would need
    $737 million in annual funding to address the unmet family planning
    needs for low-income women. We urge Congress to provide the program
    with $512 million in FY22 funding--an increase halfway towards the
    unmet need of the program--to help rebuild the Title X network and
    restore access to critical health care services.
    2. Increasing Funding for STI and HIV Prevention at the Centers for
            Disease Control and Prevention (CDC)
        Sexually-transmitted infections (STIs) are a serious and growing
    public health problem. This month the latest annual CDC surveillance
    report announced that STD rates have reached an all-time high for the
    sixth consecutive year. In 2019, more than 2.5 million cases of
    syphilis, chlamydia, and gonorrhea diagnoses were identified in the
    United States.\2\ Of particular concern were cases of congenital
    syphilis--syphilis passed from a mother to her baby during pregnancy--
    which have quadrupled between 2015. Congenital syphilis can result in
    miscarriage, stillbirth, newborn death, and severe lifelong physical
    and neurological problems. The report also identified that disparities
    in rates persist among racial and ethnic groups. For example, STD rates
    for Hispanic or Latino people ranging up to two times those of non-
    Hispanic White people. Rates for American Indian or Alaska Native and
    Native Hawaiian or Other Pacific Islander people were 3-5 times as high
    while rates for African American or Black people were five to eight
    times those of non-Hispanic White people. All of this has likely been
    exacerbated by the COVID-19 pandemic which has reduced access to
    essential screening and treatment services and stretched public health
    resources thin.
    ---------------------------------------------------------------------------
        \2\ Centers for Disease Control and Prevention (CDC). 2019 STD
    Surveillance Report. April 13, 2021. https://www.cdc.gov/nchhstp/
    newsroom/2021/2019-STD-surveillance-report.html.
    ---------------------------------------------------------------------------
        Screening and treatment for STIs-including HIV/AIDS-are an
    essential part of planning for a healthy pregnancy and healthy
    communities. Despite the CDC recommendation that all pregnant women be
    tested for STIs, many women and other sexually active adults are not
    being adequately tested, in part because of limited resources for
    screening. The CDC's National Center for HIV/AIDS, Hepatitis, STIs and
    TB Prevention (NCHHSTP) conducts critical public health surveillance,
    but also funds screenings and other important activities. Increasing
    funding for the CDC's STI prevention programs is a cost-effective
    public health investment that will improve the lives of women and all
    Americans across the country. We ask that you fund CDC/NCHHSTP at $1.4
    billion for FY22, including $252.91 million for the Division of STD
    Prevention.
    3. Increasing Funding for the Teen Pregnancy Prevention Program and the
            CDC's Division of Adolescent School Health, Eliminate Harmful
            and Ineffective Abstinence-Only-Until-Marriage Programs
        As the nation's leading provider of sex education, Planned
    Parenthood works in and with communities across the country to provide
    outstanding sex education programs. Our educators see daily how vital
    it is for young people to have access to sex education programs that
    give them knowledge and skills they need to lead fulfilling, safe, and
    healthy lives. However, less than 43 percent of all high schools and
    only 18 percent of middle schools across the country provide education
    on all of the CDC's identified topics that are critical to ensuring
    sexual health.\3\ Congress should continue to make investments in
    programs that are proven to promote adolescent health by increasing
    young people's access to medically accurate and age-appropriate sexual
    health information that they need to make safe and healthy decisions.
    ---------------------------------------------------------------------------
        \3\ Centers for Disease Control and Prevention. School Health
    Profiles 2018: Characteristics of Health Programs Among Secondary
    Schools. Atlanta: Centers for Disease Control and Prevention; 2019.
    ---------------------------------------------------------------------------
        Since fiscal year 2010 (FY10), the Teen Pregnancy Prevention
    Program (TPPP) has supported projects and programs that deliver
    community-driven, evidence-based or informed, medically accurate, and
    age-appropriate approaches that incorporate involvement from parents,
    educators, and health providers. Beginning in 2015, 84 organizations in
    33 states, the District of Columbia, and the Marshall Islands were
    awarded TPPP funds to replicate evidence-based programs in communities
    with the greatest needs; conduct rigorous evaluation of new and
    innovative approaches to prevent unintended teen pregnancy; or build
    capacity to support implementation of evidence-based programs. The
    positive outcomes of the program have been well-documented. In
    September 2017, the bipartisan Commission on Evidence-Based
    Policymaking, established by then-House Speaker Paul Ryan and Senator
    Patty Murray, highlighted TPPP as a model example of a federal program
    that has developed evidence in support of good policy.
        Planned Parenthood urges you to increase TPPP funding to $150
    million. This $49 million funding increase from FY21 to FY22 is
    partially offset by eliminating $35 million for discretionary sexual
    risk avoidance (SRA) grants. Additionally we urge you to support $6.8
    million for dedicated evaluation transfer authority, and ask that
    $900,000 of the $6.8 million in Public Health Service Act funding for
    ``Evaluation of Teen Pregnancy Prevention Approaches'' be allocated
    specifically to reactivate the Teen Pregnancy Prevention Evidence
    Review. Furthermore, urge you to eliminate funding for the abstinence-
    only-until-marriage ``sexual risk avoidance'' competitive grant
    program.
        The CDC's Division of Adolescent and School Health (DASH) provides
    funding to local education agencies across the country to implement
    school-based programs and practices designed to prevent HIV and other
    STIs among young people, and also integrates approaches aimed at
    substance use and violence prevention. In addition, the program expands
    the research and evidence base of how to best meet the respective needs
    of young people, including LGBTQ youth and other adolescents.
    Currently, DASH provides funding to 28 school districts across the
    country. Providing a significant increase ($66 million over the FY21
    enacted level) to DASH funding would considerably expand the number
    served through this important program. We ask that you provide CDC/DASH
    with $100 million in FY22.
    4. Eliminating Harmful and Discriminatory Policy Riders That Undermine
            Access to Abortion and Reject Any New Anti-Sexual and
            Reproductive Health Provisions
        Opponents of sexual and reproductive health and rights have long
    used the appropriations process to undermine access to comprehensive
    reproductive care, including access to abortion. Through policy riders
    in bills under the jurisdiction of multiple subcommittees, including
    the original Hyde Amendment in the Labor/HHS bill, opponents have
    limited access for women on Medicaid, women who work for the federal
    government, women in prison, and others, including women living in the
    District of Columbia, which is even prohibited from spending non-
    federal funds on these services. Separately, the Weldon Amendment has
    been used to interfere with policies that expand abortion coverage and
    access, emboldening health entities to refuse to provide, cover, pay
    for, or refer for abortion services.When elected officials deny certain
    categories of women insurance coverage for or access to abortion, they
    either are forced to carry the pregnancy to term or pay for care out of
    their own pockets or simply do not get the care they need. The result
    is unfair and discriminatory policy that further exacerbates poor
    public health outcomes for those who already face significant barriers
    to care, such as low-income women, immigrant women, young women, and
    women of color. We urge the Committee to eliminate all such
    restrictions on access to abortion.
        In addition, the Committee should reject any harmful new policy
    riders we have seen proposed in years past that would roll back
    progress, including proposals to ``defund'' Planned Parenthood.
                                    ********
        PPFA issues these requests in the hopes that we can protect and
    build upon federal investments to make quality reproductive health care
    affordable and accessible so that women and their families can lead
    healthier lives. We welcome the opportunity to discuss these requests
    with you or your staff. If you have questions about any of the above
    requests, please don't hesitate to contact me at
    (jacqueline.ayers@ppfa.org). For more information about domestic
    priorities, please contact Jack Rayburn, Director, Legislative Affairs
    at (jack.rayburn@ppfa.org).
        Sincerely.

        [This statement was submitted by Jacqueline Ayers, Vice President
    of Public
    Policy and Government Affairs, Planned Parenthood Federation of
    America.]
                                     ______

          Prepared Statement of the Population Association of America/
                       Association of Population Centers
        Thank you, Chair Murray and Ranking Member Blunt for this
    opportunity to express support for the National Institutes of Health
    (NIH), National Center for Health Statistics (NCHS), Institute of
    Education Sciences (IES), and Bureau of Labor Statistics (BLS). These
    agencies are important to the members of the Population Association of
    America (PAA) and Association of Population Centers (APC) because they
    provide direct and indirect support to population scientists and the
    field of population, or demographic, research overall. In FY 2022, we
    urge the Subcommittee to adopt the following funding recommendations:
    $46.1 billion, NIH; $200 million, NCHS; $700 million, IES; and $800
    million, BLS. In addition, we urge the subcommittee to accept report
    language, previously submitted, regarding population research programs
    and surveys supported by the National Institutes of Health.
                         national institutes of health
        Demography is the study of populations and how or why they change.
    The health of our population is fundamentally intertwined with the
    demography of our population. Recognizing the connection between health
    and demography, NIH supports population research programs primarily
    through the National Institute on Aging (NIA) and the National
    Institute of Child Health and Human Development (NICHD). PAA and APC
    thank Chair Murray and Ranking Member Blunt for their bipartisan
    leadership and for working together in recent years to provide the NIH
    with robust, sustained funding increases. As members of the Ad Hoc
    Group for Medical Research, PAA and APC recommend the Subcommittee
    continue to prioritize NIH funding by endorsing an appropriation of at
    least $46.1 billion for the NIH, a $3 billion increase over the NIH's
    program level funding in FY 2021. We urge that NIA and NICHD, as
    components of the NIH, receive commensurate funding increases in FY
    2022.
                          national institute on aging
        The NIA Division of Behavioral and Social Research (DBSR) is the
    primary source of federal support for basic population aging research.
    The NIA Division of Behavioral and Social Research (DBSR) supports a
    scientifically innovative population aging research portfolio that
    reflects some of the Institute's, and nation's, highest scientific
    priorities including Alzheimer's disease and social inequality in
    health and the aging process. With additional support in FY 2022, DBSR
    could expand its existing research portfolio to encourage more research
    on the short and long-term social, behavioral, and economic health
    consequences of COVID on older people and their families. The
    population research community is especially eager to see NIA use
    existing large-scale, longitudinal and panel surveys, such as the
    Health and Retirement Study, the National Health and Aging Trends
    Study, and Understanding America Study, to facilitate scientific
    research on the complex, multifaceted effects of the pandemic on older,
    diverse populations. Further, the field believes NIA should sustain its
    support for developing data infrastructure to promote research on
    racial, ethnic, gender and socioeconomic disparities in health and
    well-being in later life and the long-term effects of early life
    experiences. With additional funding in FY 2022, DBSR could support
    these activities as well as fully fund the NIA Centers on the
    Demography and Economics of Aging, which are conducting research on the
    demographic, economic, social, and health consequences of U.S. and
    global aging at 12 universities nationwide.
      eunice kennedy shriver national institute on child health and human
                                  development
        Since the Institute's inception in 1962, NICHD has had a clear
    mandate to support a robust research portfolio focusing on maternal and
    child health, the social determinants of health, and human development
    across the lifespan. The NICHD Population Dynamics Branch meets this
    mandate by supporting innovative and influential population science
    initiatives, including: (1) large-scale longitudinal surveys, with
    population representative samples, such as The National Longitudinal
    Study of Adolescent to Adult Health and Fragile Families and Child Well
    Being Study; (2) a nationwide network of population science research
    and training centers; and, (3) numerous scientific research initiatives
    that have advanced our understanding of specific diseases and
    conditions, including obesity, autism, and maternal mortality, and,
    further, how socioeconomic and biological factors jointly determine
    human health. Given the dearth of data being collected regarding the
    short and long-term social, economic, developmental, and health effects
    of the COVID pandemic on children and families, the field of population
    research urges NICHD to consider expanding data collection through
    existing surveys and the NICHD Population Dynamics Centers Research
    Infrastructure Program. Further, population scientists encourage NICHD
    to explore the use of existing and new mechanisms to enhance research
    regarding the effects of COVID on fertility trends and reproductive
    health overall. With additional funding in FY 2022, the Institute could
    sustain its existing population research activities as well as
    implement our field's recommended COVID related research expansions.
                     national center for health statistics
        NCHS is the nation's principal health statistics agency, providing
    data on the health of the U.S. population. Population scientists rely
    on large NCHS-supported health surveys, especially the National Health
    Interview Survey and National Health and Nutrition Examination Survey,
    to study demographic, socioeconomic, and behavioral differences in
    health and mortality outcomes. They also rely on the vital statistics
    data that NCHS releases to track trends in fertility, mortality, and
    disability. NCHS health data are an essential part of the nation's
    statistical and public health infrastructure. In order for NCHS to
    continue monitoring the health of the American people and to allow the
    agency to make much-needed investments in the next generation of its
    surveys and products, PAA and APC, as a member of the Friends of NCHS,
    recommends the agency receive $200 million in FY 2022. In addition, our
    organizations urge the Subcommittee to reiterate its support for the
    agency's participation in the Centers for Disease Control (CDC) Data
    Modernization Initiative (DMI). The CDC should be encouraged to provide
    NCHS with a greater share of the agency's DMI funding--especially given
    NCHS has received less than 4 percent of the $600 million that DMI has
    received since FY 2020. NCHS should be benefitting from DMI funds, as
    the Committee intended, and applying them to make long overdue and
    necessary systematic and technological upgrades as well as facilitating
    enhanced use of Electronic Health Records.
                           bureau of labor statistics
        Population scientists who study and evaluate labor and related
    economic policies use BLS data extensively. The field also relies on
    unique BLS-supported surveys, such as the American Time Use Survey and
    National Longitudinal Surveys, to understand how work, unemployment,
    and retirement influence health and well-being outcomes across the
    lifespan. As members of the Friends of Labor Statistics, PAA and APC
    are very grateful for $40 million programmatic increase that BLS
    received in FY 2020 and for maintaining the agency's funding level in
    FY 2021. We are also pleased that BLS received $10 million in FY 2020,
    and report language in FY 2021, to plan for a new youth cohort for the
    National Longitudinal Survey of Youth (NLSY). As the Subcommittee
    knows, the current NLSY 1979 and 1997 cohorts cannot provide adequate
    information about teens and young adults entering the labor market. PAA
    and APC hope that this planning process will provoke a new, necessary
    NLSY cohort. We urge the Subcommittee to give the agency increased
    support in FY 2022 by providing BLS with $800 million and to adopt,
    once again, report language urging the agency to maintain its plans for
    a new NLSY cohort.
                        institute of education sciences
        The Institute of Education Sciences (IES) plays a critical role in
    supporting research used in developing and examining the effectiveness
    of education programs and curricula. The National Center for Education
    Statistics (NCES), the statistical arm of IES, provides objective data,
    statistics, and reports on the condition of education in the U.S.
    Population scientists rely on NCES surveys to conduct research on
    topics, such as linkages between educational access/attainment to
    health outcomes of specific populations, economic well-being, and
    incarceration rates. The field is pleased NCES is ramping up a new
    School Pulse Survey (SPS), to begin in August, that will collect data
    on how schools are adapting during the recovery phase of the pandemic.
    PAA continues to be concerned, however, that NCES has inadequate
    staffing to effectively manage the agency's broad array of surveys and
    other data collection and evaluation programs, and to maintain data
    quality and program rigor--particularly as it takes on new initiatives
    such as SPS. Years of staff attrition combined with bureaucratic
    hurdles have hindered the agency's ability to replace key personnel and
    maintain an adequate staffing level. We urge the Committee to continue
    to exert careful oversight of this situation.
        Thank you for considering our support for these agencies as the
    Subcommittee drafts the FY 2022 Labor, Health and Human Services and
    Education Appropriations bill.
                                     ______

             Prepared Statement of the Port Gamble S'Klallam Tribe
    _______________________________________________________________________

    Requests and Recommendations:
        1. Increase in funding for the Tribal Opioid Response grant program
    to a minimum of $75 million;
        2. Increase in funding for the Temporary Assistance for Needy
    Families Program to a minimum of $17.8 billion;
        3. Increase in funding for the Child Support Program to a minimum
    of $4.424 billion;
        4. Increase in funding for the Head Start Program to a minimum of
    $17.8 billion;
        5. Increase in funding for the Child Care and Development Block
    Grant to a minimum of $7.3 billion; and
        6. Increase in funding for the Low-Income Home Energy Assistance
    Program to a minimum of $3.85 billion and a tribal set-aside.\1\
    ---------------------------------------------------------------------------
        \1\ We also support the National Congress of American Indians' FY
    2022 budget requests. See NCAI, Indian Country FY 2022 Budget Request:
    Restoring Promises, https://www.ncai.org/resources/ncaipublications/
    NCAI_IndianCountry_FY2022_BudgetRequest.pdf.
    ---------------------------------------------------------------------------
    _______________________________________________________________________

                                  introduction
        The Port Gamble S'Klallam Tribe is a sovereign Indian nation
    comprised of over 1,342 citizens located on the northern tip of the
    Kitsap Peninsula in Northwest Washington State. The 1855 Point No Point
    Treaty reserved hunting, fishing, and gathering rights for our Tribe,
    and the United States agreed to respect the sovereignty of our Tribe
    and to protect and provide for the well-being of our Tribe. The United
    States, therefore, has both treaty and trust obligations to protect our
    lands and resources and provide for the health and well-being of our
    citizens. The current COVID-19 pandemic has necessitated the need for
    more resources and services to provide for the health, safety, and
    welfare of our tribal citizens as well as American Indian and Alaska
    Native (AI/AN) people across the United States.
        Overarching Comments. Thank you for your commitment to honor and
    uphold the United States' trust and treaty obligations, strengthen the
    government-to-government relationship between the United States and
    tribes, and empower tribes to govern their own communities and make
    their own decisions. As you know, federal programs and services are
    critical components of building strong tribal governments, economies,
    and communities. We look to the Subcommittee to help address the
    chronic underfunding of unmet federal obligations and duties owed to
    Indian Country. This includes providing funding and support for the
    delivery of reliable and quality health care to AI/AN people, ensuring
    tribal communities are safe and secure, and expanding economic
    opportunity and community development in tribal communities. We ask the
    Subcommittee to support increased funding for critical Indian programs
    and the inclusion of helpful report language on many significant issues
    impacting Indian Country.
        Funding for Tribal Health Care. Appropriations to support health
    care services are needed to, among other things, address the
    significant health disparities that persist among AI/AN people, treat
    chronic diseases that plague tribal communities, update and improve
    tribal health clinics, and modernize equipment and health information
    technology within Indian Country. Our Tribe has administered health
    services to its members for several years, and was one of the first
    tribes to join the Tribal Self-Governance Project in 1990. We are the
    only Indian health care provider of both primary and behavioral health
    services in Kitsap County. Our health programs aim to provide the
    highest quality medical care and treatment to individuals within our
    tribal community, but we still face significant challenges related to
    funding, facilities, and program administration. Due to the COVID-19
    pandemic, our health programs have run short of resources and need
    additional funding to support the services we provide. To strengthen
    our health programs, we ask for the following in the FY 2022
    appropriations:
        Tribal Opioid Response. We appreciate the President's proposed
    funding of $75 million to the Tribal Opioid Response grant program, but
    more is needed. This program to critical to address the opioid
    substance use needs in tribal communities. Indian Country, including
    our Tribe's Reservation, has been severely affected by the opioid
    epidemic. Increased funding for the Tribal Opioid Response grant
    program will address increasing rates of opioid dependence, overdose,
    and other negative consequences stemming from opioid use. Funding is
    essential to combat the opioid crisis that imposes threats to Indian
    Country.
        Temporary Assistance for Needy Families (TANF). We support the
    President's FY 2022 request of $17.8 billion to support the TANF
    Program, which would be an increase in $600 million over FY 2021. The
    TANF Program is a capped entitlement program that has continued to
    receive the same funding level since it was established. The Tribe
    strongly encourages reauthorization of the TANF Program with higher
    funding levels in order to provide temporary assistance and economic
    self-sufficiency for children and families. The Tribe currently
    receives $516,680 from the TANF Program to support its members and
    strongly encourages a continuation of at least this amount. However,
    there remains an unmet need to operate programs for the benefit of low-
    income families. These programs are necessary for the United States to
    fulfill its trust responsibility and contribute to the overall well-
    being of the Tribe's members.
        Child Support Program. We reject the President's request to reduce
    funding for the Child Support Program by $233 million to a total of
    $4.16 billion. Instead, funding for the Program should be at $4.424
    billion, the FY 2020 level. The Tribe operates a robust Child Support
    Program. The Tribe's Child Support Program has a need of $781,955 to
    enhance its services offered to children with need and to improve
    activities offered to children, including an increase of staff members,
    support staff training, child counseling, and ensuring that the
    physical environments of the Tribe's Head Start Program is conducive to
    providing effective program services, increased hours of operation,
    improved strategic planning for the program, and safe transportation of
    children in the program safely, An increase in funding for the Child
    Support Program would allow the Tribe to increase and enhance services
    to its members. Any decrease in the level of funding for the Child
    Support Program would cause hardship to the Tribe's members.
        Head Start Program. We support the President's request of $11.9
    billion for the Head Start Program-an increase of $1.2 billion over the
    FY 2021 enacted level. The Head Start Program promotes the school
    readiness of our tribal youth as well as early learning and
    development, health, and family well-being of children from low-income
    families. Funding from the Head Start Program greatly assists the Tribe
    in offering competitive wages to its employees in its Early Head Start
    Program. The Tribe needs additional funding over and above its current
    funding to pay its teachers to ensure equitable wages that support Head
    Start Performance Standard Regulations. Such funding will also help the
    Tribe recruit and maintain teachers and teaching assistants, which is
    critical to our education programs and the children the Tribe serves.
    The Tribe estimates that it needs at least $235,000 to be able to offer
    competitive wages to its program employees. In addition, the Tribe
    would like to invest $18,000 in an outdoor learning environment and
    $75,000 to support Head Start Program Performance Standards. Indigenous
    learning is based on outdoor environments that reflect tribal culture.
    The Tribe is in need of funds to plan and develop an outdoor learning
    environment to support exploration and discovery in forest/beach/
    wetland/stream. Lastly, the Tribe requests an increase in quality
    improvement funds to support our students, staff, and families based on
    community need.
        Child Care and Development Block Grant. Our Tribe supports the
    President's request for providing $7.3 billion in discretionary funds
    for the Child Care and Development Block Grant. This program supports
    low-income, working families within our Tribe by providing access to
    affordable, high quality child care. Adequate child care is essential
    for our tribal members. The pot of child care money going to Tribal
    governments from this program needs to be bigger so that the portions
    of it that Tribes receive can meet their needs. The overall funding
    amount for the Child Care Development Fund needs to be increased and
    Tribes should get a 5% set-aside from it. Indian Country, including our
    Tribe, have a strong need to access the Fund for facility purposes. An
    increase in funding for the Child Care and Development Block Grant
    would allow the Tribe to increase and enhance services intended to
    serve its youth.
        Low-Income Home Energy Assistance Program (LIHEAP). We appreciate
    the President's request to increase funding for the LIHEAP Program by
    $100 million for a total of $3.85 billion. The LIHEAP Program assists
    low-income households to pay a proportion of household income for home
    energy, primarily in meeting their immediate home energy needs.
    Currently, the Tribe receives $23,979 from LIHEAP to assist its
    members, but there continues to be an unmet need. The Tribe requests an
    increase in LIHEAP funding to assist our tribal members in paying their
    home energy bills. Any decrease or in the current level of funding in
    the LIHEAP Program would cause significant hardship to the Tribe's
    members. We also request that a tribal set-aside for the LIHEAP Program
    be established.
                                   conclusion
        Thank you for the opportunity to share our interests regarding FY
    2022 appropriations for programs and services that will greatly benefit
    us as well as other tribes across the United States. On behalf of the
    Port Gamble S'Klallam Tribe, we thank you and your dedication and
    continued hard work in protecting the tribal interests. We know that
    you will be fighting for Indian Country in the appropriations process.

        [This statement was submitted by Jeromy Sullivan, Chairman, Port
    Gamble S'Klallam Tribe.]
                                     ______

         Prepared Statement of Public Health-Seattle & King County, WA
        Chair Murray, Ranking Member Blunt, and members of the
    Subcommittee, my name is Brad Finegood and I work for King County (WA)
    as a Strategic Adviser for Public Health-Seattle & King County in
    Seattle, WA.
        I am pleased to submit testimony on behalf of King County, WA to
    urge Congress to appropriate $120 million for the Infectious Diseases
    and the Opioid Epidemic program at the Centers for Disease Control and
    Prevention (CDC) at the Department of Health and Human Services (HHS)
    to save lives and address the overdose crisis by supporting and
    expanding access to syringe services programs (SSPs).
        King County, WA is seeing an unprecedented surge in overdose
    deaths. In 2020, there were 510 confirmed overdoses in the county,
    which is more than the 422 experienced in 2019. There has been a year
    over year rise over the past decade when there were 245 overdose
    fatalities in 2011. The majority of the drug overdoses include opioids,
    although a rising number of overdoses also contain stimulants both
    alone and in polysubstance use overdoses. Our county is also besieged
    by fentanyl rising from 3 fentanyl related overdose deaths in 2015, to
    172 in 2020 with 135 confirmed fentanyl overdoses already in 2021 (as
    of date authored). We know that access to sterile use equipment is one
    of the evidence-based interventions that keeps individuals engaged in
    health services, decreases the likelihood of transmissible diseases and
    keeps individuals alive.
        The United States is experiencing an urgent and unprecedented drug
    overdose crisis, with more than 100,000 overdose deaths expected to be
    counted in 2020 and potentially more in 2021. Overdose deaths are
    expected to have increased by more than 40% than the previous record
    year of 2019. According to the Washington Department of Health,
    overdose deaths accelerated in Washington in 2020, increasing by 38% in
    the first half of 2020 compared to the first half of 2019. The
    infectious diseases associated with opioid and other drug use also have
    dramatically increased. Since 2010, the number of new hepatitis C
    infections has increased by 380%. Outbreaks of viral hepatitis and HIV
    among people who inject drugs continue to occur nationwide.
        Overdose deaths have increased more dramatically among Black people
    and communities of color. From 2015 to 2018, overdose deaths among
    African Americans more than doubled (by 2.2 times) and among Hispanic
    people increased by 1.7 times while increasing among white, non-
    Hispanic people by 1.3 times. In Washington, the increase in overdose
    deaths was highest among groups already dealing with inequitable health
    outcomes: American Indian/Alaska Natives, Hispanic/Latinx, and Black
    people.
        SSPs are an essential component of preventing overdose deaths.
    Tacoma Needle Exchange proudly services clients, who can exchange their
    used injection supplies for sterile syringes, which helps prevent the
    spread of blood-borne pathogens like HIV. Other services include safe
    injection supplies, naloxone training and distribution, safer sex
    supplies, and referrals for medication assisted treatment and other
    medical services. Our outreach staff attempts to meet people where they
    are at, and to help them address their needs in the safest and
    healthiest way possible, free of judgement and stigma.
        Congress must respond to the overdose crisis, as well as work to
    prevent and reduce infectious diseases related to drug use, such as HIV
    and hepatitis C by supporting and expanding access to syringe services
    programs (SSPs). The CDC has documented over 30 years of studies that
    show that SSPs reduce overdose deaths and infectious diseases
    transmission rates as well as increase the number of individuals
    entering substance use disorder treatment. These studies also confirm
    that SSPs do not increase illicit drug use or crime and save money.
        SSPs are among the only health care services trusted and used by
    people who use drugs and so can effectively engage this highly
    stigmatized population. SSPs help protect the community (including
    first responders) by ensuring safe disposal of syringes, reducing rates
    of infectious diseases, and can help providing a pathway to effective
    mental health and alcohol and other drug treatment and to other medical
    care.
        SSPs are the most effective way to get naloxone--a drug which
    reverses an opioid overdose--into the hands of people who use drugs,
    who are most likely to be at the scene of an overdose. People who use
    drugs are an essential partner in preventing overdose fatalities and
    are best reached by SSPs. With additional resources, SSPs can reach
    more people with naloxone, which would help reduce the dramatically
    increasing number of overdose deaths.
        Unfortunately, the nation has insufficient access to SSPs and the
    COVID-19 pandemic has decreased access to these life-saving services
    during a time when the need for services has increased dramatically. In
    January 2021, Drug Policy Alliance conducted a survey of SSPs that
    showed that 91% of respondents experienced an increase in clients in
    2020, many as a result of the COVID-19 pandemic. During this time of
    skyrocketing need, 42% of respondents experienced funding cuts in 2020
    and expect such shortfalls to continue in 2021. As a response to
    funding shortfalls, many SSPs have been forced to lay off staff and
    reduce services. In King County service availability has been limited
    so individuals experienced limited access to life saving interventions
    like needle exchange and naloxone. Consequently, because of these
    decreased and limited resources, SSPs cannot reach the millions of
    people who may benefit from their life-saving services.
        Federal funding would expand access to these critical and effective
    programs. Tacoma, WA's NASEN's statistics show that there are only
    approximately 400 SSPs operating nationwide. Experts estimate that to
    sufficiently expand access to SSP programs, the U.S. would require at
    least 2,000 programs--5 times the number in existence now.
        A recent study that assessed the startup costs of an individual
    program estimated that it would cost (in 2020 dollars) $490,000 for a
    small rural program and $2.1 million for a large urban program,
    resulting in an average start-up cost of $1.3 million per program.
    Based on these numbers the requested funding would provide an 10%
    increase to currently operating SSPs to help address funding shortfalls
    and also expand the number of SSPs nationwide.
        Finally, expanding access to SSPs will reduce health care costs,
    including for infectious diseases treatment. Hepatitis C treatment can
    cost more than $30,000 per person, while HIV treatment can cost upwards
    of $560,000 per person. Averting even a small number of cases would
    save millions of dollars in treatment costs in a single year.
        The Infectious Diseases and Opioid Epidemic Program at CDC helps to
    eliminate infections related to injection drug-use and improve their
    prevention, surveillance, and treatment. It also strengthens and
    expands access to syringe services programs. In FY2019, CDC began
    several projects to expand capacity of SSPs nationwide through
    technical assistance to ensure high-quality, comprehensive services and
    best practices. With additional FY22 funding, CDC could significantly
    expand SSPs at this critical time to help prevent overdose deaths, the
    spread of HIV and viral hepatitis and connect people to life-saving
    medical care.
        On a personal note--in addition to leading the overdose prevention
    work for King County, I am the brother of overdose victim. Every single
    person who counts as a fatal overdose is a family member to someone and
    an individual that could have been saved. We have the tools; we just
    need the funding to help implement.
        I want to thank the Subcommittee for its past funding of the CDC
    Infectious Diseases and Opioid Epidemic program and urge Congress to
    provide $120 million for the program in FY22. Thank you also for your
    time and consideration of my testimony, and please do not hesitate to
    contact me at brad.finegood@kingcounty.gov if you have questions or
    need additional information.
        Sincerely.

        [This statement was submitted by Brad Finegood, MA, LMHC, Strategic
    Adviser, Public Health-Seattle & King Co., King County, WA.]
                                     ______

          Prepared Statement of the Pulmonary Hypertension Association
          pha's fiscal year 2022 l-hhs appropriations recommendations
    _______________________________________________________________________

      --At least $46.1 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); the National Institute of
                Child Health and Human Development (NICHD), and the
                National Center for Advancing Translational Sciences
                (NCATS).
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt and distinguished members
    of the Subcommittee, thank you for your time and your consideration of
    the priorities of the pulmonary hypertension (PH) community as you work
    to craft the FY2022 L-HHS Appropriations bill.
                          about pulmonary hypertension
        Pulmonary hypertension (PH) is high blood pressure that occurs in
    the arteries of the lungs. It reflects the pressure the heart must
    apply to pump blood from the heart through the arteries of the lungs.
    As with a tangled hose, pressure builds up and backs up forcing the
    heart to work harder and less oxygen to reach the body. PH symptoms
    generally include fatigue, dizziness and shortness of breath with the
    severity of the disease correlating with its progression. If left
    undiagnosed or untreated it can lead to heart failure and death. In
    recent years, innovative treatment options have been developed and
    approved for PH. The effectiveness of current treatment options depends
    on accurate diagnosis and early intervention.
                                   about pha
        Headquartered in Silver Spring, Md., the Pulmonary Hypertension
    Association (PHA) is the country's leading PH organization. PHA's
    mission is to extend and improve the lives of those affected by PH. PHA
    achieves this by connecting and working together with the entire PH
    community of patients, families, health care professionals and
    researchers. The organization supports more than 200 patient support
    groups; a robust national continuing medical education program; a PH
    clinical program accreditation initiative; and a national observational
    patient registry.
                  health resources and services administration
        Due to the serious and life-threatening nature of PH, it is common
    for patients to face drastic health interventions, including heart-lung
    transplantation. To ensure HRSA can continue to make improvements in
    donor lists and donor-matching please provide HRSA with an increase in
    discretionary budget authority in FY2022.
                         national institutes of health
        Please provide NIH with meaningful increases--including at least
    $46.1 billion in program funding in FY2022--to facilitate expansion of
    the PH research portfolio and continued improvement in diagnosis and
    treatment. NHLBI and PHA have partnered on a groundbreaking clinical
    study, the Redefining Pulmonary Hypertension through Pulmonary Vascular
    Disease Phenomics (PVDOMICS) program (RFA-HL-14-027 and RFA-HL-14-030).
    By collecting information from nearly 1,200 participants with various
    types of PH, subjects at risk for PH, and healthy controls, PVDOMICS
    hopes to find new similarities and differences between the current WHO
    classifications of PH. This research is intended to lead to
    identification of both endophenotypes of lung vascular disease and
    biomarkers of disease that may be useful for early diagnosis or for
    assessment of interventions to prevent or treat PH.
        Data from the original cohort is currently being prepared for
    publication and the rich resources of PVDOMICS have spurred many
    presentations at national and international meetings. With its novel
    approach to enrollment and data analysis, PVDOMICS is poised to change
    our thinking about pulmonary hypertension and its classification in the
    upcoming years.
                       proper health coverage and access
        The PH community is concerned that the Centers for Medicare and
    Medicaid Services (CMS) is allowing insurance payers to refuse to
    accept charitable copay and premium assistance on behalf of patients
    with complex, chronic and life-threatening conditions like PH. Because
    of breakthroughs in research, PH patients are able to utilize life-
    sustaining treatments that allow them to manage this potential fatal
    condition and lead relatively normal lives. When patients are denied
    access to financial assistance they are forced to choose between
    necessities: between dramatically shortening their lives by giving up
    medication in order to afford housing and food or continuing medication
    while starting their families on the road to bankruptcy. We aware of
    the Subcommittee's continued requests for an explanation of this
    practice targeting rare disease patients. We ask that this Subcommittee
    once again ask CMS to explain this decisions and encourage them to fix
    this problem that is greatly affecting the rare disease community.
        PHA also asks the Subcommittee to urge CMS to increase incentives
    for the supply of oxygen that affects all oxygen modalities including
    both liquid and portable supplies. This increased flexibility will
    increase patient's quality of life at home and in their communities.
                              patient perspectives
        Chandani's three-year-old son was diagnosed with severe PH in July
    2020 at the age of two. Chandani is a physician herself and so she
    understands all too well the seriousness of her son's prognosis. Since
    his diagnosis last year, her son's medical care team has tried
    progressively increasing therapies in a stepwise fashion, which is
    often required by insurance companies but is known to lead to worse
    outcomes than when patients are allowed to immediately begin the
    treatment prescribed by their doctor.
        Currently, Chandani's toddler is receiving three oral drugs in
    addition to a subcutaneous infusion, all for PH. As of the end of
    April, he has not been responsive to these therapies which
    unfortunately indicates a poor prognosis. Currently, without a
    transplant, her son has a 60% chance of survival over the next five
    years, and if he were to receive a double-lung transplant, it would
    statistically add 2.7 years to his life. Studies show that self-
    reported quality of life for patients with pulmonary hypertension ranks
    worse than cancer patients. Research and treatment are vitally needed
    for this disease that has such a fatal prognosis and a poor quality of
    life.
        Denise has a health insurance plan with a $3,000 deductible. She
    uses a manufacturer copay card to pay for the first of her life-
    sustaining pulmonary hypertension (PH) medications. However, Denise's
    health insurance plan will not apply the copay card to her deductible,
    so when Denise fills the prescription for her second medication, she is
    responsible for her entire deductible out-of-pocket. When Denise was
    renewing her health insurance coverage for the year, this information
    was hidden from her. She was told about other changes to the plan, but
    the shift to a copay accumulator was never mentioned, nor could Denise
    find the relevant information online.
        Barbara has lived with PH for 21 years and with the treatment of
    liquid oxygen, she has managed to develop a comparatively active life
    filled with volunteer work and visits with her children and
    grandchildren. However, that changed in April 2021 when Barb's
    Medicare-contracted oxygen supplier stopped delivering liquid oxygen
    without notice. Instead, they began providing compressed oxygen gas
    tanks.
        Liquid oxygen tanks are light enough to be carried hands-free
    strapped to the back and hold a sufficient volume of oxygen to provide
    a continuous stream for 6-8 hours at a time so that Barb is able to
    breathe easily while still walking around. By contrast, compressed
    oxygen tanks are heavier and hold a smaller volume of oxygen, so they
    sustain her for only a fraction of the time that liquid oxygen tanks
    do. To carry a compressed oxygen tank with her, she must wheel it
    behind her or struggle with the weight and bulk of the tank if
    attempting to carry them on her back and change them out every couple
    of hours.
        These new limitations to her lifestyle due to the loss of
    appropriate treatment for her PH have caused a steep decline in her
    mood and quality of life and she has quickly become depressed; at a
    recent visit with her physician, she was told ``I've never seen you
    this bad.'' The mobility and ease that using a liquid oxygen tank
    provides Barb is the difference between struggling to complete one
    errand in a day, versus running multiple errands, feeling capable of
    going out to have lunch with friends, or being able to comfortably
    visit her seven grandchildren.
        In the past weeks, Barb has spent precious energy calling 30
    suppliers within a 100-mile radius of her home searching unsuccessfully
    for anyone else to provide her with the correct treatment for her PH
    condition. In her efforts to find out more about the loss of access to
    liquid oxygen, Barb has heard from many other PH patients from across
    the country who are experiencing the same situation. This restriction
    of access to liquid oxygen represents a collective loss in quality of
    life for the community of PH patients that could have long-lasting and
    far-reaching consequences for an already serious, degenerative disease.
        Thank you again for your consideration of the PH community's
    priorities as you develop the FY2022 L-HHS Appropriations bill.

        [This statement was submitted by Matt J. Granato, LL.M., MBA,
    President and CEO, Pulmonary Hypertension Association.]

                                     ______

                    Prepared Statement of Reamer Andrew deg.
                      Prepared Statement of Andrew Reamer
        I write to request that the report of the Senate Committee on
    Appropriations accompanying appropriations legislation for Labor,
    Health and Human Services, Education, and Related Agencies include
    language that directs the Bureau of Labor Statistics (BLS), U.S.
    Department of Labor, to provide memoranda to the Subcommittee, and to
    the Senate Committee on Health, Education, Labor, and Pensions,
    regarding the following topics:
      --Approaches to accurately measuring the extent and nature of
            telework and remote work in the United States, by geography and
            industry, with the implications for future appropriations.
      --Approaches to creating a new principal federal economic indicator
            on well-being, with implications for future appropriations.
      --Possible impacts of the Census Bureau's new Disclosure Avoidance
            System on BLS data derived from Census Bureau statistics and
            used to determine the allocation of federal financial
            assistance to states, local areas, and households.
        I provide information below in support of this request. I write as
    a research professor at the George Washington Institute of Public
    Policy, George Washington University, with a focus on the role of the
    federal government in facilitating national economic development and
    competitiveness.
        Measures of Telework and Remote Work. News reports make clear that
    the pandemic has catalyzed a substantial increase in the number of
    employees who telework from home in lieu of commuting to an office and
    those who work from a geographic location different than the office to
    which they report. For the purposes of public policy and business
    decision-making, BLS statistics should provide reliable estimates of
    telework and remote work by geography and industry.
        My research (available here) identifies 14 federal data collections
    that independently measure the extent and nature of remote work. Eight
    collected such data before the pandemic; six added telework questions
    in response to the pandemic. Six are household surveys, six are
    establishment surveys, and two prepare occupational profiles. Six are
    conducted by BLS, five by the Census Bureau, and one each by the
    Employment and Training Administration, the Federal Highway
    Administration, and the Office of Personnel Management.
        While BLS and other federal agencies are to be lauded for their
    proactive efforts, it would be desirable to rationalize the plethora of
    data collections so that BLS may point to a single data series as the
    most appropriate measure. The choice made will have implications for
    future appropriations. Consequently, I recommend that the Senate
    Appropriations Committee report accompanying Labor Department
    appropriations legislation include a directive that BLS provide the
    Subcommittee with its views on the preferred approach to measuring
    telework and remote work and resource requirements to implement it.
        Measures of Well-being. Numerous scholars, such as Carol Graham of
    the Brookings Institution and Angus Deaton and Anne Case of Princeton
    University, demonstrate through their research the significant increase
    in despair and deaths of despair, particularly among the white working
    class. As with telework, several federal agencies are independently
    seeking to measure the extent of and reasons for despair inside
    American households and, at present, there is no single reliable,
    consensus measure of well-being akin to Principal Federal Economic
    Indicators such as the unemployment rate and the poverty rate.
        For FY2021, Congress appropriated funds for BLS to conduct the
    Well-Being Module of the American Time Use Survey (ATUS). I recommend
    that Senate Appropriations Committee report language for FY2022
    appropriations direct BLS provide the Subcommittee with its views on
    approaches to creating a reliable, useful well-being indicator and the
    resources necessary to produce it.
        Impacts of Census Differential Privacy Protocols on BLS-guided
    Federal Financial Assistance. To ensure adherence to Title 13
    requirements for confidentiality, the Census Bureau is implementing a
    new Disclosure Avoidance System (DAS) based on differential privacy
    protocols that inserts distortions within certain agency datasets while
    maintaining system-wide statistical accuracy. BLS labor force and price
    statistics rely on Census Bureau data collections that may be affected
    by the new DAS; several federal departments use BLS state and local
    statistics, such as unemployment rate, to determine program eligibility
    and allocate by formula billions of dollars in federal financial
    assistance. At the moment, the effect of the new DAS on the geographic
    allocation of federal funding is not understood. Consequently, I
    encourage the Subcommittee to direct BLS to identify which of its
    datasets might be affected by the new Census DAS and, by extension,
    which federal funding programs might be affected as well, and how.
        Note: I gathered the information contained above through my
    sponsored research and as the research organization representative on
    the Workforce Information Advisory Council (WIAC) of the U.S. Secretary
    of Labor. I submit the above request as a private citizen and not as a
    representative of any organization or body.

        [This statement was submitted by Andrew Reamer, Research Professor,
    George Washington Institute of Public Policy, George Washington
    University.]
                                     ______

                     Prepared Statement of Research!America
        On behalf of the Research!America alliance, thank you for this
    opportunity to submit testimony to the Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies on Fiscal Year 2022 (FY22) appropriations. We are
    grateful that for FY21, the base budgets of the National Institutes of
    Health (NIH) and the Centers for Disease Control and Prevention (CDC)
    were increased and the base budget of the Agency for Healthcare
    Research and Quality (AHRQ) was maintained, and that the Subcommittee
    additionally provided dedicated funding for critical research programs.
    The need for faster medical and public health progress has never been
    more apparent. Our nation has an opportunity, and on behalf of every
    American, the obligation, to fight health threats faster, learn from
    this pandemic to bolster public health capacity and preparedness, and
    leverage evidence as never before to optimize health care delivery. In
    that context, we ask that you provide an increase in the base budget
    (exclusive of new initiatives) for NIH of at least $4.29 billion, for a
    total of $47.22 billion; an increase of at least $2.18 billion for CDC,
    for a total of $10 billion; and an increase of at least $162 million
    for AHRQ, for a total of $500 million, in FY22.
                       the national institutes of health
        We believe it is in the strategic interests of the U.S. to increase
    funding for NIH to at least $47.22 billion in FY22, an increase of 10%
    over FY21 funding. Our nation and the global community have witnessed
    the broadscale impact of a global pandemic, but the reality is that
    every American either experiences directly or is the loved one of an
    individual who dies prematurely of a health threat that we can
    overcome. NIH-conducted and funded research uncovers new knowledge that
    is the prerequisite to conquering these threats. No entity, in the U.S.
    or across the globe, has done more to propel academic and private
    sector progress that saves lives.
        NIH funds almost 50,000 competitive grants that are awarded to
    researchers at over 500 universities, medical schools, and educational
    institutions in every state. NIH also plays an integral role in
    educating and training America's future scientists and medical
    innovators by sponsoring fellowships and training grants.
        We believe our nation should seize the opportunity to change the
    course of history such that we can out-innovate emerging threats and
    all live longer, healthier lives. Please allocate at least $47.22
    billion in FY22 for the base budget of NIH, an increase of 10% over
    FY21 funding.
                 the centers for disease control and prevention
        We urge you to fund the Centers for Disease Control and Prevention
    (CDC) at a level of $10 billion in FY22, a 27% increase over FY21
    enacted. As demonstrated by the ongoing COVID-19 pandemic, public
    health threats do not respect international borders, and in our
    increasingly globalized world, we are more vulnerable than ever to
    emerging, deadly infectious diseases.
        CDC is tasked with protecting and advancing the nation's health,
    and over the past 70 years it has worked diligently to thwart deadly
    outbreaks and debilitating disease. Moreover, CDC plays a key role in
    research that leads to life-saving vaccines, bolsters our nation's
    defense against and response to bioterrorism, and improves health
    tracking and data analytics.
        CDC has been an integral part of the effort to mitigate and defeat
    COVID-19. Their 24/7 response and the guidance that has emerged from
    their efforts has empowered our nation to weather this pandemic, but
    their role as the key first responder when major threats emerge is just
    part of their contribution to Americans' health, safety, and wellbeing.
        CDC is at the forefront of prevention; is working hard and
    effectively to forestall antibiotic resistance; is the lead federal
    agency responsible for tracking and forestalling foodborne illness and
    other local and regional outbreaks; investigates cancer clusters; and
    protects, investigates, and advances the health of every one of us in
    myriad ways. Our nation has underfunded CDC at risk to every American:
    we need to empower this agency to advance the best interests of every
    American by protecting and advancing the health of all Americans.
        The ongoing COVID-19 pandemic, in addition to past outbreaks of
    Ebola, Zika, influenza, and measles, have shown just how critical CDC
    is to the health of our nation and have also revealed the enormity of
    the challenge the agency faces as it works to safeguard American lives.
    To protect us, CDC scientists must be on the ground fighting public
    health threats wherever and whenever they occur. We cannot allow a gap
    between the funding provided to CDC and the demands and challenges
    placed before the agency. We request that CDC receive at least $10
    billion in FY22, $2.18 billion over FY21 funding, to ensure the agency
    can carry out its crucially important responsibilities.
                   agency for healthcare research and quality
        We urge you to fund AHRQ at a level of $500 million, a 47.9%
    increase over FY21 funding, in FY22. AHRQ has been grossly underfunded
    for decades relative to its mission and the lives and dollars this
    agency could save if appropriately equipped. AHRQ is the lead federal
    agency tasked with making sure our nation is not simply making medical
    progress, but that this progress translates into more effective,
    efficient, and affordable health care for Americans across the country.
    As it stands, our nation overspends by an estimated $1 trillion each
    year and abides deadly medical errors that cost at least 100,000 lives
    each year because we don't deploy strategies to address inefficiencies
    and errors in health care. Now is the time to empower AHRQ to address
    this massive, counterproductive challenge.
        AHRQ-funded research identifies and highlights how to stop waste of
    limited health care dollars, empowering patients to receive the right
    care at the right time in the right settings. For example, AHRQ-funded
    research informed the creation of an Antibiotic Stewardship Program
    (ASP) in 402 hospitals across the U.S. to address the overprescription
    of antibiotics, which can ultimately lead to them being ineffective.
    This research program successfully reduced the length of time patients
    needed to be on antibiotic therapy by an average of 30 days. The
    research also identified key improvements for future ASPs.
        The value of medical discovery and development hinge on smart
    health care delivery. If we underinvest in AHRQ, we are inviting
    unnecessary health care spending and wasting the opportunity to ensure
    patients receive the quality care they need.
        We appreciate your consideration of our funding requests and thank
    you, and your respective staff members, for your stewardship over these
    critically important federal spending priorities.
        Sincerely.

        [This statement was submitted by Ellie Dehoney, Vice President of
    Policy and
    Advocacy, Research!America.]
                                     ______

          Prepared Statement of the Restless Legs Syndrome Foundation
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Subcommittee, as you work to develop the fiscal year (FY) 2022
    Labor-Health and Human Services Appropriations bill, thank you for
    considering the views of the community of physicians, researchers,
    patients, and caregivers affected by Restless Legs Syndrome (RLS).
    Please keep the needs of this community in mind, especially as you
    continue to work to address the opioid crisis.
                            about the rls foundation
        The Restless Legs Syndrome Foundation is a nonprofit Sec. 501(c)(3)
    organization dedicated to improving the lives of men, women, and
    children living with this often--devastating neurological condition.
    The Foundation works to increase awareness, improve treatments, and
    support research to find a cure. From a few volunteers meeting in a
    member's home in 1992, the Foundation has grown steadily; it now has
    members in every state, local support groups, and a track record that
    includes nearly $2 million provided to support translational research.
                                   about rls
        Restless legs syndrome (RLS) is essentially an irregular biological
    drive, like hunger or thirst, that forces affected individuals to keep
    moving, thus reducing their ability to rest. Patients with this disease
    experience a deep, viscerally-irritating sensation in the legs that
    continues to increase until they are literally forced to move their
    legs or get up and walk; and this sensation only abates so long as the
    individual keeps moving. RLS is best characterized as a neurological,
    sensory-motor disorder with symptoms that are triggered from within the
    brain itself. It is estimated that up to 5 to 7 percent of the U.S.
    population may have RLS, of which half will have moderate to severe
    stages of the disease. RLS impacts men, women, and children, though it
    is 3 to 4 times more common in women and twice as common in older
    Americans.
        Due to the inability to sleep and work, RLS can cause disability,
    depression, and suicidal ideation, as well as increased risk for co-
    morbid conditions such as heart attack, stroke, and Alzheimer's. There
    is no cure, and the current standards of care features several
    medications, which do not provide life-long coverage. One of the
    established effective treatment options for this disease is low--total
    daily dose opioid medications. These are commonly used when all other
    drug classes have failed. Research and clinical experience indicates
    that the dose of opioids typically used to manage RLS effectively
    without addiction or drug tolerance issues is significantly lower than
    dosages used to treat chronic pain.
                fiscal year 2022 appropriations recommendations
        The RLS Foundation joins the broader medical research community in
    thanking Congress for continuing to support the National Institutes of
    Health with sustainable growth. Please continue to advance scientific
    progress through proportional funding increases by providing at least a
    $3 billion funding increase for FY 2022 to bring NIH's budget up to
    $46.1 billion.
        In this regard, please provide proportional funding increases for
    all NIH Institutes and Centers, including, but not limited to the
    National Institute of Neurological Disorders and Stroke (NINDS), the
    National Heart, Lung, and Blood Institute (NHLBI), the National
    Institute on Drug Abuse (NIDA), and the National Institute of Mental
    Health (NIMH). Research on RLS and similar neurological movement
    disorders is directly related to efforts targeting the opioid epidemic,
    as many patients with these disorders utilize very low total daily
    doses of opioid therapies to manage their condition. Additionally,
    related sleep disorders research activities impact many conditions and
    are studied across various Institutes and Centers at NIH.
        Please provide $5 million for the National Neurological Conditions
    Surveillance System (NNCSS) for FY 2022. The NNCSS at the Centers for
    Chronic Disease Control and Prevention (CDC) collects and synthesizes
    data to help increase our understanding of neurological disorders and
    to support further neurologic research. RLS remains a severely
    misunderstood and underdiagnosed neurological disorder, and increased
    surveillance is vital to improving patient outcomes.
        Please provide at least $5,000,000 for the Chronic Diseases
    Education and Awareness Program at the Centers for Disease Control and
    Prevention (CDC). With the cessation of the National Healthy Sleep
    Awareness Project (NHSAP), CDC presently has no active public health
    activities dedicated to sleep or sleep disorders, despite the fact that
    sleep affects nearly every body system and many chronic diseases.
    Please allow the valuable scientific and public health efforts started
    during the NHSAP to continue.
                           rls and the opioid crisis
        While you consider the Committee's work to address the opioid
    epidemic through this fiscal year's appropriations bill, the RLS
    Foundation asks that you protect the needs of patient communities who
    depend on appropriate access to low total daily doses of opioid
    therapies to manage their debilitating condition. RLS is not a chronic
    pain condition, and many in our community utilize these medications to
    treat underlying neuropathology issues and not sensations of pain.
    Studies have shown that appropriate access to these therapies allows
    patients to live productive lives without an increased risk of
    developing opioid use disorder. As you consider various legislative
    proposals and work with federal agencies, please consider the needs of
    patients who rely on the regular use of low total daily doses of
    opioids to manage RLS by supporting a diagnosis-appropriate safe harbor
    for RLS patients, so they do not face arbitrary barriers.
        I would like to share with you the experience of Stephen Smith from
    Colorado, a RLS Foundation Discussion Board Moderator. Like all those
    with RLS, night can bring a feeling of dread. Is this going to be one
    of those nights when my RLS acts up and I don't get any sleep or will
    it just be one of those standard nights when my sleep is just poor?
        About a year ago, I had one of those nights when my RLS acted up
    and I knew that I wasn't going to get any sleep at all. So I called my
    doctor's night service and was instructed to go to the local hospital's
    Emergency Room and to tell them to call my doctor.
        Contrary to hospital policy, the ER doctor decided not to call and
    also didn't understand RLS or my insomnia complaints. But he jumped on
    my depressed feelings from insufficient sleep combined with my RLS
    pacing, which he assumed was agitation, and the opioid that I take for
    RLS. He then incorrectly concluded I had a drug problem and was
    suicidal in spite of being told that I was not. So he placed me under a
    72hr psychiatric hold and sent me to a psych hospital 3 hours away. I
    was shipped 180 miles confined to the back seat of a car with raging
    RLS. The psych hospital didn't carry one of my RLS meds, tramadol, and
    forced me to go into withdrawal rather than go to the effort to replace
    it. The abrupt withdrawal from tramadol led to hours of shakes and
    sweats followed by even more hours of RLS--like pacing for the second
    night in a row. Since tramadol also acts as an SNRI anti-depressant,
    the abrupt withdrawal caused me to develop SNRI Withdrawal Syndrome.
    This caused migraine headaches, severe anxiety and depression,
    nightmares and dreams centered on the horrible experience of being
    involuntarily confined to the psych hospital due to a neurological
    disorder. These symptoms went on for months and required drug treatment
    for anxiety and psychotherapy for the severe depression.
        So, now nightfall brings a feeling of trepidation. Is this going to
    be another night when my RLS acts up or I cannot fall asleep? If I do
    manage to sleep, will I once again dream of the nightmare of being
    confined to the psych hospital all due to failure of a number of
    doctors to understand RLS or to even listen to their patient who is
    trying to educate them?
        Thank you again for the opportunity to share the views of the RLS
    community.

        [This statement was submitted by Karla M. Dzienkowski, RN, BSN,
    Executive
    Director, Restless Legs Syndrome Foundation.]
                                     ______

                   Prepared Statement of Rotary International
        Chairwoman Murray, members of the Subcommittee:
        Rotary appreciates the opportunity to encourage continuation of
    funding for FY 2022 to support the polio eradication activities of the
    U.S. Centers for Disease Control and Prevention (CDC). The CDC is a
    spearheading partner of the Global Polio Eradication Initiative (GPEI),
    an unprecedented model of cooperation among national governments, civil
    society and UN agencies which reach the most vulnerable children
    through the safe, cost-effective polio immunization. Rotary
    International requests the Subcommittee provide $176 million for the
    polio eradication activities of the CDC to ensure recovery of polio
    eradication progress disrupted by the COVID-19 pandemic, stop polio
    transmission, protect polio free areas, and leverage the resources
    developed through this global effort for continued value-added impact.
    The 300,000 members of Rotary clubs in the US appreciate the United
    States' generous support and longstanding leadership. Rotary, including
    matching funds from the Gates Foundation, has contributed more than
    $2.2 billion and thousands of hours of volunteer service to protect
    children from polio; and will continue this work until the world is
    certified polio free. Continued US leadership will help achieve a polio
    free world and ensure the continued global health contribution of polio
    eradication infrastructure and resources.
               progress in the global program to eradicate polio
        Since the launch of the GPEI in 1988, eradication efforts have led
    to more than a 99.9% decrease in cases. Thanks to this committee's
    support, over 19 million people have been spared disability, and over
    900,000 polio-related deaths have been averted. In addition, more than
    1.5 million childhood deaths have been prevented, thanks to the
    systematic administration of Vitamin A during polio campaigns.
        In 2020, the WHO AFRO region was certified wild polio virus-free
    after four years without detecting any cases, making it the fifth of
    six WHO regions to eliminate the virus. This achievement follows the
    certification of the eradication of Type 3 (WPV3) in October 2019 and
    wild poliovirus type 2 (WPV2) in September 2015. The eradication of
    wild polio virus from regions and eradication of strains of the polio
    virus is further proof that a polio-free world is achievable.
        Only two countries, Afghanistan and Pakistan, have confirmed cases
    of wild polio since August of 2016. As of 3 June 2021, only 2 cases of
    wild polio virus have been confirmed--one each in Pakistan and
    Afghanistan. Significant reductions in detection of virus transmission
    in environmental samples in 2021 are also cause for cautious optimism.
    Both countries are working to capitalize on low levels of virus
    transmission by working to reach missed children, prioritizing
    communities which have had low coverage or which have been resistant to
    immunization; and ensuring thorough microplanning of immunization and
    other eradication activities. In Afghanistan, there are increased
    efforts to target children living in areas which have been
    inaccessible. This ongoing work is challenging within the context of
    the NATO withdrawal of troops and related insecurity.
        Outbreaks of circulating vaccine-derived poliovirus are ongoing in
    several countries across Africa and Asia and require continued focus
    and attention. These were further exacerbated by COVID-19 pandemic-
    related disruptions in immunization campaigns. These outbreaks are not
    a failure of the vaccine, but result from a failure to sustain
    sufficiently high levels of routine immunization which causes the live,
    but weakened form of the virus used in the vaccine to revert over time
    to a more virulent, wild-like form. The program has developed a
    specific Strategy for the Response to Type 2 Circulating Vaccine-
    Derived Poliovirus, including the use of a new, more genetically stable
    vaccine, the novel oral polio vaccine type 2 (nOPV2), for outbreak
    response.
        The COVID-19 pandemic has posed new challenges for global polio
    eradication activities. In order to protect communities and staff, the
    Global Polio Eradication Initiative paused immunization campaigns and
    other essential activities for several months in 2020. In countries
    that have successfully resumed activities, the programme has developed
    strategies for prevention and control of COVID-19 and is providing
    resources such as masks and hand sanitizer to keep frontline health
    workers protected while ensuring that campaign elements meet physical
    distancing requirements.
        As a result of the pause on activities, and also due to the
    potential exposure to COVID, the number of vulnerable children has
    increased the real threat for wider spread of the virus. UNICEF, WHO
    and Gavi estimate that at least 80 million children under the age of
    one are at risk due to the COVID-19 related disruption to vaccination
    activities. These challenges are further compounded by the
    extraordinary economic and financial constraints in both at-risk
    countries and from donors which may divert essential political and
    financial commitments.
        This combination of progress in the midst of ongoing challenges
    underscores the urgency of continued focus to protect the vulnerable
    gains made toward polio eradication as the COVID-19 pandemic continues
    to disrupt polio immunization and eradication activities; and to stop
    polio virus transmission in these most complex environments while
    sustaining high levels of population immunity in polio free areas.
    Continued support for global surveillance is also essential to monitor
    and detect cases and virus transmission and provide confidence in the
    absence of cases.
             cdc's vital role in global polio eradication progress
        The United States is the leader among donor nations in the drive to
    eradicate polio globally. Congressional support to CDC has supported
    the following essential polio eradication activities:
        Leadership on surveillance and disease detection. CDC's Atlanta
    laboratories serve as a global reference center and training facility,
    providing expertise in virology, diagnostics, and laboratory
    procedures, including quality assurance, and genomic sequencing of
    samples obtained worldwide, and training virologists from around the
    world in advanced poliovirus research and public health laboratory
    support. CDC also provides the largest volume of operational
    (poliovirus isolation) and technologically sophisticated (genetic
    sequencing of polio viruses) lab support to the 145 laboratories of the
    Global Polio Laboratory Network (GPLN). CDC also developed methods to
    directly detect poliovirus from patient stool specimens, allowing
    faster detection. Specific support was also provided to expand
    environmental surveillance to detect and respond to vaccine-derived
    poliovirus outbreaks in Democratic Republic of the Congo, Nigeria,
    Somalia, and Kenya.
        CDC provides critical technical capacity and program management
    expertise which directly contributes to polio eradication activities
    and is also used to build in-country capacity.
      --CDC supported the international assignment of technical staff on
            direct 2-year assignments to WHO and UNICEF to assist polio-
            endemic and polio-reinfected priority countries. Funding was
            also provided to WHO for surveillance, technical staff and
            immunization activities' operational costs, primarily in
            Africa.
      --CDC's Stop Transmission of Polio (STOP) members continue to play a
            key role in providing expertise on polio surveillance, data
            management, campaign planning, implementation and evaluation,
            program management, and communications in high-risk countries.
            In 2020, 210 public health professionals were deployed in 42
            countries with two-thirds deployed to the African Region,
            contributing substantially to the region's achievement of wild
            polio-free status in 2020. STOP program participants worked to
            improve broader vaccine-preventable disease (VPD) surveillance.
            In 2020 STOP participants also supported local governments to
            promote awareness of COVID-19 and provide contract tracing.
      --In Afghanistan, CDC led a comprehensive data review in 2020 that
            evaluated and streamlined data collection to increase
            efficiency of the evidence-based decision making in campaigns.
      --In Pakistan, CDC worked with the government to transform structural
            and managerial components of the polio program. CDC and NSTOP
            assumed a new role to improve evidence-based decision making
            through data usage and risk assessment in the core reservoir
            districts/towns. CDC also provided broad support to the COVID-
            19 response in Pakistan, including trainings, case
            identification, investigation and tracking, and lab sample
            collection.
      --CDC also provided expertise in technical advisory groups, EPI
            manager and other key global polio meetings.
      --CDC also provided instrumental support internationally and
            domestically in the areas of disease surveillance, health
            worker training, contact tracing, risk communications and
            testing through extensive assignment of Atlanta-based polio
            staff to the CDC COVID-19 response and through support provided
            to the COVID-19 pandemic response by polio staff in
            Afghanistan, Pakistan, and across Africa. CDC's commitment to
            polio eradication is firm and knowing that CDC's polio
            eradication program operates in some of the most vulnerable
            places in the world, the agency is determined to do its part in
            defeating the COVID-19 pandemic.
    CDC also works to build Country-level Capacity.
      --In collaboration with the Pakistan Ministry of Health, WHO and
            USAID's mission in Islamabad, CDC trained 88 national
            epidemiologists from CDC's Field Epidemiology Training Program
            (FETP) and deployed them to the highest risk districts for
            circulation of wild polio virus to help improve the quality of
            surveillance and immunization activities there and to
            strengthen routine immunization systems.
      --CDC also trained and supported 230 staff at the Local Governing
            Area level in the highest risk states through CDC's National
            STOP program for Nigeria, playing a key role in interrupting
            transmission of wild polio. CDC also contributed to UNICEF's
            expansion of a Community Based Vaccinator Program in Pakistan
            that includes over 24,000 workers who reach 4 million children
            annually with both oral and inactivated polio vaccine (IPV);
            and $3 million for operational costs for NIDs in all polio-
            endemic countries and outbreak countries. Most of these NIDs
            would not take place without the assurance of CDC's support.
        CDC provided key leadership in development and rollout of novel
    oral poliovirus vaccine (nOPV), a new tool for polio eradication
    through preclinical development, laboratory testing and support for
    nOPV clinical trials. The new vaccine has low neurovirulence, is
    genetically stable (low reversion rate), can be scaled to production
    levels, is highly immunogenic, and was safe and well tolerated in
    vaccine trials. Initial use of nOPV2 is taking place in countries that
    have secured national immunization and regulatory group approvals and
    have met strict criteria.
                        fiscal year 2022 budget request
        We respectfully $176 million in FY2022 for the polio eradication
    activities of CDC, the level appropriated by Congress in FY 2021. CDC's
    priorities are to stop virus transmission in the remaining polio
    endemic and outbreak countries. CDC will also work with governments and
    partners in countries experiencing cVDVP outbreaks to resume high
    quality vaccination campaigns and to boost routine immunization to
    close immunity gaps. This includes reaching an estimated 80 million
    children who are vulnerable due to COVID-19 pandemic related
    disruptions. CDC will also work to address pandemic-related
    surveillance gaps to safeguard global disease detection and response
    capacity. CDC will continue planning for a post-polio transition to
    advance broader global vaccine-preventable diseases (VPD) control and
    elimination/eradication targets as outlined in CDC's Global
    Immunization Strategic Framework 2021-2030.
                        the role of rotary international
        Rotary is a global network of leaders who connect in their
    communities and take action to solve pressing problems. Since 1985,
    polio eradication has been Rotary's flagship project, with members
    donating time and money to help immunize nearly 3 billion children in
    122 countries. Rotary's chief roles are fundraising, advocacy
    (including resource mobilization and political advocacy), raising
    awareness and mobilizing volunteers. There are nearly 300,000 members
    throughout the United States who have raised more than US$400 million
    of the more than US$2.2 billion Rotary has contributed to the Global
    Polio Eradication Initiative. This represents the largest contribution
    by an international service organization to a public health initiative
    ever. These funds have benefited 122 countries to buy vaccine and the
    equipment needed to keep it at the right temperature, and support the
    means to ensure it reaches every child. More importantly, tens of
    thousands of our volunteers have been mobilized to work together with
    their national ministries of health, UNICEF and WHO, and with health
    providers at the grassroots level in thousands of communities.
        Rotary also plays a key role in encouraging country level
    accountability. Rotary has National PolioPlus Committees, in the
    endemic countries and over 20 outbreak/at-risk countries. These
    national committees work to keep the spotlight on polio eradication
    amidst competing priority from the community level to the federal
    level.
                         benefits of polio eradication
        Since 1988, tens of thousands of public health workers have been
    trained to manage massive immunization programs and investigate cases
    of acute flaccid paralysis. Cold chain, transport and communications
    systems for immunization have been strengthened. The global network of
    146 laboratories and trained personnel established by the GPEI also
    tracks measles, rubella, yellow fever, meningitis, and other deadly
    infectious diseases including COVID-19 and will do so long after polio
    is eradicated. $27 billion in health cost savings has resulted from
    eradication efforts since 1988. A sustained polio free world will
    generate $14 billion in expected cumulative cost savings by 2050, when
    compared with the cost countries will incur for controlling the virus
    indefinitely. Polio eradication is a cost-effective public health
    investment with permanent benefits. As many as 200,000 children could
    be paralyzed annually in the next decade if the world fails to
    capitalize on the more than $18 billion already invested in
    eradication. Success will ensure that the investment made by the US,
    Rotary International, and many other countries and entities, is
    protected in perpetuity.

        [This statement was submitted by Anne L. Matthews, Chair, Rotary's
    Polio
    Eradication Advocacy Task Force.]
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
        Chairwoman Murray, Ranking Member Blunt, and members of the
    Subcommittee, my name is Dr. Rachel Bender Ignacio and I serve as an
    HIV primary care physician at the Madison Clinic and Director of the
    AIDS Clinical Trials Unit at Harborview Medical Center in Seattle,
    Washington. I am pleased to submit testimony on behalf of the Ryan
    White Medical Providers Coalition (RWMPC) of the HIV Medicine
    Association (HIVMA). I currently serve on the Board of Directors of
    HIVMA. RWMPC is a national coalition of medical providers and
    administrators who work in healthcare agencies supported by the Ryan
    White HIV/AIDS Program funded by the HIV/AIDS Bureau (HAB) at the
    Health Resources and Services Administration (HRSA).
        First, I would like to thank the Subcommittee for increasing FY21
    funding for both the Ryan White Program and the Bureau of Primary
    Health Care at HRSA by funding the bipartisan Ending the HIV Epidemic
    (ETE) initiative. Supporting the ETE initiative will help target
    jurisdictions scale up their ability to end the HIV epidemic by
    increasing access to HIV testing, prevention, care, and treatment
    services critical to reducing HIV transmission. However, expanding the
    Ryan White Program even further now would help jurisdictions nationwide
    address ending the HIV epidemic. To achieve this expansion, I request
    $225.1 million (a 10% or $24 million increase) in FY22 for Ryan White
    Part C, which supports approximately 350 HIV medical clinics
    nationwide.
        RWMPC also requests additional resources for the ETE initiative to
    expand access to HIV prevention, care, and treatment, including $364
    million for HRSA's ETE program. This funding would include $212 million
    for the Ryan White Program to provide additional HIV care and
    treatment, as well as $152 million for the Bureau of Primary Health
    Care to support HIV prevention services, including providing Pre-
    Exposure Prophylaxis (PrEP), medication to prevent HIV. These funding
    levels also were requested by the President's FY22 budget request.
        It is especially important now that increases for Ryan White Part C
    or for the ETE initiative be new, additional funding and not a
    repurposing of current resources. The additional pressure that the
    COVID-19 pandemic has placed on public health infrastructure and
    medical facilities, including Ryan White clinics, is significant and
    limited resources cannot be further stretched.
        In fact, COVID-19 has demonstrated why our nation needs to
    strengthen the public heath infrastructure and medical clinics serving
    people living with HIV. Ryan White clinics have been critical to
    providing an effective COVID-19 response and many Ryan White medical
    providers have been pulled in as leaders of the pandemic response in
    their jurisdictions. This has worked well as these providers are
    infectious diseases experts who have significant experience caring for
    vulnerable populations.
        The flexibility of the Ryan White Program and the knowledge and
    innovation of its medical providers also has allowed Part C clinics to
    respond to the changing needs of patients and the health care system
    throughout the transitions and challenges of the COVID-19 pandemic.
    Part C clinics have helped people with HIV by sustaining access to
    health care and medication through telehealth and key services, such as
    case management and transportation; by enrolling new patients who lost
    their health insurance as a result of the economic downturn; and by
    providing PPE, food, and housing security during this emergency.
    Madison Clinic at Harborview Medical Center in Washington Has Expanded
            Access to HIV Prevention, Care, & Treatment
        Since 1986, the Madison Clinic has served as the leading source of
    HIV primary care in the Pacific Northwest when its HIV care program was
    expanded with the assistance of Ryan White Program funding. Since then,
    the clinic has grown dramatically and now serves 2,800 individuals
    living with HIV, most with complex medical and psychosocial needs.
    Approximately 30% of our population is Black or African American
    (Seattle overall has 7% Black representation), 15% is Latinx, and 10%
    is Asian, Pacific Islander, or Native American. 47% of patients live at
    or below the federal poverty level. Like other HIV clinics across the
    US, ours serves an increasingly aging population, with 60% of patients
    over the age of 45. As a result, the burden of co-morbid illnesses,
    such as cancer, cardiovascular disease, and metabolic complications
    such as diabetes is extremely high. Alarmingly, 12% of patients lack
    permanent housing, and many patients were negatively impacted by the
    intersection of housing instability; the opioid epidemic and HIV
    epidemics; and the COVID-19 pandemic. Madison Clinic, like most Ryan
    White Part C clinics, also receives support from other parts of the
    Ryan White Program that help us provide medications, additional medical
    care, and support services, such as case management and transportation,
    all key to the comprehensive Ryan White care model that produces
    outstanding outcomes.
        Madison Clinic also provides Pre-Exposure Prophylaxis (PrEP)
    services across the clinic. This critical HIV prevention tool is
    integrated at Madison Clinic as part of prevention and primary care
    services. However, more support for the PrEP program, including for
    PrEP navigators and lab tests, is needed to scale up these services to
    meet patient needs.
        Many Harborview patients struggle with HIV, substance use disorder
    (SUD), and related infectious diseases, such as hepatitis C. In
    response, in partnership with the Public Health Department for Seattle-
    King County, the Max Clinic was established to care for people living
    with HIV who have not yet achieved viral suppression and who experience
    multiple barriers to care. The Max Clinic serves approximately 200
    patients, and receives support from Part B of the Ryan White Program as
    well as funding from the local Health Department.
    Ryan White Part C Clinics are Effective Medical Homes and Public Health
            Programs
        Ryan White Part C directly funds approximately 350 community health
    centers and clinics that provide comprehensive HIV medical care
    nationwide, serving more than 300,000 patients each year. These clinics
    are the primary method for delivering HIV care to rural jurisdictions--
    approximately half of all Part C providers serve rural communities. The
    program's comprehensive services engage and keep people in HIV care and
    treatment. This is critical, because HIV disease is infectious, so
    identifying, engaging, and retaining individuals living with HIV in
    effective care and treatment saves lives and benefits public health by
    stopping HIV transmission when individuals are virally suppressed.
        In 2019, more than 88% of Ryan White patients were virally
    suppressed--an almost 27% increase in the program-wide viral
    suppression rate since 2010. In 2020, 94% of Madison Clinic patients
    have been virally suppressed in spite of the complex challenges the
    COVID-19 pandemic has presented. The Ryan White Part C program's
    comprehensive services engage and keep people in HIV care and
    treatment. For example, 98% of HIV patients are on antiretroviral
    therapy at Madison Clinic. Early, reliable access to HIV care and
    treatment helps patients with HIV live healthy and productive lives and
    is more cost effective.
    Part C Clinics Are on the Frontlines of the Opioid Epidemic and Provide
            SUD Treatment
        Ryan White clinics serve a significant number of individuals living
    with both substance use disorder (SUD) and HIV. The majority of Madison
    Clinic providers have the credentials to prescribe buprenorphine
    therapy (medication assisted treatment for Substance Use Disorder), and
    our providers treat viral hepatitis, supported by a multidisciplinary
    team in our clinic. Part C clinics are able to deliver a range of
    medical and support services, including overdose prevention and harm
    reduction services, needed to prevent, intervene, and treat substance
    use disorder as well as related infectious diseases, including HIV,
    hepatitis C, and sexually-transmitted infections. The experience and
    expertise of Ryan White Part C medical providers should be leveraged to
    effectively respond to the opioid epidemic and overdose crisis and to
    help rapidly expand access to urgently needed SUD services.
    Funding for Prevention and Harm Reduction at CDC and Research at NIH is
            Critical
        While my testimony has focused on HRSA programs, the ability to
    effectively respond to the syndemics of HIV, substance use disorder,
    and related infectious diseases such as hepatitis C; sexually
    transmitted infections; and skin, soft tissue, and endovascular
    infections depends on CDC funding to enhance surveillance and
    prevention activities, and on NIH to continue to improve the tools to
    prevent and treat HIV and SUD and to learn how to effectively implement
    them. The AIDS Clinical Trials Unit, a member of the AIDS Clinical
    Trials Group funded by the NIH, is co-located within Madison Clinic and
    provides direct access for our patients to participate in research that
    pushes the envelope on HIV and viral hepatitis treatment, including a
    focus on HIV remission/cure strategies.
        We request $371 million for CDC to provide surveillance, response,
    and other HIV prevention services as part of the ETE initiative, as
    well as $120 million for CDC to address the infectious diseases
    consequences of the opioid epidemic, including by supporting and
    expanding access to syringe services programs, harm reduction, and
    overdose prevention. Finally, we support continued robust funding for
    NIH, including for HIV research. This funding supports discoveries that
    will help to end the HIV, hepatitis C, and opioid epidemics and that
    have informed the treatment and prevention of COVID-19.
        Thank you for your time and consideration of these requests, and
    please don't hesitate to contact me or Jenny Collier, Convener of the
    Ryan White Medical Providers Coalition, at
    jcollier@colliercollective.org if you have any questions or need
    additional information.

        [This statement was submitted by Rachel Bender Ignacio, MD, MPH,
    HIV
    Physician and Clinical Researcher at the Madison HIV Clinic.]
                                     ______

                     Prepared Statement of Safer Foundation
        Thank you, Chairwoman Murray, Ranking Member Blunt, and members of
    the Subcommittee, for inviting me to submit testimony on behalf of the
    Safer Foundation. My name is Kevin Brown and I serve as the Director of
    Policy, Advocacy, and Legislative Affairs for the Safer Foundation. For
    almost 50 years, Safer has provided comprehensive workforce development
    and reentry services for individuals with criminal legal histories
    seeking employment. There is dignity in work, and Safer Foundation
    believes that individuals who have made mistakes should have the
    opportunity to be self-sufficient and contribute to their families and
    communities through gainful, living wage employment. Clients come to
    Safer Foundation because they want and need to work, and Safer helps
    clients discover career path employment that is personally fulfilling
    and that pays a living wage.
        A critical federal program that supports these efforts is the
    Reentry Employment Opportunities (REO) program (also known as the
    Reintegration of Ex-Offenders (RExO) program) within the Department of
    Labor's Employment & Training Administration. I thank the Subcommittee
    for providing REO with $100 million in FY21. Given the need to train
    people for the jobs our economy requires in industries such as health
    care, technology, and logistics; to help employers identify the
    qualified workers they need now; and to help people with criminal legal
    histories find living wage employment to support successful, long-term
    reentry, I urge the Subcommittee to provide $150 million for the REO
    program in FY22.
           employment reduces recidivism and improve reentry outcomes
        1 in 3 adults in the United States has a criminal record that
    interferes with their ability to find a job.\1\ The COVID-19 pandemic
    has underscored existing barriers to employment for people with
    criminal legal histories. Research shows that sustained, living wage
    employment and life skills are critical components to long-term reentry
    success. One study found that individuals who were employed and earning
    higher wages after release were less likely to return to prison within
    the first year.\2\ The REO program improves reentry success by working
    with individuals to overcome employment barriers with training for jobs
    in local high-demand industries through career pathways and industry-
    recognized credentials and by providing needed reentry supports.
    Increasing REO funding would expand access to these comprehensive
    workforce development and reentry services that are especially needed
    now.
    ---------------------------------------------------------------------------
        \1\ ``Research Supports Fair-Chance Policies'' (March 2016),
    National Employment Law Project, footnote 1 on p. 7. Available at
    http://www.nelp.org/publication/researchsupports-fair-chance-policies.
        \2\ Visher, C., Debus, S., & Yahner, J. Employment After Prison: A
    Longitudinal Study of Releasees in Three States. Washington, DC: Urban
    Institute (2008).
    ---------------------------------------------------------------------------
        Authorized by section 169 of Workforce Innovation and Opportunity
    Act (WIOA), the REO program provides workforce preparation and reentry
    services for both adults and young people. REO includes a set-aside to
    provide services to prepare youth who are justice-system involved and/
    or who have not completed school or other educational programs for
    employment. Research has found that incarceration reduces a formerly
    incarcerated person's earning potential by more than 52 percent,\3\
    making workforce development services essential for long-term
    employment and reentry success. In light of the costs of the criminal
    legal system at the state, local, and federal levels, the REO program
    is crucial to incubating community-based models of successful reentry
    through employment.
    ---------------------------------------------------------------------------
        \3\ Craigie Terry-Ann; Grawert, Ames; Kimble, Cameron, Stiglitz,
    Joseph (2020); Conviction, Imprisonment, and Lost Earnings: How
    Involvement with the Criminal Justice System Deepens Inequality:
    https://www.brennancenter.org/our-work/research-reports/conviction-
    imprisonment-and-lost-earnings-how-involvement-criminal.
    ---------------------------------------------------------------------------
        COVID-19 has impacted employment opportunities for people with
    criminal legal histories. During the last economic downturn in 2008,
    the unemployment rate for people with criminal legal histories was
    27%--2 points higher than the unemployment rate during the Great
    Depression. Increasing support for the REO program is an effective way
    to ensure that individuals with criminal legal histories, who are
    disproportionately Black people and people of color, are not left out
    of the nation's economic recovery.
    safer's reo-supported services increase employment by working with both
                            employers and employees
        Safer Foundation offers comprehensive workforce development and
    reentry services that train individuals, address their reentry
    obstacles and needs, and help them obtain sustained employment. This
    holistic approach has rendered outstanding results for participants and
    employers. In 2006, decades of experience and success led Safer to
    become one of the original REO grantees.
        In addition to working with reentering individuals and their
    communities, Safer also works closely with employers to identify what
    types of trained employees are needed. In November 2020, the National
    Federation of Independent Business (NFIB) reported that 53% of
    businesses overall (and 89% of those hiring or trying to hire) reported
    few or no qualified applicants for available positions. While the
    demand for qualified workers exists, many newly unemployed individuals
    may not meet the qualifications for particular industries. Safer can be
    responsive to employer needs by tailoring its programs to develop
    skilled, qualified workers for specific employment sectors and has
    partnered with hundreds of employers to do so.
        Safer's Training to Work (T2W) program, that was funded in part
    with a REO grant, improved long-term employment prospects for clients
    at Safer's Adult Transition Centers (ATC). Participants received case
    management, education, and training that led to industry-recognized
    credentials for in-demand employment, such as forklift operation,
    welding, computer numerical control (CNC) operation, and licensed
    commercial driving (CDL) occupations, and Microsoft technologies
    training. Given the program's strong employer and credentialing
    components, REO is uniquely positioned to assist local organizations in
    developing and providing services that meet the needs of both the local
    business community and reentering individuals. Increasing REO funding
    in FY22 to $150 million, including funding for earn and learn
    apprenticeship opportunities for in demand skills development, would
    expand these efforts and help provide employers with more qualified
    employees who are trained, talented, motivated to work.
    safer's reo grant produced outstanding employment outcomes and reduced
                                   recidivism
        Safer's REO grant for the Training to Work (T2W) program
    significantly outperformed employment targets and dramatically reduced
    recidivism. For the first cohort of REO T2W participants, 69% of
    participants obtained employment--15% higher than the grant's
    employment target. Given the success of this first cohort of
    participants, T2W was expanded to include a second cohort who did even
    better with an employment rate of 78%--30% higher than the grant's
    target. Safer's REO T2W grant also reduced recidivism rates beyond
    original targets. T2W's first participant cohort had an 11% recidivism
    rate, and its second participant cohort had a 9% recidivism rate--75%
    and 80% lower respectively than the national recidivism rate of 44%.\4\
    ---------------------------------------------------------------------------
        \4\ Durose, Matthew R., Alexia D. Cooper, and Howard N. Snyder,
    Recidivism of Prisoners Released in 30 States in 2005: Patterns from
    2005 to 2010 (pdf, 31 pages), Bureau of Justice Statistics Special
    Report, April 2014, NCJ 244205.
    ---------------------------------------------------------------------------
        Program evaluation has shown that such success is related to the
    comprehensive service model that grantees such as Safer provide.
    Effective, comprehensive services can include interventions such as
    relationship building between staff and participants, employment
    verification, trauma-informed training, life skills training,
    employment preparation, mentoring, intensive case management, strong
    training provider relationships and support, family involvement, and
    post-release follow-up and support. These comprehensive services are
    cost-effective--a 2016 Illinois study found that for every $1 invested
    in community-based employment and training programs, tax payers saw a
    net benefit of $20.26, and found that employment and training programs
    had the highest cost-benefit ratio for reducing recidivism.\5\ By
    increasing and improving employment outcomes, the REO program invests
    in formerly incarcerated people and their families, provides for a more
    equitable recovery, and improves public safety.
    ---------------------------------------------------------------------------
        \5\ Illinois Sentencing Policy Advisory Council (2016). A Cost-
    Benefit Tool for Illinois Criminal Justice Policymakers, pp. 2-3:
    http://www.icjia.state.il.us/spac/pdf/Illinois_Results_First_
    Consumer_Reports_072016.pdf, pp. 2-3.
    ---------------------------------------------------------------------------
         investments in reentry programs are consistent with the fy22
                           president's budget request
        Reentry and workforce development are a priority for the current
    administration, and the FY22 President's Budget requests includes $150
    million for the REO program to provide support for ``reentry services,
    and recidivism-reducing programming...'' The budget request also calls
    for increases in skills-building that ``advances the goal of developing
    pathways for diverse workers to access training and career
    opportunities by also investing in critical programs that serve
    disadvantaged groups, including justice-involved individuals, [and] at-
    risk youth.''
        The REO funding request also is consistent with the
    administration's goal of pursuing racial equity. Black people and other
    people of color are disproportionately impacted by the criminal legal
    system. Black people are incarcerated at more than 5 times the rate of
    white people. In 2018, the incarceration rate of Black men was 5.8
    times higher than that of white men, and Black young men ages 18-19
    years old were 12.7 times as likely to be incarcerated as white young
    men in the same age group. In 2018, Black women were almost twice as
    likely to be incarcerated as white women, and Black girls were 3 times
    more likely to be incarcerated than white girls.
        Upon release, these disparities persist as a result of systemic and
    institutional racism and discrimination; collateral consequences of
    conviction that ban or limit legal access to employment, licensure, and
    education supports; and a limited investment in resources for the large
    number of people returning each year who come back to their communities
    without the basic support and tools needed for long-term success.
    Providing federal resources for workforce development and reentry helps
    to ensure greater success and helps to address unfair barriers that
    exist as a result of systemic racism and inequities that disadvantage
    individuals directly impacted by the criminal legal system.
        Finally, the REO program is critical for economic recovery for
    people with criminal legal histories, especially Black people and
    people of color, who also have been disproportionately impacted by
    COVID-19. There has been very limited COVID-19 relief for incarcerated
    people and people with criminal legal histories, and REO is the only
    federally appropriated program that focuses on workforce development
    and employment for people with records (1 out of 3 adults in the U.S.
    has an arrest or conviction record). As the economy recovers and
    workforce needs continue to evolve and change, it is essential to
    ensure that this significant population has the reentry and workforce
    supports to facilitate gainful employment and long-term reentry
    success.
                                   conclusion
        By making effective workforce development and reentry services a
    priority, we fulfill labor market demands, contribute to the economy,
    and build strong and safe communities. Given the extensive employment
    and reentry needs nationwide, as well as the significant return on
    investment related to reduced incarceration costs and reduced crime
    costs borne by victims, families, and communities, I urge Congress to
    allocate $150 million to the REO program in FY22.
        Thank you so much for your time and consideration of this important
    program. If you have questions or need additional information, please
    don't hesitate to contact me or Jenny Collier at
    jcollier@colliercollective.org.

        [This statement was submitted by Kevin Brown, Director of Policy,
    Advocacy, and Legislative Affairs.]
                                     ______

                Prepared Statement of the Scleroderma Foundation
     the foundation's fiscal year 2022 l-hhs appropriations recommendations
    _______________________________________________________________________

      --$10 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --A proportional funding increase for CDC's National Center for
                Chronic Disease Prevention and Health Promotion (NCCDPHP).
        --$5 million for the Chronic Disease Education and Awareness
                Program which seeks to improve public health and lower
                healthcare costs through targeted awareness, physician
                education, and public health campaigns conducted in
                collaboration with stakeholder organizations and
                communities.
      --At least $46.1 billion in program funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS);
                National Center for Advancing Translational Sciences
                (NCATS).
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt and distinguished members
    of the Subcommittee, thank you for your time and your consideration of
    the scleroderma community's priorities while working to craft the
    FY2022 L-HHS Appropriations Bill.
                               about scleroderma
        Scleroderma is a chronic connective tissue disease affecting
    approximately 300,000 Americans. The word scleroderma means hardening
    of the skin, which is one of the most visible manifestations of the
    condition. The cause of this progressive and potentially fatal disease
    remains unknown. There is no cure, and treatment options are limited.
        Symptoms vary greatly and are dependent on which organ systems are
    impacted. Prompt diagnosis and treatment by a qualified physician may
    improve health outcomes and lessen the chance for irreversible damage.
    Serious complications of the disease can include pain, skin ulcers,
    anemia and pulmonary hypertension.
                              about the foundation
        The Scleroderma Foundation is dedicated to the concerns of people
    whose lives have been impacted by the autoimmune disease scleroderma,
    also known as systemic sclerosis, and related conditions. The
    foundation's mission is to 1) support individuals affected, 2) promote
    education and public awareness, and 3) advance critical research and
    improve scientific understanding to improve treatment options and find
    the causes and a cure. The foundation has a research program that funds
    basic, translational and clinical research through a peer review
    process to find the cause and cure for scleroderma and related
    conditions.
                   centers for disease control and prevention
        Early recognition and an accurate diagnosis of scleroderma can
    improve health outcomes and save lives. CDC in general and the NCCDPHP
    specifically have programs to improve public awareness of scleroderma
    and other rare, life-threatening conditions. Please increase funding
    for CDC and NCCDPHP so that the agency can invest in additional,
    critical education and awareness activities that have the potential to
    improve health and save lives. The Foundation supports the continued
    support of the Chronic Disease Education and Awareness Program, this
    program seeks to provide collaborative opportunities for chronic
    disease communities that lack dedicated funding from ongoing CDC
    activities. Such a mechanism allows public health experts at the CDC to
    review project proposals on an annual basis and direct resources to
    high impact efforts in a flexible fashion.
                         national institutes of health
        NIH continues to work with the Foundation to lead the effort to
    enhance our scientific understanding of the mechanisms of scleroderma
    with the shared-goal of improving diagnosis and treatment, and
    ultimately finding a cure. Since scleroderma is a systemic fibrotic
    disease it is inexorably linked to other manifestations of fibrosis
    such as cirrhosis, pulmonary fibrosis, and the fibrotic damage
    resulting from heart attack. Scleroderma is a prototypical
    manifestation of fibrosis as it impacts multiple organ systems. In this
    way, it is important to promote cross-cutting research across such
    Institutes as NIAMS and NHLBI.
        Please provide NIH with a significant funding increase to the
    scleroderma research portfolio can continue to expand and facilitate
    key breakthroughs.
      --NIH continues to support the Trans-NIH Working Group on Fibrosis
            which is working to promote cross-cutting research across
            Institutes.
      --NHLBI, which is leading Scleroderma Lung Study II, is comparing the
            effectiveness of two drugs in treating pulmonary fibrosis in
            scleroderma.
      --NIAMS, is leading efforts to discover whether three gene expression
            signatures in skin can serve as accurate biomarkers predicting
            scleroderma, and investigations into progression and response
            to treatment to clarify the complex interactions of T cells and
            interleukin-31 (IL-31) in producing inflammation and fibrosis,
            or scarring in scleroderma.
                              patient perspective
        ``My constantly aching hands begged for mercy of just one day
    without pain. My joints started to feel like they were being torn away
    from my body. Anytime I touched something cold, my hands would tingle
    and burn. Painful sores started appearing on my knuckles. You stole my
    skin color and with that went my confidence. It was like I was turning
    into a mummy as my skin tightened with collagen, day by day. I was
    beginning to need help performing small tasks. Opening a water bottle
    or turning a key in the door started to become difficult. Standing for
    long periods of time made my hips radiate with pain. In 2012 I had to
    stop working, at 24 years old. The definition of normal as I knew it
    was being torn down and built into something completely new. And so was
    my soul.
        I now need help with everything! Getting dressed, washing my hair,
    cleaning, doing laundry; pretty much anything I have to use my hands
    for. You stole my independence. I had to learn to swallow my pride and
    ask for help. It's a tough thing to do, especially when you're at an
    age that's supposed to be your prime. Friends and family around me have
    blossomed into caregivers and helping me has become second nature to
    them. It's a beautiful thing when those surrounding you automatically
    adapt to your disability. Support is the lifeboat that keeps me
    afloat.''

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

        [This statement was submitted by Mr. David Murad, Director of
    Advocacy, Scleroderma Foundation.]
                                     ______

             Prepared Statement of the Seattle Indian Health Board
        Chair Murray, Ranking Member Blunt, and members of the Senate
    Committee on Appropriations--Subcommittee on Labor, Health, and Human
    Services, Education, and Related Agencies, my name is Esther Lucero. I
    am Dine, and of Latina descent and as the third generation in my family
    to live outside of our reservation, I strongly identify as an urban
    Indian. I serve as the President & CEO of the Seattle Indian Health
    Board (SIHB), one of 41 Urban Indian Health Programs (UIHP) nationwide.
    I have had the privilege of serving SIHB for five years. I am honored
    to have the opportunity to submit my testimony today, including a
    request for the following 1) Address Department of Health and Human
    Services (HHS) grant eligibility and grant restrictions 2) Develop an
    HHS urban confer policy; 3) Ensure HHS public health data access to
    Tribal Epidemiology Centers (TEC) 4) Create National Institutes of
    Health (NIH) research funding opportunities specific to urban Indian
    populations; 5) Invest in Indian healthcare and public health
    infrastructure, including culturally attuned integrated workforce
    development.
                        indigenous resilience in action
        I would like to thank the Subcommittee for COVID-19 supplemental
    funding which has included at least $18 million for UIHPs from the
    Centers of Disease Control and Prevention (CDC); $9.5 billion for
    Federally Qualified Health Centers (FQHC) from the Health Resources and
    Services Administration (HRSA), and; at least $140 million to Indian
    Health Care Providers through the Substance Abuse and Mental Health
    Services Administration (SAMHSA). Supplemental funding has demonstrated
    how successful and resilient our Indian healthcare system can be when
    properly resourced. I would also like to acknowledge the President's
    Budget for FY 22 which includes $131.7 billion for HHS, including $12.6
    billion for HRSA, and $9.7 billion for SAMHSA. We hope President
    Biden's proposed increases will support significant investments to
    FQHCs, tribal and urban Indian populations, and reducing chronic health
    disparities in Black, Indigenous, and Communities of Color (BIPOC).
        As one of 41 Indian Health Service (IHS) designated UIHPs and a
    HRSA 330 FQHC, SIHB serves over 5,000 patients annually of which 70%
    identify as American Indian and Alaska Native. UIHPs are a critical
    component of the Indian healthcare system and offer culturally attuned
    health services to the 2.2 million American Indians and Alaska Natives
    who live in 115 counties across 24 states. We also house the Urban
    Indian Health Institute (UIHI), an IHS designated TEC and public health
    authority, which conducts research and evaluation, collects and
    analyzes data, and provides disease surveillance for 62 urban Indian
    communities nationwide.
        As an Indian Health Care Provider, we are actively limiting the
    spread of COVID-19 in tribal and urban Indian communities. In December
    2020, SIHB was the first organization in Seattle to receive a shipment
    of the Moderna vaccine and since has vaccinated over 12,500
    individuals. Locally, we serve as a COVID-19 testing site at our main
    clinical facility and operate a community-based walk-up testing site at
    our satellite clinic serving American Indian and Alaska Native people
    experiencing homelessness in Seattle, Washington. With the support of
    federal supplemental funding, we continue to secure pharmacy supplies
    and equipment to respond to the immediate and forthcoming COVID-19
    needs in the greater Puget Sound region, including testing kits,
    panels, and a diagnostic testing machine to improve testing capacity
    and response times. We have implemented a telehealth program, expanded
    outpatient behavioral health services, provided rental assistance, and
    developed a pediatrics clinic to increase child immunization rates.
    Throughout the pandemic, UIHI has disseminated culturally attuned
    COVID-19 information through fact sheets, reports, and a COVID-19
    Vaccine Poster series to address vaccine hesitancy in the Native
    community. Recently, UIHI launched For the Love of Our People, a
    webpage dedicated to bringing Native health experts and creatives to
    provide engaging, up-to-date information about COVID-19 vaccines and
    COVID-19 related topics. UIHI has also led local to national public
    health surveillance for UIHPs through weekly reporting and analysis of
    local to state COVID-19 case surveillance data.
                 continued gaps for urban indian organizations
        Address Department of Health and Human Services (HHS) grant
    eligibility and grant restrictions: UIOs offer culturally responsive
    services for the 71% of American Indians and Alaska Natives in urban
    areas. Given that the average IHS grant to an UIHP is $280,000, most
    UIHPs must seek additional resources from HHS agencies to ensure robust
    access to health and social services that allow our communities to
    thrive. Yet, many HHS agencies exclude UIHPs from grant eligibility or
    apply restrictive grant terms that hinder our ability to provide
    culturally specific and low-barrier services. To ensure HHS resources
    for American Indian and Alaska Native people fulfill trust and treaty
    obligations, we ask Congress to:
        Ensure Urban Indian Organizations are included in grant
    eligibility: If the intent of Congressional funds is to reach all
    American Indian and Alaska Native people, then legislative and
    administrative language must include 'tribes, tribal organizations, and
    Urban Indian Health Programs as defined in Section 4 of the Indian
    Health Care Improvement Act (authorized under 25 U.S.C. Ch. 18.
    Subchapter IV Sec. 1653). This ensures federal resources reach American
    Indian and Alaska Native people, regardless of where they reside.
        Address barriers created by GPRA tools: Current requirements of the
            Government Performance and Results Act (GRPA) performance data
            is burdensome to patients and providers. To operate a truly
            culturally attuned and low-barrier Medication Assisted
            Treatment (MAT) programs, we must address the longstanding
            issues with cumbersome and onerous GPRA reporting requirements.
            For example, SIHB provides an unduplicated service of low-
            barrier MAT services for urban American Indians and Alaska
            Natives who are disproportionately affected by substance use in
            Washington State. Our American Indian and Alaska Native
            patients come to SIHB for our integrated patient-centered care
            model that promotes the wellness of our patients and is
            centered on Traditional Indian Medicine. Lengthy and invasive
            GPRA survey tools directly affect our service delivery system
            to provide accessible low-barrier and culturally attuned MAT
            services. We ask that Congress address barriers created by GRPA
            tools to better support culturally attuned and low barrier
            services provided by Indian Health Care Providers.
        Develop an HHS urban confer policy: To ensure trust and treaty
    obligations are upheld to all American Indian and Alaska Native
    citizens, we request the development of an Urban Confer policy across
    all agencies and departments within HHS jurisdiction. The federal
    government has an obligation to consult with Tribal Nations on issues
    that impact tribal communities. In the Indian healthcare system, UIHPs
    have an Urban Confer mechanism with the IHS that provides an
    opportunity for an exchange of information and opinions that lead to
    mutual understanding and emphasize trust, respect, and shared
    responsibility between UIHPs and government agencies. Urban Confer
    policies do not substitute for nor invoke the rights of a Tribe as a
    sovereign nation. An Urban Confer supports the advocacy for the urban
    Indian community by Indian Health Care Providers who are part of the
    Indian healthcare system.
        The importance of an Urban Confer was made evident in the COVID-19
    supplemental resources from Congress. Without an Urban Confer policy,
    HHS agencies outside of IHS had no formal mechanism for gathering
    feedback from UIOs and vice versa. As a result, submitting feedback to
    HRSA, SAMHSA, and the CDC was a significant barrier to accessing COVID-
    19 supplemental resources for UIOs. For example, the CDC created a
    funding opportunity for 11 of the 12 TECs by selecting a grant
    mechanism that failed to include UIOs as eligible entities. This
    barrier leaves UIOs without access to federal resources, despite
    Congressional intent.
        Ensure HHS public health data access to Tribal Epidemiology Centers
    (TEC): Despite Congressional authorization to access HHS data as a
    public health authority, CDC continues to deny UIHI and other TECs
    access to data collected through the National Notifiable Disease
    Surveillance System (NNDSS). Timely analysis of NNDSS data and other
    CDC collected COVID-19 data is critical to supporting both tribes and
    UIOs to prevent, prepare, and respond to system health inequities
    experienced by American Indian and Alaska Native communities. A failure
    to uphold data access perpetuates systemic health inequities in
    American Indian and Alaska Native communities. With the limited COVID-
    19 case surveillance data provided, TECs have been able to monitor,
    evaluate, and respond to COVID-19 through contact tracing, primary
    collection and secondary analysis of epidemiological data, and
    development of culturally attuned public health resources. The COVID-19
    resources developed by TECs range from public health guidance to
    treatment and vaccine information that have been disseminated to
    tribes, tribal organizations, UIOs, and government agencies. We ask
    Congress to ensure compliance with data sharing requirements by all HHS
    agencies with TECs.
        Create NIH research funding opportunities specific to urban Indian
    populations: Current NIH initiatives often are not inclusive of urban
    Indian populations, despite 71% of all American Indian and Alaska
    Native people living in urban settings and a growing body of
    documentation of health disparities among urban Native populations. In
    addition, the COVID-19 pandemic has highlighted the lack of diversity
    in clinical trials which perpetuates bias in research studies. In
    Indian Country, the lack of an American Indian and Alaska Native
    population samples in clinical trials contributed to vaccine hesitancy
    and has been used by anti-vaccination advocates to push misinformation
    into Native communities. We do not advocate for taking away funding for
    tribally based research. Instead, we urge Congress to ensure NIH create
    dedicated funding for research and clinical trials that are inclusive
    of urban Indian populations.
    Invest in Indian healthcare infrastructure:
        Public health infrastructure: The COVID-19 pandemic has exacerbated
            the crumbling infrastructure of our public health systems,
            specifically data systems. Many of the data quality issues
            identified by UIHI in the Data Genocide report are linked to
            outdated public health data infrastructure systems that limit
            the ability to appropriately collect and report data for
            national public health surveillance and epidemiology. There is
            an urgent need to invest significant resources in data
            modernization, specifically across our Indian healthcare
            system--including tribal health programs, UIHPs, and TECs. Data
            modernization increases inter-operability of data systems and
            advances data standards so information can be stored and shared
            across systems, and facilitate complete reporting of data
            critical for achieving equity in public health responses. We
            recommend an increased investment dedicated to infrastructure
            improvement and construction specifically for UIHPs that does
            not divert any resources from tribal communities that are also
            in desperate needs of public health infrastructure investments.
        UIHP healthcare facilities: There is no national level data on the
            infrastructure needs of UIHPs, yet we know from experience our
            facilities are inefficient and overcrowded, which compromises
            the provision of critical health services and contribute to
            health disparities among urban Indian communities. UIHPs are
            ineligible for the Health Care Facilities Construction line
            item in the IHS budget. Recent COVID-19 supplements have
            allowed for some flexible spending to address the overwhelming
            infrastructure needs of UIHPs, yet lack we still lack the
            resources needed to develop integrated care settings that are
            patient-centric and culturally attuned. We ask that Congress
            identify resources for UIHPs for the construction, expansion,
            alteration, and renovation of healthcare facilities.
        Culturally attuned integrated workforce development: Our healthcare
            systems are in need of additional investments to fulfill
            integration of behavioral health and medical care. A 2018 GAO
            report on IHS found a 25% vacancy rate for nurses, physicians,
            and other care providers. It is a critical time to make
            targeted investments in building up a culturally attuned
            workforce across the Indian healthcare system that is prepared
            to provide integrate care that address pervasive health
            disparities among American Indian and Alaska Native
            populations. We ask Congress to invest in recruitment and
            retention of health professionals to address chronic health
            care provider shortages in Indian Country.
        Thank you for your support and consideration of the requests. We
    look forward to our continued work to improve the health and well-being
    of American Indian and Alaska Native people.
        Sincerely.

        [This statement was submitted by Esther Lucero (Dine), MPP,
    President & CEO, Seattle Indian Health Board.]
                                     ______

       Prepared Statement of the Sleep Research Society and Project Sleep
                fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --The sleep community joins the broader research community in
            requesting $46.1 billion in discretionary funding for the
            National Institutes of Health (NIH), an increase of $3.2
            billion over FY 2021. Sleep impacts nearly every system of the
            body and various disease processes, please provide proportional
            funding increases for all NIH Institutes and Centers to further
            support sleep, circadian, and sleep disorders research
            activities.
        --Please support adequate funding to establish the new Advanced
                Research Projects Agency for Health (ARPA-H) at NIH as
                proposed in the Administration's Budget Request to Congress
                to facilitate robust and tangible scientific progress on a
                variety of conditions.
      --The sleep community joins the broader public health community in
            requesting $10 billion in overall funding for the Centers for
            Disease Control and Prevention (CDC) to reinvigorate meaningful
            professional education, public awareness, and surveillance
            activities.
        --Please provide the new CDC Chronic Disease Education and
                Awareness Program with $5 million, an increase of $3.5
                million over FY 2021, to facilitate additional cooperative
                agreements to advance timely public health efforts with
                community stakeholders.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Subcommittee, thank you for considering the views of the sleep,
    circadian, and sleep disorders advocacy community as you work on FY
    2022 appropriations for medical research and public health programs. We
    would like to take this opportunity to thank you for providing ongoing
    investment in the National Institutes of Health (NIH) and the Centers
    for Disease Control and Prevention (CDC) through FY 2021
    appropriations, particularly for establishing and funding the new CDC
    Chronic Disease Education & Awareness Program. Please bolster the
    commitments to NIH and, in particular, CDC as you and your colleagues
    work on appropriations for FY 2022.
                        about the sleep research society
        The Sleep Research Society (SRS) was established in 1961 by a group
    of scientists who shared a common goal to foster scientific
    investigations on all aspects of sleep, circadian rhythmicity, and
    sleep disorders. Since that time, SRS has grown into a professional
    society comprising over 1,300 researchers nationwide. From promising
    trainees to accomplished senior level investigators, sleep and
    circadian research has expanded into areas such as pulmonology,
    psychology, neurology, pharmacology, cardiology, immunology,
    metabolism, genomics, learning and memory, and healthy living. SRS
    recognizes the importance of educating the public about the connection
    between sleep, circadian rhythmicity, and health outcomes. SRS promotes
    training and education in sleep and circadian research, public
    awareness, and evidence-based policy, in addition to hosting forums for
    the exchange of scientific knowledge pertaining to sleep and circadian
    rhythms.
                              about project sleep
        Project Sleep is a 501(c)(3) non-profit organization raising
    awareness about sleep health and sleep disorders by working with
    affected individuals and families across the country. Believing in the
    value of sleep, Project Sleep aims to improve public health by
    educating individuals and policymakers about the importance of sleep
    health and sleep disorders. Project Sleep will educate and empower
    individuals using events, campaigns, and programs to bring people
    together and talk about sleep as a pillar of health.
                         nih sleep research activities
        Over recent years, NIH has seen a meaningful infusion of critical
    funding. This investment has improved grant funding pay lines, led to
    significant scientific advancements, and helped to prepare the next
    generation of young investigators. For FY 2014, the sleep research
    portfolio at NIH was $233 million annually. For FY 2020, the sleep
    research portfolio at NIH had grown to $436 million annually, which has
    been transformative for the field. However, there are still meaningful
    opportunities for further scientific progress and improved patient
    care.
    Underserved Sleep Disorders State of the Science Conference
        While research in sleep and circadian has moved forward in
    significant ways (including the 2017 Nobel Prize in Medicine), research
    into specific sleep disorders at NIH remains relatively modest.
    Narcolepsy, hypersomnia, Kleine Levin syndrome and many other sleep
    disorders have only a few active grants at any given time. To ensure
    scientific progress in sleep is translated to innovative therapies,
    improved diagnostic tools, and meaningful health information, the time
    is now for a State-of-the-Science conference on sleep disorders. This
    collaborative opportunity will help create a long-range research plan
    across NIH that features specific activities for various sleep
    disorders. Committee recommendations and related interest in this
    regard would be timely.
    Sleep Health & Health Disparities
        Racial-ethnic minorities are more likely to get insufficient sleep,
    and are more likely to have sleep disorders. Since sleep plays
    important roles in cardiovascular function, metabolism, immunity,
    mental health, and brain function, this sleep disparity creates a
    situation where racial/ethnic minorities are systematically set up for
    worse health outcomes. Not only does poor sleep lead to worse outcomes
    on its own, it interacts with other conditions, worsening the already-
    important problems associated with heart disease, diabetes, obesity,
    cancer, depression, and other medical conditions. The causes of these
    sleep disparities are complex and involve a combination of
    socioeconomic, environmental, and other factors. Unfortunately, there
    is almost no research on targeting sleep disorders diagnosis and
    treatments for racial/ethnic minorities, and securing funding for sleep
    disparities research is extremely difficult. As NIH works to address
    health disparities, promote health equity, and enhance workforce
    diversity, sleep and sleep research should be incorporated into
    emerging activities.
    National Heart, Lung, and Blood Institute/National Center on Sleep
            Disorders Research
        NCSDR has a new Director, Dr. Marishka Brown, who is taking the
    field of sleep research in new and exciting directions while
    reinvigorating the enthusiasm for sleep research across the federal
    government. Under Dr. Brown's leadership, NCSDR is preparing to release
    a strategic plan for research. We ask Congress to provide Dr. Brown
    with the support she needs, including adequate resources for NHLBI and
    NCSDR to coordinate ongoing and emerging initiatives.
    CDC Chronic Disease Education & Awareness Program
        Thank you for establishing the CDC Chronic Disease Education &
    Awareness program and providing an initial investment of $1.5 million
    for FY 2021. CDC currently lacks meaningful public health activities
    focused on sleep and the community plans to engage this new funding
    mechanism. For FY 2022, please provide $5 million in annual support.
    Stacy's Story
        Stacy Edwards, of Langley, Washington, first started seeing doctors
    for fatigue at the age of 15. As she got older, her health declined
    significantly and she couldn't figure out why. Stacy could sleep 15-18
    hours and still felt tired. Doctors were sympathetic, but usually
    tested for anemia and mono and sent her on her way with no solutions.
    At age 31, Stacy was finally referred for a sleep study. The results
    showed that she woke up 29 times per hour due to breathing
    obstructions, making her diagnosis of sleep apnea on the high side of
    moderate (almost severe).
        Once diagnosed, Stacy started using a CPAP machine and now raises
    awareness and reduces stigma via her website and social media campaign
    called CPAP Babes. More recently, at age 34, Stacy was diagnosed with a
    second sleep disorder, idiopathic hypersomnia. She continues to look
    for better treatment options to reduce her daytime sleepiness, brain
    fog, and other associated symptoms. Stacy is passionate about sleep
    research and awareness because she believes that she lost many years of
    her life in bed and doesn't want others to suffer for years without
    answers the way she did. Educating the public and the medical community
    is a high priority for Stacy.

        [This statement was submitted by H. Craig Heller, PhD, President,
    Sleep
    Research Society and Project Sleep.]
                                     ______

         Prepared Statement of the Society for Maternal-Fetal Medicine
        On behalf of SMFM, I am pleased to submit testimony in support of
    the important work related to optimizing the health of birthing people
    and infants being conducted at HHS for FY 2022. SMFM urges Congress to
    ensure that the National Institutes of Health (NIH), Centers for
    Disease Control and Prevention (CDC), Health Resources and Services
    Administration (HRSA), and Agency for Healthcare Research and Quality
    (AHRQ) are adequately funded in FY 2022. Specifically, SMFM urges the
    Committee to provide at least the following in base program level
    funding:
      --$46.1 billion for the NIH, with $1.7 billion of that funding to
            support the Eunice Kennedy Shriver National Institute of Child
            Health and Human Development (NICHD);
      --$10 billion for the CDC, including $89 million for the Safe
            Motherhood Initiative, $100 million for the Surveillance for
            Emerging Threats to Moms and Babies initiative, and $200
            million for the National Center for Health Statistics (NCHS);
      --$9.2 billion for the HRSA, including $822.7 million for the Title V
            Maternal and Child Health Services Block Grant; and
      --$500 million for AHRQ.
        Established in 1977, SMFM is the national voice for clinicians and
    researchers with expertise in high-risk pregnancies. A non-profit
    association representing more than 5,000 individuals, the core of
    SMFM's membership is comprised of maternal-fetal medicine (MFM)
    subspecialists. MFM subspecialists are obstetricians with an additional
    three years of formal education and who are board certified in MFM
    making them highly qualified experts and leaders in the care of
    complicated pregnancies. Additionally, SMFM welcomes physicians in
    related disciplines, nurses, genetic counselors, ultrasound
    technicians, MFM administrators, and other individuals working toward
    optimizing the care of people with high-risk pregnancies. SMFM members
    see the most at-risk and complex patients, with the goal of optimizing
    outcomes for pregnant people and their children.
    NIH/NICHD
        The NICHD's investment in maternal and child health outcomes is
    essential to understanding and combatting the rising maternal mortality
    and severe morbidity rates and to optimizing maternal and child health.
        Task Force Specific to Pregnant Women and Lactating Women (PRGLAC):
    SMFM urges Congress to continue its strong support for NIH's efforts to
    advance the inclusion of pregnant and lactating people in clinical
    trials and research, specifically by taking necessary steps to
    implement the recommendations of the PRGLAC Task Force, which was
    convened by NICHD. PRGLAC submitted its report to the Secretary in the
    fall of 2018 with 15 recommendations on including pregnant and
    breastfeeding people in clinical trials and broad research initiatives,
    and the Task Force further outlined how to implement those
    recommendations in a follow-up report submitted to the Secretary of
    Health and Human Services in 2020. In that implementation report, the
    PRGLAC Task Force described the need to convene an expert panel to
    develop a framework for addressing medicolegal and liability issues
    when planning or conducting research specific to pregnant people and
    lactating people. SMFM requests $1.5 million for NICHD to contract with
    the National Academies of Sciences, Engineering, and Medicine to
    convene a panel tasked with developing that framework (language below).
        The COVID-19 pandemic again emphasized the importance of including
    pregnant and lactating people in clinical research. This population was
    largely excluded from clinical trials for treatments and vaccines,
    leaving them and their health care providers without clear evidence on
    safety and efficacy to guide clinical decision-making. It is essential
    that Congress support broader inclusion of pregnant and lactating
    people in research, so that lifesaving interventions and treatments can
    be addressed for mother and their infants.

        NICHD Report Language
          Liability Study.--Pregnant and Lactating Individuals. The
            Committee includes $1,500,000 for NICHD to contract with NASEM
            to convene a panel with specific legal, ethical, regulatory,
            and policy expertise to develop a framework for addressing
            medicolegal and liability issues when planning or conducting
            research specific to pregnant people and lactating people.
            Specifically, this panel should include individuals with
            ethical and legal expertise in clinical trials and research;
            regulatory expertise; plaintiffs' attorneys; pharmaceutical
            representatives with tort liability and research expertise;
            insurance industry representatives; federally funded
            researchers who work with pregnant and lactating women;
            representatives of institutional review boards (IRBs) and
            health policy experts.
        Maternal-Fetal Medicine Units Network (MFMU): SMFM urges continued
    strong support of the MFMU and asks that Congress allocate $30 million
    to support the Network's ongoing work. Established in 1986, MFMU
    pursues the development of treatments for medical complications during
    and after pregnancy, including maternal mortality and morbidity,
    preterm birth, low birth weight, fetal growth abnormalities, and fetal
    mortality. MFMU is a critical resource to stemming the nation's growing
    maternal health crisis and addressing emerging threats to maternal and
    infant health. For instance, during the COVID-19 pandemic, the MFMU was
    able to quickly pivot resources to monitor the health impact of COVID-
    19 on pregnant people and their infants, as well as researching
    effective treatments for pregnant populations. We hope that the NICHD
    will ensure the MFMU's continued success by maintaining its highly
    efficient structure of multicenter collaborative research. The MFMU has
    a strong history of changing and improving clinical practice and
    obstetric management, improving outcomes of pregnant people and babies
    in the United States, and is extremely successful. 25.6 percent of all
    publications from the network are cited in clinical practice
    guidelines. These guidelines are relied upon by Medicaid and Medicare
    programs to define evidence-based services covered under the plans. The
    work of the network is even more urgent given the recent increase in
    maternal mortality and severe morbidity in the United States. We urge
    Congress to ensure stable and sustained funding and infrastructure for
    the MFMU, and to ensure that any proposed change in the funding
    mechanism or structure for the MFMU not compromise the ability of the
    network to remain nimble and directly address the changing landscape of
    women's health, including to reduce health disparities.
        Preterm Birth: Delivery before 37 weeks gestation is associated
    with increased risk of death in the immediate newborn period as well as
    in infancy and can cause long-term complications. Although the survival
    rate is improving, many preterm infants have life-long disabilities
    including cerebral palsy, intellectual disabilities, respiratory
    problems, and hearing and vision impairment. Preterm birth costs the
    United States $25.2 billion annually.\1\ Great strides are being made
    through NICHD-supported research to address the complex situations
    faced by mothers and their babies. One of the most successful
    approaches for testing research questions is the NICHD research
    networks, which allow researchers from across the country to
    collaborate and coordinate their work to change the way we think about
    pregnancy complications and to change medical practice across the
    country.
    ---------------------------------------------------------------------------
        \1\ Waitzman NJ and Jalali A. Updating National Preterm Birth Costs
    to 2016 with Separate Estimates for Individual States. Salt Lake City,
    UT: University of Utah; 2019. Available at: https://
    www.marchofdimes.org/peristats/documents/Cost_of_Prematurity_2019.pdf.
    ---------------------------------------------------------------------------
    CDC
        The CDC's Division of Reproductive Health (DRH) and National Center
    for Birth Defects and Developmental Disabilities (NCBDDD) are doing
    important work related to pregnancy. Data collection efforts related to
    pregnancy outcomes, maternal mortality, and medications in pregnancy
    must continue.
        For instance, CDC's ongoing support for state-based perinatal
    quality collaboratives and new funding for state maternal mortality
    review committees (MMRCs) is essential to address the nation's
    unacceptable maternal death rate. According to the NCHS, the maternal
    mortality rate in 2019 was 20.1 deaths per 100,000 live births, and
    racial disparities persisted with a maternal mortality rate of 44.0 per
    100,000 live births among non-Hispanic black women compared to 17.9
    among non-Hispanic white women.\2\ SMFM fully supports Congress'
    attention to reducing maternal mortality through CDC's Safe Motherhood
    Initiative, and we ask that you provide at least $89 million for this
    work. Of that, we ask Congress to allocate the full $43 million
    included in the President's FY 2022 budget request to fund additional
    state MMRCs.
    ---------------------------------------------------------------------------
        \2\ Hoyert DL. Maternal mortality rates in the United States, 2019.
    NCHS Health E-Stats. 2021.Available at https://www.cdc.gov/nchs/data/
    hestat/maternal-mortality-2021/maternal-mortality-2021.htm.
    ---------------------------------------------------------------------------
        SMFM also urges Congress to allocate $100 million for the CDC's
    Surveillance for Emerging Threats to Moms and Babies initiative housed
    at the NCBDDD. The state-level surveillance infrastructure supported by
    the initiative allows state public health departments to monitor health
    threats stemming from maternal exposures, including infectious diseases
    such as COVID-19.
    HRSA
        The work of HRSA is critical to maternal and child health. HRSA's
    initiatives reduce infant mortality, improve maternal health and
    wellbeing, and serve more than 50 million people through the Maternal
    and Child Health (MCH) Block Grant. The funds provided through the MCH
    Block Grant increase access to comprehensive prenatal and postnatal
    care--especially for patients who are most at risk for adverse health
    outcomes. The Title V MCH Block Grant programs save federal and state
    governments money by expanding the delivery of preventive services to
    avoid more costly chronic conditions later in life. Additionally,
    HRSA's family planning initiatives ensure access to comprehensive
    family planning and preventive health services for more than 4 million
    people, thereby reducing unintended pregnancy rates. Finally, HRSA's
    support for the Alliance for Innovation in Maternal Health Care (AIM)
    reduces maternal mortality through implementation of care bundles at
    the state and institutional level. These bundles help reduce maternal
    mortality through quality improvement in various areas including
    postpartum hemorrhage and hypertension. We encourage Congress to
    provide at least $822.7 million for this important program that will
    help improve maternal and infant health across the United States.
    AHRQ
        Projects conducted at AHRQ are critical to translate research from
    bench to bedside through comprehensive implementation in the everyday
    practice of medicine. AHRQ is the only federal agency that funds
    research on ``real-life'' patients--those with comorbidities and co-
    existing conditions, including high-risk pregnant people. The agency's
    work is instrumental in collecting data; funding health services
    research; and, most importantly, disseminating findings to clinicians
    to improve maternal health care. Together, AHRQ's intramural programs,
    such as the Healthcare Cost and Utilization Project (HCUP), Evidence-
    Based Practice Center Program and Safety Program in Perinatal Care, and
    extramural research are essential to reducing maternal deaths and
    adverse pregnancy outcomes. By providing at least $500 million to AHRQ
    in FY 2022, Congress will allow AHRQ to expand its maternal health
    portfolio, improving care for nearly 4 million pregnant patients each
    year.
                                   conclusion
        The COVID-19 pandemic has further exposed existing inequities and
    gaps within our healthcare system for people across the country,
    including pregnant people. It is more important than ever to prioritize
    the needs of pregnant people and their infants in federal programs from
    research, to public health surveillance, to care. We urge HHS to
    prioritize and adequately fund maternal health efforts for that aim to
    reduce maternal mortality and severe morbidity during and after the
    pandemic.
        With your support of vital HHS programs, obstetric researchers,
    clinicians, and patients can address the complex problems of pregnancy
    and truly improve the health and wellbeing of mothers and infants.
    Please direct any inquiries about this testimony to Rebecca Abbott,
    SMFM's Director of Government Relations (rabbott@smfm.org).
                                     ______

               Prepared Statement of the Society for Neuroscience
        Chair DeLauro, Ranking Member Cole, and members of the
    Subcommittee, on behalf of the Society for Neuroscience (SfN), we are
    honoured to present this testimony in support of robust appropriations
    for biomedical research at the National Institutes of Health (NIH). SfN
    urges you to provide at least $46.1 billion, a $3.2 billion increase
    over FY21, in funding for existing institutes and centers at NIH for
    FY22, including $496 million from the NIH Innovation Account for 21st
    Century Cures programs and $560 million for the Brain Research through
    Advancing Innovative Neurotechnologies (BRAIN) Initiative. Dr. Moses
    Chao and I, as Chair of the Government and Public Affairs Committee and
    President of SfN respectively, understand the critical importance of
    federal funding for neuroscience research in the United States. I
    currently serve as a researcher and as a Professor in the Department of
    Psychology at Cambridge University and Dr. Chao is a professor of Cell
    Biology, Physiology and Neuroscience, and Psychiatry at the New York
    University School of Medicine. Our research serves as two examples of
    the wide variety of neuroscience research advancing our collective
    understanding of the brain.
        My own research focuses on the neural and psychological basis of
    drug addiction and is dedicated to understanding the maladaptive
    engagement of the learning, memory, and motivational mechanisms
    underlying compulsive drug use. Drug abuse and addiction have
    devastating consequences at the individual, family, and society levels.
    My research group made significant advances in showing structural and
    neurochemical changes in the brain associated with behavioral
    impulsivity confer a major risk on vulnerability to develop cocaine
    addiction. We have also demonstrated the neural circuit basis of
    transition from recreational to compulsive use of opioids, stimulants,
    and alcohol, revealing commonalities as well as differences in the
    neural basis of addiction to these drugs. This understanding has opened
    the door to development of novel pharmacological and psychological
    treatments for addiction that may promote and maintain abstinence from
    drug use.
        Dr. Chao's research efforts focus on growth factors (also called
    neurotrophins) in the brain. These proteins are crucial for everything
    from neuron differentiation, growth, and survival during development to
    learning and memory in children and adults. Deficits in neurotrophins
    are involved in neurodegenerative disorders such as Alzheimer's,
    Parkinson's and Huntington's diseases, and Amyotrophic Lateral
    Sclerosis (ALS), as well as limiting recovery after stroke or brain
    injury.
        Dr. Chao and I cover different areas of neuroscience research,
    though we have come together to convey the need for further and ongoing
    investment in neuroscience research. SfN believes strongly in the
    research continuum: basic science leads to clinical innovations, which
    leads to translational uses impacting the public's health. Basic
    science is the foundation upon which all health advances are built. To
    cure diseases, we need to understand them through fundamental
    discovery-based research. However, basic research depends on reliable,
    sustained funding from the federal government. SfN is grateful to
    Congress for its investments in biomedical research and increases for
    NIH over the last six years. Growing the NIH budget over $12 billion in
    that period is exactly the kind of sustained effort that is needed, and
    your continued support will pay dividends for years to come.
                    the importance of the research continuum
        NIH funding for basic research is critical for facilitating
    groundbreaking discoveries and for training researchers at the bench.
    For the United States to remain a leader in biomedical research,
    Congress must continue to support basic research that fuels discoveries
    as well as the economy. The deeper our grasp of basic science, the more
    successful those focused on clinical and translational research will
    be. We use a wide range of experimental and animal models not used
    elsewhere in the research pipeline. These opportunities create
    discoveries--sometimes unexpected discoveries--expanding knowledge of
    biological processes, often at the molecular level. This level of
    discovery reveals new targets for research to treat all kinds of brain
    disorders affecting millions of people in the United States and beyond.
        NIH basic research funding is also a key economic driver of science
    in the United States through funding universities and research
    organizations across the country. Federal investments in scientific
    research fuel the nation's pharmaceutical, biotechnology and medical
    device industries. The private sector utilizes basic scientific
    discoveries funded through NIH to improve health and foster a
    sustainable trajectory for American's Research and Development (R&D)
    enterprise. Basic science generates the knowledge needed to uncover the
    mysteries behind human diseases, which leads to private sector
    development of new treatments and therapeutics. This important first
    step is not ordinarily funded by industry given the long-term path of
    basic science and the pressures for shorter-term return on investments
    by industry. Congressional investment in basic science is irreplaceable
    on the pathway for development of drugs, devices, and other treatments
    for brain-related diseases and disorders.
        For example, in 2019, NIH launched--at Congress's direction--the
    cross-institute Helping to End Addiction Long-term (HEAL) Initiative to
    respond to the ongoing opioid public health crisis. Through this
    program, NIH supports the development of new medications to treat all
    aspects of the opioid addiction cycle and invests in preclinical and
    translational research in pain management. This work is vital to the
    translation of exciting new discoveries in the treatment of addiction.
    In our lab, we have shown a novel opioid receptor antagonist greatly
    decreases opioid, cocaine, and alcohol use in animal models, as well as
    showing its efficacy and safety in experimental studies in humans. We
    have further revealed reducing the impact of maladaptive drug memories
    can promote abstinence from drug use, as well as be effective in
    treatment of anxiety disorders and post-traumatic stress disorder
    (PTSD). The NIH, especially NIDA and NIAAA, supports the great majority
    of the global research on addiction and its treatment; this is a
    shining example of how governmental funding for research in the US
    leads the world and inspires related and collaborative research
    internationally on this major brain disorder.
        Another example of NIH's success in funding neuroscience is the
    BRAIN Initiative. While only one part of the research landscape in
    neuroscience, the BRAIN Initiative has been critical in promoting
    future discoveries across neuroscience and related scientific
    disciplines. By including funding in 21st Century Cures, Congress
    helped maintain the momentum of this endeavor. Note, however, using
    those funds to supplant regular appropriations would be
    counterproductive. There is no substitute for robust, sustained, and
    predictable funding for NIH. SfN appreciates Congress' ongoing
    investment in the BRAIN Initiative and urges its full funding in FY22.
    Some recent exciting advancements in NIH funded neuroscience research
    include the following:
    Personalized Medicine for Treating Depression
        Major depressive disorder (often referred to as ``depression'') is
    one of the most common mental disorders in the United States, affecting
    more than 17 million adults each year in the United States alone. While
    there have been great strides in pharmacological treatments for
    depression, a patient's response to any given antidepressant will vary
    widely based on their particular brain chemistry. A group of
    researchers funded by NIH recently used a machine learning algorithm to
    analyze patients' brain waves and predict their response to sertraline,
    a popular antidepressant. These data were taken from an NIMH funded
    study that used electroencephalography (EEG) to measure the brain's
    response to taking either a placebo or sertraline. Using an algorithm
    specially designed to analyze EEG data, the researchers were able to
    predict whether patients would respond to sertraline treatment based on
    brain waves measured before treatment. This work is a critical step
    towards quickly determining the most effective treatment for patients
    based on their personal brain chemistry and illness.
    Understanding How COVID Affects the Brain
        In addition to its well-documented effects on the respiratory
    system, it has become clear that SARS-CoV-2, the virus responsible for
    COVID-19, has a profound effect on the brain, with neurological
    symptoms from dizziness and mental fogginess to encephalitis and stroke
    appearing in COVID-19 patients. SARS-CoV-2 has been found in the
    cerebrospinal fluid (CSF) of some of these patients, indicating the
    virus was able to cross into the brain. To understand how the virus
    could enter the brain, researchers with NIH COVID-19 research funding
    used stem cells created from human skin cells to make clusters of brain
    cells called organoids. These organoids were made of cells found in
    different areas of the brain, and the researchers found that SARS-CoV-2
    had a high infection rate for cells from a specialized region called
    the choroid plexus. The choroid plexus is the region of the brain that
    creates the CSF cushioning the brain and spinal cord; it is known as a
    site of infection for other viruses. This finding provides a lead on
    the location through which SARS-CoV-2 may be entering the brain and a
    potential target for developing treatments of the neurological effects
    of COVID-19.
       covid-19 is a challenge and opportunity for neuroscience research
        Unfortunately, the COVID-19 pandemic slowed progress in
    neuroscience research, with social distancing requirements hampering
    ongoing research related to the brain. Investment in neuroscience
    research, including on the neurological aspects of the SARS-CoV-2 virus
    and the COVID-19 pandemic itself is needed but cannot be allowed to
    eclipse or replace regular funding for neuroscience research. We urge
    you to identify ways to ensure current necessary funding increases to
    address the COVID-19 emergency do not slow progress on other important
    and innovative research, including the groundbreaking research in
    neuroscience and mental health. SfN is grateful Congress requested NIH
    seek to understand the psychosocial and behavioral health consequences
    of COVID-19. SfN encourages the Subcommittee to fund basic research on
    the biology of COVID-19 impacts on brain function as well as impacts on
    the nervous system in preclinical models and, by extension, on humans.
    In doing so, SfN encourages Congress and the NIH to prioritize
    intentional collaboration and coordination to effectively allocate
    scarce resources so researchers may investigate all facets of
    infectious and non-infectious disease.
        Ongoing research already demonstrates the need for scientists to
    examine the neurological impacts of COVID-19. While mortality due to
    SARS-CoV-2 may be primarily due to its effects on the lungs, it is now
    apparent the virus damages many other organs, including the central
    nervous system. We need to understand how these direct and indirect
    effects on other organ systems are producing chronic diseases and long-
    term disability, making people more susceptible to other chronic
    disorders covered by the different NIH Institutes. A recent study
    (Lancet article, Taquet et al 2020) shows an increased risk of
    psychiatric conditions after COVID-19 diagnosis. Symptoms, such as
    anxiety, depression, post-traumatic stress disorder, and insomnia were
    reported. These data, though incomplete, suggest brain impairment
    occurs as a result of COVID-19 infection. Furthermore, it was found
    people with two copies of the risk gene for Alzheimer's disease were
    more likely to have severe COVID-19 (Kuo et al J. Gerontology 2020).
    These findings, coupled with incidents of memory loss, brain fog and
    hallucinations reported in the New York Times (3/23/21) demand
    increased resources to study the impact of this virus on the peripheral
    and central nervous systems, as well as the immune and inflammatory
    systems. The COVID-19 public health emergency provides an important
    example of the critical need for collaborative research and
    coordinating data and resources across institutes. A balanced and
    collaborative research effort across institutes will likely be the path
    toward solving these multiple issues.
    congress & nih must support access to models necessary for neuroscience
                                   discovery
        Adequate NIH funding is necessary to advancing our understanding of
    the brain; however, full realization of this funding's promise requires
    appropriate access to research models, including non-human primate and
    other animal models. Animal research is highly regulated to ensure the
    ethical and responsible care and treatment of the animals. SfN and its
    members take their legal and ethical obligations related to this
    research very seriously. While SfN recognizes the goal of the
    reduction, refinement, and eventual replacement of nonhuman primate
    models in biomedical research, much more research and time is needed
    before such a goal is attainable. Premature replacement of non-human
    primate and other animal models may delay or prevent the discovery of
    treatments and cures-not only for neurological diseases like
    Alzheimer's disease, addiction, and traumatic brain injury, but also
    for communicable diseases and countless other conditions. There are
    currently no viable alternatives available for studying biomedical
    systems that advance our understanding of the brain and nervous system;
    or when seeking treatments for diseases and disorders like depression,
    addiction, Parkinson's Disease, and emotional responses. This research
    is critically important and has the opportunity to benefit countless
    people around the world. SfN urges Congress to work with the NIH to
    ensure this important research can continue.
                            funding in regular order
        SfN joins the biomedical research community supporting an increase
    in NIH funding to at least $46.1 billion for existing NIH institutes
    and centers, a $3.2 billion increase over FY21. This increase is
    consistent with those provided by this committee for the past few years
    and provides certainty to the field of science, allowing for the
    exploitation of more scientific opportunity, more training of the next
    generation of scientists, more economic growth and more improvements in
    the public's health. Equally as important as providing a reliable
    increase in funding for biomedical research is ensuring funding is
    approved before the end of the fiscal year. Your success in 2018 in
    completing appropriations prior to the start of the fiscal year was a
    tremendous benefit to research. Continuing Resolutions have significant
    consequences on research, including restricting NIH's ability to fund
    grants. For some of our members, this means waiting for a final
    decision to be made on funding before knowing if their perfectly scored
    grant will be realized, or operating a lab with 90 percent of the
    awarded funding until appropriations are final. All of the positive
    benefits research provides in this country may be negatively impacted
    by these real time considerations. SfN strongly supports the
    appropriation of NIH funding in a timely manner which avoids delays in
    approving new research grants or causes reductions in funding for
    already approved research funding. Meeting the example Congress set in
    2018 would be another substantial benefit to science.
        SfN thanks the subcommittee for your strong and continued support
    of biomedical research and looks forward to working with you to ensure
    the United States remains the global leader in neuroscience research
    and discovery. Collaboration among Congress, the NIH, and the
    scientific research community has created great benefits for not only
    the United States but also for people around the globe suffering from
    brain-related diseases and disorders. On behalf of the Society for
    Neuroscience, we urge you to continue this strong support of biomedical
    research.

        [This statement was submitted by Barry Everitt, Sc.D., F.R.S.,
    President, and Moses Chao, PhD, Chair, Government and Public Affairs
    Committee, Society for Neuroscience.]
                                     ______

         Prepared Statement of the Society for Women's Health Research
        On behalf of the Society for Women's Health Research (SWHR)--whose
    mission is dedicated to promoting research on biological sex
    differences in disease and improving women's health through science,
    policy, and education--I am pleased to submit testimony describing
    SWHR's funding requests for fiscal year 2022. While SWHR supports
    strong funding across all federal public health programming, we
    specifically urge appropriators to support at least $46.1 billion for
    the National Institutes of Health (NIH), including at least $1.7
    billion for the Eunice Kennedy Shriver National Institute of Child
    Health and Human Development (NICHD), and $55.4 million for the Office
    of Research on Women's Health (ORWH).
        Biological differences between women and men influence disease
    development, progression, and response to treatment, while social
    determinants of health, including gender, affect disease risk, health
    care access, and outcomes.
        Over the past 15 months, as the world has collectively faced the
    myriad consequences of the COVID-19 pandemic, we have also seen an
    array of health disparities exposed, including significant sex and
    gender differences. For example, men are more likely to develop severe
    complications from COVID-19 and have a heightened risk of death, while
    women are more likely to be diagnosed with post-acute sequelae of
    COVID-19 and report more adverse events following vaccination.
    Additionally, women have been disproportionately affected by layoffs
    and socioeconomic challenges, food insecurity, domestic violence, and
    mental health concerns related to COVID-19.
        Nevertheless, much of the ongoing COVID-19 research fails to
    thoroughly investigate the impact of sex and gender. We have long known
    that robust funding for federal institutes and offices that prioritize
    women's health research is critical to achieve health equity for women.
    Therefore, SWHR urges Congress to prioritize women's health and women's
    health research in FY 2022 funding legislation, which includes
    supporting the NIH, ORWH, and NICHD.
                       the national institutes of health
        The NIH is America's premier medical research agency and the
    largest source of funding for biomedical and behavioral research in the
    world. As such, its public health mission is vital to promote the
    overall health and well-being of Americans by fostering creative
    discoveries and innovative research, training and supporting
    researchers to ensure continued scientific progress, and expanding the
    scientific and medical knowledge base.
        Within the NIH, there are several initiatives aimed at improving
    the health of women. Among these initiatives was the agency's Trans-NIH
    Strategic Plan for Women's Health Research, released in April 2019. The
    Strategic Plan laid out broad NIH goals that complement its more
    targeted women's health programs. These initiatives--along with the
    NIH's continued emphasis on improving standard research methodologies
    to address sex and gender and providing funding for women's health
    research--make continued support of NIH necessary in our mission to
    support women's health.
        SWHR urges Congress to provide at least $46.1 billion for the NIH,
    a $3.2 billion increase over current funding, in FY 2022. This funding
    level would sustain and bolster NIH's ability to award competitive
    research grants, support the work of researchers within NIH, and build
    upon efforts to mitigate the COVID-19 pandemic's impact on ongoing and
    future research. We also encourage the Committee to work with NIH to
    ensure that the agency studies the impact of COVID-19, including the
    race and gender breakdown of participation in the workforce in the wake
    of the pandemic and how sex as a biological variable impacts short- and
    long-term health outcomes due to infection with SARS-CoV-2.
                    the office of research on women's health
        For decades, and as late as the 1990s, women were treated as small
    men in research. Research on diseases and treatments were conducted
    almost exclusively on male subjects, as researchers sought to avoid the
    presumed ``complications'' introduced by including female subjects in
    their work. Unfortunately, this approach ignored the impact of sex and
    gender on human development, disease progression, and ultimately, on
    approaches to research as a whole.
        As the NIH focal point for coordinating women's health research,
    ORWH ensures women are represented across all NIH research and works to
    improve representation of women and women's health issues within
    federally funded research. ORWH provides critical leadership to
    programs, such as the Specialized Centers of Research Excellence, which
    advances translational research on the role of sex differences in the
    health of women, and the Implementing a Maternal health and Pregnancy
    Outcomes Vision for Everyone (IMPROVE) Initiative, which coordinates
    interdisciplinary research on factors impacting maternal mortality.
        In order to allow the Office to continue to coordinate and drive
    the conversation on women's health across NIH, SWHR recommends $55.4
    million in funding for ORWH, an increase on par with the overall NIH
    budgetary recommendations, for FY 2022. SWHR also recommends an
    additional $3 million be allocated to the Building Interdisciplinary
    Research Careers in Women's Health program, an initiative that trains
    investigators to research sex and gender influences on health. This
    program has the potential not only to improve women's health by
    advancing our understanding of sex and gender differences, but also to
    support a diverse research workforce.
      eunice kennedy shriver national institute of child health and human
                                  development
        The NICHD provides a home for women's health research in areas
    including reproductive sciences and maternal health. While the
    Institute is conducting several areas of critical research, there are
    two key areas of need within NICHD that could be further supported
    through additional funding in FY 2022:
        Pregnant and Lactating Individuals: Nearly 94% of women take at
    least one medicine during pregnancy, and 50% take at least one
    medication during the postpartum period. Yet, pregnant and lactating
    individuals are excluded from the majority of biomedical research.
    Consequently, these women and their health care providers do not have
    access to the information they need to make confident decisions about
    their health care.
        SWHR supports the appropriate inclusion of these populations in
    clinical research. The federal Task Force on Research Specific to
    Pregnant Women and Lactating Women, housed within the NICHD, has been
    crucial to outlining next steps for improving research in pregnant and
    lactating populations. Based on the Task Force recommendations from
    August 2020, SWHR requests that Congress include report language
    recommending that NICHD contract with the National Academy of Medicine
    to convene a panel with specific legal, ethical, regulatory, and policy
    experts to develop a framework for addressing legal and liability
    issues in research specific to pregnant and lactating people.
        Uterine Fibroids: There is also need for improved attention to
    uterine fibroids, one of the most common gynecological conditions
    nationwide. Approximately 26 million individuals in the United States
    from ages 15 to 50 have fibroids, and 15 million experience symptoms
    like severe menstrual bleeding, anemia, impaired fertility, and
    pregnancy complications. Fibroids cost the health care system $5.9 to
    $34.4 billion annually.
        Additionally, prominent and troubling health disparities exist in
    fibroids prevalence, onset, and severity. Black women are two to three
    times more likely to develop fibroids than white women. Black patients
    also tend to develop fibroids at earlier ages, develop more and larger
    tumors, and show increased symptom severity.
        Yet, despite the prevalence of fibroids, fibroid research remains
    drastically underfunded compared to disease burden. In 2019, fibroid
    research received about $17 million in NIH funding, putting it in the
    bottom 50 of 292 funded conditions.
        SWHR calls on Congress to provide at least $1.7 billion for NICHD
    in FY 2022 and to urge the NICHD to prioritize funding to expand basic,
    clinical, and translational research pathophysiology to identify early
    diagnostic methods and fertility-preserving treatments and to
    understand and mitigate the impact of health disparities.
                                      ****
        The Society for Women's Health Research appreciates the opportunity
    to submit this testimony and thanks the Subcommittee for considering
    our requests of at least $46.1 billion for NIH, $55.4 million for ORWH,
    and at least $1.7 billion for NICHD. We look forward to working with
    you to support medical and health services research and, therein, the
    health of the nation. If you have questions or would like more
    information, please do not hesitate to contact me at kathryn@swhr.org.

        [This statement was submitted by Kathryn G. Schubert, President &
    CEO,
    Society for Women's Health Research.]
                                     ______

           Prepared Statement of the Society of Gynecologic Oncology
        The Society of Gynecologic Oncology thanks the Subcommittee for the
    opportunity to submit comments for the record regarding our report
    language recommendations for prioritizing research activities on
    gynecologic cancers at the NIH National Cancer Institute in Fiscal Year
    2022. The Society of Gynecologic Oncology (SGO) is the premier medical
    specialty society for health care professionals trained in the
    comprehensive management of gynecologic cancers. The SGO's 2,000
    members in the United States and abroad represent the entire
    gynecologic oncology team dedicated to the treatment and care of
    patients with gynecologic cancers. The SGO's strategic goals include
    advancing the prevention, early diagnosis, and treatment of gynecologic
    cancers by establishing and promoting standards of excellence. Key
    priorities for the SGO are to advocate for more equitable care for all
    patients and support research aimed to improve outcomes for diverse
    patient populations.
        Gynecologic cancers are cancers that start in a patient's
    reproductive organs. There are five types of gynecologic cancers:
    cervical cancer, ovarian cancer, uterine also referred to as
    endometrial cancer, vaginal cancer, and vulvar cancer. Cervical,
    ovarian, and uterine cancers have both the highest incidence and
    mortality rates of all the gynecologic cancers.
        The American Cancer Society estimates that this year in the United
    States over 100,000 people will be diagnosed with gynecologic cancers,
    including 66,570 new cases of uterine cancer, 21,410 cases of ovarian
    cancer, and 14,480 new cases of cervical cancer. More than 30,000
    people will die from these malignancies, including 12,940 deaths from
    uterine cancer, 13,770 deaths from ovarian cancer, and 4,290 deaths
    from cervical cancer.
        What is most alarming is the American Cancer Society's Annual
    Report to the Nation on the Status of Cancer, 1975-2014, which compared
    overall cancer survival rates from 1975-1977 and from 2006-2012 and
    reported that survival rates increased significantly for all but two
    cancer types in women, cancer of the cervix and of the uterus.
        Furthermore, there are significant health disparities among
    patients who are diagnosed with these cancers. Despite overall declines
    in cervical cancer mortality in the U.S. over the past 6 decades,
    racial and socioeconomic disparities continue to exist in cervical
    cancer screening, incidence, and mortality, resulting in a
    disproportionate impact on low-income patients and patients of color.
    Hispanic patients are most likely to get cervical cancer, followed by
    African Americans, American Indians and Alaskan natives, and Whites.
    Hispanic patients are sixty percent (60%) more likely to be diagnosed
    with and thirty percent (30%) more likely to die from cervical cancer
    than white patients. Black patients are approximately twice as likely
    to die of cervical cancer. Socioeconomic status plays a role in these
    disparities. Patients living below the poverty level and without a high
    school education are 4.9 and 6.3 times more likely to die of cervical
    cancer than patients with the highest income and education levels,
    respectively. As concerning as these figures remain, they may in fact
    represent an underestimation of the problem especially in black
    patients. A patient that is diagnosed with invasive cervical cancer
    often reflects a patient who did not have access to or failed to
    receive a Pap smear test.
        Uterine or endometrial cancer is the most common gynecological
    cancer, and the fourth most common malignancy among women in the United
    States. There are significant racial disparities in endometrial cancer
    as well. Endometrial cancer has been reported to be thirty-one percent
    (31%) lower among black patients compared to white patients. However,
    both black and Hispanic patients are less likely to receive evidenced
    based care. These racial disparities in treatment likely contribute to
    racial disparities in outcome. The age-adjusted mortality among black
    patients is approximately 84% higher.
        Disparities in access to genetic testing, preventive services, and
    other aspects of providing care for patients with gynecologic cancers
    are creating enormous inequities in outcomes and survivorship in our
    health care system, particularly for endometrial cancer and cervical
    cancer. Research is needed to help understand barriers to screening
    programs, discover new approaches to screening, and promote wider
    implementation of known strategies to facilitate optimal treatments and
    improved mortality for minority populations with these diseases.
        The SGO urges the Subcommittee to adopt the following report
    language focused on gynecologic cancers in the report accompanying the
    Fiscal Year 2022 Labor-HHS-Education appropriations bill.
    National Institutes of Health
    National Cancer Institute
        Gynecologic Cancers.--The Committee continues to be concerned about
    the growing racial, socioeconomic, and geographic disparities in
    gynecologic cancers. In contrast to most other common cancers in the
    United States, relative survival for women with newly diagnosed
    advanced cervical or endometrial cancer has not significantly improved
    since the 1970s.\1\ Furthermore, historical data demonstrates that
    Black and Latinx women with gynecologic cancers are not as likely to
    receive standard therapy and/or die more frequently.\2\ The current
    COVID-19 pandemic has only exacerbated the health care disparities that
    were already present in minority and underrepresented communities. For
    example, in early 2021 the Centers for Disease Control (CDC) published
    findings that cervix cancer screenings in California decreased by as
    much as 78% during the pandemic--and have not recovered. They
    specifically noted concern because ``cervical cancer incidence and
    mortality rates are disproportionately higher in Hispanic women and
    non-Hispanic Black women.'' \3\ Therefore, the Committee urges the NCI
    to expand the number of program projects, clinical trials, research
    grants, and contract opportunities for investigators that focus on
    discoveries that will positively impact access to prevention, early
    detection, diagnosis, and treatment for gynecologic cancers and address
    these now well documented disparities. Accelerated progress in reducing
    gynecologic cancer mortality has been a need for some time. The
    Committee requests an update on NCI's research program for gynecologic
    cancers in the fiscal year 2023 Congressional Budget Justification,
    including specific grants and strategies where the intent is to
    overcome these racial disparities in gynecologic cancers outcomes,
    including the underrepresentation of minority women in gynecologic
    cancer clinical trials.
    ---------------------------------------------------------------------------
        \1\ Jemal A, et al. Annual report to the nation on the status of
    cancer, 1975-2014, featuring survival. J Natl Cancer Inst 2017; 109(9):
    djx030.
        \2\ Rauh-Hain JA, et al. Racial and ethnic disparities over time in
    the treatment and mortality of women with gynecological malignancies.
    Gynecol Oncol 2018; 149(1): 4-11.
        \3\ Miller MJ, et al. Impact of COVID-19 on cervical cancer
    screening rates among women aged 21-65 years in a large integrated
    health care system. CDC Morbidity and Mortality Weekly Report. January
    29, 2021; 70(4): 109-113.
    ---------------------------------------------------------------------------
        Thank you in advance for your favorable consideration of this
    report language request. The SGO believes that pursuit of these
    important research objectives will help alleviate disparities in
    prevention, diagnosis, treatment, and survivorship of gynecologic
    cancers, benefitting minority patients and all patients who are
    impacted by these diseases.
                                     ______

           Prepared Statement of the Society of Nuclear Medicine and
                               Molecular Imaging
        Madam Chair and members of the Subcommittee, I am Richard L. Wahl,
    MD, President of the Society of Nuclear Medicine and Molecular Imaging
    and the Elizabeth E. Mallinckrodt Professor and head of radiology at
    Washington University School of Medicine in St. Louis, MO.
        The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is a
    nonprofit scientific and professional organization that promotes the
    science, technology, and practical application of nuclear medicine and
    molecular imaging. Research in this field has led to breakthroughs for
    diagnosing and treating patients with deadly conditions such as cancer,
    heart disease, and Alzheimer's disease. SNMMI strives to be a leader in
    unifying, advancing, and optimizing molecular imaging, with the
    ultimate goal of improving human health through noninvasive procedures
    and therapeutic approaches utilizing internally-administered
    radiopharmaceuticals. With over 15,000 members worldwide, SNMMI
    represents nuclear medicine and molecular imaging professionals,
    including physicians, physicists, radiochemists, pharmacists, and
    technologists, all of whom are committed to the advancement of the
    field. It is my pleasure to submit this testimony on behalf of SNMMI.
    We strongly support the President's request of $52 billion for the
    National Institutes of Health and ask that no less than $46.111 billion
    of that be for the NIH's base program budget for FY2022.
        Moreover, SNMMI supports a proportional increase to the National
    Institute of Biomedical Imaging and Bioengineering (NIBIB), resulting
    in at least $441.1 million for FY2022--a $30.4 million increase over
    FY2021. These base increases reflect approximately 5% above the
    biomedical research and development price index (BRDPI). Through
    consistent, strong funding for NIH and our national research
    infrastructure we can continue to make advancements that will improve
    the lives of patients with a wide spectrum of diseases and disorders.
    SNMMI is grateful for the Subcommittee's past support of NIH and
    encourages the Subcommittee to continue advancing discovery and
    innovation in nuclear medicine and molecular imaging.
        Nuclear medicine, in particular, is undergoing a renaissance as a
    precision medicine specialty, with new radiopharmaceuticals,
    radiopharmaceutical therapies, and instrumentation to elucidate biology
    and benefit patients. Federal research funding allows our members,
    partners, and stakeholders to improve imaging tools and therapies,
    which, in turn, broadens the resources available to address many
    challenging conditions. As a physician/clinician-scientist, my work has
    been greatly impacted by NIH funding, resulting in 18 patents, over 450
    peer-reviewed scientific manuscripts, and several FDA-approved
    theranostic (therapy + diagnostics) drugs and devices. I use state-of-
    the-art technologies like positron emission tomography (PET) combined
    with computer tomography (CT) and other advanced imaging modalities to
    improve the diagnosis and treatment of cancer types, including
    prostate, breast, neuroendocrine, and pancreatic, while also
    researching rare and orphan diseases.
       nuclear medicine and molecular imaging: precise and personalized
                                    medicine
        Nuclear medicine and molecular imaging procedures are used in a
    wide array of diseases and disorders, including cancer, Alzheimer's and
    Parkinson's Diseases, and cardiac disease, among others.\1\ Congress's
    support of NIH has helped to advance the science and the researchers
    who make these discoveries. NIH support is often the foundation of the
    newest technologies that go on to help patients. This subcommittee's
    continued support of the NIH, especially the National Cancer Institute
    (NCI), NIBIB, National Institute on Aging (NIA), National Institute of
    Neurological Disorders and Stroke (NINDS), National Institute of Mental
    Health (NIMH), and National Heart, Lung, and Blood Institute (NHLBI),
    will help scientists address many unmet medical needs. Some of the
    advances from the nuclear medicine and molecular imaging community in
    detecting and treating cancer and selecting the right patient for the
    right therapy are detailed below.
    ---------------------------------------------------------------------------
        \1\ Wahl RL, Chareonthaitawee P, Clarke B, Drzezga A, Lindenberg L,
    Rahmim A, Thackeray J, Ulaner GA, Weber W, Zukotynski K, Sunderland J.
    Mars Shot for Nuclear Medicine, Molecular Imaging, and Molecularly
    Targeted Radiopharmaceutical Therapy. J Nucl Med. 2021 Jan;62(1):6-14.
    doi: 10.2967/jnumed.120.253450. PMID: 33334911.
    ---------------------------------------------------------------------------
    Radiopharmaceutical Imaging and Therapy for Cancer
        In the last month alone, two major advancements in the fight
    against prostate cancer were in the news. Pylarify, a radioactive
    imaging agent, was approved by FDA on May 27. This radiotracer seeks
    out prostate cancer cells throughout the body so the active foci of
    cancer can be seen on a PET/CT scan. This class of agents targeting
    prostate specific membrane antigen or PSMA, can identify cancer months
    or years ahead of standard imaging such as CT or MRI, allowing patients
    to receive appropriate treatment sooner when it can be more effective.
    One week later, the results from the VISION trial were announced. This
    phase III trial enrolled men with late-stage castrate-resistant
    prostate cancer that had spread and were treated with either a PSMA
    targeting molecule with the radioisotope lutetium-177 (\177\Lu)
    attached, or with the best standard of care. The PSMA part of the drug
    acts like GPS to seek out prostate cancer cells. The attached lutetium-
    177 radioisotope destroys the cancer cells while leaving healthy tissue
    intact. Combined, the radiopharmaceutical therapy is in effect a
    ``smart bomb'' to selectively destroy foci of prostate cancer. The men
    treated with \177\Lu-PSMA had a four-month longer median survival than
    men receiving best standard of care alone. These results prompted FDA
    to label the treatment as a breakthrough therapy which will accelerate
    its approval time and allow it to reach patients in need faster. None
    of this would have been possible without the early support of 13 NIH
    grants.\2\
    ---------------------------------------------------------------------------
        \2\ Szabo Z, Mena E, Rowe SP, et al. Initial Evaluation of
    [(18)F]DCFPyL for Prostate-Specific Membrane Antigen (PSMA)-Targeted
    PET Imaging of Prostate Cancer. Mol Imaging Biol. 2015;17:565-574.
    ---------------------------------------------------------------------------
        Imaging and therapy molecule pairs, such as those using PSMA
    molecules as targeting agents, are often referred to as theranostics, a
    rapidly developing area of personalized medicine. If the diagnostic
    version of the molecule can find the cancer with a PET scan, then the
    same molecule with a therapeutic isotope can be used to attack the
    cancer. Further advancements in the theranostics space are anticipated.
    This treatment principle is being applied to cancer types for which we
    have no or few treatment options, such as pancreatic cancer. An
    exciting new class of theranostic molecules are those targeting
    fibroblast-activation-protein (FAP).\3\ This protein (FAP) is
    overexpressed in many cancer types including breast, pancreas, lung,
    kidney, and ovarian. The FAP molecule can be labeled as a diagnostic
    agent and then as a therapy. This treatment paradigm gives doctors a
    new tool in the fight against cancer. The NCI is currently supporting a
    phase 1 clinical trial (NCT04457258) on this promising new agent.
    ---------------------------------------------------------------------------
        \3\ Kratochwil C, Flechsig P, Lindner T, Abderrahim L, Altmann A,
    Mier W, Adeberg S, Rathke H, Rohrich M, Winter H, Plinkert PK, Marme F,
    Lang M, Kauczor HU, Jager D, Debus J, Haberkorn U, Giesel FL. 68Ga-FAPI
    PET/CT: Tracer Uptake in 28 Different Kinds of Cancer. J Nucl Med. 2019
    Jun;60(6):801-805. doi: 10.2967/jnumed.119.227967. Epub 2019 Apr 6.
    PMID: 30954939; PMCID: PMC6581228.
    ---------------------------------------------------------------------------
        None of these advances would be possible without the support of
    radiochemistry and isotope production research. The next generation of
    radioisotopes, alpha emitting therapeutic isotopes, which have much
    greater cancer killing power per radioactive decay, are in clinicals
    trials and are expected to provide better patient outcomes. Support of
    that research is critical.
    Quantitative Molecular Imaging
        A PET scanner is often thought of as an imaging tool; however, it
    is inherently a highly specific measuring tool. Recent advances in PET
    technology such as PET/MRI and total-body PET, where the whole body can
    be imaged at once, have opened new research possibilities.\4\ To
    realize the full potential of these advances, quantitative analysis
    will be required to appreciate the sensitivity of the scanner and the
    tracers it measures. The NCI has supported the harmonization of PET/CT
    scanners through numerous grants including NIH R01CA169072, and for the
    last decade, the NCI, through their Cancer Imaging Program has
    developed and supported a consortium of academic sites called the
    Quantitative Imaging Network performing and advancing quantitative
    imaging mostly in support of clinical trials.
    ---------------------------------------------------------------------------
        \4\ Meikle SR, Sossi V, Roncali E, Cherry SR, Banati R, Mankoff D,
    Jones T, James M, Sutcliffe J, Ouyang J, Petibon Y, Ma C, El Fakhri G,
    Surti S, Karp JS, Badawi RD, Yamaya T, Akamatsu G, Schramm G, Rezaei A,
    Nuyts J, Fulton R, Kyme A, Lois C, Sari H, Price J, Boellaard R, Jeraj
    R, Bailey DL, Eslick E, Willowson KP, Dutta J. Quantitative PET in the
    2020s: a roadmap. Phys Med Biol. 2021 Mar 12;66(6):06RM01. doi:
    10.1088/1361-6560/abd4f7. PMID: 33339012.
    ---------------------------------------------------------------------------
    Imaging of the brain in Alzheimer Disease
        In the past weeks, the FDA approved an innovative antibody therapy
    for Alzheimer's disease which removes amyloid plaque from the brain. At
    present, PET scanning using radiotracers that target the amyloid
    protein or the abnormal tau protein seen in dementias of the Alzheimer
    type have been key to identifying patients who may be suitable
    candidates for such clinical trials and these emerging therapies. The
    support of the NIH was key to developing these brain imaging agents and
    continued NIH support is essential to allow PET to probe the earliest
    changes of dementia and to monitor the effects of emerging innovative
    therapies. There are now several FDA approved PET imaging agents to
    identify patients with amyloid or tau deposition, helping identify how
    to best target limited resources to patient groups most likely to
    benefit from such therapies. The ability to select patients most likely
    to respond to therapy is expected to save tens of billions in
    healthcare dollars per year.
    Immuno-oncology Imaging
        In 1980, the NCI added $13.5M to their budget for new Biological
    Response Modifiers, this triggered a search for agents able to modify a
    body's response to tumor cells.\5\ That investment spawned the multi-
    billion-dollar drug class of immune checkpoint inhibitors (ICI),
    starting with the approval of Yervoy (ipilumimab) in 2011. In the US
    in 2020, a year severely impacted by the COVID-19 pandemic, sales of
    the top three ICI topped $17B. ICIs are generally considered to be safe
    and effective treatment options for numerous cancer types including
    lung cancers and melanoma, and some people like former US President
    Jimmy Carter had a remarkable response to ICI therapy. However, they do
    not work in all patients; indeed over half of patients treated with
    these agents die of their disease. New radiotracers are in development
    to image the immune system in conjunction with a PET or SPECT camera.
    Clinical trials with these tools have demonstrated the ability to
    predict response to ICI therapy after just one cycle of therapy. Future
    studies will aim to pre-select, with imaging, patients who are likely
    to respond to immune checkpoint inhibitors thus enabling effective
    therapy earlier and eliminating side effects of futile treatments. The
    ability to select patients likely to respond to therapy will also save
    billions in healthcare dollars.
    ---------------------------------------------------------------------------
        \5\ https://www.whatisbiotechnology.org/index.php/timeline/science/
    immunotherapy/80.
    ---------------------------------------------------------------------------
    Data Science and Workforce
        The field of nuclear medicine and molecular imaging is rapidly
    expanding with new diagnostic imaging tracers, radiopharmaceutical
    therapies (RPT), and technologies. With new diagnostic tracers comes a
    need to properly interpret the innovative scans. Artificial
    intelligence (AI) algorithms can assist with the tedious components of
    image interpretation and even help with quality report generation.
    Development of well-credentialed registries of studies to train and
    validate such AI algorithms, reflecting diverse sets of patients will
    help advance this field. Radiopharmaceuticals therapies (RPTs), like
    other oncology therapies, are often studied in and approved for
    patients with late-stage disease, for example, after all other
    treatments have failed. To harness the full potential of RPTs, use
    earlier in the disease course may be advisable. Image and clinical data
    registries are needed to capture post-approval information on the use
    of RPTs and the patient outcomes to further guide their use. Recent
    imaging and therapy FDA approvals in prostate cancer and Alzheimer's
    disease, two highly prevalent conditions, require that the highly
    specialized field of nuclear medicine and molecular imaging train a
    cadre of qualified individuals to diagnose and treat these patients. It
    is critical for the NIH to fund and expand training grants so that our
    brightest scientists have the skills to develop a sustainable career
    pathway. Funding for AI technologies and registries will improve
    patient care and outcomes.
                             summary and conclusion
        Robust NIH funding is crucial to advancing our efforts to detect
    and treat serious medical conditions. NIH investments help to sustain
    both our local and national research institutions across every state in
    the nation. China is advancing rapidly in the high technology medical
    space notably in AI. Funding NIH's base program with at least $46.111
    billion will help researchers, scientist and physicians retain its
    competitive edge.
        Thank you for your strong, continued support of NIH, NCI, NIMH,
    NIBIB and all the Institutes and Centers working to advance molecular
    imaging and radiopharmaceutical therapies to improve the lives of
    patients worldwide. On behalf of the Society of Nuclear Medicine and
    Molecular Imaging, I urge you to continue your strong support of our
    nation's research and innovation enterprise.

        [This statement was submitted by Richard L. Wahl, MD, President,
    Society of
    Nuclear Medicine and Molecular Imaging.]
                                     ______

                 Prepared Statement of the Student Support and
                          Academic Enrichment Program
        Dear Chairwoman Murray, Ranking Member Blunt, Chairwoman DeLauro,
    and Ranking Member Cole:
        As you consider Fiscal Year 2022 appropriations for the U.S.
    Departments of Labor, Health and Human Services, and Education, we
    encourage you to help close opportunity and resource gaps in our
    nation's public schools by funding the Student Support and Academic
    Enrichment (SSAE) grant program authorized by Title IV-A of the Every
    Student Succeeds Act (ESSA) at $2 billion, which represents a $780
    million increase over FY2021.
        Title IV-A is a flexible grant that supports state and district
    efforts to: (1) support safe and healthy students by providing
    comprehensive mental and behavioral health services, implementing
    violence prevention programs, trauma informed care, school safety
    trainings; and other evidenced based initiatives; (2) increase student
    access to a well-rounded education, such as: STEM; computer science and
    accelerated learning courses; career and technical education; physical
    education; music; the arts; foreign languages; college and career
    counseling; effective school library programs; and social and emotional
    learning; and (3) provide students with access to technology and
    digital learning materials and educators with professional development
    and coaching opportunities necessary to effectively use those
    resources.
        Over the last four fiscal years, on a bipartisan basis, Congress
    has provided a $4 billion investment for Title IV-A, which has allowed
    districts to meaningfully invest in programs that provide direct
    educational services and equitable supports to students. Its
    flexibility has allowed districts to provide funding for critical
    programs that support educators, school leaders, and students. As
    district leaders continue to leverage the flexibility of the SSAE
    grants, they are eager to plan for the continuance and/or expansion of
    existing programs and services, and to create new programs.
        To address unprecedented interruptions to learning caused by COVID-
    19, we call on Congress now to go beyond what was authorized in ESSA by
    providing $2 billion for the SSAE block grant. This will allow
    additional school districts, especially in rural areas, to make
    investments in not just one, but all three areas that this grant
    supports. Right now--more than ever--districts need the continued
    investments in the Title IV-A program.
        The continued funding in these critical areas, especially during
    these uncertain times, will give districts the opportunity to build on
    the successes from the past 5 fiscal years as well as the ability to
    use Title IV-A funds to address issues that the COVID-19 crisis has
    made apparent and exacerbated. This pandemic has made clear that
    districts face a wide range of unique challenges, whether it's ensuring
    all children have access to technology for remote or blended learning
    or the ability to provide mental health supports from afar. As school
    systems prepare for the return to the classroom, they will need the
    flexibility of Title IV-A funds to provide social and emotional
    learning programs, engaging well-rounded classes like music and
    physical education, and active learning opportunities enabled through
    technology.
        In order to support a safe and healthy school environment and make
    sure our students receive a well-rounded education that puts them on a
    path to success, we must continue to invest in our nation's schools,
    educators, and most importantly, our students. For these reasons, we
    urge Congress to fund the SSAE flexible grant program at $2 billion in
    FY 2022.
        Thank you for the consideration of this request, we are grateful
    for the continued investments in the Student Support and Academic
    Enrichment grant program under Title IV-A of the Every Student Success
    Act (ESSA).
        Sincerely.

                                     ______

         Prepared Statement of Susan G. Komen Breast Cancer Foundation
        Susan G. Komen (Komen) is the world's leading nonprofit breast
    cancer organization representing the millions of Americans who have
    been diagnosed with breast cancer and are currently living in the
    United States. Komen has an unmatched, comprehensive 360-degree
    approach to fighting this disease across all fronts--we advocate for
    patients, drive research breakthroughs, improve access to high-quality
    care, offer direct patient support and empower people with trustworthy
    information. Komen is committed to supporting those affected by breast
    cancer today, while tirelessly searching for tomorrow's cures. We
    advocate on behalf of the estimated 284,200 women and men in the United
    States that will be diagnosed with breast cancer and the more than
    44,000 that will die from the disease in 2021 alone.
        Screening tests are used to find breast cancer before it causes any
    warning signs or symptoms. Regular screening enables us to detect
    potential cancers at earlier stages and refer patients to further care,
    often yielding better outcomes for patients and resulting in decreased
    financial pressure on our healthcare system. Without access to early
    detection programs, many individuals are forced to delay or forgo
    screenings, which can lead to disease progression and later-stage
    breast cancer diagnoses. To ensure access to early detection programs,
    Komen is requesting that Congress fully fund the Centers for Disease
    Control's (CDC) National Breast and Cervical Cancer Early Detection
    Program (NBCCEDP) at the authorized amount of $275 million in Fiscal
    Year (FY) 2022.
        NBCCEDP was established with the passage of the Breast and Cervical
    Cancer Mortality Prevention Act in 1990. The program plays a critical
    role in helping low-income, uninsured, and underinsured women who do
    not qualify for Medicaid receive timely breast and cervical cancer
    screening, diagnostic and treatment services that are free or low-cost.
    The covered services include clinical breast examinations, mammograms,
    pelvic examinations, Pap tests, human papillomavirus (HPV) tests,
    diagnostic tests if screening results are abnormal, and referrals to
    treatment. Additionally, the NBCCEDP provides patient navigation
    services to help women overcome barriers and get timely access to
    quality care.
        For 30 years, NBCCEDP has provided lifesaving breast cancer
    screening and diagnostic services to eligible women in all 50 states,
    the District of Columbia, six territories and 13 American Indian/Alaska
    Native tribes or tribal organizations. NBCCEDP has served more than 5.8
    million women since it launched in 1991, detecting over 72,000 breast
    cancers, nearly 23,000 premalignant breast lesions, 4,900 cervical
    cancers and 226,000 premalignant cervical lesions. More statistics on
    the number of women served by the program in each state is available
    here.
        The program, which is a partnership between the CDC and state
    health departments, also provides public education, outreach, care
    coordination and quality assurance to increase breast cancer screening
    rates and reach underserved, vulnerable populations. Each state program
    operates within the national framework of legislation, policy, and
    oversight; however, programs vary in funding, infrastructure,
    populations served and geographical barriers. Programs can prioritize
    the population they serve based on their cancer burden, environment,
    available resources and goals. Unfortunately, these are often
    influenced and limited by state funding and state legislative
    constraints.
        The COVID-19 pandemic highlighted the broad systemic trend that
    exists with almost every public health crisis: consequences are more
    commonly and more severely experienced in low-income, minority and
    rural communities. Black women in the United States have a breast
    cancer mortality rate about 40 percent higher than white women.
    Similarly, Hispanic/Latina and American Indian/Alaska Native women are
    30 percent more likely to be diagnosed with advanced stage breast
    cancer compared with white women. NBCCEDP funding supports
    interventions which help address inequities in breast cancer screening
    and diagnosis since the program places special emphasis on women who
    are geographically or culturally isolated and who identify as racial or
    ethnic minorities. The program focuses on factors at the interpersonal,
    organizational, community and policy levels that influence screening.
    NBCCEDP invests in evidence-based interventions, for health care
    systems and communities, which reflect cultural competencies needed to
    reach communities that often distrust the medical system. Use of
    multicomponent interventions of this type are found to be more
    effective at connecting historically marginalized communities to
    services. However, the CDC and state health departments need more
    support.
        More than 2.6 million women are eligible for NBCCEDP breast cancer
    screening services. Authorized at $275 million, the program is
    currently funded at approximately $197 million. Unfortunately, at
    current funding levels NBCCEDP serves fewer than 15 percent of the
    estimated number of eligible women for breast cancer screening services
    and less than seven percent of eligible women for cervical cancer
    screening.
        An increase in funding in FY22 will be especially crucial as the
    nation recovers from the COVID-19 pandemic. Data show that the pandemic
    has caused people to delay life-saving breast cancer screenings.
    Models, based on data from the 3-month period from early March 2020
    through early June 2020, suggest there could be as many as 36,000
    missed or delayed diagnoses of breast cancer because of COVID-19.\1\
    This delay can mean women will not seek care until the cancer is more
    advanced, leading to worse outcomes for the patient and much more
    costly treatment. Furthermore, with many Americans experiencing job
    loss and financial difficulties related to the COVID-19 pandemic, with
    resulting loss of healthcare benefits, continued access to NBCCEDP is
    needed now more than ever.
    ---------------------------------------------------------------------------
        \1\ IQVIA Institute for Human Data Science, Shifts in Healthcare
    Demand, Delivery and Care During the COVID-19 Era (April 2020).
    ---------------------------------------------------------------------------
        The availability of the NBCCEDP impacts every taxpayer and people
    in every congressional district, as the uninsured will eventually seek
    care at our states' hospitals with late-stage disease, putting an even
    greater strain on the patients, the health system and state budgets.
    Ensuring adequate NBCCEDP funding is key to ensuring that low-income,
    uninsured, and underinsured women across the country continue to have
    access to vital screening services, health education and patient
    navigation services, as well as enabling proper monitoring of state and
    local breast cancer patterns and trends.
        An increased investment in the NBCCEDP will allow the CDC and its
    state and local partners to broaden its reach and pursue important
    goals such as implementing innovative strategies and new methods to
    find eligible women currently not using the program, including those
    with no source of care, and lower incomes, education, and health
    literacy levels, ultimately helping to create a more equitable health
    care system.
        The NBCCEDP has bipartisan support in both the Senate and House of
    Representatives, with letters being submitted in both chambers in
    support for full authorized funding for the program this year.
    Increasing funding for NBCCEDP to the authorized level of $275 million
    in the FY 22 Labor, HHS, Education Appropriations Bill will result in
    more women being screened, more cancers being diagnosed at earlier
    stages and ultimately better outcomes for women and lower costs for our
    health care system.

        [This statement was submitted by Molly Guthrie, Sr., Director,
    Public Policy and Advocacy.]
                                     ______

             Prepared Statement of the Task Force for Global Health
        Thank you for this opportunity to provide testimony on polio
    activities at The Task Force for Global Health. I write to express our
    support for full funding for CDC's polio initiatives.
        The Task Force for Global Health, founded nearly 40 years ago to
    advance health equity, works with partners in more than 150 countries
    to eliminate diseases, ensure access to vaccines and essential
    medicines, and strengthen health systems to protect populations. Our
    expertise includes polio, influenza, COVID-19, hepatitis, neglected
    tropical diseases; vaccine safety, distribution and access; and health
    systems strengthening. Our COVID-19 activities include working with 50
    countries to deliver vaccines, address vaccine hesitancy, provide
    vaccine safety guidelines; advise on digital contact tracing; train
    epidemiologists in disease surveillance and response; distribute
    essential protection and treatment to hard-hit communities; work
    through existing health programs to ensure protection for vulnerable
    groups, such as those afflicted with other diseases; and leverage our
    existing supply chains to support ongoing response and assist countries
    in delivering vaccines.
        CDC has been engaged in the fight against polio for over 31 years.
    Its leadership, in providing technical guidance and expertise in
    countries, regionally and globally as part of the Global Polio
    Eradication Initiative, has resulted in a reduction in the number of
    worldwide polio cases from an estimated 350,000 in 1988 to 176 in
    2019--a decline of more than 99% in reported cases. It has also
    resulted in polio-free certification in five of the six regions of the
    world--the African Region, the Americas, Europe, South East Asia and
    the Western Pacific. Only two polio-endemic countries (nations that
    have never interrupted the transmission of wild poliovirus) remain--
    fghanistan and Pakistan. Without CDC's polio eradication efforts, more
    than 18 million people who are currently healthy would have been
    paralyzed by the virus.
        At the Task Force for Global Health, we are providing surge
    capacity expertise and technical assistance to outbreak countries and
    those at high risk of future outbreak in the African region. Since
    April 2018, the Global Polio Surge Capacity Team, consisting of a
    project manager and four senior epidemiologists, have deployed a total
    of 17 times to Ghana, Ethiopia, Indonesia, Congo-Brazzaville, and
    Zambia, with a total of nearly 1,250 person days. In a time of growing
    scale and scope of circulating type 2 vaccine-derived poliovirus
    (cVDPV2) outbreaks, the team provides highly respected and valued
    expertise across the Global Polio Eradication Initiative (GPEI)
    partnership.
        In Ministry of Health forums, the team is considered a crucial
    component of polio outbreak response efforts, often working closely
    with Emergency Operations Centers and national public health institute
    staff. They have provided technical assistance for improving active
    case search, enhancing surveillance efforts, and preparation and
    implementation of vaccination campaigns. Supplementary immunization
    activities have targeted hundreds of millions of children since the
    team was created, and the long-term nature of their deployments has
    provided essential continuity in settings that often see high staff
    turnover.
        Since CDC began the Frontline Polio Surge activities in October
    2019, the team has provided supervision and direction to the deployed
    staff, connecting them with district surveillance staff, WHO
    colleagues, and Ministry of Health staff. They serve as in-country
    experts and resources to teams deployed at district levels for
    campaigns and surveillance strengthening activities. A training program
    to prepare 100 NSTOP (National Stop Transmission of Polio) staff for
    field deployments was developed and conducted.
        In Ethiopia and Zambia, members of the team have taken the lead on
    supporting the Ministries of Health in developing comprehensive
    surveillance proposals for continued active case search of Acute
    Flaccid Paralysis (AFP) cases, with SOPs and protocols for district
    surveillance staff. These include the utilization of Field Epidemiology
    Training Program (FETP) residents as sources of valuable local human
    resource capacity. The institutionalization of this expertise is
    crucial for these countries working towards controlling outbreaks and
    ultimately eradicating polio.
        Moving forward, we will continue to provide in-person technical
    assistance to countries facing circulating vaccine-derived type 2
    poliovirus outbreaks, to meet surveillance and response needs. This
    work will include pre-, intra-, and post-vaccination campaign
    activities. Additionally, the team will apply its extensive breadth of
    experience in using data for action to strengthen surveillance
    networks, country outbreak preparedness and response plans, and
    training materials.
        Lastly, we will provide remote technical assistance as needed on
    campaign data quality, monitoring and evaluation of campaigns,
    strengthening of EOCs, and supervision of local consultants. Members of
    the team will continue to provide guidance on various long-term
    requests from Ministries of Health and international agencies.
        Due to Congress's support in FY 2019 and FY 2020, select CDC polio
    accomplishments include:
      --Provide instrumental support internationally and domestically
            through extensive details to the CDC COVID-19 response and
            through polio-supported staff to the COVID-19 pandemic response
            in Afghanistan, Pakistan, and across Africa in the areas of
            disease surveillance, health worker training, contact tracing,
            risk communications and testing.
      --Provide $56.13 million in FY 2020 to UNICEF for the expansion of
            Community Based Vaccinator Program in Pakistan that now
            includes over 24,000 workers (nearly 90% are women) who reach 4
            million children annually, approximately 60 million doses of
            oral polio vaccine, 2.9 million doses of inactivated polio
            vaccine, and $3 million for operational costs for NIDs in all
            polio-endemic countries and outbreak countries. Most of these
            NIDs would not take place without the assurance of CDC's
            support.
      --Provide expertise in virology, diagnostics, and laboratory
            procedures, including quality assurance, and genomic sequencing
            of samples obtained worldwide; provide the largest volume of
            operational (poliovirus isolation) and technologically
            sophisticated (genetic sequencing of polio viruses) lab support
            to the 145 laboratories of the global polio laboratory network.
            CDC has the leading specialized polio reference lab in the
            world.
      --Deploy 210 Stop Transmission of Polio (STOP) members in 42
            countries with two-thirds deployed to the African Region which
            has significantly benefited from STOP support, contributing
            substantially to the region's achievement of wild polio-free
            status in 2020. CDC's Stop Transmission of Polio (STOP) program
            trained and deployed 2100 public health professionals to
            improve vaccine-preventable disease surveillance and to help
            plan, implement, and evaluate vaccination campaigns.
      --Use STOP participants to support local governments, health
            facilities, and communities during the COVID-19 pandemic to
            promote awareness of COVID-19 and provide contract tracing
            while still supporting VPD surveillance, essential immunization
            services, and polio eradication efforts.
        Global polio initiatives are leading us to a day when polio will be
    eradicated from our planet. The Task Force for Global Health is honored
    to support CDC's leadership in its mission and to serve as part of this
    strong global partnership to end polio in our lifetime.
        With Congress' continued support, we will be able to support CDC's
    outbreak priorities, which include strengthening surveillance for
    polioviruses in all areas currently below certification standard and
    rapidly responding to the detection in a population of the types of
    polioviruses included in discontinued oral polio vaccines. We will also
    ensure that populations are not exposed to the types of polioviruses
    included in discontinued oral polio vaccines while laying the logistic
    and epidemiologic groundwork for the complete cessation of use of all
    oral polio vaccines.
        Thank you for the opportunity to provide this testimony.

        [This statement was submitted by Dr. Fabien Diomande, Director,
    Polio Surge Program: Task Force for Global Health.]
                                     ______

             Prepared Statement of the Task Force for Global Health
        Thank you for allowing me to provide written remarks on behalf of
    the Coalition for Global Hepatitis Elimination of the Task Force for
    Global Health. I want to express the Coalition's strong support for
    funding of at least $250 million for the Department of Health and Human
    Services' national strategy for the elimination of viral hepatitis and
    the global and domestic activities needed to achieve the plan's goals
    for hepatitis elimination.
        As the COVID-19 pandemic has taught us, we must eliminate deadly
    viral threats when we have the opportunity. Now is the time to
    eliminate hepatitis B virus (HBV) and hepatitis C virus (HCV).
        The Task Force for Global Health, founded in 1984 to advance health
    equity, works with partners in more than 150 countries to eliminate
    diseases, ensure access to vaccines and essential medicines, and
    strengthen health systems to protect populations. Our expertise
    includes neglected tropical diseases and other infectious diseases;
    vaccine safety, distribution and access; and health systems
    strengthening.
        The Coalition for Global Hepatitis Elimination, a program of the
    Task Force for Global Health, with support of CDC and NIH, assists the
    work of public health authorities, clinicians and community
    organizations working on the front lines to prevent, detect and treat
    HBV and HCV.
            hbv and hcv infections are large global health problems
        In 2015, a total of 296 million and 58 million persons worldwide
    were living with HBV and HCV infections, respectively, which cause over
    1 million deaths per year. In the United States, as many as 2.3 million
    persons are living with HBV infection and 3.5 million persons are
    living with HCV infection. The United States has the third largest
    burden of HCV in the world, after only China and India. Of HBV and HCV
    infected persons, if undiagnosed and untreated, 20%-25% will die of
    liver disease or liver cancer. Three of four liver cancer deaths are
    caused by HBV or HCV.
        Hepatitis is a health disparity for racial/ethnic minority
    populations and for rural America. The health threat of hepatitis B is
    greatest for Asian Americans who were not vaccinated as children before
    arriving in the United States. Hepatitis-infected persons in
    communities of color have limited access to testing and lifesaving
    treatment, leading to higher death rates for American-Indians/Alaskan
    Natives and Black Americans. New infections of HCV are rising at an
    alarmingly fast pace, fueled by the opioid crisis and increases in
    injection drug use with unsafe equipment. HCV infections rates are
    increasing the most among young adults in Appalachian states.
        All of the public health and biomedical tools needed to address
    these gaps in hepatitis prevention, testing, and treatment are
    available. HBV vaccines have been in use for decades. Indeed, the 2020
    Nobel Prize in Medicine was awarded to two American scientists for work
    leading to the discovery of HCV and making possible the reliable tests
    and first curative therapies for a chronic viral infection. Rarely in
    public health do we have this opportunity. Now is the time to act
    within our borders and globally to eliminate viral hepatitis.
    Support for the Viral Hepatitis National Strategic Plan for the United
            States: A Roadmap to Elimination 2021-2025
        In January 2021, the Department of Health and Human Services
    released the Viral Hepatitis National Strategic Plan for the United
    States: A Roadmap to Elimination 2021-2025. The Plan is the first to
    join with the global goals adopted by other nations and to aim for
    elimination of viral hepatitis as a public health threat in the US.
    With the support of this Committee and of Congress, the nation can act
    on this first national elimination plan and strengthen efforts to stop
    hepatitis in its tracks and ensure all people benefit from disease
    elimination.
        The Coalition activities supported by federal agencies, including
    CDC and NIH, assist the implementation of the HHS strategic plan and
    achievement of goals for hepatitis elimination. With federal partners,
    the Coalition is focused on 4 key objectives for advancing hepatitis
    elimination. The US must advance these priorities at home to ensure the
    success of the national strategic plan and also provide global
    leadership in addressing this public health threat.
        Priority 1. Assure all newborns receive Hepatitis B vaccination and
    are protected from HBV infection and liver cancer. A birth dose of
    hepatitis B vaccine followed by two doses of infant immunizations
    decreases risk of mother-to-child HBV transmission by 90%. However,
    less than 50% of children globally receive hepatitis B vaccine within
    24 hours, a critical intervention interrupting mother-to-child
    transmission. Coverage is lowest (10%) in Africa where the prevalence
    of HBV is the highest in the world. In collaboration with CDC, the
    Coalition is training public health officials and assisting countries
    to develop improved vaccination policies. Over 200 Ministry of Health
    officials, research partners, and civil society members are
    participating in training sessions to support more governments in
    adopting hepatitis B newborn vaccine policies and improving coverage.
    Through these efforts, the Coalition limits continued introduction of
    HBV into the US and reduces HBV as a health disparity for Asian and
    African-born Americans.
        Priority 2. Implement simple models of care to detect and treat
    persons living with HBV and HCV. The therapies for HBV and HCV are low
    cost and safe. Therapies for HCV cure 95% of persons who receive
    treatment. Most persons globally remain undiagnosed and untreated.
    Proven models of care by non-specialists increase access to lifesaving
    testing and treatment. in the US and globally. The Coalition assists
    health systems simplify care and eliminate HBV and HCV as major causes
    of death.
        Priority 3. Develop tools for tracking progress in elimination.
    Over the course of the next year, the Coalition will develop national
    hepatitis elimination profiles for the United States and other high-
    burden countries bringing together the latest data regarding hepatitis
    burden and status of policy development with trends in access to
    vaccination, testing and treatment. These profiles will help countries
    identify gaps in hepatitis services and assist US Government agencies
    to prioritize support.
        Priority 4. Create additional opportunities to disseminate lessons
    on effective hepatitis prevention care and treatment. Despite effective
    tools and model programs, many countries like the United States are
    facing a rise in new cases or low screening rates. Programs in the
    United States and across the world benefit from sharing lessons
    learned, saving time and avoiding redundant research. Over the past
    year, the Coalition has reached over 1,000 individuals in 64 countries
    through over 20 stakeholder meetings and web-based educational and
    training sessions. These events are opportunities for programs to share
    experiences and resources. The Coalition is collaborating with NIH to
    publically share NIH-funded research advancing hepatitis elimination
    and identify further research priorities.
        Thank you again for this opportunity to support full funding of the
    HHS roadmap for hepatitis elimination. The Coalition looks forward to
    continued collaborations with HHS on the domestic and global activities
    needed to eliminate viral hepatitis in the United States and globally.

        [This statement was submitted by William P. Nichols, Executive Vice
    President and Chief Operating Officer, Task Force for Global Health.]
                                     ______

          Prepared Statement of the Task Force for Global Health, Inc.
        Thank you for this opportunity to provide testimony on influenza
    activities at The Task Force for Global Health. I write to express our
    support for full funding for CDC's influenza initiatives.
        The Task Force for Global Health, founded nearly 40 years ago to
    advance health equity, works with partners in more than 150 countries
    to eliminate diseases, ensure access to vaccines and essential
    medicines, and strengthen health systems to protect populations. Our
    expertise includes polio, influenza, COVID-19, hepatitis, neglected
    tropical diseases; vaccine safety, distribution and access; and health
    systems strengthening. Our COVID-19 activities include work with 53
    countries to deliver vaccines, address vaccine hesitancy, provide
    vaccine safety guidelines; advise on digital contact tracing; train
    epidemiologists in disease surveillance and response; distribute
    essential protection and treatment to hard-hit communities; work
    through existing health programs to ensure protection for vulnerable
    groups, such as those afflicted with other diseases; and leverage our
    existing supply chains to support ongoing response and assist countries
    in delivering vaccines. The Task Force's influenza program has provided
    the framework for our work in COVID-19.
        In 2013 with funding from CDC, the Task Force for Global Health
    established the Partnership for Influenza Vaccine Introduction (PIVI)
    to create sustainable, seasonal influenza vaccination programs in low-
    and middle-income countries. The initiative protects communities from
    the annual impact of flu, and also builds the adult immunization
    infrastructure, capacity, and vaccine delivery systems critical for
    future influenza pandemics and other infectious disease epidemics.
        During the 2009 influenza pandemic, countries with seasonal
    influenza vaccination programs were able to import, and use vaccines
    much faster than countries without such programs.\1\ With financial and
    technical support from CDC, PIVI supports countries in building legal,
    programmatic, policy-making, and regulatory capacity to quickly import
    and deploy influenza vaccines. The public-private collaboration
    provides influenza vaccines allowing countries to annually exercise and
    evaluate program effectiveness while moving towards country ownership
    and sustainability. In support of this objective, PIVI funds and
    fosters creation of regional collaborations that establish multi-
    country region-level working groups to share data, programmatic
    experience and explore opportunities for joint vaccine procurement
    efforts.
    ---------------------------------------------------------------------------
        \1\ Porter, R. M. et al. (2020) 'Does having a seasonal influenza
    program facilitate pandemic preparedness? An analysis of vaccine
    deployment during the 2009 pandemic', Vaccine. Elsevier, 38(5), pp.
    1152-1159.
    ---------------------------------------------------------------------------
        The influenza program infrastructure has supported, and continues
    to support, the efforts to fight COVID-19. From disease risk education
    and prevention, surveillance, the collection and analysis of laboratory
    specimens, and the sharing of information and genetic sequence data--
    the global and national influenza infrastructure is an indispensable
    component of the public health response to COVID-19. The same influenza
    vaccine delivery systems that enabled timely and efficient use of
    seasonal influenza vaccine are, and will be, utilized to deploy COVID-
    19 vaccine(s) as they become available. PIVI is at the forefront of
    this work.
        In 2020, building on the expertise, the experience, and the lessons
    learned from the program, the Task Force quickly developed a new
    program called CoVIP, a public-private partnership between CDC and the
    Task Force engaging a global collaboration of public health technical
    experts, to ensure that low and middle-income countries are ready and
    able to deploy and evaluate COVID-19 vaccines as they become available.
        With funding from the CARES Act, the Task Force's influenza program
    is currently supporting 53 countries with technical assistance and some
    funding to develop national deployment plans, evaluate programmatic
    approaches, and refine their vaccine program approaches.
        Applying the influenza program tools to the COVID-19 vaccine
    rollout provides a unique opportunity to rapidly gather information to
    improve and sustain the vaccines for global use, and establish long-
    lasting national capacities for future use.
        Thank you for the opportunity to provide this testimony.

        [This statement was submitted by Dr. Mark McKinlay, Director,
    Center for
    Vaccine Equity: Task Force for Global Health, Inc.]
                                     ______

           Prepared Statement of the Tourette Association of America
        Dear Chairwoman Murray, Ranking Member Blunt and Members of the
    Subcommittee:
        The Tourette Association of America (TAA) would like to take this
    opportunity to thank the members of the Subcommittee for the
    opportunity to submit written testimony and for considering our request
    for funding for Fiscal Year 2022 (FY22). The Centers for Disease
    Control and Prevention (CDC) play a pivotal role in educating the
    public. To that end, the Tourette Syndrome Public Health Education and
    Research Program at the CDC is critically important to the TS and Tic
    Disorder community. We respectfully request that you continue funding
    the enacted level $2 million appropriation for the program in FY22
    Labor, Health and Human Services (LHHS), Education and Related Agencies
    Appropriations. The program on Tourette Syndrome is administered within
    the National Center on Birth Defects and Developmental Disabilities
    (NCBDDD) at the CDC, in partnership with the TAA. This program was
    established by Congress in the Children's Health Act of 2000 (PL. 106-
    310 Title 23) and is the only such program that receives federal
    funding for Tourette Syndrome (TS) public health education. With your
    support at the previously enacted level of $2 million, CDC can ensure
    critically necessary progress continues in the areas of public
    education, research and diagnosis for TS and Tic Disorders.
        The TAA is the premier national non-profit organization working to
    make life better for all people affected by TS and Tic Disorders. We
    have served in this capacity for 49 years. Tics are involuntary,
    repetitive movements and vocalizations. They are the defining feature
    of a group of childhood-onset, neurodevelopmental conditions known
    collectively as Tic Disorders and individually as Tourette Syndrome,
    Chronic Tic Disorder (Motor or Vocal Type), and Provisional Tic
    Disorder. People with TS and Tic Disorders often have substantial
    healthcare costs across their lifespan for healthcare visits, special
    educational services, medication, and psychological and behavioral
    counseling. In a recent survey conducted by the TAA (2018 TAA Impact
    Survey: https://tourette.org/research-medical/impact-survey/), 63% of
    parents struggle to cover the high costs of services for their child
    such as counseling, appointments and tutoring; 34% of parents report
    they lost their job or they are not able to work as often due to the
    increased caregiver duties of having a child living with TS; and, 18%
    of parents are not able to afford medications and/or desired medical
    care for their child. A recent Coronavirus impact survey, conducted by
    TAA (https://tourette.org/coronavirus-and-tourette-syndrome/), found
    that 82% of respondents said their tics or other symptoms worsened
    during the pandemic.
        The CDC Tourette Syndrome Website (https://www.cdc.gov/ncbddd/
    tourette/data.html) on data and statistics states that data suggest
    roughly 50% of children and teens with TS are not diagnosed. Studies
    including children with both with diagnosed and undiagnosed TS have
    estimated that 1 out of every 162 children (0.6%) have TS. However,
    these numbers do not include children with Chronic or Provisional Tic
    Disorders. The estimated combined total of all school-aged children
    with TS or another related Tic Disorder is approximately 1-in-100.
    Factoring in lifelong prevalence, we estimate 1 million adults and
    children are living with Tourette Syndrome or another Tic Disorder in
    the United States today. These statistics outline the need for
    additional research on prevalence. Diagnosis is often complicated.
    Among children diagnosed with TS, 83% have been diagnosed with at least
    one additional mental, behavioral, or developmental condition according
    to the CDC website. These co-occurring conditions include Attention
    Deficit-Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder
    (OCD), Autism, Oppositional Defiance Disorder, anxiety, depression,
    learning difficulties among others and can significantly impact the
    lives of those affected by TS. In fact, in TAA's 2018 Impact Survey,
    42% of children felt that dealing co-occurring conditions was one of
    the biggest challenges in managing TS. In addition, 32% of children and
    51% of adults have considered suicide or participated in self-harming
    behaviors. This underscores the need to increase the diagnosis rate so
    physicians, teachers and parents can ensure that adequate support
    services are in place. The CDC TS Program works to ensure primary care,
    family doctors or pediatricians are equipped with the additional
    knowledge necessary either to diagnose or to refer a patient for
    optimal treatment.
        Education professionals often do not receive detailed instruction
    on how to assess and accommodate students who may have TS and Tic
    Disorders. A study published in the Journal of Developmental &
    Behavioral Pediatrics and written in partnership between the CDC and
    the Tourette Association of America, ``Impact of Tourette Syndrome on
    School Measures in a Nationally Representative Sample'', found children
    with Tourette were more likely to have an individualized IEP, have a
    parent contacted about school problems and have incomplete homework as
    compared to children without Tourette or a Tic Disorder. Additionally,
    most children with Tourette Syndrome had other mental, behavioral, or
    emotional disorders or learning and language disorders. In TAA's 2018
    Impact Survey, 83% of children felt that TS negatively impacted their
    school experience and education and 69% of parents noted their child
    having an individualized education plan (IEP) or 504 plan in place at
    their school. Educators spend a significant amount of time with their
    students providing more opportunities to assess symptoms and behavior
    over a longer period of time. By increasing their knowledge base and
    understanding of Tourette Syndrome, Tic Disorders and associated co-
    morbidities, educators can refer students for medical assessment and
    can also better serve the needs of this population whose challenges are
    unique to the disorder. Educators can then begin to work more closely
    with medical providers to develop effective, individualized education
    plans.
        TS and Tic Disorders are greatly misunderstood and often suffer
    from misinformation and stigma. For example, coprolalia, the
    involuntary utterance of obscene and socially unacceptable words and
    phrases, is an extreme and rare symptom often sensationalized by the
    media. Less than 10% of those diagnosed have this symptom, it is not
    required for diagnosis, and does not persist in many cases. The CDC TS
    Public Health, Education and Research Program provides important
    information on symptoms/diagnostic criteria on their website and
    through the outreach program educating the public and parents on
    Tourette Syndrome and Tic Disorders to ensure a better understanding
    which can lead to better diagnosis, earlier treatment and a better
    understanding.
        Delayed diagnosis or the lack of diagnosis can increase health care
    costs, increase education costs and delay important treatment and
    therapy for the patient. Comprehensive Behavior Intervention for Tics
    (CBIT) is a non-medicated treatment consisting of three important
    components: training the patient to be more aware of his or her tics
    and the urge to tic; training patients to do competing behavior when
    they feel the urge to tic; and, making changes to day-to-day activities
    in ways that can be helpful in reducing tics. CBIT is now recognized as
    a first line treatment by the American Academy of Neurology: https://
    www.aan.com/Guidelines/Home/GuidelineDetail/958. The CDC Tourette
    Syndrome Public Health, Education and Research Program strives to
    increase the understanding and awareness among these critically
    important medical and education professionals to increase the
    percentage of school aged children with TS who are diagnosed, improve
    the timeframe from symptoms to diagnosis and educate them about
    treatment options like CBIT.
        We appreciate the opportunity to submit testimony and appreciate
    your thoughtful consideration of our request. TAA urges you to provide
    continued funding for Fiscal Year 2022 for the Tourette Syndrome Public
    Health Education and Research Program at CDC's National Center for
    Birth Defects and Developmental Disabilities at the previously enacted
    level of $2 million.
                                     ______

    Prepared Statement of the Training Programs in Epidemiology and Public
                          Health Interventions Network
        Thank you for this opportunity to provide written testimony on
    behalf of the Training Programs in Epidemiology and Public Health
    Interventions Network, known as TEPHINET, based at The Task Force for
    Global Health.
        The Task Force for Global Health, founded in 1984 to advance health
    equity, works with partners in more than 150 countries to eliminate
    diseases, ensure access to vaccines and essential medicines, and
    strengthen health systems to protect populations. Our expertise
    includes neglected tropical diseases and other infectious diseases;
    vaccine safety, distribution and access; and health systems
    strengthening. Our COVID-19 activities include: working with 50
    countries to help vaccinate their populations, providing vaccine safety
    guidelines; advising on digital contact tracing; training
    epidemiologists on disease surveillance and response; distributing
    essential protection and treatment to hard-hit communities; using
    existing health programs to ensure protection for vulnerable groups,
    such as those afflicted with other diseases; overcoming vaccine
    hesitancy in the United States and leveraging our existing supply
    chains for ongoing response and to help countries deliver vaccines.
        As the Director of TEPHINET, one of the Task Force's 16 global
    health programs, I am sharing my support for efforts to build the
    global field epidemiology workforce needed to advance global health
    security by detecting and responding to disease outbreaks before they
    become pandemics with devastating human and economic consequences. I
    would also like to share with you the incredible impact that U.S.
    funding is already having on building a public health workforce of
    field epidemiologists worldwide.
        TEPHINET, is the global network of Field Epidemiology Training
    Programs (FETPs) that is funded primarily through the Centers for
    Disease Control and Prevention (CDC). You might be wondering what a
    field epidemiologist does and why it is important to train more field
    epidemiologists around the world. Think of it this way: when there is a
    fire, we call upon trained and skilled firefighters to rush to the
    scene of the fire and put it out as soon as possible. Not only are
    field epidemiologists the firefighters of public health, but they set
    up the fire alarm systems by developing disease surveillance systems to
    catch cases early. When there is a disease outbreak, a natural
    disaster, or a humanitarian crisis unfolding that threatens people's
    health, field epidemiologists are deployed to the scene. Their task is
    to understand how and why the health threat is occurring, who is
    affected, and how to stop its spread at the source. For this reason,
    field epidemiologists are known as ``Disease Detectives.'' They conduct
    outbreak investigations, perform contact tracing, monitor travelers at
    points of entry and attendees at mass gatherings, engage with
    communities on disease prevention measures, and much more. They are
    based at ministries of health, national public health institutes (like
    our CDC) and are in many ways the lynchpin of the overall public health
    system in a country.
        TEPHINET consists of 75 Field Epidemiology Training Programs
    training field epidemiologists in more than 100 countries. To date,
    trainees and graduates of our member programs have investigated more
    than 12,000 outbreaks or acute health events and developed more than
    5,000 disease surveillance systems to improve case detection.
    Worldwide, more than 19,000 FETP alumni have trained as the ``boots on
    the ground'' to detect and respond to public health threats.
        The need for greater public health capacity to prevent, detect, and
    respond to public health threats and emerging infectious diseases is a
    matter of life or death for people around the world. Such capacity
    makes countries better able to sustain their own national systems,
    leading to economic growth and reducing the likelihood of political or
    economic instability.
        Never has the need for increased field epidemiology capacity around
    the globe been more apparent than now, as the world has grappled
    socially and economically with COVID-19. The field epidemiologists in
    our network have been working around the clock to trace contacts,
    investigate and manage cases, analyze COVID-19 data, educate their
    communities, and much more. Without them, the governments of most
    countries, like my former home of South Africa, would not have access
    to reliable data on the spread of COVID-19 in their populations. In
    many countries, especially the poorest, there is simply no other
    workforce in place to conduct contact tracing or case investigations.
    Field Epidemiology Training Programs supported by TEPHINET fill that
    gap and have been steadily expanding since their founding by the CDC
    and other partners nearly 40 years ago.
        FETPs have trained an estimated 19,000 ``Disease Detectives'' so
    far, but the world needs more. COVID-19 and other emerging diseases are
    not the only threats--FETPs fight every health threat known to us, from
    well-known issues like Ebola, measles, and polio to lesser known but
    deadly and debilitating diseases like Lassa fever and monkeypox. While
    COVID-19 is clearly an emergent threat, there will always be a
    ``disease X'' that poses a grave threat to the health of Americans.
        In Guinea, a resource-challenged country in West Africa, the FETP
    housed within the Ministry of Health is providing critical support to
    help control a recent Ebola outbreak. As of April 13, 2021, Guinea had
    23 reported cases of Ebola. FETP trainees and graduates made vital
    contributions to slowing the outbreak, particularly in the areas of
    coordination and epidemiology surveillance. They led the development of
    a surveillance system to detect Ebola cases, as well as the country's
    Ebola response plan, contact tracing guides, and case definitions for
    Ebola patients. FETP trainees and graduates consisted the leading
    Ministry of Health workforce deployed in the field to conduct Ebola-
    related surveillance. Thanks to the involvement of the FETP, the vast
    majority (83%) of reports of suspected cases are being investigated.
    Because of the Guinea FETP, established after the 2014-2016 Ebola
    outbreak in West Africa had claimed thousands of lives, today Guinea is
    seeing a dramatically different response compared to the 2014-2016
    outbreak--including a significant increase in the known number of
    contacts traced: 95% of contacts have been traced in the current
    response.
        Before coming to The Task Force, I was the director of the South
    African Field Epidemiology Training Program (SAFETP), which was started
    with CDC funding in partnership with the Ministry of Health and the
    University of Pretoria, which conferred the Master of Public Health
    degree to graduates. Over time, the program became owned by the
    National Institute of Communicable Disease, but CDC Pretoria continued
    to provide support in the form of a Resident Advisor, Scientific
    Writer, and Statistician. There was an outbreak of diarrheal disease in
    a small town in Free State province, and the FETP trainees or residents
    identified the root cause to be poor maintenance at the water treatment
    plant. Diarrheal disease from drinking unsafe water causes dehydration,
    which is a killer of children under five. As a result of the
    investigation done by the FETP residents, the town installed a new
    water reticulation plant that ultimately benefited residents of the
    town and improved their quality of life with fewer days of productivity
    lost due to gastrointestinal illness.
        Without enough ``Disease Detectives'' or boots on the ground to
    detect and respond to public health emergencies, it will not be long
    before another outbreak becomes a pandemic with severe human and
    economic costs. There will be other outbreaks, and no single
    institution has all the capacity required to be adequately prepared to
    face future threats. We need to harness the resources and capacities of
    a wide range of partners and stakeholders and we need political
    leadership, whole-of-government and whole-of-society commitment. We
    need to continue the United States' tradition of helping to build
    sustainable public health systems across the world that ultimately
    protect all people, including the American people.
        In addition to supporting the development of Field Epidemiology
    Training Programs, TEPHINET and The Task Force for Global Health have
    been instrumental in developing the Global Field Epidemiology Roadmap,
    a plan to advance field epidemiology training and capacity building
    worldwide. As we speak, we at TEPHINET are coordinating a Strategic
    Leadership Group of more than a dozen public health experts from around
    the world to lead the implementation of this Roadmap, so that all
    countries can develop the field epidemiology capacity needed to protect
    and promote the health of their own populations and collaborate with
    others to promote global health.
        Thank you for your ongoing support of FETPs through the vital
    funding you provide. Because of this support, more than 100 countries
    now have a field epidemiology workforce that did not exist prior to the
    establishment of their FETPs. However, we are still working to achieve
    the International Health Regulations' target of having one trained
    field epidemiologist per 200,000 population in every country. The good
    news is that this goal is achievable with continued investment. A
    global commitment to improving global health security by investing in
    field epidemiology capacity building strengthens health systems by
    training our world's ``Disease Detectives'' to respond to public health
    emergencies, humanitarian crises and natural disasters, and in so
    doing, saving money, saving resources, and saving lives.

        [This statement was submitted by Dr. Carl Reddy, Director, Training
    Programs in Epidemiology and Public Health Interventions Network.]
                                     ______

         Prepared Statement of the Trauma Center Association of America
        As you consider Labor Health and Human Services appropriations for
    Fiscal Year FY (2022), the Trauma Center Association of America (TCAA)
    asks the Committee to provide $11.5 million in funding for the Military
    and Civilian Partnership for the Trauma Readiness Grant Program.
        In 2016, the National Academies of Science, Engineering, and
    Medicine (NASEM) released a report titled, ``A National Trauma Care
    System: Integrating Military and Civilian Trauma Systems to Achieve
    Zero Preventable Deaths After Injury.'' This report finds that one of
    four military trauma deaths and one of five civilian trauma deaths
    could be prevented if advances in trauma care reach all injured
    patients. In the report, the National Academies recommended that the
    United States adopt an overall aim for trauma care of ``zero
    preventable deaths after injury,'' and sets forth elements of system
    redesign that would provide military personnel with real-world training
    and experience at civilian trauma centers. This training has the dual
    benefit of maintaining military surgical battle readiness between wars
    while at the same time improving civilian access to trauma care. The
    report concludes that military and civilian integration is critical to
    saving these lives both on the battlefield and at home, preserving the
    hard-won lessons of war, and maintaining the nation's readiness and
    homeland security.
        Section 204, of S. 1379, the Pandemic and All-Hazards Preparedness
    and Advancing Innovation Act of 2019 (PAHPAI), known as the MISSION
    ZERO Act was signed into law June 24, 2019 (Public Law No: 116-22).
    MISSION ZERO takes the recommendations of the NASEM report to create a
    U.S. Department of Health and Human Services (HHS) grant program to
    cover the administrative costs of embedding military trauma
    professionals in civilian trauma centers. These partnerships will allow
    military trauma care teams and providers to gain experience treating
    critically injured patients and increase readiness for when these units
    are deployed. Similarly, best practices from the battlefield are
    brought home to further advance trauma care and provide greater
    civilian access.
        According to the Centers for Disease Control and Prevention trauma
    is the leading cause of death for children and adults under age 44,
    killing more Americans than AIDS and stroke combined.
        Fully funding of MISSION ZERO will allow us to continue to save
    lives, enhance trauma training for our military healthcare personnel
    and help trauma centers manage and recover from mandatory furloughs of
    surgeons, nurses and other staff that were a direct result of the COVID
    19 pandemic.
        We are grateful for your consideration of this important request.
    Please do not hesitate to contact us directly if you have any questions
    or need additional information regarding the MISSION ZERO Act.
                                     ______

                Prepared Statement of the Treatment Action Group
        Treatment Action Group (TAG) thanks the esteemed members of the
    subcommittee for the opportunity to submit testimony regarding funding
    for the U.S. Centers for Disease Control and Prevention (CDC) Division
    of Tuberculosis Elimination (DTBE) for fiscal year 2022 (FY22)
    appropriations. TAG is an independent, activist and community-based
    research and policy think tank fighting for better treatment,
    prevention, a vaccine, and a cure for HIV, tuberculosis (TB), and
    hepatitis C virus (HCV). TAG works to ensure that all people with HIV,
    TB, or HCV receive lifesaving treatment, care, and information. We are
    science-based treatment activists working to expand and accelerate
    vital research and effective community engagement with research and
    policy institutions. Together with a broad coalition of stakeholders in
    the TB advocacy community, TAG requests that the Subcommittee
    appropriate $225 million to CDC DTBE for FY22, in particular to expand
    critical TB research activities at the TB Trials Consortium (TBTC) and
    mitigate the impact of the COVID-19 pandemic on struggling TB programs
    across our country.
        TAG works in close partnership with TB program practitioners and
    researchers across the country to advance the collective goal of
    eliminating TB through comprehensive, safe, and effective TB prevention
    and treatment. TB cases continue to be reported in every state in the
    United States (US) every year, with 8,916 cases reported in 2019.\1\ It
    is estimated that approximately 13 million people in the US are
    currently living with latent TB infection, which can progress to active
    and contagious disease if left untreated.\2\ TB trends in the US are
    also influenced by many of the same social determinants of health that
    determine other health disparities--including poverty, lack of access
    to healthcare, overcrowded housing and homelessness, and other
    structural factors.\3\ This leaves many of the most vulnerable and
    marginalized members of our society at greater risk of being exposed to
    TB and developing active disease.
    ---------------------------------------------------------------------------
        \1\ U.S. Centers for Disease Control and Prevention. U.S. TB
    Statistics. Division of TB Elimination. https://www.cdc.gov/tb/
    statistics/default.htm.
        \2\ Ibid.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        The state and local TB programs that are on the frontlines of
    preventing and treating TB are engaged in critical work, and they rely
    on the support of the CDC DTBE for guidance and funding. One important
    way DTBE supports state and local TB programs is through its research
    initiatives, including the TBTC. Housed within DTBE, the TBTC is a
    unique partnership between CDC, health departments, academic research
    institutions, and trial sites throughout the US and across the
    globe.\4\ TBTC's research is mandated to be programmatically relevant
    to health departments, meaning that investments in this research
    network are some of the most cost-effective of any federal research
    program. Tax payers' investments in the work of the TBTC have supported
    dozens of studies of critical import to advancing the field and
    improving TB treatment and prevention for people and communities
    affected by TB at home and abroad.
    ---------------------------------------------------------------------------
        \4\ U.S. Centers for Disease Control and Prevention. Tuberculosis
    Trials Consortium. Division of TB Elimination. https://www.cdc.gov/tb/
    topic/research/tbtc/default.htm.
    ---------------------------------------------------------------------------
        This research is sorely needed to advance more tolerable and
    effective options for TB prevention and treatment. Current treatment
    guidelines for drug-sensitive TB have been the same for almost four
    decades, leaving programs and patients reliant on a regimen made up of
    four drugs taken for 6-9 months requiring long periods of isolation and
    management of difficult side effects necessitating intensive treatment
    monitoring. However, promising results from a pivotal phase III trial,
    TBTC's Study 31 demonstrated that a different combination of medicines
    enables treatment for drug-sensitive TB to be shortened to just four
    months without compromising any efficacy.\5\ This groundbreaking
    finding has the potential to dramatically improve rates of treatment
    completion, drive down TB transmission, and allow TB patients to return
    to their loved ones and support themselves more quickly than ever
    before.\6\ Study 31 and prior TBTC research at DTBE has had profound
    global health security implications, where TB was the world's leading
    cause of death to an infectious disease prior to COVID-19. Research at
    CDC's TBTC has been the basis for public health treatment and
    prevention guidelines developed by the World Health Organization (WHO)
    that are critical for country TB programs where TB is particularly
    endemic and claims 1.6 million lives a year.
    ---------------------------------------------------------------------------
        \5\ Dorman SE, Nahid P, Kurbatova EV, Goldberg SV, Bozeman L,
    Burman WJ, Chang KC, Chen M, Cotton M, Dooley KE, Engle M, Feng PJ,
    Fletcher CV, Ha P, Heilig CM, Johnson JL, Lessem E, Metchock B, Miro
    JM, Nhung NV, Pettit AC, Phillips PPJ, Podany AT, Purfield AE,
    Robergeau K, Samaneka W, Scott NA, Sizemore E, Vernon A, Weiner M,
    Swindells S, Chaisson RE; AIDS Clinical Trials Group and the
    Tuberculosis Trials Consortium. High-dose rifapentine with or without
    moxifloxacin for shortening treatment of pulmonary tuberculosis: Study
    protocol for TBTC study 31/ACTG A5349 phase 3 clinical trial. Contemp
    Clin Trials. 2020 Mar;90:105938. doi: 10.1016/j.cct.2020.105938. Epub
    2020 Jan 22. PMID: 31981713; PMCID: PMC7307310. https://
    pubmed.ncbi.nlm.nih.gov/31981713/.
        \6\ Treatment Action Group. TAG Statement: Finally a New Four Month
    Treatment for Drug Susceptible TB. 2020 October. https://
    www.treatmentactiongroup.org/statement/finally-a-new-four-month-
    treatment-for-drug-susceptible-tb/.
    ---------------------------------------------------------------------------
        While these results are certainly cause for celebration, much work
    remains to be done to translate these findings into real public health
    impact and ensure the availability of shorter treatment regimens to all
    TB patients and programs. Many other areas of research are also still
    on the horizon, including better TB prevention options and tools for
    children and pregnant people. Some of this research is already underway
    through other TBTC studies.\7\ The recent process by TBTC to solicit
    research proposals (i.e. TBTC re-competition) sets up this heralded
    research network for the next 10 years of programmatically-relevant
    research that could include many of these pressing priorities for TB
    R&D. But this progress is marred by decades of insufficient federal
    funding for DTBE, which limits the ambition and scientific integrity of
    how TBTC can approach its research agenda. In turn, the historical lack
    of funding to DTBE limits the possibilities of implementation of such
    research through state and local TB programs.
    ---------------------------------------------------------------------------
        \7\ U.S. Centers for Disease Control and Prevention. Tuberculosis
    Trials Consortium--Research Projects. Division of TB Elimination.
    https://www.cdc.gov/tb/topic/research/tbtc/projects.htm.
    ---------------------------------------------------------------------------
        Decades of stagnant appropriations for DTBE have led to the
    Division currently being funded at nearly the same level as it was in
    fiscal year 1994 (see right figure on impact of inflation). Factoring
    in the rate of inflation over that period, that stagnant funding level
    has drastically reduced the purchasing power of DTBE.\8\ In addition,
    the costs of TB diagnosis and treatment have steadily risen, especially
    for drug-resistant forms of TB which can now cost up to several hundred
    thousand dollars to treat per person.\9\ As a direct result, DTBE has
    been forced to do more with less, necessitating difficult decisions
    about resource allocation to its lifesaving programmatic and research
    initiatives. Without sufficient funding to bolster our nation's TB
    programs, implementation of U.S.-led TB treatment strategies and
    interventions made possible through publicly funded research at TBTC,
    remains severely limited.
    ---------------------------------------------------------------------------
        \8\ Treatment Action Group. The TB Research Engine That Could:
    Sustaining the Success of the Tuberculosis Trials Consortium in
    Turbulent Times. 2021 April. https://www.treatmentactiongroup.org/
    publication/the-tb-research-engine-that-could/.
        \9\ U.S. Centers for Disease Control and Prevention. CDC Fact
    Sheet: The Costly Burden of Drug Resistant TB Disease in the U.S..
    National Center for HIV, Hepatitis, STD, and Tuberculosis Prevention--
    Newsroom. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/costly-
    burden-dr-tb-508.pdf.
    ---------------------------------------------------------------------------
        The COVID-19 pandemic has worsened these capacity constraints.
    According to a survey of TB program staff in the US, 87% of respondents
    reported that they or their colleagues had been either partially or
    completely reassigned to work on COVID-19.\10\ In many cases, these
    reassignments were indefinite, and state and local TB programs continue
    to operate under reduced capacity and temporary leadership. Many TB
    clinics, hospitals, and other resources were also designated
    exclusively for use in the COVID-19 pandemic response, as they were
    uniquely outfitted for airborne isolation. The expertise of TB public
    health clinicians, researchers and practitioners in particular, are
    drawn upon in the COVID-19 response for their critical experience in
    addressing an airborne infection.
    ---------------------------------------------------------------------------
        \10\ Stop TB Partnership. The Impact of COVID-19 on the TB
    Epidemic: A Community Perspective. Geneva: March 2021 https://
    spark.adobe.com/page/xJ7pygvhrIAqW/.
    ---------------------------------------------------------------------------
        Some of the impacts of the pandemic are not yet visible. TB case
    reporting dropped by 20% in 2020 compared to 2019. Unprecedented
    barriers to accessing testing and care stemming from COVID-19 health
    service disruptions and the reallocation of TB staff and resources from
    conducting contact tracing, community outreach, and TB treatment
    monitoring, to COVID-19 response efforts are likely the major causes of
    this steep drop in TB notifications.\11\ The impacts of this reduced
    capacity to prevent and respond to TB cannot be overstated, and the
    costs of recovering from such impacts will be much higher than current
    funding levels allow.
    ---------------------------------------------------------------------------
        \11\ Deutsch-Feldman M, Pratt RH, Price SF, Tsang CA, Self JL.
    Tuberculosis--United States, 2020. MMWR Morb Mortal Wkly Rep
    2021;70:409-414. DOI: https://www.cdc.gov/mmwr/volumes/70/wr/
    mm7012a1.htm?s_cid=mm7012a1_w.
    ---------------------------------------------------------------------------
        Stagnant funding, and the additional damage wrought by the COVID-19
    pandemic, also threaten TB research and development efforts at DTBE. In
    the aforementioned recent TBTC ``re-competition'' process for the next
    10-year funding cycle, four of the prominent academic institutions that
    housed some of the crucial leadership for TBTC's most promising studies
    were excluded in the subsequent cycle due to shrinking research dollars
    to expand this highly successful clinical trials network.\12\ The
    collective TB expertise held within these institutions is
    irreplaceable. Higher funding levels for DTBE and its research
    initiatives, such as TBTC, are vital to retain the invaluable
    experience necessary to complete study enrollment, data collection,
    analysis, publication, and translation into policy. Furthermore,
    expanded resources would position TBTC to embark on a new era of
    clinical research led by these partners, building on its success
    shortening treatment and prevention of TB and looking to future
    opportunities, such as the possibility of TBTC trialing novel TB
    vaccines. However, without an increase in funding, this experience will
    be lost, taking with it the promise of TB research breakthroughs like
    those shown in TBTC Study 31, which demonstrated the first effective
    short course TB treatment in over 40 years.\13\
    ---------------------------------------------------------------------------
        \12\ Treatment Action Group. The TB Research Engine That Could:
    Sustaining the Success of the Tuberculosis Trials Consortium in
    Turbulent Times.
        \13\ U.S. Centers for Disease Control and Prevention. Landmark TB
    Trial Identifies Shorter-Course Treatment Regimen. National Center for
    HIV, Hepatitis, STDs, and Tuberculosis Prevention--Newsroom. 21 October
    2020 https://www.cdc.gov/nchhstp/newsroom/2020/landmark-tb-trial-media-
    statement.html.
    ---------------------------------------------------------------------------
        In order to avert further devastating impacts on TB programs,
    prevention, care, and research, increased funding for CDC DTBE is
    critically important. TAG requests that the subcommittee appropriate
    $225 million--an increase of $90 million--to safeguard the lifesaving
    progress that DTBE has made against TB in the US, sustain and grow the
    government's vital TB research agenda at TBTC by retaining critical R&D
    expertise, and to bring us closer to the elimination of TB once and for
    all, here and abroad. We thank you for your support of public health
    programs and research, and we look forward to working with you to
    ensure the health of all those impacted by TB in the US and around the
    world.
                                     ______

                Prepared Statement of the Treatment Action Group
        Treatment Action Group (TAG) thanks the esteemed members of the
    subcommittee for the opportunity to submit testimony regarding funding
    for the government's End the HIV Epidemic (EHE) at the U.S. Centers for
    Disease Control (CDC) Division for HIV Prevention (DHAP) for fiscal
    year 2022 (FY22) appropriations. TAG is an independent, activist, and
    community-based research and policy think tank committed to racial,
    gender, and LGBTQ+ equity; social justice; and liberation, fighting to
    end HIV, tuberculosis (TB), and hepatitis C virus (HCV). We work
    closely with community partners and stakeholders in the jurisdictions
    funded by the federal government's EHE initiative towards an inclusive,
    community-centered approach to end the HIV epidemic across our country.
        TAG requests that the Subcommittee exceed the President's budget
    proposal for the CDC EHE initiative of an $100 million increase in FY22
    with an additional increase of $96 million to a total of $196 million
    for DHAP ETE. In particular these resources would be critical to expand
    EHE efforts, advance and expand vital community partnership activities,
    and mitigate the impact of the COVID-19 pandemic among the hardest-hit
    jurisdictions.
        While there has been immense progress in the HIV epidemic with
    rates declining from 37,500 new infections in 2015 to 34,800 infections
    in 2019--much work remains on truly ending the epidemic in the hardest-
    hit jurisdictions and populations in the U.S.\1\ HIV rates are not
    evenly distributed across the nation and continue to be primarily
    skewed towards the Southern states as the bulk of new diagnoses.\2\
    Even more concerning, HIV disparities continue to severely persist
    among the Black and Latinx communities. We see these troublesome trends
    particularly among Black and Latinx gay and bisexual men, as well as
    Black women. Black communities represent 13% of the U.S. population,
    but make up 44% of new diagnoses.\3\ Similarly, Latinx communities
    represent 18% of the U.S. population and account for 30% of new HIV
    diagnoses.\4\ HIV comparably disparages Native American community,
    people of trans experience, and people who use drugs with stark
    disparities.
    ---------------------------------------------------------------------------
        \1\ Health Resource and Services Administration. HIV Data and
    Trends. HIV.gov. https://www.hiv.gov/hiv-basics/overview/data-and-
    trends/statistics.
        \2\ Ibid.
        \3\ U.S. Centers for Disease Control and Prevention. Racial and
    Ethnic HIV Rates--African Americans and Hispanic/Latinos. Division of
    HIV/AIDS Prevention. https://www.cdc.gov/hiv/group/racialethnic/
    africanamericans/index.html.
        \4\ Ibid.
    ---------------------------------------------------------------------------
        It is of no surprise that social determinants of health deeply
    impact these communities. These include housing, food security,
    employment and economic justice, as well as undoing numerous policies
    that violate the human rights of these communities and limit their
    ability to seek treatment and care. Criminalization for example is
    intertwined with the HIV epidemic, with many states continuing to have
    arcane laws that do not align with science and only further stigmatize
    communities of people living with, and vulnerable to HIV. Without
    addressing the myriad of social, economic and legal needs of
    communities impacted by HIV through a combination of targeted resources
    and a human-rights policies, reaching the vision for ending the
    epidemic across all communities will remain unclear and unattainable.
        The previous administration ambitiously approached this challenge
    of ending the HIV epidemic once and for all, by redoubling U.S. efforts
    and formulating the landmark EHE initiative that would direct federal
    resources towards 57 jurisdictions hardest-hit by HIV through CDC and
    HRSA. While Congress, has responded in lockstep with bipartisan
    increases to EHE since its inception, we believe that the COVID-19
    pandemic has significantly impacted efforts at the community-level,
    requiring a significant scale up in assistance to these jurisdictions.
        Organizations and partners involved in the ACT NOW:END AIDS
    coalition--of which TAG is a cofounder--report significant impact upon
    services and outreach efforts to communities impacted by HIV. The lack
    of swift and robust federal guidance on COVID-19 to HIV organizations
    in the early stages of the pandemic led to many organizations having to
    decide between either risking the safety of their staff by continuing
    essential services, or temporarily closing programs. Additionally, many
    already financially strained organizations struggled to obtain the
    technologies necessary for telemedicine and many reported that
    clients--especially low-income, and unstably housing individuals--could
    not access these tools. Such delays led to clients missing care and
    contributed to an overall sense of burnout among HIV professionals.
        In addition to the direct impact upon services for PLHIV and
    communities vulnerable to HIV, we have noted a significant shift in
    human resources and public health personnel detailed to the COVID-19
    pandemic. CDC HIV program staff are also contributing significantly to
    the nation's COVID-19 response. The pandemic has caused severe
    disruptions to care and treatment activities of the National Center for
    HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). According
    to research from the Kaiser Family Foundation, nearly 700 CDC staff
    (with 1,125 cumulative deployments) from NCHHSTP have been detailed and
    deployed to the COVID response since the early days of the pandemic.\5\
    This is primarily due to the Center staff's expertise in infectious
    diseases. HIV public health practitioners from the CDC are drawn upon
    for the COVID-19 pandemic, primarily for their expertise in centering
    communities in prevention efforts and their ability to form key
    relationships, conduct outreach, while grounding public health
    prevention work in respect for human rights. However, scarce public
    health resources and personnel corresponds to a shift away from EHE
    efforts.
    ---------------------------------------------------------------------------
        \5\ Dawson L, Kates J. Issue Brief: Key Questions on HIV and COVID-
    19. Kaiser Family Foundation. 20 May 2021. https://www.kff.org/
    coronavirus-covid-19/issue-brief/key-questions-hiv-and-covid-19/.
    ---------------------------------------------------------------------------
        Furthermore, HIV community contributions to the COVID-19 response
    have been significantly extended through HIV/AIDS research investments
    at the National Institutes of Health (NIH) as well. For example, HIV
    research first piloted the of use mRNA as a vaccine platform for HIV
    prevention. These previous investments in HIV vaccine research boosted
    the development of widely disseminated COVID-19 vaccines that
    increasingly leveraged the well-developed research infrastructure of
    HIV research.\6\
    ---------------------------------------------------------------------------
        \6\ Chibbaro L. HIV Research Sped the Develop of the COVID-19
    Vaccine. Washington Blade. 23 June 2021 https://
    www.washingtonblade.com/2021/06/23/hiv-research-sped-development-of-
    covid-vaccine/.
    ---------------------------------------------------------------------------
        In sum, the programmatic and research contributions of HIV have
    been invaluable to the nation's COVID-19 response. But the shift in HIV
    sector resources leaves EHE efforts in peril and limited in reaching
    its ambitious goals for treatment and prevention of HIV. Due to the our
    weakened public health infrastructure that COVID-19 leaves in its wake,
    without significantly targeted and expanded resources, HIV disparities
    will continue to be deeply entrenched in our nation's historically
    disenfranchised and marginalized communities. We urge the subcommittee
    to maximize resources to backfill the contributions of the HIV sector
    and launch our HIV response with the same level of vigor that we saw
    with the COVID-19.
        To that end, we request an allocation of at least $196 million in
    FY22 for CDC DHAP EHE Plan to begin to align the necessary resources to
    mitigate the effects of COVID-19 upon struggling HIV programs and
    shore-up the necessary HIV infrastructure. We applaud the
    administration's and Congressional attention towards rooting out
    systemic racism, and believe that these investments will go a long way
    to begin addressing HIV as health disparity that primarily effects
    communities of color.
        Thank you for the members of the subcommittee for this opportunity
    to submit testimony in support of CDC DHAP ETE initiative. We hope you
    will take action and recommit to realizing the end of the HIV epidemic
    with urgent, new resources.
                                     ______

                Prepared Statement of Trust for America's Health
        Trust for America's Health (TFAH) is pleased to submit this
    testimony on the fiscal year (FY) 2022 Labor, Health and Human
    Services, Education, and Related Agencies (LHHS) appropriations bill.
    TFAH is a non-profit, non-partisan organization that promotes optimal
    health for every person and community. Communities across the country
    are overwhelmed with responding to the Coronavirus Disease 2019 (COVID-
    19) pandemic with a depleted public health infrastructure and
    workforce, while also responding to longstanding issues due to
    increases in chronic diseases, substance misuse and suicide, health
    disparities, and environmental health risks. TFAH's recent report, The
    Impact of Chronic Underfunding on America's Public Health System, finds
    that although health threats continue to increase, core public health
    budgets at the federal and state levels remain stagnant.\1\ While
    Congress has allocated billions of dollars to address COVID-19, this
    funding is short-term and largely for use in response to the pandemic.
    It follows a similar pattern since 9/11 of annually underfunding core
    public health and then providing significant infusions of emergency
    funding for a short time when a disaster hits. This is like building a
    house on a shaky foundation. Without an investment in public health
    year in and year out, problems cannot be prevented, or emergencies
    reduced. While many thanks are due for your support during COVID, now
    is the time to fix an underfunded system so we can ensure every
    resident of the nation has the chance for optimal health and wellbeing.
    Bold action is needed to strengthen and modernize public health. TFAH
    urges Congress to fund the Centers for Disease Control and Prevention
    (CDC) at $10 billion for the FY2022 budget, including investing in
    these effective public health programs (unless otherwise noted, all
    programs are in CDC):
    ---------------------------------------------------------------------------
        \1\ The Impact of Chronic Underfunding of America's Public Health
    System. Trust for America's Health 2021. https://www.tfah.org/report-
    details/pandemic-proved-underinvesting-in-public-health-lives-
    livelihoods-risk/.
    ---------------------------------------------------------------------------
                             emergency preparedness
        The COVID-19 response was weakened because the CDC's emergency
    preparedness funding had been repeatedly cut, reducing essential
    training and eliminating expert personnel. The CDC's Public Health
    Emergency Preparedness (or PHEP) cooperative agreement has been reduced
    by a quarter since FY2003 (48 percent when inflation is considered).
    PHEP grants support 62 state, territorial, and local grantees to
    develop core public health capabilities, including in areas of public
    health laboratory testing, health surveillance and epidemiology,
    community resilience, countermeasures and mitigation, incident
    management, and information management. TFAH recommends at least $824
    million for the PHEP (CDC), the level authorized in 2006.
        The pandemic has also demonstrated the impact of failing to invest
    in comprehensive readiness and surge capacity of the healthcare
    delivery system. Funding for the Hospital Preparedness Program (HPP),
    administered by the Assistant Secretary for Preparedness and Response,
    has been cut in half since FY2003 (62 percent when inflation is
    considered). HPP provides critical funding and technical assistance to
    health care coalitions (HCCs) across the country to meet the disaster
    healthcare needs of communities. There are 360 HCCs, comprised of
    public health agencies, hospitals, emergency management and others,
    that develop and implement healthcare and medical readiness plans;
    response coordination; continuity of healthcare services delivery; and
    medical surge. TFAH recommends at least $474 million for HPP (PHSSEF),
    the level authorized in 2006.
                              environmental health
        Not all federal emergencies are caused by infectious disease. Many
    occur due to environmental factors. Here, too, core funding has been
    insufficient. Since CDC's National Environmental Public Health Tracking
    Network began in 2002, grantees have taken over 400 data-driven actions
    to eliminate risks to the public. Data includes asthma, drinking water
    quality, lead poisoning, flood vulnerability, and community design.
    State and local health departments use this data to conduct targeted
    interventions in communities with environmental health concerns.
    Currently, 25 states and one city are funded to participate in the
    Tracking Network. With a $1.44 return in health care savings for every
    dollar invested, the Tracking Network is a cost-effective program that
    examines and combats harmful environmental factors.\2\ Yet only half
    the states receive funding. TFAH recommends at least $40 million for
    National Environmental Public Health Tracking Network (CDC), which
    would enable at least three additional states to join the network.
    ---------------------------------------------------------------------------
        \2\ Return on Investment of Nationwide Health Tracking, Washington,
    DC: Public Health Foundation, 2001.
    ---------------------------------------------------------------------------
                     obesity and chronic disease prevention
        The COVID-19 pandemic has been exacerbated by preventable, chronic
    health conditions, including obesity. In 2017-2018, 42.4 percent of
    adults had obesity.\3\ Even though obesity accounts for nearly 21
    percent of U.S. healthcare spending, funding for CDC's Division of
    Nutrition, Physical Activity, and Obesity (DNPAO) is only equal to
    about 31 cents per person.\4\ This Division funds state health
    departments to protects the health of all Americans by promoting
    healthy eating, active living, and obesity prevention in early care and
    education facilities, hospitals, schools, and worksites and
    neighborhoods; building capacity of state health departments and
    national organizations to prevent obesity; and conducting research,
    surveillance, and evaluation studies. However, DNPAO only has enough
    money to implement its State Physical Activity and Nutrition Programs
    (SPAN) in 16 states. TFAH recommends at least $125 million for DNPAO to
    allow CDC to continue building its capacity and scaling its
    interventions.
    ---------------------------------------------------------------------------
        \3\ State of Obesity 2020. Trust for America's Health. Sept 2020.
    https://www.tfah.org/report-details/state-of-obesity-2020/.
        \4\ J. Cawley and C. Meyerhoefer, ``The Medical Care Costs of
    Obesity: An Instrumental Variables Approach,'' Journal of Health
    Economics 31, no. 1 (2012): 219-30, doi: 10.1016/
    j.jhealeco.2011.10.003.
    ---------------------------------------------------------------------------
        Additionally, this year we once again saw the impact of inequities
    in social and economic conditions facing people of color and tribal
    nations. Among the programs at CDC that are effective in reducing
    racial and ethnic health disparities are Racial and Ethnic Approaches
    to Community Health (REACH) program and Good Health and Wellness in
    Indian Country (GHWIC). CDC's REACH) program, within DNPAO, works in 31
    communities across the country. It supports innovative, community-based
    approaches to develop and implement evidence-based practices, empower
    communities, and reduce racial and ethnic health disparities. As we are
    seeing the effect that underlying health disparities are having on
    COVID-19 patients, we urge renewed investment in programs such as REACH
    that promote health equity. TFAH recommends at least $102.5 million for
    REACH (CDC) to restore funds historically diverted from core REACH
    programs. Within that total, TFAH recommends at least $27 million for
    the Good Health and Wellness in Indian Country (GHWIC) program. Also
    within DNPAO, GHWIC works with 21 tribes directly and funds 15 Urban
    Indian Health Centers and 12 Tribal Epidemiology Centers (TECs). GHWIC
    supports healthy behaviors in Native communities by supporting
    coordinated and holistic approaches to chronic disease prevention,
    continuing to support culturally appropriate, effective public health
    approaches, and expanding the program's reach and impact by working
    with more tribes and tribal organizations, including Urban Indian
    Organizations. In addition, these GHWIC funds support the Tribal
    Epidemiology Centers for Public Health Infrastructure (TECPHI).
        Healthy Outcomes in Schools: Specialized efforts are needed within
    certain age groups as well. CDC's Division of Adolescent and School
    Health (DASH) provides evidence-based health promotion and disease
    prevention education for less than $10 per student. Through school-
    based surveillance, data collection, and skills development, DASH
    collaborates with state and local education agencies to increase health
    surveillance and services, promote protective factors, and reduce risky
    behaviors. DASH programs reach approximately 2 million of the 26
    million middle and high school students. TFAH recommends at least $100
    million for DASH (CDC) to expand its work to 20 percent of all middle
    and high school students.
        Age-Friendly Public Health: The COVID-19 outbreak has shown that
    collaboration between the public health and aging sectors is vital.
    Every day 10,000 Americans turn 65 years of age, yet there have been
    limited collaborations between the public health and aging sectors.
    Public health interventions play a valuable role in optimizing the
    health and well-being of older adults by prolonging their independence,
    reducing their use of expensive health care services, coordinating
    existing multi-sector efforts, and identifying gap areas, as well as
    disseminating and implementing evidence-based policies. Yet as of now,
    there is no comprehensive health promotion program for older adults. We
    recommend the Committee provide CDC at least $50 million to administer
    and evaluate an Age Friendly Public Health program to promote and
    address the public health needs of older adults and collaborate with
    partners in the aging sector.
        Social Determinants of Health: Social determinants of health (SDOH)
    such as housing, employment, food security, and education have a major
    influence on individual and community health,\5\ as illustrated by
    disparate outcomes and risk from COVID-19. Public health agencies are
    uniquely situated to build these collaborations across sectors,
    identify SDOH priorities in communities, and help identify strategies
    that promote health. Currently most public health departments lack
    funding and tools to support such cross-sector efforts and are limited
    by disease-specific federal funding. TFAH thanks for the Committee for
    $3 million in FY2021 to establish a new CDC SDOH program. We recommend
    the Committee fund CDC to support local and state public health
    agencies to convene across sectors, gather data, identify priorities,
    establish plans, and take steps to address and improve community social
    and economic conditions that promote health. Aligned with the
    President's budget request, TFAH recommends at least $153 million to
    further develop CDC's Social Determinants of Health Program and enable
    grants to states and localities.\6\ More than 200 organizations have
    endorsed this funding level.\7\
    ---------------------------------------------------------------------------
        \5\ Taylor, L et.al, ``Leveraging the Social Determinants of
    Health: What Works?'' Yale Global Health Leadership Institute and the
    Blue Cross and Blue Shield Foundation of Massachusetts, June 2015
        \6\ The President's request for fiscal year (FY) 2022 discretionary
    funding. (2021). Executive Office of the President. https://
    www.whitehouse.gov/wp-content/uploads/2021/04/FY2022-Discretionary-
    Request.pdf.
        \7\ Letter to House Appropriations LHHS Subcommittee. April 26,
    2021. https://www.tfah.org/wp-content/uploads/2021/04/
    CDC_SDOHFunding_SignOn.pdf.
    ---------------------------------------------------------------------------
                               suicide prevention
        In 2019, suicide took 47,500 lives, and rates increased by 33
    percent between 1999 and 2019.\8\ The complex nature of this issue
    requires a comprehensive program that focuses on vulnerable
    populations, data collection to inform efforts, and research on risk
    factors. CDC's work helps identify and disseminate effective strategies
    for preventing suicide, from strengthening access and delivery of
    suicide care to promoting policies and programs that reduce the risk.
    The programs consist of multisector partnerships, use of data to
    identify vulnerable populations and risk and protective factors,
    leveraging existing suicide programs and filling gaps through
    complementary strategies and effective communications. TFAH recommends
    at least $36 million to expand innovative prevention activities to an
    estimated 25 sites from its current number of nine, and to support
    state health departments as they develop and implement comprehensive
    suicide prevention plans.
    ---------------------------------------------------------------------------
        \8\ Suicide Prevention, CDC. https://www.cdc.gov/suicide/.
    ---------------------------------------------------------------------------
                         adverse childhood experiences
        CDC estimates that if Adverse Childhood Experiences (ACEs) such as
    abuse and neglect were prevented, there would be 21 million fewer cases
    of depression, 1.9 million fewer cases of heart disease, and 2.5
    million fewer cases of obesity.\9\ Preliminary evidence suggests the
    pandemic is likely to increase children's exposure to ACEs due to
    economic hardship, increased stresses on families, and reduced access
    to school-based services and supports.\10\ CDC's approach to ACEs
    prevention involves translating research into action and helping states
    identify and implement effective prevention strategies. In 2020, four
    state health departments were awarded funding to enhance or build
    infrastructure for ACEs surveillance, implement strategies to prevent
    ACEs, and leverage multisector partnerships to coordinate prevention
    activities. TFAH recommends at least $7 million to expand innovative
    ACEs prevention activities to four additional state health departments
    and to build upon CDC's work on preventing early adversity in life and
    mitigating the impact of ACEs on healthy child development.
    ---------------------------------------------------------------------------
        \9\ BRFFS 2015-2017, 25 states, CDC Vital Signs, November 2019.
    https://www.cdc.gov/vitalsigns/aces/index.html.
        \10\ MMWR 2021, https://www.cdc.gov/mmwr/volumes/69/wr/
    mm6949a1.htm.
    ---------------------------------------------------------------------------
                                   conclusion
        The COVID-19 pandemic has underscored the dangers of the chronic
    underfunding of public health. It has also exposed and exacerbated
    longstanding disparities that have plagued our nation for far too long.
    It is imperative that we not wait for the next emergency to fix this
    problem. Instead, now is the time to invest in public health and fund
    CDC at $10 billion in FY 2022, to become a more resilient and healthy
    nation. Thank you for the opportunity to present this testimony to the
    Committee.

        [This statement was submitted by J. Nadine Gracia, MD, MSCE,
    President & CEO, Trust for America's Health.]
                                     ______

             Prepared Statement of United for Charitable Assistance
           summary of fiscal year 2022 appropriations recommendations
    _______________________________________________________________________

      --Please continue to support and advance committee recommendations,
            as well as related funding and policy initiatives, which
            further encourage HHS and the Centers for Medicare and Medicaid
            Services (CMS) to address arbitrary barriers that disrupt
            patient access to essential charitable assistance in a
            meaningful and timely way.
      --Please work with your colleagues to encourage HHS to establish a
            transparent and patient-centered regulatory system formally
            governing charitable assistance programs that is consistent
            with the current framework of OIG opinions and ensures all
            policymakers and stakeholders have appropriate mechanism to
            address challenges and opportunities in this space.
      --Please provide meaningful funding increases for medical research
            and public health progress to initiate further progress and
            improve outcomes for the patient community.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the Subcommittee, thank you for your leadership on patient care, and
    coverage and access issues. On behalf of United for Charitable
    Assistance (UCA), we deeply appreciate the opportunity to provide a
    critical, patient-centered perspective as you consider FY 2022
    appropriations issues that impact healthcare coverage and patient
    access. Most notably, we urge you to continue to advance committee
    recommendations that feature and emphasize the need to quickly restore
    access to critical charitable assistance programs that serve patients
    with no other options. Moreover, please continue the investment in
    medical research and public health activities. The COVID-19 pandemic
    has hit the patient community hard and identified a litany of reasons
    to enhance resources for medical research and public health while
    addressing critical coverage and access challenges for those with the
    greatest need (such as due to pandemic related job loss). Thank you
    again for this important opportunity. Please consider UCA a resource on
    moving forward.
                     about united for charitable assistance
        We are a growing ad hoc group of patient community leaders that
    seek to protect access to the charitable financial support programs,
    which serve as a crucial part of the healthcare safety net for
    individuals with rare, chronic, and life-threatening medical
    conditions. We work together to educate policymakers so they understand
    the value, impact, and vital nature of these programs and ultimately
    support efforts to actively defend the lives and livelihoods of those
    facing serious conditions that can now be better-managed through proper
    care and innovative therapies.
                          about charitable assistance
        Over recent years, CMS promulgated rules that effectively allow
    private insurance companies to simply deny (or reserve the right to
    deny at will) any premium or related healthcare payments made on behalf
    of a patient. While these restrictions initially started in marketplace
    plans, they have spread to Medigap plans, and various other forms of
    coverage. The tangible result of these policies is that patients are
    often denied access to mission-driven charitable support from non-
    profits, civic groups, and houses of worship. Ultimately, these
    restrictions form a back-door to pre-existing condition discrimination
    where they are targeted at the most vulnerable populations and patients
    lose their coverage due to an inability to utilize available support or
    are simply steered towards one of the few remaining plans that has not
    implemented restrictions (if they are available in their state).
    Recently, the practice of copay accumulators has taken hold where some
    assistance is accepted, but it is never applied to the patient's out-
    of-pocket limits, thus rendering the support inconsequential for the
    seriously ill. Finally, there is now an emerging practice for employer-
    provided insurance known as the ``alternative funding model''. This
    prescription drug procurement model improperly utilizes drug
    manufacturers' free assistance programs to the detriment of patients
    who are forced to continually switch drugs. Further, any costs
    associated with filling the prescriptions or obtaining the medications
    are not counted toward a patient's out-of-pocket insurance costs.
        The situation is particularly dire for patients with rare, chronic,
    and life-threatening illness that rely on innovative life-sustaining
    medications and who occasionally turn to charities following a job loss
    or similar hardship to ensure there is no catastrophic disruption in
    access to care. Often times, when properly medicated, these patients
    work and contribute to society, and they do not qualify for Medicaid or
    similar need-based programs. Further, despite the severity of their
    illness, the therapy or medical intervention likely blunts or slows the
    progression of their disease meaning they also do not readily qualify
    for disability programs. When assistance and access to proper care is
    lost, a dangerous situation is created where the dramatic decline in
    health rapidly outpaces the patient's ability to transition on to tax-
    payer funded safety net programs.
        We cannot overlook the fact that many patients in the
    aforementioned situation also continue to turn to charitable assistance
    during the process of transitioning on to federal programs as their
    illness progresses. The disability waiting periods alone would be
    insurmountable for many without charitable assistance. In this regard,
    the need for charitable assistance is certainly not mitigated in
    Medicare and related programs with some patients utilizing charitable
    assistance to make ends meet and cover cost-sharing requirements.
           contemporary examples of charitable assistance challenges
        Ms. Lisa Wright is a patient advocate for the Fabry Disease
    Community. Fabry disease is a rare genetic disorder that prevents the
    body from making a certain enzyme called alpha-galactosidase A. The
    symptoms of Fabry Disease are varied and progressive including kidney,
    heart and neurological damage. There are several FDA approved
    treatments for Fabry Disease. However, those treatments are very
    expensive and as more and more costs are shifted to patients they need
    access to financial assistance programs. Lisa is a wonderful example of
    the importance of patient assistance. Lisa receives health insurance
    premium and copayment assistance from a charitable assistance program.
    This enables Lisa to remain working and volunteering for her community.
    Patient assistance groups help Lisa and many other Fabry disease
    patients obtain access to these expensive treatments and therapies
    which mitigate the symptoms of the disorder and keep patients living
    productive lives. Congress should work to ensure access to these
    programs.
        The situation of Dr. Jeffrey Swigert is an example of the new
    Alternative Funding. Dr. Swigert is the father of two children with
    Cystic Fibrosis. Cystic Fibrosis is a progressive, genetic disease that
    causes persistent lung infections and limits the ability to breathe
    over time. Dr. Swigert's employer is a self-insured plan that has
    implemented a carve out for specialty treatments such as those for
    cystic fibrosis. The employer will not cover treatments but instead
    attempts to obtain them free of charge from manufacturer compassionate
    treatment programs. However, the manufacturer programs are individual
    with their own specific criteria. These programs are often time limited
    and reserved for patients who are uninsured. Congress needs to review
    this practice and potentially introduce legislation to modify.
                                 recommendation
        Please include committee recommendations, similar to the language
    below, in the committee report accompanying the FY22 Senate L-HHS
    Appropriations Bill. Please also work through the annual appropriations
    process to facilitate a meaningful dialogue between the community and
    HHS on challenges, opportunities, and potential solutions. Thank you
    for your time and for your consideration of this request.
         centers for medicare and medicaid services program management
        Charitable Assistance and the Healthcare Safety Net.--The Committee
    notes the important role that third-party charitable assistance plays
    in regards to maintaining access to care and therapies, particularly
    for patients impacted by life-threatening illness that have no other
    options. The Committee notes the current significance of premium
    assistance, co-pay assistance, travel assistance, and related programs
    due to COVID-19 related economic challenges and loss of employment, and
    their disproportionate role in ensuring access to care for those with
    health disparities and from underserved communities. CMS is encouraged
    to re-evaluate policies that facilitate pre-existing condition
    discrimination for patients with serious illness by allowing covering
    entities to reject or simply not apply assistance from independent
    charities.

        [This statement was submitted by James Romano, Executive Director,
    United for Charitable Assistance.]
                                     ______

         Prepared Statement of the United States Workforce Associations
        Dear Chairman Murray and Ranking Member Blunt:
        The undersigned organizations make up the United States Workforce
    Association (USWA), a collaborative effort of local workforce boards,
    businesses, educational institutions, and organizations involved in
    workforce and economic development activities across the country. These
    organizations are directly involved in the implementation of the
    bipartisan Workforce Innovation and Opportunity Act (WIOA) of 2014,
    specifically promoting the successful execution by local workforce
    boards of the law to serve businesses, employers, and job--and career-
    seekers. As our country grapples with unprecedented demand for
    unemployment insurance and economic recession within the COVID-19
    pandemic, the employer-led, local workforce development system
    continues to respond with critical supports and services. Adequate
    federal funding would ensure the system is poised to address these
    community needs as we continue to recover from the devastating health
    and economic effects of COVID-19.
        As the Senate Appropriations Committee considers the Fiscal Year
    2022 Labor-HHS Appropriations Bill, we urge you to support further
    federal investment into WIOA and fully fund the law beyond its FY2020
    authorized levels. Appropriated levels have fallen short of authorized
    levels specifically in Title I accounts at the Department of Labor
    (Adult Employment and Training Services, Youth Workforce Investment
    Activities, and Dislocated Worker Employment and Training Services). An
    expanded federal investment across WIOA programs leads to more job
    training, education, skills development and innovative, proven
    practices like industry-based sector partnerships, career pathways, and
    apprenticeships. These strategies need to be implemented seamlessly to
    respond to the effects of COVID-19. The established local workforce
    system is well-positioned to enhance efforts for an equitable recovery;
    low wage, low skill workers and minority populations were hit hardest
    by COVID-19. The federal funding structure, which allows these funds to
    be invested locally, provides for intentional investments to help those
    most in need.
        Local workforce development leaders are engaged directly with
    businesses to help keep individuals employed and design training/
    education programs to prepare the workforce for the future. We continue
    to work with unemployed individuals to help them stay connected to the
    workforce and evaluate other opportunities; recent BLS data suggests
    nearly 41% of those unemployed have been unemployed for at least 27
    weeks (long-term unemployed).\1\ Business services, especially for
    small and medium-sized enterprises, have been critical during the
    COVID-19 pandemic as employers sought to maintain payrolls and find
    workers as businesses began to re-open. Increased federal
    appropriations are greatly needed to address this unprecedented health,
    economic, and social destabilization.
    ---------------------------------------------------------------------------
        \1\  https://www.bls.gov/charts/employment-situation/unemployed-27-
    weeks-or-longer-as-a-percent-of-total-unemployed.htm.
    ---------------------------------------------------------------------------
        The Fiscal Year 2022 Labor, Health and Human Services, Education,
    and Related Agencies Appropriations bill must fully fund all Titles I,
    II, III, and IV at a minimum to the level authorized by the Workforce
    Innovation and Opportunity Act (WIOA).
        The funding levels we are requesting in the FY2022 Labor, HHS,
    Education Appropriations Bill are listed below:
        Title I--Department of Labor
      --At least $899.987 million for Adult Employment and Training
            Services,
      --At least $963.837 million for Youth Workforce Investment
            Activities, and
      --At least $1.436 billion for Dislocated Worker Employment and
            Training Services
        Title II--Department of Education
      --$678.640 million for Adult Education
        Title III--Department of Labor
      --$692,370,000 for Wagner-Peyser (FY2021 Enacted)
        Title IV--Department of Education
      --$3,675,021,000 for Vocational Rehabilitation Services (FY2021
            Enacted)
        This training, support and business partnership is vital to our
    country's economic prosperity. For further information, please contact
    Chris Andresen.
        Sincerely,

                                     ______

       Prepared Statement of the University of California San Francisco
                               School of Medicine
        Committee Members,
        I am writing in support of a FY 2022 budget request for Department
    of Health and Human Services to develop a strategic plan and national
    strategy to improve the diagnosis, treatment and prevention of herpes
    simplex virus, types 1 and 2 (HSV). According to the Centers for
    Disease Control and Prevention, over half of Americans have been
    infected with HSV type 1 which can cause cold sores and genital ulcers,
    and one in eight Americans are currently infected with HSV type 2,
    which causes recurrent genital ulcers and is associated with
    significant stigma. There are significant disparities by race and
    sexual orientation, with HSV-2 impacting nearly half of all Black
    women, and approximately one in three men who have sex with men, with
    HSV being linked to HIV acquisition and transmission. Similar to HIV,
    HSV can be transmitted from mother to child during birth, which causes
    approximately 1,000 infant deaths annually. However, due to the poor
    quality of currently available antibody tests, routine testing in
    pregnancy or of the general population is not recommend by the United
    States Preventive Services Task Force. Finally, there is a growing body
    of evidence associating HSV to neurodegenerative diseases such as
    Alzheimer's, highlighting the urgency to develop better prevention and
    treatment strategies.
        As a practicing clinician in the field of sexual health, I cannot
    overstate the negative impact of herpes simplex virus on patients'
    mental health. Countless studies have documented the mental health toll
    of an HSV diagnosis on a patient's well-being, and though not usually a
    fatal or serious infection itself, can lead to significant anxiety and
    depression given the burden of living with a chronic infection which
    must be disclosed to all future sex partners.
        There is currently no national strategy to address HSV in the
    current Federal STI Strategic Plan (2021-2025). There is no
    surveillance for the condition, including its fatal outcomes among
    neonates. The majority of disease spread is via asymptomatic carriers
    unaware of their status. While antibody testing is readily available,
    it is prone to false positive results and there is poor access to
    confirmatory testing such as the Western Blot (previously used widely
    for confirmation of positive HIV results, but not widely available for
    herpes simplex virus). Given the implications for neonatal health, HIV
    transmission, and potential impact on general population of sexually
    active Americans, there is an urgent need for investment into the
    development of more accurate diagnostic testing, prophylactic and
    therapeutic vaccines, and antiviral medication that is more effective
    at viral suppression.
        In short, if we care about maternal-child health, the health of
    communities of color, LGBTQ and other at-risk communities, and the
    mental health of Americans, we must prioritize funding to address
    herpes simplex virus infections.
        Sincerely.

        [This statement was submitted by Ina Park, MD, MS, Associate
    Professor,
    Departments of Family and Community Medicine & Obstetrics, Gynecology,
    and
    Reproductive Sciences, UCSF School of Medicine.]
                                     ______

           Prepared Statement of the Washington State Association of
                              Head Start and ECEAP
        Dear Chairman Murray, Ranking Member Blunt, and Members of the
    Subcommittee,
        On behalf of the Head Start community, thank you for this
    opportunity to share the FY22 recommendation for Head Start funding.
        I have the distinct pleasure of serving as the Executive Director
    of the Washington State Association of Head Start and ECEAP (WSA)--a
    statewide non-profit organization composed of representatives from Head
    Start, Early Head Start, Migrant/Seasonal Head Start, Native American
    Head Start and the Early Childhood Education and Assistance Program
    (ECEAP, the statewide early childhood program). WSA represents 52 Head
    Start programs from Bellingham to Walla Walla, including migrant and
    seasonal and tribal programs. We are immensely proud of our efforts to
    build early learners and support families facing financial hardships.
        These past 16 months have been like none other. The COVID-19
    pandemic has tested and challenged the nation's 1,600 Head Start
    programs and required program managers and directors to adapt
    overnight, think creatively, and juggle the complexities of supporting
    children and families while also protecting them as well as staff and
    meeting local, state, and federal guidelines. Last program year, little
    did we know, social distancing, virtual learning, higher health and
    sanitation standards, and workforce safety would emerge as daily issues
    and priorities.
        Thankfully, Congress and this Committee stood with us through this
    turbulent season. Because of you, Head Start programs by and large were
    able to return to services quickly, stay open, and support children
    with in-person learning. When the first major outbreak overtook
    Washington state, in-person services had to be re-thought and virtual
    learning options made swiftly available. Quickly and competently,
    programs responded to emerging family needs including delivering food,
    learning materials, and cleaning supplies to doorsteps, holding Zoom
    dance parties with preschoolers, and supporting the mental health needs
    of parents and guardians. Several Head Start programs remained open
    onsite during the entirety of the pandemic including the Denise Louie
    Education Center in Seattle which provided childcare to many front line
    and essential workers and parents that needed to be at work in person.
        These heroic efforts undertaken by the Head Start community this
    past year would not have been possible without COVID-19 relief funding
    from Congress. Thank you.
        As Head Start increasingly returns to regular programming and
    doubles down on recruitment and enrollment, and the nation comes out
    from underneath the cloud of COVID-19, the National Head Start
    Association (NHSA) is seeking $12.1 billion in FY22. This level of
    funding will help Head Start programs get back on track in three
    distinct ways:

          (1) by reassuring and bolstering the workforce ($247 million);
          (2) by addressing growing and compounded childhood trauma through
            staff training and additional counseling support ($363
            million); and
          (3) by extending program duration for programs and families
            desperate for more hours of care and support ($730 million).
        These are all long-standing priorities for NHSA and for programs
    across the country--workforce investment, Quality Improvement Funding
    for trauma-informed care, and extended duration--and we look forward to
    working with Congress to meet these goals. Addressing these critical
    needs is foundational to delivering the best results for children from
    at-risk backgrounds.
        Equally important to the quality of our programs and the health,
    safety, and future success of Head Start is a long-overdue, often
    overlooked issue: infrastructure.
        Five years ago, the US Department of Health and Human Services
    identified over $4.2 billion in Head Start capitalization needs, yet
    Head Start's facilities needs have largely gone unaddressed. Local
    programs are unable to afford critical health and safety updates, to
    support access and compliance with the Americans with Disabilities Act,
    to acquire licensable space in new neighborhoods, or to make modest
    updates to align with what we know is best for early childhood
    facilities. Head Start programs are serving children and families from
    the most at-risk backgrounds-those below the poverty line and a
    disproportionate share of children of color. In many cases, these
    children are in buildings that are a half-century old, crumbling, and
    out-of-date. Our Head Start programs, the children who spend most of
    their days in these centers, and the communities that house these
    facilities are in desperate need of long overdue investment.
        In the state of Washington, our programs have persistently
    underfunded facility construction and classroom upgrades. Washington
    State Head Start programs are in desperate need of:

      --HVAC systems and air filtration.
      --Building repairs, including stairs and railings.
      --Updated and/or new buses to ensure children can consistently get
            back and forth to school.
      --New classrooms to handle an influx of children who need in person
            services; and
      --Funds to build and construct new early learning facilities.
        Please allow me to share specific examples from Head Start
    providers in my state:
        Tulalip Tribe Head Start currently serves 74 Early Head Start
    children, 80 state funded preschool children, 112 child care spots, and
    112 tribally funded kids. They need $1.6 million to add three
    classrooms to their Head Start/Child Care wing. This expansion project
    would address social distancing needs to meet licensing requirements
    and the influx of children moving from remote to in-person learning
    this fall as well as enable programing for another 30 children and
    families.
        This year has highlighted the need for outdoor play and learning
    spaces. Family Services of Grant County in Moses Lake has active plans
    to acquire neighboring property to create outdoor classroom space for
    each preschool room. This expansion would add gardens and make critical
    safety improvements. The cost of this project totals $1 million.
        Moses Lake is also in immediate need for a larger transportation
    and maintenance building, additional parking, and improved drop-off
    vehicle access. The existing garage space is restrictive and lacks on-
    site storage. Moses Lake would like to turn the current garage into
    storage space, and build a new bus barn with more bays, so that the
    current space could be used as a small mechanical repair shop and
    perform preventative maintenance, reducing costs and extending the life
    of existing buses. They estimate that the cost for this project is
    about $1.7 million.
        Finally, Okanogan County Child Development Association (OCCDA) in
    Northeast Washington has struggled to find long-term, sustainable
    educational space for five years and COVID-19 guidelines exacerbate
    this concern. OCCDA previously partnered with the Tonasket School
    District but after failed levy attempts, and the school district's own
    struggles for space, the lease was terminated in 2017. This forced
    OCCDA to relocate Tonasket Head Start and ECEAP programs to the
    building that was used for Early Head Start and subsequently relocate
    Early Head Start to a local church for a short period before landing at
    a workable, but not ideal downtown location. These moves have squeezed
    more children and staff into fewer and fewer square feet.
        In 2018, OCCDA applied and was awarded and the Early Learning
    Facilities Technical Assistance Grant to plan for a potential future
    consolidated learning center; however, funds to purchase the property
    and build the facility are still lacking. The estimated cost for
    purchase and build at the time of our Feasibility Study was $1.5
    million. For OCCDA, the pandemic has made a bad infrastructure concern
    far worse. As a result, current facility size and availability limits
    OCCDA's ability to conduct five-day per-week in-person classes to two
    days a week in Tonasket.
        These examples are replayed over and over again in the 52 Head
    Start programs in the State of Washington. While there is a strong
    desire to return to pre-COVID-19 conditions, for Head Start programs,
    the road back is harder and longer. Candidly, we are not interested in
    simply ``going back.'' We want to go forward. The pandemic has shone a
    bright light on deferred maintenance and strained or inadequate
    childcare facilities. Every Head Start program would welcome more
    children, however, the present-day constraints in many ways prevent
    expansion. Meaningful investments in our infrastructure--alongside
    funding for our workforce, sustained support for mental health and
    trauma response, and strengthening our existing program service hours--
    are critical in FY22 to helping children and families make a strong
    return.
        In the days and weeks ahead, the Head Start community would
    appreciate Congress's full embrace of the NHSA FY22 Recommendation of
    $12.1 billion. The community also urges Congress to commit to an
    examination of Head Start's infrastructure constraints and how the
    federal government might partner with local programs to address these
    urgent needs.
        Thank you for your consideration.

        [This statement was submitted by Joel Ryan, Executive Director,
    Washington State Association of Head Start and ECEAP.]
                                     ______

            Prepared Statement of the Women First Research Coalition
        The Women First Research Coalition (WFRC) appreciates the
    opportunity to provide this outside witness testimony to the Senate
    Committee on Appropriations Subcommittee on Labor, Health and Human
    Services, Education, and Related Agencies (Labor-HHS) for the Fiscal
    Year (FY) 2022 LHHS appropriations bill. As you begin work on FY 2022
    appropriations, we respectfully request that you provide $46.11 billion
    for the National Institutes of Health (NIH) as well as additional
    emergency funds to support the biomedical research enterprise recover
    from the COVID-19 pandemic. We also request that you consider including
    our report language on ``Diversity of the Biomedical Research
    Workforce'' and the ``BIRCWH Fellows Program'' in the report that
    accompanies the final FY 2022 Labor-HHS appropriations bill.
        WFRC is a coalition comprised of the nation's leading professional
    medical and research organizations specializing in women's health. Our
    coalition was formed to address pressing challenges in women's health
    research and to raise awareness among federal policymakers, Executive
    Branch officials and the public about the need for sustained and
    strengthened investment in women's health research, the prioritization
    of research in conditions that are specific to women or those
    conditions that may present differently in women than men, advance an
    equitable and appropriate investment in women's health research that
    improves the health outcomes of women, and ensure an adequate women's
    research workforce.
                                funding for nih
        Robust, sustained and predictable funding is important for all
    biomedical research, particularly research on conditions that are
    unique to or predominately occur in women. As Congress appropriates
    funding for FY 2022, the WFRC is requesting that Congress provide
    $46.11 billion, an increase of $3.1 billion, to the NIH, which would
    allow for meaningful growth above inflation that would expand NIH's
    capacity to support promising science in all disciplines. Any funding
    increases should be allocated proportionately to all NIH institutes and
    centers to ensure that meritorious research in women's health is
    supported across the NIH. This would build on Congress' recent
    investments in NIH that have allowed for advances in discoveries toward
    promising therapies and diagnostics, supported current and new
    scientists nationwide and advanced the potential of medical research.
    It will also allow NIH to support meritorious research in women's
    health.
        As the country continues to address the COVID-19 pandemic, WFRC
    also requests additional emergency supplemental funding for NIH to
    address the costs associated with restarting biomedical research
    including the increased costs of research related to personal
    protective equipment, reagents, and existing drugs in the COVID-era as
    well as ensure early stage and early established investigators remain
    part of the biomedical research workforce. We are deeply appreciative
    of the emergency funds Congress has already appropriated, but
    additional emergency funding is needed to enable a full recovery from
    the pandemic.
        We urge Congress to designate a portion of these emergency funds
    for the Eunice Kennedy Shriver National Institute for Child Health and
    Human Development (NICHD), the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK), and the National Institute on
    Aging (NIA), three institutes that support significant amounts of
    women's health research and have not yet received specific emergency
    funding. It is clear that there are significant impacts on patients
    with chronic conditions, as well as differences between how COVID-19
    impacts women and men and the impact on older adults. We also must
    study the effects that COVID-19 has on conditions that are unique to or
    predominantly occur in women, such as pregnancy. Without additional
    funding, NICHD, NIDDK, and NIA will not have the capacity to continue
    adequately supporting existing research projects within their mission
    while also undertaking new research on COVID-related complications and
    comorbidities.
             support diversity of the biomedical research workforce
        Recent reports demonstrate that women in the workforce have been
    disproportionately impacted during the COVID-19 pandemic. While women
    comprise 47 percent of the US labor force, they accounted for 54
    percent of initial COVID-related job losses and continue to make up 49
    percent of losses.\1\ The recent May jobs report further emphasized
    this point, with unemployment among women showing little
    improvement.\2\ During the COVID-19 pandemic, women in academia are
    balancing work with child care and virtual learning, financial issues,
    and other issues at a disproportionate rate to men. OBGYNs have been
    uniquely impacted during the pandemic since not only has their work not
    slowed down during the pandemic, but has become more complicated. For
    physician-researchers, there is little to no support currently in the
    system that addresses their situation. This is exacerbated for women of
    color, who are already underrepresented in obstetrics and gynecology.
    We are concerned that the losses we have seen thus far represent just
    the tip of the iceberg, and these inequities may result in loss of
    women from the research workforce for many more years to come even as
    the country continues to recover from the pandemic.
    ---------------------------------------------------------------------------
        \1\ https://www.wsj.com/articles/how-the-coronavirus-crisis-
    threatens-to-set-back-womens-careers-
    11601438460#::text=Women%20have%20already%20lost%20a%20disproportionate%

    20number%20of%20jobs.&text=While%20women%20are%2047%25%20of,%2C%20accord
    ing%20
    to%20McKinsey%20%26%20Co.
        \2\ https://www.bls.gov/news.release/empsit.nr0.htm.
    ---------------------------------------------------------------------------
        Therefore, the WFRC respectfully requests that you include the
    following report language in the report that accompanies the FY 2022
    LHHS appropriations bill under the NIH Office of the Director:

          Diversity of the Biomedical Research Workforce.--The Committee is
            concerned with the impact of COVID-19 on the diversity of the
            biomedical research workforce, particularly women and women of
            color early stage and midcareer investigators. The Committee
            directs NIH to study the race and gender breakdown of the
            impact of COVID on participation in the workforce by monitoring
            the types of awards applied for and granted by gender and race
            for two years. If the data demonstrate that less women are
            applying for grants, then it is imperative that NIH take steps
            to address this disparity. The Committee requests a status
            update from NIH on this research in the FY 2023 Congressional
            Justification as well as the steps being taken to maintain the
            diversity of the research workforce.
                     support for the bircwh fellows program
        Administered by the NIH Office of Research of Women's Health
    (ORWH), the Building Interdisciplinary Research Careers in Women's
    Health (BIRCWH) program is a mentored career-development program
    designed to connect junior faculty, known as BIRCWH Scholars, to senior
    faculty with shared interest in women's health and sex differences
    research. There are currently 20 active BIRCWH programs across the
    country--each one is a 2-year program, and costs approximately $170,000
    per fellow per year. BIRCWH research areas include cardiovascular
    disease, aging, cancer, neurosciences, musculoskeletal conditions,
    autoimmunity, mental health, reproductive health, health disparities,
    and infectious diseases/emerging infections & HIV/AIDS. Since its
    creation in 2000, the BIRCWH program has trained over 700 fellows and
    has an extremely strong track record of training successful women and
    URiM Scholars and preparing them for independence.
        Approximately 70 percent of BIRCWH fellows supported during 2000-
    2018 received at least one successful R-level grant from the NIH and
    many received private grants as well. To continue this important work,
    more funding is necessary to support additional BIRCWH fellows at all
    existing sites with a goal of increasing the diversity of the scholars,
    sites, research areas supported by the program, and ultimately the
    diversity of the biomedical research workforce.
        Therefore, the WFRC respectfully requests that you include the
    following report language in the report that accompanies the FY 2022
    LHHS appropriations bill under the NIH Office of the Director:

          BIRCWH Fellows Program.--The Committee allocates $3 million to
            the ORWH's Building Interdisciplinary Research Careers in
            Women's Health (BIRCWH) program to fund additional BIRCWH
            fellows at all existing sites with a goal of increasing the
            diversity of the scholars, sites, and research areas supported
            by the program. These funds would support additional
            researchers focused on women's health and sex differences,
            which are priority research areas, as well as expand the
            program's work in the reproductive sciences. The Committee
            recognizes the effectiveness of the BIRCWH program, which is a
            mentored career-development program designed to connect junior
            faculty and senior faculty with shared interests.
                                   conclusion
        Thank you again for the opportunity to submit testimony to the
    Committee as you begin your work on the FY 2022 appropriations bills.
    We look forward to working with you to ensure that there is appropriate
    funding for women's health research at the NIH, and to improve the
    diversity of the biomedical workforce.
                                     ______

             Prepared Statement of the Yale School of Public Health
        To the Committee Members:
        In my personal capacity, I am writing in support of a FY 2022
    budget request for DHHS to develop a strategic plan and national
    strategy for treatment and prevention of Herpes Simplex Virus (HSV)
    Types 1 and 2. As you know, HSV is a chronic viral infection that
    disproportionately affects women of color, LGBTQ populations, and
    adolescents. HSV is well-known risk factor for HIV acquisition since it
    disrupts and is a widely recognized driver of the HIV epidemic. As a
    pediatrician, I wish to highlight the devastation that HSV causes
    through neonatal herpes, often fatal to newborns or the cause of
    overwhelming developmental abnormalities. Other neurodegenerative
    diseases have been linked to HSV.
        There is currently no centralized national strategy to address HSV,
    it is not tracked or tested for, and the majority of spread is via
    asymptomatic carriers unaware of their status. We can and should be
    doing more to stop the spread and provide better treatment to the 1 in
    3 Americans with this chronic condition.
        I chaired a recent Committee for the National Academies of
    Sciences, Engineering, and Medicine that produced a 2021 report for the
    CDC entitled: Sexually Transmitted Infections: Advancing a Sexual
    Health Paradigm. This report highlights the crisis of rising rates of
    sexually transmitted infections in the United States. I hope that you
    support the HSV Strategic Plan mandate for DHHS. Thank you.
        Sincerely yours.

        [This statement was submitted by Sten H. Vermund, Anna M.R. Lauder
    Professor of Public Health, and Dean of the Yale School of Public
    Health, and Professor in Pediatrics at the Yale School of Medicine.]

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    Academy:
        for Radiology & Biomedical Imaging Research, Prepared
          Statement of the...........................................   443
        of Nutrition and Dietetics, Prepared Statement of the........   445
    Ad Hoc Group for Medical Research, Prepared Statement of the.....   447
    AIDS:
        Institute, Prepared Statement of The.........................   449
        United, Prepared Statement of................................   452
    Alzheimer's:
        Association and Alzheimer's Impact Movement, Prepared
          Statement of the...........................................   455
        Foundation of America, Prepared Statement of the.............   457
    American Academy of:
        Allergy, Asthma & Immunology, Prepared Statement of the......   459
        Pediatrics, Prepared Statement of the........................   461
    American Alliance of Museums, Prepared Statement of the..........   463
    American Association for:
        Cancer Research, Prepared Statement of the...................   466
        Clinical Chemistry, Prepared Statement of the................   466
        Dental Research, Prepared Statement of the...................   468
    American Association of:
        Colleges of Nursing, Prepared Statement of the...............   470
        Colleges of Osteopathic Medicine, Prepared Statement of the..   472
        Immunologists, Prepared Statement of the.....................   473
        Neuromuscular & Electrodiagnostic Medicine, Prepared
          Statement of the...........................................   476
        University Professors, Prepared Statement of the.............   478
    American College of:
        Cardiology, Prepared Statement of the........................   479
        Obstetricians and Gynecologists, Prepared Statement of the...   481
        Physicians, Prepared Statement of the........................   484
        Surgeons, Prepared Statement of the..........................   486
    American Educational Research Association, Prepared Statement of
      the............................................................   487
    American Foundation for Suicide Prevention, Prepared Statement of
      the............................................................   488
    American Gastroenterological Association, Prepared Statement of
      the............................................................   491
    American Geophysical Union, Prepared Statement of the............   493
    American Geriatrics Society, Prepared Statement of the...........   494
    American Heart Association, Prepared Statement of the............   496
    American Indian Higher Education Consortium, Prepared Statement
      of the.........................................................   498
    American Liver Foundation, Prepared Statement of the.............   501
    American Lung Association, Prepared Statement of the.............   503
    American Massage Therapy Association, Prepared Statement of the..   505
    American National Red Cross and the United Nations Foundation,
      Prepared Statement of the......................................   507
    American Nurses Association, Prepared Statement of the...........   509
    American Psychological Association Services, Inc., Prepared
      Statement of the...............................................   511
    American Public Health Association, Prepared Statement of the....   513
    American Society for:
        Engineering Education, Prepared Statement of the.............   515
        Microbiology, Prepared Statement of the......................   517
        Nutrition, Prepared Statement of the.........................   519
    American Society of:
        Hematology, Prepared Statement of the........................   521
        Human Genetics, Prepared Statement of the....................   522
        Nephrology, Prepared Statement of the........................   524
        Nephrology, the American Society of Pediatric Nephrology, and
          the National Kidney Foundation, Prepared Statement of the..   740
        Plant Biologists, Prepared Statement of the..................   526
    American Speech-Language-Hearing Association, Prepared Statement
      of the.........................................................   528
    American Thoracic Society , Prepared Statement of the............   530
    American Urogynecologic Society, Prepared Statement of the.......   532
    America's Public Television Stations and the Public Broadcasting
      Service, Prepared Statement of.................................   435
    Anti-Defamation League, Prepared Statement of the................   534
    Association for:
        Career and Technical Education and Advance CTE, Prepared
          Statement of the...........................................   535
        Clinical Oncology, Prepared Statement of the.................   540
        Psychological Science, Prepared Statement of the.............   543
        Research in Vision and Ophthalmology, Prepared Statement of
          the........................................................   545
    Association of:
        American Cancer Institutes, Prepared Statement of the........   547
        American Educators Fellows, Prepared Statement of the........   549
        American Medical Colleges, Prepared Statement of the.........   550
        Farmworker Opportunity Programs, Prepared Statement of the...   552
        Independent Research Institutes, Prepared Statement of the...   553
        Minority Health Professions Schools, Prepared Statement of
          the........................................................   555
        State and Territorial Health Officials, Prepared Statement of
          the........................................................   557
        University Programs in Occupational Health and Safety,
          Prepared Statement of the..................................   559

    Becerra, Hon. Xavier, Secretary, Office of the Secretary,
      Department of Health and Human Services........................   155
        Prepared Statement of........................................   163
        Questions Submitted to.......................................   196
        Summary Statement of.........................................   161
    Bennett, Katherine, MD, FACP, Prepared Statement of..............   561
    Beyond AIDS Foundation, Prepared Statement of the................   563
    Bianchi, Diana W., M.D., Director, Eunice Kennedy Shriver
      National Institute of Child Health and Human Development.......    69
        Prepared Statement of........................................    77
        Questions Submitted to.......................................   136
    Big Cities Health Coalition, Prepared Statement of the...........   564
    Blunt, Senator Roy, U.S. Senator From Missouri:
        Prepared Statements of ....................... 6, 74, 160, 252, 370
        Questions Submitted by .....  54, 124, 146, 150, 152, 217, 353, 420
        Statements of ...............................  4, 72, 157, 250, 368
    Braun, Senator Mike, U.S. Senator From Indiana, Questions
      Submitted by...................................................   427

    Campaign for Tobacco-Free Kids, Prepared Statement of the........   567
    Capito, Senator Shelley Moore, U.S. Senator From West Virginia,
      Questions Submitted by ...............................  147, 151, 426
    Cardona, Hon. Miguel, Secretary, Office of the Secretary,
      Department of Education........................................   247
        Prepared Statement of........................................   255
        Questions Submitted to.......................................   282
        Summary Statement of.........................................   253
    Caregiver Action Network, Prepared Statement of the..............   569
    CDC Coalition, Prepared Statement of the.........................   571
    Centers for Disease Control and Prevention, Prepared Statement of
      the............................................................   573
    Christopher & Dana Reeve Foundation, Prepared Statement of the...   577
    Coalition for:
        Clinical and Translational Science, Prepared Statement of the   578
        Health Funding, Prepared Statement of the....................   581
        Service Learning, Prepared Statement of the..................   583
    College on Problems of Drug Dependence, Prepared Statement of....   586
    Collins, Francis S., M.D., Ph.D., Director, National Institutes
      of Health......................................................    69
        Prepared Statement of........................................    77
        Questions Submitted to.......................................   115
        Summary Statement of.........................................    75
    Congressional Fire Services Institute, Prepared Statement of the.   588
    Consortium of Social Science Associations, Prepared Statement of
      the............................................................   588
    Council of Academic Family Medicine, Prepared Statement of the...   590
    Covenant House International, Prepared Statement of the..........   592
    Creutzfeldt-Jakob Disease Foundation, Prepared Statement of the..   593
    Crowley, Amanda Peel, Prepared Statement of......................   595
    Cure Alzheimer's Fund, Prepared Statement of the.................   597

    Dave Purchase Project, the North American Syringe Exchange
      Network, Tacoma Needle Exchange, and Coalition Partners,
      Prepared Statement of..........................................   599
    Deadliest Cancers Coalition, Prepared Statement of the...........   601
    Department of Preventive Medicine and Department of Medicine,
      Infectious Diseases, Prepared Statement of the.................   603
    Duke Health, Prepared Statement of...............................   603
    Durbin, Senator Richard J., U.S. Senator From Illinois, Questions
      Submitted by...........................  116, 133, 136, 143, 204, 297
    Dystonia Medical Research Foundation, Prepared Statement of the..   606

    Education Finance Council, Prepared Statement of.................   608
    Endocrine Society, Prepared Statement of the.....................   610
    Entomological Society of America, Prepared Statement of the......   612
    Epilepsy Foundation, Prepared Statement of the...................   614
    Evermore, Prepared Statement of..................................   616
    Evidence-Based Leadership Collaborative, Prepared Statement of
      the............................................................   619

    Fauci, Anthony S., M.D., Director, National Institute of Allergy
      and Infectious Diseases........................................    69
        Prepared Statement of........................................    77
        Questions Submitted to.......................................   133
    Federal AIDS Policy Partnership's Research Work Group, Prepared
      Statement of the...............................................   621
    Federation of:
        American Societies for Experimental Biology, Prepared
          Statement of the...........................................   623
        Associations in Behavioral and Brain Sciences, Prepared
          Statement of the...........................................   625
    Florida A&M University, Prepared Statement of....................   627
    Fred Hutchinson Cancer Research Center, Prepared Statement of
      the ........................................................ 629, 631
    Friedman, Harvey, MD, Prepared Statement of......................   655
    Friends of the:..................................................
        Health Resources and Services Administration, Prepared
          Statement of the...........................................   631
        Institute of Education Sciences, Prepared Statement of the...   633
            National Institute:......................................
                of Child Health and Human Development, Prepared
                  Statement of the...................................   635
                of Diabetes and Digestive and Kidney Diseases,
                  Prepared Statement of the..........................   637
                of Mental Health, Prepared Statement of the..........   639
                on Aging, Prepared Statement of the..................   640
                on Drug Abuse, Prepared Statement of the.............   641
    FSHD Society, Prepared Statement of..............................   643

    GBS|DCIDP Foundation International, Prepared Statement of the....   649
    GEAR UP, Prepared Statement of...................................   651
    Gibbons, Gary H., M.D., Director, National Heart, Lung, and Blood
      Institute......................................................    69
        Prepared Statement of........................................    77
        Questions Submitted to.......................................   150
    Global Health:
        Council, Prepared Statement of...............................   652
        Technologies Coalition, Prepared Statement of the............   653

    Health Professions and Nursing Education Coalition, Prepared
      Statement of the...............................................   655
    Hearing Industries Association and the Hearing Loss Association
      of America, Prepared Statement of the..........................   657
    Hepatitis B Foundation, Prepared Statement of the................   660
    HIV Medicine Association, Prepared Statement of the..............   662
    HIV+Hepatitis Policy Institute, Prepared Statement of the........   664
    Human Factors and Ergonomics Society, Prepared Statement of the..   666
    Hyde-Smith, Senator Cindy, U.S. Senator From Mississippi,
      Questions Submitted by................... 66, 129, 148, 152, 236, 358

    I AM ALS, Prepared Statement of..................................   668
    Infectious Diseases Society of America, Prepared Statement of the   669
    Integrative Health Policy Consortium, Prepared Statement of the..   672
    International Foundation for Gastrointestinal Disorders, Prepared
      Statement of...................................................   675
    Interstate Mining Compact Commission, Prepared Statement of the..   676
    Interstitial Cystitis Association, Prepared Statement of the.....   677

    Kennedy, Senator John, U.S. Senator From Louisiana, Questions
      Submitted by...................................................   236

    Leahy, Senator Patrick, U.S. Senator From Vermont, Questions
      Submitted by ...................................   129, 244, 363, 429
    Learning and Education Academic Research Network, Prepared
      Statement of the...............................................   679
    Lymphatic Education & Research Network, Prepared Statement of the   681

    Manchin, Senator Joe, III, U.S. Senator From West Virginia,
      Questions Submitted by....................49, 121, 134, 215, 352, 415
    March of Dimes, Prepared Statement of the........................   683
    Meals on Wheels America, Prepared Statement of...................   685
    Medical Library Association and Association of Academic Health
      Sciences Libraries, Prepared Statement of the..................   688
    METAvivor Research and Support, Inc., Prepared Statement of the..   692
    Michelson Center for Public Policy, Prepared Statement of the....   694
    Midwest Urban Strategies, Prepared Statement of the..............   696
    Moore Center for the Prevention of Child Sexual Abuse, Prepared
      Statement of the...............................................   697
    Moran, Senator Jerry, U.S. Senator From Kansas, Questions
      Submitted by .................................................66, 234
    Murray, Senator Patty, U.S. Senator From Washington:
        Opening Statements of......................... 1, 69, 155, 247, 365
        Questions Submitted by ..............   41, 115, 140, 196, 282, 394
    NAF, Prepared Statement of.......................................   699
    National Alliance:
        for Caregiving, Prepared Statement of the....................   700
        for Eye and Vision Research , Prepared Statement of the......   703
        for Public Charter Schools, Prepared Statement of the........   706
        on Mental Illness, Prepared Statement of the.................   708
        to End Sexual Violence, Prepared Statement of the............   710
    National Alopecia Areata Foundation, Prepared Statement of the...   712
    National Association for State Community Services Programs,
      Prepared Statement of the......................................   714
    National Association of:.........................................
        Councils on Developmental Disabilities, Prepared Statement of
          the........................................................   717
        Drug Court Professionals, Prepared Statement of the..........   718
        Emergency Medical Technicians, Prepared Statement of the.....   719
        Nutrition and Aging Services Programs, Prepared Statement of
          the........................................................   720
        Secondary School Principals, Prepared Statement of the.......   722
        State Head Injury Administrators, Prepared Statement of the..   725
        State Long-Term Care Ombudsman Programs, Prepared Statement
          of the.....................................................   726
    National College Attainment Network, Prepared Statement of the...   729
    National Council for Diversity in the Health Professions,
      Prepared Statement of the......................................   731
    National Eczema Association, Prepared Statement of the...........   732
    National Family Planning & Reproductive Health Association,
      Prepared Statement of the......................................   734
    National Institutes of Health, Prepared Statement of the.........   736
    National Kidney Foundation, Prepared Statement of the............   738
    National Marrow Donor Program/Be The Match, Prepared Statement of
      the............................................................   742
    National Multiple Sclerosis Society, Prepared Statement of the...   744
    National Pancreas Foundation, Prepared Statement of the..........   746
    National Public Radio, Prepared Statement of the.................   440
    National Respite Coalition, Prepared Statement of the............   749
    National Technical Institute for the Deaf, Prepared Statement of
      the............................................................   752
    National Viral Hepatitis Roundtable, Prepared Statement of the...   754
    NephCure Kidney International, Prepared Statement of the.........   755
    Neurofibromatosis Network, Prepared Statement of the.............   757
    Northwest Portland Area Indian Health Board, Prepared Statement
      of the.........................................................   758
    Nursing Community Coalition, Prepared Statement of the...........   761
    Nutrition & Medical Foods Coalition, Prepared Statement of the...   764

    One Voice Against Cancer, Prepared Statement of..................   766

    Pandemic Action Network , Prepared Statement of the..............   768
    PATH, Prepared Statement of......................................   770
    Patient Services, Inc., Prepared Statement of....................   772
    Pediatric Policy Council, Prepared Statement of the..............   774
    Peel, Ann D., Prepared Statement of..............................   776
    Perez-Stable, Eliseo J., M.D., Director, National Institute on
      Minority Health and Health Disparities.........................    69
        Prepared Statement of........................................    77
        Questions Submitted to ..................................  136, 152
    Personalized Medicine Coalition, Prepared Statement of the.......   778
    Physical Activity Alliance, Prepared Statement of the............   780
    Planned Parenthood, Prepared Statement of........................   782
    Population Association of America/Association of Population
      Centers, Prepared Statement of the.............................   785
    Port Gamble S'Klallam Tribe, Prepared Statement of the...........   788
    Public Health-Seattle & King County, WA, Prepared Statement of...   790
    Pulmonary Hypertension Association, Prepared Statement of the....   792

    Reamer, Andrew, Prepared Statement of............................   794
    Reed, Senator Jack, U.S. Senator From Rhode Island, Questions
      Submitted by...................................... 144, 209, 350, 415
    Research!America, Prepared Statement of..........................   795
    Restless Legs Syndrome Foundation, Prepared Statement of the.....   796
    Rotary International, Prepared Statement of......................   798
    Rubio, Senator Marco, U.S. Senator From Florida, Questions
      Submitted by...................................................   243
    Ryan White Medical Providers Coalition, Prepared Statement of the   801

    Safer Foundation, Prepared Statement of..........................   803
    Scleroderma Foundation, Prepared Statement of the................   806
    Seattle Indian Health Board, Prepared Statement of the...........   808
    Sleep Research Society and Project Sleep, Prepared Statement of
      the............................................................   810
    Schatz, Senator Brian, U.S. Senator From Hawii, Questions
      Submitted by
    Schuchat, Anne, M.D., Principal Deputy Director, Centers for
      Disease Control and Prevention, Prepared Statement of..........     9
    Shaheen, Senator Jeanne, U.S. Senator From New Hampshire,
      Questions Submitted by ................................. 45, 137, 210
    Sharpless, Norman E., M.D., Director, National Cancer Institute..    69
        Prepared Statement of........................................    77
        Questions Submitted to.......................................   140
    Shelby, Senator Richard C., U.S. Senator From Alabama, Questions
      Submitted by............................................ 62, 135, 231
    Society for:
        Maternal-Fetal Medicine, Prepared Statement of the...........   812
        Neuroscience, Prepared Statement of the......................   815
        Women's Health Research, Prepared Statement of the...........   818
    Society of:
        Gynecologic Oncology, Prepared Statement of the..............   820
        Nuclear Medicine and Molecular Imaging, Prepared Statement of
          the........................................................   822
    Student Support and Academic Enrichment Program, Prepared
      Statement of the...............................................   825
    Susan G. Komen Breast Cancer Foundation, Prepared Statement of...   828

    Task Force for Global Health, Prepared Statement of the .......830, 832

    Task Force for Global Health, Inc., Prepared Statement of the....   833
    Tourette Association of America, Prepared Statement of the.......   834
    Training Programs in Epidemiology and Public Health Interventions
      Network, Prepared Statement of the.............................   836
    Trauma Center Association of America, Prepared Statement of the..   838
    Treatment Action Group, Prepared Statement of the ............ 838, 841
    Tromberg, Bruce J., Ph.D., Director, National Institute of
      Biomedical Imaging and Bioengineering..........................    69
        Prepared Statement of........................................    77
    Trust for America's Health, Prepared Statement of................   842

    United:
        for Charitable Assistance, Prepared Statement of.............   846
        States Workforce Associations, Prepared Statement of the.....   848
    University of California San Francisco School of Medicine,
      Prepared Statement of the......................................   850

    Walensky, Dr. Rochelle, Director, Centers for Disease Control and
      Prevention.....................................................     7
        Prepared Statement of........................................     9
        Questions Submitted to.......................................    41
    Walsh, Hon. Martin J., Secretary, Office of the Secretary,
      Department of Labor............................................   365
    Prepared Statement of............................................   372
        Summary Statement of.........................................   371
        Questions Submitted to.......................................   394
    Washington State Association of Head Start and ECEAP, Prepared
      Statement of the...............................................   850
    Women First Research Coalition, Prepared Statement of the........   852

    Yale School of Public Health, Prepared Statement of the..........   855

                                 SUBJECT INDEX

                                  ----------

       AMERICA'S PUBLIC TELEVISION STATIONS AND THE PUBLIC BROADCASTING
                                    SERVICE

                                                                       Page

    Corporation for Public Broadcasting..............................   591
    National Public Radio............................................   440

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    Access to and use of Covid Relief Funds..........................   263
    Additional Committee Questions...................................   282
    American Rescue Plan Act.........................................   255
    Career Pathways..................................................   354
    Charter Schools .............................................. 278, 357
    Closing Remarks..................................................   259
    Community-Based Programs.........................................   257
    Department of Education Funding Levels...........................   256
    Education:
        as an Equalizer..............................................   254
        for Homeless Children and Youths.............................   249
    Enforcement of Civil Rights Laws.................................   259
    Expanding Free College Proposal to all Accredited Institutions...   262
    Financial Literacy...............................................   282
    Flexibility in Use of Covid Funding..............................   276
    For-Profit Colleges..............................................   267
    Free Community College...........................................   261
        Program......................................................   281
    Fulfilling our Roles to Improve the Education System.............   254
    Funding Inequities in State and Local Education Systems..........   256
    Higher Education.................................................   249
    Homeless Education...............................................   279
    Impact Aid.......................................................   265
    Improving Career Pathways........................................   258
    Individuals With Disabilities:
        Act..........................................................   265
        Education Act................................................   248
    In-person Instruction............................................   271
    Investment in:
        Improving Students' Physical and Mental Health...............   257
        Title I Grants to Local Educational Agencies.................   256
    Investments to Support Higher Education..........................   260
    K-12 COVID-19 Funding/School Reopening...........................   355
    Literacy.........................................................   275
    Lost Learning Time and Disparities...............................   248
    Mental Health....................................................   358
    NAEP Funding.....................................................   358
    Overview of the Budget Request...................................   254
    Postsecondary Education Investments..............................   258
    Rationale for Additional Funding.................................   269
    Resource Allocation..............................................   259
    Return on Investment in Post-Secondary Education.................   273
    School Infrastructure........................................  259, 274
    Secondary Education Alignment With Job Market....................   274
    Simplification of Free Application for Federal Student Aid.......   270
    State Plans for Esser Funding....................................   278
    Student Aid Administration.......................................   259
    Student Loan:
        Pause........................................................   355
        Repayment....................................................   264
        Servicing...............................................   272, 353
    Student Loans....................................................   267
    Support for Special Education....................................   257
    Teacher Training and Support.....................................   257
    Title I Equity Grants............................................   357
    Title IX.........................................................   249
    Transparency of Covid Relief Spending............................   271
    TRIO.............................................................   265
                                   __________

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    Advances in Vaccine and Therapeutic Delivery Systems (RADx
      Program).......................................................   106
    A.I. Detection of Cancers........................................   110
    Additional Committee Questions...................................   115
    Alzheimer's Disease Research.....................................   101
    ARPA-H:
        and Cancer Research..........................................    81
        and Diabetes.................................................    86
        Funding Level................................................    81
        Structure....................................................    79
    Autoimmune Research Breakthroughs................................    93
    Climate Change and Health........................................   110
    COVID-19:
        and Health Disparities.......................................   107
        and MIS-C....................................................   109
        Vaccine Booster Shots........................................    87
    CTSA Program  .................................................  95, 99
    Cystic Fibrosis Research.........................................    94
    Domestic Drug Supply Chain.......................................    95
    Firearms Research................................................    91
        and Firearm Registries.......................................   103
    Future of mRNA Technology........................................   113
    Gain-of-function Research in China...............................    88
    Global Vaccine Distribution......................................    85
    Impact of COVID-19 Pandemic on:
        Childhood Development........................................   113
        Research and Researchers.....................................   114
    Infectious Disease Surveillance Efforts..........................    97
    Investigation into Origin of COVID-19........................... 90, 98
    Long COVID.......................................................    84
    Lupus Research...................................................    94
    Marijuana Research...............................................   102
    NCATS Rare Disease Research......................................   100
    Non-Opioid Alternatives to Chronic Pain..........................   103
    Origin of COVID-19........................................ 85, 104, 107
    Pancreatic Cancer Research.......................................    95
    Psychedelic Drug Therapies.......................................   101
    RADx Partnerships................................................    82
    Rural Health Outcomes............................................    96
    Sexual Harassment at NIH.........................................   111
    Social Determinants of Health....................................    92
    Structural Racism and Health Equity..............................    80
    Substance Use Disorder and Methamphetamine Research..............    88
    Suicide Prevention...............................................    83
    Vaccine Development..............................................    84

                            Office of the Secretary

    340B.............................................................   184
    ACA/Uninsured Number.............................................   194
    Additional Committee Questions...................................   196
    Adverse Childhood Experiences (ACEs) in Primary Care Settings
      Demonstration Project..........................................   206
    Alternatives to Opioids for Treatment of Chronic Pain............   179
    Alzheimer's Disease..............................................   181
    BARDA Misused Funds..............................................   217
    Caring for all Americans Through Health and Human Services.......   165
    Childcare........................................................   194
        Providers....................................................   178
    Collaborative Improvement and Innovation Network for School-Based
      Health Services................................................   206
    Combating Mental Health and Substance Use Crises.................   167
    COVID-19:
        Boosters.....................................................   217
        Vaccine Goals................................................   192
        Vaccines Donated Internationally.............................   217
    Disease X........................................................   218
    Domestic Manufacturing...........................................   182
    ``Ending HIV'' Initiative........................................   226
    Excess Vaccines..................................................   177
    Fetal Tissue Research............................................   187
    Funding Core Program Operations..................................   169
    Graduate Medical Education.......................................   193
    Health:
        Disparities..................................................   195
        Insurance Subsidies..........................................   178
    Hyde Amendment ..............................................  189, 220
    Influenza........................................................   230
    Investing in Children's Futures..................................   167
    Low Income Home Energy Assistance Program........................   170
    Maternal Mortality...............................................   190
    Medicaid Reentry Act.............................................   175
    Mental Health....................................................   220
    National:
        Coordinating Committee on School Health and Safety...........   206
        Suicide Prevention Lifeline..................................   169
    Native Hawaiian Health...........................................   174
        Care Systems.................................................   214
    Opioids....................................................... 183, 222
    Organ Transplantation............................................   219
    Partial-Birth Abortions..........................................   189
    Personal Protective Equipment Manufacturers......................   170
    Preparing for and Responding to Public Health Crises.............   163
    Promoting Biomedical Research....................................   168
    Provider Relief Fund (PRF).......................................   221
    Providing Oversight and Program Integrity........................   169
    Psychological Clinical Science Accreditation System..............   221
    Public Health Emergency Fund.....................................   174
    Public Option....................................................   188
    Restoring America's Promise to Refugees..........................   168
    Short Term Plans.................................................   175
    State Opioid Response Grants.....................................   177
    Strategic National Stockpile.....................................   176
    Supplemental and Reconciliation Funding..........................   228
    Technical Assistance--Health Centers Located in Hawaii...........   214
    Telehealth.................................................... 173, 180
    Unaccompanied Children .................................. 172, 185, 218
        Emergency Intake Sites.......................................   191
                                   __________

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Adapting Training Programs to Meet Industry Needs................   378
    Addiction and Returning to Work..................................   417
    Additional Committee Questions...................................   393
    Addressing the Workforce Shortage................................   385
    Alleviating Licensing Restrictions for Military Workers and their
      Spouses........................................................   390
    American:
        Jobs Plan....................................................   373
        Rescue Plan..................................................   373
    Apprenticeships and Nontraditional Industries....................   420
    Black Lung Benefits..............................................   415
    BLS Move.........................................................   408
    Budget:
        Increases....................................................   381
        Increases for Workforce Development Programs.................   388
        Investments..................................................   371
    Cares Act and American Rescue Plan Spending......................   424
    Child Labor......................................................   397
    Combating:
        Literacy Issues..............................................   381
        Wage Theft...................................................   389
    COVID-19 Emergency Temporary Standard............................   422
    Creating A Well-Prepared Workforce...............................   377
    Davis Bacon Enforcement..........................................   396
    Demand-Driven Training Programs..................................   380
    Department of Labor Surveys......................................   383
    Diversity in Apprenticeship Programs.............................   386
    DOL Freedom of Information Act Requests..........................   427
    EBSA Consolidated Budget.........................................   410
    Empowering America's Workers.....................................   367
    Funding for:
        the Appalachian and Delta Commissions........................   391
        West Virginia Grantees.......................................   426
    Green Jobs.......................................................   421
    H-2B VISAS.......................................................   384
    ILAB Monitoring and Enforcement..................................   396
    Importance of the Job Corps Program..............................   384
    Increase in H-2B Visas...........................................   390
    IT Solutions for Aging UI Systems................................   387
    Joint Employer Rule..............................................   422
    Learning Agendas and Evaluation Plan.............................   413
    Miners And COVID-19 Protections..................................   416
    Modernizing Unemployment Insurance Systems.......................   367
    Multilingual Worker Protection Staff.............................   402
    OFCCP Enforcement................................................   399
    OSHA:
        Enforcement Budget Increase..................................   391
        Enforcement in Large Business vs. Small Business.............   392
        Farmworker Safety............................................   401
        Increases in Fiscal Year 2022 Budget.........................   376
        Increases in the American Rescue Plan........................   375
    Partners Act Apprenticeship Legislation..........................   386
    Payroll Audit Independent Determination Program..................   428
    Protecting Workers and Their Wages...............................   366
    Regional Apprenticeship Program..................................   432
    Research and Evaluation Funding..................................   410
    Restoration of DOL Staffing......................................   424
    Secretary's Calendar.............................................   428
    Short-Term Compensation Program..................................   379
    Silica Dust Rule.................................................   416
    Subminimum Wage..................................................   404
    Supporting America's Workers Through the Pandemic to Recovery, FY
      2022 Budget....................................................   374
    Tax Increases for Infrastructure Bill............................   382
    Teleworking......................................................   428
    Training America's Workforce.....................................   367
    Unemployment Insurance and:
        Consumer Finance Applications................................   426
        Returning to Work............................................   418
        Third-Party Income Verification..............................   429
    Unemployment Insurance IT Modernization..........................   429
    Vision of the Fiscal Year 2022 President's Budget................   365
    WCF Unobligated Balances.........................................   411
    WHD and OSHA FOIA Requests.......................................   409
    Whistleblower Complaints and Staffing............................   394
    WIOA and Public Libraries........................................   415
    Workforce Shortages..............................................   430
                                   __________

      REVIEW OF THE FISCAL YEAR 2022 BUDGET BLUEPRINT FOR THE CENTERS FOR
                         DISEASE CONTROL AND PREVENTION

    317 Immunization Program.........................................    20
    Additional Committee Questions...................................    41
    American:
        Medical Manufacturing........................................    29
        Rescue Plan Funds............................................    65
    Annual Appropriations............................................    63
    Cares Act Funds..................................................    64
    Changes to Mask Guidance and Reopening...........................    14
    Child Mental Health..............................................    18
    Collaboration on Biodefense Facilities...........................    30
    Community Health Workers.........................................    32
    COVID:
        in India.....................................................    26
        Therapeutics.................................................    27
        -19 Vaccines for Children and Adolescents....................    35
    Data Modernization...............................................    40
    Earliest COVID Lessons...........................................    40
    Funding Flexibility..............................................    19
    Gun Violence.....................................................    17
    HIV in West Virginia.............................................    34
    Infrastructure After Emergency...................................    13
    International Collaboration......................................    30
    Lead Poisoning Prevention........................................    21
    Learning Lessons from COVID......................................    31
    Lessons Learned..................................................    16
    Mask:
        Guidance.....................................................    21
        Guidance for Vaccinated Individuals..........................    25
        Policy Jurisdiction..........................................    35
        in Workplaces................................................    24
    Opioids in:
        New Hampshire................................................    32
        West Virginia................................................    28
    Pandemic Trajectory..............................................    13
    PFAS Contamination...............................................    33
    Public Health Communication......................................    24
    Racial:
        and Ethnic Disparities.......................................    36
        Disparities..................................................    15
    Rural Health Disparities.........................................    18
    Suicide Prevention...............................................    20
    Vaccine:
        Boosters.....................................................    38
        Hesitancy....................................................    37
        in Pregnancy.................................................    38
    Virus Origins....................................................    23
    Vulnerable Public Health System..................................    27

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