[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.
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    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\
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    \11\ clinicaltrials.gov/ct2/show/NCT03344419.
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    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\
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    \12\ clinicaltrials.gov/ct2/show/NCT03356483.
    \13\ reporter.nih.gov/project-details/10127338.
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    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\
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    \14\ reporter.nih.gov/project-details/10003396.
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    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.
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    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\)
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    \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).
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    --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.
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    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.
---------------------------------------------------------------------------
    \27\ www.nap.edu/read/25356/chapter/7.
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    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/.
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    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.
---------------------------------------------------------------------------
    \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.
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    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\
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    \45\ reporter.nih.gov/project-details/10104456.
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    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\
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    \46\ trp.cancer.gov/spores/endometrial.htm.
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    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.
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    \47\ clinicaltrials.gov/ct2/show/NCT04214067.
    \48\ clinicaltrials.gov/ct2/show/NCT03914612.
    \49\ clinicaltrials.gov/ct2/show/NCT04585958.
    \50\ clinicaltrials.gov/ct2/show/NCT04494113.
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    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.
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    \51\ www.cancer.gov/about-nci/organization/ccct/steering-
committees/nctn/gynecologic.
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    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\
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    \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.
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    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\
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    \56\ dceg.cancer.gov/research/cancer-types/cervix/cervix-
mississippi.
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    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\
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    \57\ prevention.cancer.gov/major-programs/nci-cervical-cancer-last-
mile-initiative.
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    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.
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    \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.
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    \60\ pubmed.ncbi.nlm.nih.gov/32315381/.
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                                 ______
                                 
                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.
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    \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.
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    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.
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    \64\ cancer.gov/types/childhood-cancers/ccss.
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    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\
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    \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.
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    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).
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    \68\ www.cancer.gov/research/annual-plan/scientific-topics/protac-
infographic.
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    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.
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    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.
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    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.
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                             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.
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    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.
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    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.
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    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.
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    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.
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  --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.
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                                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.
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    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.
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    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.
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    \33\ https://www.dol.gov/general/foia/readroom.
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       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.
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    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.
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    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\
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    \1\ Kennedy, J. L., Christensen, C., Maxon, T., Gerard, S., Garcia, 
E., Hupert, N., Vahey, P., & Pasnik, S. (2021).
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  --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\
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    \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.)
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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/.
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    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.
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    \3\ https://www.unitedformedicalresearch.org/wp-content/uploads/
2021/03/NIHs-Role-in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
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    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.
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    \1\ https://acl.gov/about-acl/authorizing-statutes/older-americans-
act.
    \2\ https://fas.org/sgp/crs/misc/IF10633.pdf.
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            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.
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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.
---------------------------------------------------------------------------
    \4\ https://www.cdc.gov/obesity/data/adult.html.
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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.
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Contact
    Please feel free to contact me at [email protected] 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 [email protected] or 
Frank Hood at [email protected].

    [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 [email protected].
    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 
[email protected] or Eric Sokol, AFA's senior vice president of 
public policy, at [email protected], 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 [email protected] 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 [email protected]. 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 [email protected].

    [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.
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  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/.
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    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.
---------------------------------------------------------------------------
    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 [email protected] 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.
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    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.
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    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.
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                            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.
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     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 
([email protected]) 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.
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    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\
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    \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.
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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.
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    \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\
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    \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.
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    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 [email protected].

    [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\
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    \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.
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    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/.
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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.
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    \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.
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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\
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    \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.
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                               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.
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    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.
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    \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.
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    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.
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    \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.
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    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\
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    \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.
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    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:
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    \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.
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  --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\
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    \6\ COVID-19 Pandemic Indirectly Disrupted Health Disease Care. 
American College of Cardiology. January 11, 2021. Accessed online 
February 17, 2021.
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    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\
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    \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.
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    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 
[email protected].
                                 ______
                                 
       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.
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    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.
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    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/.
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    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.
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    \6\ https://www.samhsa.gov/minority-fellowship-program/about.
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    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 [email protected].

    [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.
---------------------------------------------------------------------------
    \1\ https://www.ahajournals.org/doi/10.1161/CIR.0000000000000950.
---------------------------------------------------------------------------
    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, [email protected], 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 
[email protected], 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.
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    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 [email protected]; Rachel 
Meyer with the American Society of Nephrology at [email protected]; 
or Lauren Drew with the National Kidney Foundation (NKF) at 
[email protected].
                about the american society of nephrology
    The American Society of Nephrology is a 501(c)(3) non-profit, tax-
exempt organization that leads the fight against kidney disease by 
educating the society's more than 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, [email protected], 
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\
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    \1\ Perkins Collaborative Resource Network, State Profiles. 
Retrieved from https://cte.ed.gov/profiles/national-summary.
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    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.
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  --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.
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  --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\
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    \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.
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    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.
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    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\
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    \7\ https://www.stradaeducation.org/wp-content/uploads/2020/04/
Public-Viewpoint-Report-Week-4.pdf.
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    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\
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    \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.
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    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.
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    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.
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    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).
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    \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\
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    \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 
([email protected]) or Advance CTE's Senior Associate for 
Federal Policy Associate Meredith Hills ([email protected]).
                                 ______
                                 
      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.
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    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\
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    \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.
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                  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 [email protected] 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\
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    \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.
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    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.
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    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.
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    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;.
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    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).
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    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.
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    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 [email protected] or Sally 
Schaeffer, consultant, at [email protected].

    [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 
[email protected] 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.
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    \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).
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    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.
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  --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.
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  --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.
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  --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.
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  --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/.
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           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 
[email protected].
    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.
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Wollnik B, Binetruy B, Salort Campana E, Attarian S, Bernard R, Nguyen 
K, Amiel J, Dumonceaux J, Murphy JM, Dejardin J, Blewitt ME, Reversade 
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    \61\ Mellion ML, Ronco L, Berends CL, Pagan L, Brooks S, van Esdonk 
MJ, van Brummelen EMJ, Odueyungbo A, Thompson LA, Hage M, Badrising UA, 
Raines S, Tracewell WG, van Engelen B, Cadavid D, Groeneveld GJ. Phase 
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Safety, tolerability, pharmacokinetics, and target engagement. Br J 
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    \62\ Lu-Nguyen N, Malerba A, Herath S, Dickson G, Popplewell L. 
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FSHD-like pathology in an FSHD mouse model. Hum Mol Genet. 2021 May 
13:ddab136. doi: 10.1093/hmg/ddab136. (2021).
    \63\ Das S, Chadwick BP. CRISPR mediated targeting of DUX4 distal 
regulatory element represses DUX4 target genes dysregulated in 
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15;11(1):12598. doi: 10.1038/s41598-021-92096-0. (2021).
    \64\ Goselink RJM, Mul K, van Kernebeek CR, Lemmers RJLF, van der 
Maarel SM, Schreuder THA, Erasmus CE, Padberg GW, Statland JM, Voermans 
NC, van Engelen BGM. Early onset as a marker for disease severity in 
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Brix T, Gorlich D, Young P, Boentert M. Respiratory muscle weakness in 
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Rondeau S, Lagha N, Nigumann P, Cambieri C, Puma A, Chapon F, Stojkovic 
T, Vial C, Bouhour F, Cao M, Pegoraro E, Petiot P, Behin A, Marc B, 
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Rehman S, Jaliparthy K, Khan N, Scott CG, St Louis EK, Liewluck T, 
Somers VK, Lin G, Brady PA, Milone M. Cardiac Involvement in 
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24;12:668180. doi: 10.3389/fneur.2021.668180. (2021).
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W, Groothuis JT. The socioeconomic burden of facioscapulohumeral 
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JG, Weinert RO, Do TQN, Street N; Muscular Dystrophy Surveillance, 
Tracking, and Research Network (MD STARnet). Characterization of 
individuals with selected muscular dystrophies from the expanded pilot 
of the Muscular Dystrophy Surveillance, Tracking and Research Network 
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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.
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    \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.
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    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: [email protected], 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.
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    \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.
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    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.
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    \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 
[email protected], 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 
[email protected].

    [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.
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    \1\ https://news.harvard.edu/gazette/story/2020/11/what-might-
covid-cost-the-u-s-experts-eye-16-trillion/.
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    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\
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    \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.
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    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.
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    \4\ https://nexus.od.nih.gov/all/2018/05/04/the-issue-that-keeps-
us-awake-at-night/.
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    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.
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    \1\ https://www.bls.gov/charts/employment-situation/unemployed-27-
weeks-or-longer-as-a-percent-of-total-unemployed.htm.
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    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 
[email protected].

    [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 
[email protected].
                                 ______
                                 
           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 [email protected], or Becky Corby, NASHIA 
Government Relations at [email protected].
                                 ______
                                 
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 [email protected]. 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, 
[email protected].
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                                 ______
                                 
         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.
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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.
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    \1\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
Corporate/file/PMC_The_
Personalized_Medicine_Report_Opportunity_Challenges_and_the_Future.pdf.
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              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.
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    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.
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    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/.
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    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.
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    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.
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    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.
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                             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.
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  --Physical activity also contributes to social connectedness,\6\ 
        quality of life,\7\ and environmental sustainability.\8,9\
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    \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.
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  --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\
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    \10\ Wen CP and Wu X. Stressing harms of physical inactivity to 
promote exercise. Lancet. 2012;380:192-3.
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  --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\
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    \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.
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  --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\
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    \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.
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    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\
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    \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.
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    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.
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    \1\ https://www.hhs.gov/about/news/2021/04/14/fact-sheet-notice-of-
proposed-rulemaking-ensuring-access-to-equitable-affordable-client-
centered.html.
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    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 
([email protected]). For more information about domestic 
priorities, please contact Jack Rayburn, Director, Legislative Affairs 
at ([email protected]).
    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 [email protected] 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 
[email protected] 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 
[email protected].

    [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 ([email protected]).
                                 ______
                                 
           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 [email protected].

    [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.
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    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.
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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.
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    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.
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    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.
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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.
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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.
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    \1\ IQVIA Institute for Human Data Science, Shifts in Healthcare 
Demand, Delivery and Care During the COVID-19 Era (April 2020).
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    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
   
   
   
   
                              [all]