    [Senate Hearing 117-799]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-799

                                                            Senate Hearings

                                     Before the Committee on Appropriations

    _______________________________________________________________________

                                                      Departments of Labor,

                                                 Health and Human Services,

                                                 and Education, and Related

                                                    Agencies Appropriations

                                                           Fiscal Year 2023

                                             117th CONGRESS, SECOND SESSION

                                                                  H.R. 8295

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

                                                            S. Hrg. 117-799

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2023

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

                                    HEARINGS

                                    before a

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                       ON

                                   H.R. 8295

     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, 2023, 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

    46-665 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
                      Bill Duhnke, 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 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
                            Ann Tait Hall (Minority)

                                C O N T E N T S

                                  ----------

                                    HEARINGS
                             Wednesday, May 4, 2022

                                                                       Page

    Department of Health and Human Services: Office of the Secretary.     1

                             Tuesday, May 17, 2022

    Department of Health and Human Services: National Institutes of
      Health.........................................................    85

                             Tuesday, June 7, 2022

    Department of Education: Office of the Secretary.................   147

                            Wednesday, June 15, 2022

    Department of Labor: Office of the Secretary.....................   371

                                  ----------

                                  BACK MATTER

    Departmental Witnesses...........................................   431
        America's Public Television Stations and the Public
          Broadcasting Service.......................................   431

    List of Witnesses, Communications, and Prepared Statements.......   881

    Nondepartmental Witnesses........................................   437

    Subject Index....................................................   887
        America's Public Television Stations and the Public
          Broadcasting Service.......................................   887

        Department of Education: Office of the Secretary.............   887

        Department of Health and Human Services......................   888
            National Institutes of Health............................   888
            Office of the Secretary..................................   888

        Department of Labor: Office of the Secretary.................   889

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2023

                                  ----------

                             WEDNESDAY, MAY 4, 2022

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:35 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairman) presiding.
        Present: Senators Murray, Reed, Shaheen, Baldwin, Manchin,
    Blunt, Moran, Hyde-Smith, and Braun.

                    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 please come to order. Today we are having
    a hearing on the Biden Administration's fiscal year 2023 budget
    request for the Department of Health and Human Services.
    Senator Blunt and I will each have an opening statement, and
    then I will introduce our witness, Secretary Becerra.
        After his testimony, Senators will each have 5 minutes for
    a round of questions. And while we were unable to have the
    hearing fully open to the public or media for in-person
    attendance, live video is available on our committee website.
    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 glad to have you before our
    committee today to provide answers to the questions the
    American people have, especially this morning, given the
    alarming reporting that the Supreme Court is planning to end
    the Constitutional right to abortion in this country and
    overturn Roe v. Wade.
        If this is true, it will be devastating to many people
    across the country. I have been warning about this for years
    and I want you to know I am going to keep fighting back with
    all I have to protect every woman's rights in this country. But
    people across the country are worried.
        They need to see leadership from the Biden Administration
    on this. So I hope to hear more from you today about what the
    Administration's plan is to respond to this and protect women's
    health. Because make no mistake, women's lives are on the line.
    Later this week, you will be hearing from my constituents
    firsthand, coming out to Washington State. We will welcome you
    there.
        And Mr. Secretary, I want you to know, people are not just
    worried about this attack on abortion, they are worried about
    other challenges they are facing as well, because the past 2
    years, to say nothing of the past 2 days, have put such a
    strain on families and communities and our entire health care
    system. People are depending on the Biden Administration for
    support, for resources, and for real solutions, and I am
    pushing to make sure that they get them.
        After all of the hard won progress we have made in the
    fight against COVID-19, families in my State and across the
    country are depending on us to pass urgently needed emergency
    COVID funding for tests, for treatments, and vaccines to
    protect our communities across the country. But keeping up the
    fight against COVID is just the start.
        We have to learn from this pandemic and strengthen our
    public health system to make sure we are better prepared with
    more resources for CDC (Centers for Disease Control and
    Prevention), like this budget proposes, with sustained annual
    investments for local health departments, like my Public Health
    Infrastructure Saves Lives Act would provide, and with steps
    like my bipartisan Prevent Pandemics Act, because we know all
    too well things like modern data systems, a robust public
    health workforce, access to tests and vaccines, clearer
    information, and more can make all the difference when it comes
    to saving lives during a public health crisis.
        But Secretary Becerra, the past few years have also shone a
    harsh spotlight on the other healthcare challenges our
    communities are facing, like the mental health crisis, which
    the pandemic has made even more devastating, especially for our
    kids. Over the last 2 years, we have seen a sharp rise in youth
    mental health emergencies. I have heard from so many parents
    back home whose kids are just not okay.
        And over 200,000 kids have had their world shattered by the
    heartbreaking loss of a parent or a caregiver. And we are
    already stretched thin when it comes to providing communities
    the support they need to address these crises. In Washington
    State, our mental health workforce is only able to meet 17
    percent of our State's needs. We have just got to do better.
        This budget has crucial support for school based mental
    healthcare and training, which can help reach students in need,
    mental health support during early childhood, which is such an
    important time for kids, community health centers which help
    families across the country get connected to mental health
    services, and increased resources for the 9-8-8 Suicide
    Prevention and Crisis Lifeline.
        I will be digging in here during questioning and during
    your visit to Washington State later this week, because I want
    to know how the Administration is doing and what it is doing to
    address the mental health crisis. Secretary Becerra, I also
    want to hear more from you about how the Administration is
    working to address our Nation's substance use disorder crisis,
    which has gotten so much worse during this pandemic and has
    grown even more deadly due to fentanyl.
        I hear about the tragic consequences of this crisis every
    single day. Overdose deaths in Washington State have increased
    by two-thirds since 2019. And nationally, we recently passed
    the tragic milestone of over 100,000 overdose deaths in 1 year.
    Our communities are doing what they can. But, Mr. Secretary, we
    desperately need reinforcements.
        The significant increase in this budget for prevention,
    treatment, and recovery efforts is absolutely necessary. But it
    is going to take more to get this done. And that is why I am
    working with my Senate colleagues on bipartisan legislation.
    But I want to hear more from you about your plan to address
    this crisis.
        When it comes to women's health, I was relieved to see this
    budget does include significant resources for the Title X
    Family Planning Program, which helps get women birth control
    they need to plan a family on their own terms, lifesaving
    breast and pelvic exams that detect cancer early, and more.
        Mr. Secretary, I have fought hard to protect the Title X
    Program, and I heard from Washington State patients and
    providers recently about what this program means in their
    lives. They told me firsthand how it makes all the difference
    to people with the tightest budgets who might not have access
    to this basic lifesaving healthcare without Title X.
        It is unthinkable to me anyone would not support this
    program. But as we are being reminded every day, Mr. Secretary,
    reproductive healthcare is under attack at every angle, and we
    need to be doing everything we can to protect it. So I want to
    hear more from you today about what we can do to continue
    strengthening this program and do everything we can to support
    other programs that protect women's health.
        That is why I was so pleased to see this budget also
    increases resources to help lower our Nation's unacceptably
    high maternal mortality rate. And like so many other issues, we
    know our maternal death rate has been particularly devastating
    for black and Native American women, which is why the
    investments in this budget to advance equity and reduce health
    disparities are vital, especially the significant proposed
    increase to CDC's work in this space.
        This budget also calls for additional support in the fight
    against HIV, AIDS to increase access to lifesaving treatment,
    reduce new cases, and continue our progress towards ending this
    epidemic in our country. Finally, I want to make crystal clear
    how important it is that we invest in childcare and early
    education programs and bring down those costs for parents.
        This pandemic has made clear to everyone what I have been
    saying for years, quality, affordable childcare is not
    optional. It is essential for parents, for kids, for our
    businesses, for our economy, for everyone. When it comes down
    to it, parents not being able to work because they cannot find
    childcare is never just a problem for them, it is one more
    position a small business can't fill, and it is one less link
    in our supply chain moving things along.
        That is why I believe this has to be a top priority to help
    parents get back to work and to lower costs. That is such a
    massive strain on parents' budgets right now. Mr. Secretary, I
    know this budget includes a boost in childcare resources. I was
    glad to see that.
        But I need to be clear, right now millions of families
    across the country are struggling to find or afford childcare,
    providers are struggling to keep their doors open, and
    childcare workers cannot make ends meet and are leaving their
    jobs to find better pay.
        So we have got to go bigger to solve this problem here, and
    which is why I have been fighting so hard to make a truly
    historic investment in childcare that would bring down costs
    for families, bring up wages for workers, and all fully paid
    for simply by asking those at the top to pay their fair share.
        I am going to keep pushing to make sure we get that done
    through reconciliation, because at the end of the day, as happy
    as I am to see these boosts for childcare in this budget, which
    I have fought for a long time as well, it is clear to me we
    can't just tinker at the edges here, we need bold solutions.
        And that is why I will keep pushing to deliver on that,
    just as I am pushing for more progress in all the issues that
    we will be talking about today. I always like to say that a
    budget is a statement of values, and I am pleased to see this
    budget does make it crystal clear that the Administration's
    values are in the right place. But families back home need us
    to do more than just state our values, they need us to live up
    to them.
        They need us to act on them with steps that take stress off
    their shoulders, put money back in their pockets and actually
    solve the problems they are facing. So I look forward to
    working with you and President Biden to make sure that happens.
    Thank you again for being here. With that, I will turn it over
    to Senator Blunt.

                         statement of senator roy blunt

        Senator Blunt. Thank you, Chair Murray. Secretary Becerra,
    certainly appreciate you being here today. We served together
    in the House, but I think in the last year we have had a chance
    for our relationship to grow and I am grateful that that has
    happened. I am grateful that we have--I think you have made a
    better effort than we have seen sometimes in the past to get
    information to us as quickly as you could.
        And as you and I have talked about, sometimes we just need
    to know the direction you are headed in a quick way and find
    out all of the granular detail when you can get to it. But I am
    appreciative that I think that is headed on a better path. I
    think both Chair Murray and I are eager to try to get a bill
    completed this year.
        You are much better off if you have money to spend in next
    year's spending cycle, October 1, or even December 1 than if it
    is April 1 or March 1 or May 1, and I hope we can work together
    to continue to move this process forward. I do think that the
    completion of the process last year was late enough that some
    of the gains we made in the final appropriations bill aren't
    reflected in the budget that was submitted by the President,
    and I look forward to a chance to talk to you more about that.
        You know, at last year's hearing, my opening statement
    focused almost totally on the pandemic. At that point, we were
    a year in. The Trump Administration had provided the country
    with several FDA (Food and Drug Administration) authorized
    vaccines, tests, and treatments for COVID-19, while starting a
    campaign to vaccinate the most high risk Americans. And of
    course, the Biden Administration continued that vaccine
    campaign.
        Where we were last year was pretty significant in terms of
    the vaccines that were available and what we had done,
    considering the fact that a year earlier we had never heard of
    COVID-19, and we were making real progress. The Biden
    Administration came into the White House with lots of COVID
    promises on how it would get it under control and do so by
    following the science.
        Unfortunately, I have some concerns that the Administration
    has really abandoned the approach of following the science when
    it became clear over the last year and a half that Federal
    vaccine mandates, school closure guidance, mask requirements on
    public transportation have, I think, overreached the moment and
    overreached the science. Most recently, politics appear to have
    colored some of the COVID decisions the Department has made.
        The CDC announced the termination of the Title 42 order
    last month. They announced it would occur at a specific date in
    the future, but they announced it at a time when we were still
    trying to deal in the Congress and with your Department of the
    ongoing challenges of COVID. You know, COVID can't be a
    challenge one place and not a problem, in my view, at another
    place.
        Congress has been provided few details on the impact of the
    decision of what would happen if Title 42 goes away at the
    border. Yet no plans to see what we do with an influx of
    illegal individuals into the country, or in your Department,
    what happens with the unaccompanied children that come under
    your responsibility. I don't see the money in this budget
    reflecting every news story I see about how those numbers
    intend to grow.
        Further, CDC's decision to vastly increase the number of
    people coming into the country who are unvaccinated that was
    made after CDC said what they considered the current--this is
    their quote, ``current public health conditions and increased
    availability of tools to fight COVID-19 allowed the border to
    be looked at in a different way.'' Just days later, the
    Department made contradictory decisions to extend our own
    country's public health emergency.
        Emergency here, not a problem there really doesn't make
    much sense to many people and even people in the Congress who
    can be persuaded that things that don't make sense somehow do
    make sense. Just yesterday, the CDC updated guidance that two
    and a half years into the pandemic, it is now everyone--
    recommending everyone get tested before domestic travel.
        It seems to me that it is so out of focus with every other
    discussion that is going on, and hopefully we will have a
    chance to talk about that today also. I think these decisions
    just aren't consistent and intellectually create lots of
    problems. How do you expect Americans to follow your
    recommendations when you say it is safe to open the borders to
    unvaccinated immigrants, but not safe enough to remove mask on
    planes, and not safe enough to have even domestic travel
    without a test?
        Meanwhile, even as the borders reopen as if the pandemic is
    over, Americans remain under Federal vaccine and mask mandates.
    And the Department is asking Congress to provide additional
    funding for therapeutics, for tests, for vaccines. And I want
    to make it very clear, I am actually for that funding. You and
    I have talked about it. I have worked hard to try to come up
    with a package that would provide the money we need.
        Those accounts, on my view, need to be restored. We are not
    out of the woods yet with COVID-19, and we need to be prepared
    for a future wave that very easily could happen. We need to
    think about what needs to happen with vaccinating the under-
    five population, and to ensure that any American who needs a
    therapeutic can get one. Unfortunately, the Administration made
    two poor decisions that make this additional funding nearly
    impossible.
        First, it pushed through a $1.9 trillion COVID-19 funding
    bill that provided less than 6 percent of COVID and less than 1
    percent of funding toward vaccines and therapeutics, and only 5
    percent toward COVID public health.
        Simply put, the Administration had the opportunity to
    purchase more vaccines, more tests, more treatments, and to
    continue more research into additional therapeutics, and to
    prepare for a disease that we will likely be facing for the
    next several years, and in that huge package that went into the
    economy, not very much of it was dedicated to the purpose of
    the COVID-19 fight.
        Secondly, we were actively negotiating a bill last month to
    provide the Department with $10 billion to purchase those
    additional therapeutics, vaccines, and tests. And right at the
    end of that negotiation, before the Congress could vote on the
    bill, again CDC announced that COVID is not a problem at the
    border.
        Finally, Mr. Secretary, as it did in last year's bill,
    COVID-19, has overshadowed the budget request, and I think
    assuming that we will just continue to do all of the COVID
    spending as emergency spending. There are a lot of new plans in
    this budget that the Congress just rejected in the omnibus
    bill.
        And frankly, if we have a bill this year, and I hope we do,
    I think we have to look at what this Congress was willing to
    agree to after months of negotiation and use that as the
    blueprint. It doesn't mean the blueprint can't be adjusted, but
    assuming we are going to see dramatic changes like the removal
    of the long standing Hyde Amendment.
        You know, every person on this committee who has ever voted
    for a final Labor, HHS (Health and Human Services) bill has
    voted for Hyde since it first appeared in 1976. And the bills
    you and I voted for in the House, if we voted for the Labor,
    HHS bill, all had that amendment in them.
        Mr. Secretary, the committee been successful over the last
    several years of passing bipartisan bills because we have not
    made fundamental, drastic funding changes.
        I was concerned when I saw the money for ARPA-H (Advanced
    Research Projects Agency for Health), which I also support, but
    there was $4 billion of new money in the budget for ARPA-H and
    no money for the traditional research at NIH (National
    Institutes of Health), which of course is exactly what people
    who have been concerned about ARPA-H--have been concerned
    about, whether it was at NIH or somewhere else, does ARPA-H
    begin to slow down the momentum of the overall research that we
    need to continue to see in NIH?
        I hope we can set aside our partisan difficulties, as we
    did last year in this committee, and support programs like
    maternal mortality programs that benefit all Americans.
        The mental health programs. I will say that I was very
    heartened with the mental health program increases and had some
    concerns about some structural changes in the mental health
    agency of SAMHSA (Substance Abuse and Mental Health Services
    Administration) that you are responsible for.
        But we will get back to that and talk about that later. And
    again, while this will be a challenging hearing, as these
    always are, welcome and I have appreciated our chance to begin
    to work together with this new responsibility that you have
    taken in the last year and look forward to the time to ask
    questions today.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Thank you, Chair Murray. I appreciate Secretary Becerra being here
    today to discuss the Administration's fiscal year 2023 budget request.
        At last year's hearing, my opening statement focused on the
    pandemic. At that point, we were a year in, and the Trump
    Administration had provided the country with several FDA-authorized
    vaccines, tests, and treatments for COVID-19, while starting a campaign
    to vaccinate the most high-risk Americans. That was a significant
    accomplishment considering the year before we had never heard of COVID-
    19.
        The Biden Administration came into the White House with lots of
    COVID promises of how it would ``get it under control'' and do so by
    ``following the science.''
        Unfortunately, it appears that the Administration has all but
    abandoned that approach, instead making pandemic decisions and policies
    based purely on politics.
        This has been clear over the past year and half with Federal
    vaccine mandates, school closure guidance, and mask requirements on
    public transportation that have been overreaching and ripe with
    partisan politics.
        Most recently, politics appear to have colored every COVID decision
    the Department has made.
        When CDC announced the termination of the Title 42 Order last
    month, which is a public health protocol that limits the number of
    illegal immigrants entering the country due to the pandemic, it appears
    to have made this decision in a bid to satisfy vocal opponents, without
    fully considering the impacts on any other agency, including the
    Department of Homeland Security.
        Congress has been provided few details as to the impact of this
    decision, and as far as I can tell, there is no plan in place for the
    influx of illegal immigrants, no real strategy to deal with the
    problem, and no money in place to do so.
        Further, CDC's decision to vastly increase the number of illegal,
    unvaccinated immigrants coming into the country was made after CDC
    considered ``current public health conditions and an increased
    availability of tools to fight COVID-19.''
        Yet just days later, the Department made contradictory decisions to
    extend our own country's Public Health Emergency and to appeal the
    Federal mask mandate on public transportation that was struck down in
    the courts. Even just yesterday, the CDC updated guidance that, two-
    and-a-half years into the pandemic, it is now recommending everyone get
    tested before domestic travel.
        Mr. Secretary, these decisions make no sense. They are
    intellectually inconsistent and they send mixed messages to the
    American people.
        I am afraid that CDC and the Department have now clearly crossed a
    line with credibility. And I don't think the American public will
    follow public health guidance if they don't trust the agency providing
    the guidance. How do you expect Americans to follow your
    recommendations when you say it's safe to open the borders to
    unvaccinated illegal immigrants, but not safe enough to remove masks on
    planes?
        Meanwhile, even as the borders reopen as if the pandemic is over,
    Americans remain under Federal vaccine and mask mandates and the
    Department is asking Congress to provide additional funding for
    therapeutics, tests, and vaccines. I want to be very clear: I am
    supportive of this funding.
        We are not out of the woods yet with COVID-19 and we need to be
    prepared for a future wave, to vaccinate the under 5 population, and to
    ensure that any American who needs a therapeutic can receive one.
        Unfortunately, the Administration made two poor decisions that make
    this additional funding nearly impossible.
        First, it pushed through a $1.9 trillion, partisan COVID-19 funding
    bill that provided less than 1 percent of funding toward vaccines and
    therapeutics, and only 5 percent toward COVID-19 public health
    priorities.
        Simply put, when the Department had the opportunity to purchase
    more vaccines, tests, and treatments, to continue researching
    additional therapeutics, and to prepare for a disease that we will
    likely be facing for the next several years, it failed to do so.
        Second, as we were actively negotiating a bill last month to
    provide the Department $10 billion to purchase additional therapeutics,
    vaccines, and tests, CDC announced the termination of the Title 42
    Order.
        While this imprudent decision on Title 42 does not lessen the need
    for additional funding, it sure makes it significantly harder for
    Congress to provide it.
        Finally, Mr. Secretary, as it did last year, COVID-19 has once
    again overshadowed the budget request. That may actually be a good
    thing because this budget is wrought with recycled partisan programs
    that I had hoped had been resolved when Congress rejected them in the
    last Omnibus.
        I once again wholeheartedly disagree with the Administration's
    removal of the longstanding Hyde Amendment.
        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.
    Last year was not any different, and I do not expect this year to be
    either.
        Mr. Secretary, this Committee has been successful over the last 7
    years with passing bipartisan bills because we haven't made
    fundamental, drastic funding or policy changes. We've been able to find
    agreement on funding for important national priorities, such as ARPA-H
    and addressing the substance use disorder crisis and mental health
    needs.
        As we did in the Omnibus last year, I hope we will set aside
    partisan policies to support programs that benefit all Americans.
        Thank you, again, for being here today.

        Senator Murray. Thank you, Senator Blunt. Again, welcome,
    Secretary Becerra. Our witness today is Javier Becerra, the
    Secretary of the Department of Health and Human Services.
    Again, thank you for joining us. It is important that you are
    here. We look forward to your testimony. And with that, you may
    begin.

                    SUMMARY STATEMENT OF HON. XAVIER BECERRA

        Secretary Becerra. Chairwoman Murray, Ranking Member Blunt,
    and members of the committee, I look forward to discussing with
    you the President's fiscal year 2023 budget. But it is most
    important that I begin today by responding to the chilling news
    that certain justices on the Supreme Court appear to be
    plotting to dismantle settled legal authority that recognizes
    and protects every woman's right to make her own decisions
    about her health and her body, including abortion.
        22 years into the 21st century and nearly 50 years after
    Roe v. Wade, some, mostly men, seek to impose their judgment
    over every woman in America who may seek to exercise their
    Constitutional right to privacy in personal decisionmaking.
    That is dangerous, that is wrong, and that, we must repel with
    every just bone in our body.
        America is not a Nation prone to regression, and the
    Department of Health and Human Services is not in the business
    of stripping Americans of access and protections to care. So at
    HHS, we will double down on our authorities to protect every
    American's right and access to reproductive healthcare,
    including abortion.
        Turning to the budget first, to recap, today more than 250
    million Americans have received at least one dose of a COVID-19
    vaccine, and two-thirds of adults over age 65 have gotten a
    booster shot. We have also closed the glaring gap in vaccine
    rates across communities often left behind. It has paid
    dividends to surge resources, including tests and treatment to
    our hardest hit and highest risk communities.
        340 million free COVID-19 at home test shipped across
    America. 270 million free N95 masks. 100 million booster shots.
    Almost $186 billion in provider relief funds distributed
    through more than 800,000 payments to over 441,000 providers
    for COVID losses and expenses. That is 441,000 hospitals,
    community health centers, doctors, pharmacies, nursing homes,
    rural health clinics, behavioral health providers, and many
    more. Real money, real relief, real results.
        That is why it is critical that we have the funds to finish
    the fight on COVID-19. It is not just a good investment for our
    health and all of our people's health, it is a smart investment
    for the health of our economy. Beyond COVID-19, today more
    Americans have insurance for their healthcare than ever before
    in our country.
        That includes a record breaking 14.5 million Americans who
    secured health insurance through the Affordable Care Act. Many
    of those insured Americans are paying less than $10 per month
    in premiums for that solid insurance coverage and the peace of
    mind that comes with it. I am also pleased that last week the
    FDA issued two proposed tobacco product standards, one
    prohibiting menthol as a flavor in cigarettes, and another
    prohibiting all flavors in cigars.
        These standards are based on scientific evidence and would
    improve the health of all Americans. In addition, we launched
    Operation Allies Welcome, an HHS led effort that has helped
    over 68,000 of our Afghan brothers and sisters resettle as
    refugees in America. And we have begun to extend support to
    Ukrainian refugees fleeing the Russian invasion of their
    homeland.
        As you know, we are working to tackle America's mental
    health challenges. We are coordinating nearly $300 million with
    our 50 States, Tribal governments, and territories to prepare
    for the launch of the new three digit 9-8-8 National Suicide
    Prevention Lifeline this July. What 9-1-1 is for local
    emergency, we are working hard to make 9-8-8 for Americans
    experiencing a mental or behavioral health crisis.
        On sexual and reproductive healthcare, including access to
    abortion care, which is still legal and available, the
    Department has worked to restore the Title X Family Planning
    Program, awarding $256.6 million in grant funding to restore
    access to care nationwide and strengthen program rules. This
    importantly, fills service gaps caused by more than a quarter
    of Title X providers withdrawing from the program under the
    previous Administration's rule.
        We have also made funds available to help with clinics in
    dire need. Issued guidance under EMTALA (Emergency Medical
    Treatment and Active Labor Act) to help patients' access
    emergency services safely, and guidance to support providers
    against discrimination. We are continuing to do our work to
    ensure access to quality care for all patients.
        We made these investments to close holes in our public
    health system in areas like maternal health, where we have
    extended Medicaid coverage for postpartum care for a new mother
    and her baby, from 2 months to 12 months. We recently awarded
    $16 million to community health organizations to expand HHS
    Maternal and Child Home Visiting Program. And we are working
    across agencies to make more children eligible for high quality
    early education programs like Headstart.
        The President's 2023 budget lets us build on that record of
    unprecedented investment in America's health. It proposes $127
    billion in discretionary budget authority and $1.7 trillion in
    mandatory funding, including a standout and historic investment
    to transform the mental health infrastructure in our country, a
    priority I know you share.
        We also ask for $82 billion for the President's pandemic
    preparedness and response to get ready for whatever might come
    next after COVID-19. Considering that COVID has cost our
    country more than $4.5 trillion in direct support from the
    Federal Government so far, this is a no brainer to continue
    fighting COVID-19 and prepare for any future pandemic.
        Madam Chair, members, we are here to turn hardship into
    hope, inclusion into opportunity. We look forward to working
    with you. And I look forward to answering any questions you may
    have.
        [The statement follows:]
                      Prepared Statement of 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) 2023 Budget for the Department of Health and Human Services (HHS).
    I am pleased to appear before you today, and I look forward to
    continuing to work with you to serve the American people.
        HHS addresses many of the challenges facing our country today--
    ending the COVID-19 pandemic, reducing healthcare costs, expanding
    access to care, improving health equity, ending HIV/AIDS, enhancing
    child and family well-being, addressing the overdose epidemic, and
    strengthening behavioral health--and we are making meaningful progress
    on these priorities. Our work has never been more important, and I am
    honored to lead HHS at this critical moment.
        The Budget advances the HHS mission to enhance and protect the
    health and well-being of all Americans. We are proud to be Congress'
    partner in supporting the American people, and we are grateful for the
    funding you have provided in support of the HHS mission. We take very
    seriously our commitment to ensure we are good stewards of every dollar
    in our budget.
        Before I dive deeper, I first want to reflect on the Department's
    incredible achievements over the past year to save lives and improve
    health. Thanks to our work to develop and distribute vaccines and
    boosters, nearly 220 million Americans are fully vaccinated against
    COVID-19, and two-thirds of adults over age 65 have gotten their
    booster shots--an unprecedented accomplishment that saves lives every
    day. HHS procured and provided life-saving antivirals, monoclonal
    antibodies, and ongoing testing support, with more to come. To date,
    HHS has provided critical support that resulted in the emergency use
    authorization (EUA) of 3 vaccines (2 of which are now fully licensed),
    7 therapeutics, and 29 diagnostics against COVID-19. HHS has procured
    millions of COVID-19 treatment courses for Americans, and is supporting
    the President's pledge to directly provide 1 billion tests to American
    households for free.
        Testing capacity has dramatically increased, and we've supplied
    free, high-quality masks to the American people. HHS has invested $250
    million in U.S.-based manufacturing of personal protective equipment
    (PPE) and $950 million in manufacturing the supplies and equipment
    needed for vaccines, therapeutics, and diagnostic tests to strengthen
    the public health supply chain. We distributed Provider Relief Funds to
    support healthcare providers hit hard by the pandemic, and to reimburse
    providers for testing, treatment, and vaccine administration for
    uninsured patients. We provided guidance to support the safe return to
    the classroom, enabling schools nationwide to reopen.
        As the President has said, it is critical to get Americans back to
    our more normal routines, while still protecting people from COVID-19,
    preparing for new variants, and preventing economic and educational
    shutdowns. HHS contributions over the past 2 years position our country
    to move forward safely, and we look forward to working with you to
    continue these efforts.
        The country has seen historic increases in health insurance
    enrollment through the Marketplaces, with a record 14.5 million people
    signed up for 2022 healthcare coverage during the latest Marketplace
    Open Enrollment Period. Uninsured rates fell last year after the
    American Rescue Plan Act took effect, and continue to fall due to the
    success of innovative and targeted consumer outreach campaigns. We are
    implementing initiatives like the No Surprises Act, which establishes
    new Federal protections against certain kinds of surprise medical
    bills. We are preparing for the expansion of the Suicide Lifeline with
    the 9-8-8 implementation that will launch this summer. Working with our
    interagency partners, we also launched interagency initiatives like
    Operation Allies Welcome, a whole-of-government effort that helped over
    68,000 Afghans to permanently resettle in 2021.
        HHS has made key investments to address disparities and improve
    equity and launched new efforts to protect vulnerable communities who
    bear the brunt of climate change. We are prioritizing rural health and
    the needs of our Tribal partners. We released a new HHS Overdose
    Prevention Strategy and made significant investments in behavioral
    health. It is also an Administration priority to advance legislation
    that helps lower costs for families, including for child care,
    preschool, and long-term care, and I look forward to working with
    Congress to achieve this together.
        The President's Budget will enable us to continue these critical
    efforts and achieve our mission in fiscal year 2023. The fiscal year
    2023 Budget proposes $127.3 billion in discretionary and $1.7 trillion
    in mandatory budget authority, including newly proposed mandatory
    funding for the Indian Health Service and an historic mandatory funding
    request to transform our ability to protect the nation from future
    pandemics and other biological threats. The Labor-HHS-Education total
    is $123.4 billion, an increase of $12.9 billion. These investments
    support families through early education, behavioral health, and access
    to care. The Budget demonstrates the Administration's commitment to
    reinvesting in public health, research, and development to drive growth
    and shared prosperity for all Americans by making major investments in
    priority areas, including overdose prevention, mental health, maternal
    health, cancer, and HIV/AIDS. COVID-19 has shown that health inequities
    and insufficient Federal funding leave communities vulnerable to these
    crises. The Budget advances equity and helps ensure our programs serve
    people of color and other underserved communities with the
    opportunities promised to all Americans.
         tackling covid-19 and preparing for the next biological threat
        First, I want to highlight that although HHS has made tremendous
    progress in the fight against COVID, we now face a dire moment. As you
    know, the Administration requested $22.5 billion for immediate needs to
    avoid severe disruptions to our COVID response. We requested these
    funds as emergency resources, in the same way Congress provided
    multiple times on a bipartisan basis under the prior Administration. We
    face unavoidable impacts of not receiving these resources. Testing and
    treatment capacity will decline. The uninsured fund--which offers
    coverage of testing, treatments, and vaccinations for tens of millions
    of Americans who lack health insurance--will run out of money and stop
    paying provider claims. Already, it has stopped accepting provider
    claims for testing, treatment, and vaccine reimbursement. Many
    Americans will no longer be able to access life saving monoclonal
    antibodies and antiviral drugs. We will be unprepared for a new variant
    and unable to provide life-saving vaccines to the American people. It
    is critical that we work together to avoid these and other severe
    consequences.
        Beyond the need for investment in immediate COVID-19 response
    requirements, the fiscal year 2023 budget builds on Congress' response
    investments to transform our preparedness for biological threats and
    strengthen national and global health and health security. The Budget
    includes a historic $81.7 billion in mandatory funding over 5 years
    across the Office of the Assistant Secretary for Preparedness &
    Response (ASPR), CDC, the National Institutes of Health (NIH), and the
    Food and Drug Administration (FDA) to support the Administration's
    vision for pandemic preparedness.
        This request provides $40 billion to the Office of the Assistant
    Secretary for Preparedness and Response to invest in advanced
    development and manufacturing of countermeasures for high priority
    threats and viral families, including vaccines, therapeutics,
    diagnostics, and personal protective equipment. It provides $28 billion
    for the Centers for Disease Control and Prevention (CDC) to enhance
    public health system infrastructure, domestic and global threat
    surveillance, public health workforce development, public health
    laboratory capacity, and global health security. It provides $12.1
    billion to NIH for research and development of vaccines, diagnostics,
    and therapeutics against high priority biological threats; biosafety
    and biosecurity research and innovation to prevent biological
    incidents; and safe and secure laboratory capacity and clinical trial
    infrastructure. The Budget also includes $1.6 billion for the Food and
    Drug Administration to expand and modernize regulatory capacity
    information technology, and laboratory infrastructure to support the
    evaluation of medical countermeasures.
        Collectively, these activities will build capabilities the nation
    urgently needs to respond to future pandemics and biological threats
    from any source, strengthen international systems so that we can detect
    threats early and respond to threats quickly, and enable us to boldly
    and decisively act on the lessons from COVID-19.
        In addition to this mandatory investment, the Budget also funds
    critical ongoing response and preparedness efforts through
    discretionary budgets. The HHS Coordination Operations and Response
    Element (H-CORE) within ASPR is responsible for coordinating the
    development, production, and distribution of COVID-19 vaccines and
    therapeutics. The Budget requests $133 million for H-CORE, which is
    critical to beat COVID-19 and for future emergency response efforts
    beyond the pandemic, as ASPR builds an enduring response
    infrastructure. These resources will support the necessary staffing,
    acquisition support, and data analytics for COVID-19 countermeasures
    when emergency funding is no longer available to cover these costs.
        The Budget requests $828 million for the Biological Advanced
    Research and Development Authority (BARDA), to develop novel medical
    countermeasure platforms to enable quicker, more effective public
    health and medical responses to detect and treat infectious diseases.
    The Budget also requests $975 million for the Strategic National
    Stockpile to sustain and expand the current inventory of supplies to
    ensure readiness for potential future pandemics.
        COVID-19 has shown the importance of timely, reliable data to
    respond effectively to public health threats. The Budget makes robust
    investments in science and public health to improve and protect health
    at home and abroad, including at CDC for public health infrastructure
    and capacity, data modernization, global public health protection, and
    the Center for Forecasting and Outbreak Analytics. The Budget also
    includes $197 million to expand state, local, tribal, territorial, and
    international capacity to combat antibiotic resistance at CDC, as well
    as an HHS-wide mandatory proposal to encourage the development of
    innovative antimicrobial drugs.
                         advancing science and research
        The Budget prioritizes research and scientific advancement. We are
    grateful for the support from Congress to establish the Advanced
    Research Projects Agency for Health (ARPA-H), and the Budget proposes
    $5.0 billion to revolutionize how to prevent, treat, and even cure a
    range of diseases including cancer, infectious diseases, Alzheimer's
    disease, and many others. This funding is part of a proposed $49.0
    billion in discretionary funds for NIH to continue its incredible track
    record of turning discovery into health. NIH invests in basic research
    and translation into clinical practice to address the most urgent
    challenges including preparing for future pandemics, reducing health
    disparities and inequity, driving innovative mental health research,
    and ending the overdose crisis.
        The Budget proposes investments in NIH, CDC, and FDA to reignite
    the President's Cancer Moonshot with an ambitious goal to reduce the
    death rate from cancer by at least 50 percent over the next 25 years,
    improve the experience of people and their families living with and
    surviving cancer, and end cancer as we know it today. The Budget
    includes increases for CDC to enhance a range of cancer related
    programs and for FDA's Oncology Center of Excellence.
        The Budget proposes $6.8 billion for FDA to continue to work with
    developers, researchers, manufacturers, and other partners to help
    expedite the development and availability of therapeutic drugs and
    biological products, and to apply the best science in its food and
    tobacco work. The Budget also proposes $527 million program level
    resources for the Agency for Healthcare Research and Quality (AHRQ) to
    support evidence-based research, data, and tools to make healthcare
    safer, higher quality, more accessible, equitable, and affordable for
    all Americans.
        Importantly, the Budget also includes $25 million for CDC and $20
    million for AHRQ to launch Centers for Excellence to study long COVID
    conditions and equip healthcare providers and systems to deliver
    patient-centered, coordinated care for this patient population.
            reducing health care costs and expanding access to care
        To enhance the health and well-being of all Americans, the Budget
    makes access to more affordable healthcare a top priority. The
    Affordable Care Act (ACA), bolstered by the American Rescue Plan, has
    expanded health insurance coverage to historic numbers of Americans and
    the Budget builds on that legacy.
        The American Rescue Plan made groundbreaking investments in the ACA
    by expanding premium subsidies to make coverage affordable for millions
    more Americans. As I mentioned earlier, a record-breaking 14.5 million
    people have signed up for 2022 healthcare coverage through the
    Marketplaces during the latest Marketplace Open Enrollment Period,
    including nearly 6 million people who have newly gained coverage. The
    American Rescue Plan lowered healthcare costs for most consumers and
    increased enrollment to record levels. In fact, consumers saw their
    average monthly premium fall by 23 percent compared to the prior open
    enrollment period. As you know, the American Rescue Plan subsidies will
    expire at the end of 2022 and without new legislation this will result
    in millions of Americans losing this more affordable coverage. I look
    forward to working with the Congress on this key priority. We are also
    concerned about millions of vulnerable Americans who could lose their
    Medicaid coverage when the COVID-19 Public Health Emergency ends. To
    address this concern, CMS has provided multiple rounds of guidance to
    state Medicaid and CHIP agencies that include a robust selection of
    best practices and recommended strategies allowed under current law
    when returning to routine operations after the Public Health Emergency
    ends. For example, recently, CMS released a State Health Official
    Letter that extends the time states have to process Medicaid
    redeterminations after the end of the Public Health Emergency from 12
    months to 14. HHS is also working to increase awareness of coverage
    options through targeted outreach campaigns and making renewal of
    coverage for those eligible easier to navigate. We also look forward to
    working with the Congress to find solutions to providing coverage
    options for the nearly 4 million Americans in non-covered states.
    Additionally, the Administration supports strengthening home and
    community-based services as an alternative to institutionalized care,
    to ensure people have access to safe options that work for them.
        Rising healthcare costs affect all Americans. HHS has taken steps
    to increase competition, improve transparency, and strengthen consumer
    protections. Under the No Surprises Act, a critical bipartisan law
    passed by Congress, HHS continues to implement the law that shields
    consumers from certain kinds of surprise medical bills and requires
    greater transparency from providers. HHS also issued a proposed rule to
    make hearing aids available to individuals over-the-counter that can
    help provide consumers with more affordable options and lead to a more
    competitive market.
        I look forward to working with the Congress to lower healthcare
    costs and expand and improve coverage for all Americans. Reaffirming
    the President's charge in his State of the Union address, we will work
    to lower the costs of prescription drugs, such as by capping the cost
    of insulin at $35 per month, and to allow Medicare to negotiate payment
    for certain high-cost drugs.
        During the COVID-19 public health emergency, telehealth has been a
    reliable resource for providers to reach patients directly in their
    homes to ensure access to care and continuity of services. The
    Administration is committed to supporting a temporary extension of
    broader telehealth coverage under Medicare beyond the declared COVID-19
    Public Health Emergency to study its impact on utilization of services
    and access to care. I want to thank Congress for provisions included in
    the fiscal year 2022 Omnibus spending bill that extend Medicare
    telehealth flexibilities for 5 months after the end of the public
    health emergency.
        Additionally, the COVID-19 pandemic highlights the importance of
    vaccines and prevention. Long- standing, deep disparities exist in
    adult vaccination coverage based on race and ethnicity, particularly
    among Black and Hispanic populations as compared to other groups. The
    Budget proposes Vaccines for Adults, a new mandatory program modeled
    after the existing Vaccines for Children (VFC) program, to provide
    uninsured adults with access to vaccines, free of charge, that are
    recommended by the Advisory Committee on Immunization Practices. The
    Budget further expands the VFC program to include all children under
    age 19 enrolled in the Children's Health Insurance Program. The Budget
    also includes a proposal to consolidate Medicare coverage of vaccines
    under Part B, which will make vaccines more accessible, remove
    financial barriers, and streamline the process for Medicare
    beneficiaries and providers.
        The Budget continues to support the fourth year of the Ending the
    HIV Epidemic initiative with $850 million in funding across CDC, HRSA,
    IHS, and NIH for fiscal year 2023. The initiative is critical to
    achieve President Biden's plan to end the HIV/AIDS epidemic by 2030 and
    ensure access to HIV prevention, care, and treatment. HHS works closely
    with communities to support the four key strategies--Diagnose, Treat,
    Prevent, and Respond--to end the HIV epidemic. The Budget also creates
    a national program that invests $9.8 billion over 10 years to provide a
    financing and delivery system to ensure everyone has access to pre-
    exposure prophylaxis, also known as PrEP, and essential wraparound
    services.
                 tackling health and human services disparities
        Advancing equity is at the core of the Budget. HHS works to close
    the gaps in access to healthcare and human services to advance
    equitable outcomes for all, including people of color and others who
    have been historically underserved, marginalized, and adversely
    affected by persistent poverty and inequality. HHS is committed to
    carrying out the President's Executive Order 13985 on Advancing Racial
    Equity and Support for Underserved Communities Through the Federal
    Government. Even before the pandemic, we were not doing enough to
    provide equitable preventive measures, services, and treatment options
    in every community--and COVID has only made this disparity worse.
        Maternal mortality in the United States is significantly higher
    than most other developed nations and is especially high among Black
    and Native American/Alaska Native women, regardless of their income or
    education levels. The Biden-Harris Administration is committed to
    promoting maternal health and ensuring equitable access to affordable,
    quality healthcare for our nation's mothers. The Budget invests over
    $470 million across AHRQ, CDC, HRSA, IHS, and NIH to reduce maternal
    mortality and morbidity. This includes increased funding to CDC's
    Maternal Mortality Review Committees and other Safe Motherhood
    programs, HRSA's State Maternal Health Innovation Grants program and a
    new Healthy Start program initiative, and other maternal health
    programs across HHS.
        The Budget also invests in maternal and broader women's health and
    health equity, including $86 million for the Office of Minority Health
    to focus on areas with high rates of adverse maternal health outcomes
    and areas with significant racial or ethnic disparities. In addition,
    the Budget also includes $42 million for the Office on Women's Health
    to fund prevention initiatives that address health disparities for
    women.
        Black and Latino/Hispanic people, along with American Indian/Alaska
    Native people, are much less likely than white people to have health
    insurance. Evidence shows that expanding coverage is not only essential
    for facilitating equitable access to healthcare, but also is associated
    with reduced morbidity and mortality, poverty reductions, and
    protection from debilitating financial bills. The Budget supports
    policies to promote a stronger and more equitable health insurance
    system beginning with new requirements for data on race and ethnicity
    in Medicare.
        The Budget also invests $35 million for a new initiative to
    systematically identify and resolve barriers to equity in each Centers
    for Medicare & Medicaid Services (CMS) program through research, data
    collection and analysis, stakeholder engagement, building upon rural
    health equity efforts, and technical assistance. CMS is committed to
    obtaining more accurate and comprehensive race and ethnicity data on
    Medicare beneficiaries, and to require reporting on social determinants
    in post-acute healthcare settings. CMS also proposes to add Medicare
    coverage for services furnished by community health workers who often
    play a key role in addressing public health challenges for underserved
    communities. These proposals will help identify, mitigate, and lessen
    health disparities.
        Health Centers are the first line of defense in addressing
    behavioral health issues nationwide when resources are available. This
    is particularly true for underserved populations, including low-income
    patients, racial and ethnic minorities, rural communities, and people
    experiencing homelessness. The Budget provides $5.7 billion for health
    centers, including $3.9 billion in mandatory resources.
        The COVID-19 pandemic has further disrupted access to reproductive
    health services and exacerbated inequalities in access to care. HHS
    commits to protecting and strengthening access to reproductive
    healthcare, and the Budget proposes $400 million to the Title X family
    planning program to address increased need for family planning
    services. Title X is the only Federal grant program dedicated solely to
    providing individuals with comprehensive family planning and related
    preventive health services in communities across the United States.
        The Budget increases services to prevent child maltreatment and the
    need for foster care, and supports states in moving towards child
    welfare systems that provide more tailored and comprehensive prevention
    services to a broader, more diverse group of families. Prevention
    services and support are particularly important for at-risk Black,
    Latino, Indigenous, Native American, and members of other under-served
    communities, which have disproportionate involvement with the child
    welfare system.
        The Budget provides $3.1 billion for the Administration for
    Community Living (ACL), reflecting significant demand increases for
    critical services caused by population growth and pandemic impacts. ACL
    supports caregivers and advances equitable access to healthcare,
    education, employment, transportation, recreation, and other systems,
    resources, and opportunities. ACL advances equity by targeting those in
    greatest social and economic need, with particular attention on people
    with disabilities and older adults who are marginalized due to race,
    ethnicity, sexual orientation, gender identity, poverty, language
    spoken, and who are at risk of institutionalization.
        Lastly, the Budget takes a historic first step toward redressing
    health disparities faced by American Indians and Alaska Natives by
    proposing all funding for the Indian Health Service (IHS) as mandatory.
    In fiscal year 2023, the Budget provides $9.3 billion, which includes
    $147 million in current law funding for the Special Diabetes Program
    for Indians. This substantial funding increases of $2.5 billion above
    fiscal year 2022 enacted will support direct healthcare services,
    facilities and IT infrastructure, and management and operations. It
    also provides targeted increases to address key health issues that
    disproportionately impact American Indians and Alaska Natives such as
    HIV, Hepatitis C, opioid use, and maternal mortality. With current law
    funding for the Special Diabetes Program for Indians, the total program
    level for IHS is $9.3 billion in fiscal year 2023.
        To address chronic underinvestment in IHS, the Budget increases
    funding for each year over 10 years, building to $36.7 billion in
    fiscal year 2032. This increase of 296 percent over the ten-year budget
    window accomplishes funding growth beyond what can be accomplished
    through discretionary spending. Over a five-year period, the budget
    will reduce existing facilities backlogs, fully fund the level of need
    identified by the Federal-Tribal Indian Health Care Improvement Fund
    workgroup and support the modernization of the IHS electronic health
    record system. Additionally, the Budget grows IHS funding to keep pace
    with inflation and population growth. This request responds to the
    long-standing recommendations of tribal leaders shared in consultation
    with HHS to make IHS funding mandatory, and HHS will continue
    consulting with tribes to inform future policy and budget requests. HHS
    appreciates the strong partnership with Congress to grow funding for
    the IHS budget over the last decade, and looks forward to continuing
    our shared efforts to improve healthcare in Indian Country.
                        strengthening behavioral health
        HHS is committed to combating America's mental health and substance
    use crises. The pandemic has had a devastating impact on mental health,
    particularly for young people, by dramatically changing Americans'
    experience of home, of school, of work, and in their communities. The
    President has outlined a bold strategy for tackling the nation's mental
    health crisis, calling for an increased focus on building system
    capacity, connecting more people to care, and creating a continuum of
    support to keep people healthy and help Americans thrive. I also
    recently launched a National Tour to Strengthen Mental Health, to hear
    directly from Americans across the country about the mental health and
    substance use challenges they're facing and to engage with local
    leaders to strengthen the mental health and crisis care system in our
    communities. We are also working with the Department of Education to
    develop and align resources to ensure children have the physical and
    behavioral health services and supports that they need to build
    resilience and thrive. Individuals who develop substance use disorders
    are often also diagnosed with mental disorders--the budget addresses
    the significant connection between mental health and substance use by
    investing in a broad spectrum of behavioral health services.
        The Budget includes new, historic mandatory investments in totaling
    $51.7 billion over 10 years to address the nation's behavioral health
    crisis. In support of the President's call for reforming our mental
    healthcare system to fully meet the needs of our communities, the
    Budget includes a new $7.5 billion Mental Health Transformation Fund,
    allocated over a 10 year period, to increase access to mental health
    services through workforce development and service expansion, including
    through healthcare and community settings that have not traditionally
    provided mental health services but that are well-positioned to reach
    more people. The Mental Health Transformation Fund will also support
    the expanded use of evidence-based practices for mental healthcare, to
    ensure that families and communities affected by mental illness receive
    the highest quality care and supports.
        The Budget improves Medicare coverage of mental healthcare and
    makes access to such care more affordable by eliminating the 190-day
    lifetime limit on psychiatric hospital services and requiring Medicare
    to cover three behavioral health visits per year without cost-sharing.
    In addition, the Budget would recognize licensed professional
    counselors and marriage and family therapists as independent
    practitioners who are authorized to furnish and receive direct Medicare
    payment for their mental health services, aligns the criteria for
    psychiatric hospital terminations from Medicare with that of other
    healthcare providers, and applies the Mental Health Parity and
    Addiction Equity Act to Medicare.
        Additionally, the Budget establishes a Medicaid provider capacity
    demonstration program for mental health treatment and establishes a
    performance bonus fund to improve behavioral health services in
    Medicaid. The Budget also expands and converts the Demonstration
    Program to Improve Community Mental Health Services into a permanent
    program. Further, the Budget prevents states from prohibiting same day
    billing and allows providers to be reimbursed for Medicaid mental
    health and physical health visits provided to a Medicaid beneficiary
    that occur on the same day and requires that Medicaid behavioral health
    services, whether provided under fee-for-service or managed care, be
    consistent with current and clinically appropriate treatment
    guidelines.
        For people with private health insurance, the Budget requires all
    health plans to cover mental health and substance use disorder benefits
    and ensures that plans have an adequate network of behavioral health
    providers. The Budget also establishes grants to states to enforce
    parity between mental and substance use disorder and other medical
    benefits.
        The Budget also proposes $20.8 billion in discretionary funding for
    behavioral health programs in fiscal year 2023, including significant
    investments in mental health programs such as the National Suicide
    Prevention Lifeline, a free, confidential 24/7 phone line that connects
    individuals in crisis with trained counselors across the United States.
    The Lifeline receives calls from people with substance use; depression;
    mental and physical illness; economic worries; loneliness; and concerns
    about relationships and sexual identity. Ensuring the success of the
    Lifeline particularly as it transitions to the universal 3-digit number
    988 is a top priority for HHS.
        To support the health workforce, the Budget includes $397 million
    for Behavioral Health Workforce Development Programs and $25 million in
    the National Health Service Corps funding specifically for mental
    health providers. The Budget also includes $50 million for the Health
    Resources and Services Administration (HRSA) for Preventing Burnout in
    the Health Workforce. This investment will provide crucial support for
    health workforce retention and recruitment, which is essential for
    addressing current and future behavioral health workforce shortages.
        Suicide remains the second leading cause of death among young
    people between the ages of 10 and 34. Many youth, especially young
    people of color, Indigenous youth, and LGBTQ+ youth, still lack access
    to affordable healthcare coverage that is necessary for them to receive
    treatment for mental health conditions.
        The Budget also includes $308 million for Project AWARE and the
    Mental Health Awareness Training program to expand support for
    comprehensive, coordinated, and integrated state and tribal efforts to
    adopt trauma-informed approaches and increase access to mental health
    services. School and community-based programs like Project AWARE have
    been shown to improve mental health and emotional well-being of
    children at low cost and high benefit. Prevention is an investment in
    our future, and it lowers adverse outcomes with high societal impact.
        According to CDC data, drug overdose deaths increased nearly 30
    percent in 2020. Last fall, I announced the release of a new,
    comprehensive HHS Overdose Prevention Strategy for the nation, designed
    to increase access to the full range of care and services for
    individuals with substance use disorders and their families. This new
    strategy focuses on the multiple substances responsible for overdose
    and the diverse treatment approaches needed to address them.
        The Budget invests $11.0 billion to combat the overdose crisis
    across HHS in support of four key target areas--primary prevention,
    harm reduction, evidence-based treatment, and recovery support--and
    reflects the Biden-Harris Administration principles of equity for
    underserved populations, reducing stigma, and evidence-based policy.
        The Budget also proposes $553 million for Certified Community
    Behavioral Health Centers Expansion Grants to provide coordinated,
    high-quality, comprehensive behavioral health services. The Budget also
    proposes to remove the word ``abuse'' from the agency names within
    HHS--including the Substance use And Mental Health Services
    Administration, the National Institute on Alcohol Effects and Alcohol-
    Associated Disorders, and the National Institute on Drugs and
    Addiction. Individuals do not choose to ``abuse'' drugs and alcohol;
    they suffer from addiction, which is a chronic medical condition. It is
    a high priority for this Administration to move past outdated and
    stigmatizing language that is harmful to these individuals and their
    families.
                   supporting children, families, and seniors
        HHS has a responsibility to ensure our programs serve children
    equitably, and the high-quality care of children positively impacts
    their success later in life. The Budget proposes $20.2 billion in
    discretionary funding for the Administration for Children and Families'
    early care and education programs. This includes $12.2 billion for Head
    Start to provide services to more than a million children, pregnant
    women, and families, $7.6 billion for the Child Care and Development
    Block Grant, and $450 million for Preschool Development Grants to
    increase capacity of states to expand preschool programs.
        The Budget expands home visiting programs over 5 years to provide
    economic assistance, child care, and health support for up to 165,000
    additional families at risk for poor maternal and child health
    outcomes. This funding will help strengthen and expand access to home
    visiting programs that provide critical services directly to parents
    and their children in underserved communities.
        The mandatory budget includes a $4.9 billion expansion of services
    to prevent child maltreatment and the need for foster care. For
    children who must be removed from their parents, the Budget includes
    $1.3 billion in support for states to prioritize placing children with
    kin, as well as a $3 billion increase for programs to stabilize and
    support families and adoptive families, and a $1 billion increase in
    support for the transition to adulthood for youth who experienced
    foster care. While not part of HHS's budget, the Budget proposes to
    make the adoption tax credit fully refundable so that more families can
    benefit and to expand the credit to include qualifying legal
    guardianships.
        We face a public health crisis of violence in our communities,
    which disproportionately affects communities of color. The Budget
    includes $250 million for CDC for the Community Violence Intervention
    initiative, in collaboration with Department of Justice to implement
    evidence-based community violence interventions at the local level, as
    well as funding for firearm violence prevention research. The Budget
    also promotes prevention of and early intervention after adverse
    events, like community violence, to mitigate longer term impacts,
    including $15 million for CDC to advance surveillance and research
    aimed at preventing Adverse Childhood Experiences. The Budget also
    includes $519 million for ACF's Family Violence Prevention and Services
    programs, including $250 million to provide direct cash assistance to
    survivors of domestic violence.
        The Budget supports FDA's public education campaigns to educate
    youth about the dangers of e-cigarette use; provide resources to
    educators, parents, and community leaders to prevent youth use; and
    provide resources to help kids who are already addicted to e-cigarettes
    quit using these harmful products. The Budget includes $812 million for
    FDA's tobacco program, an increase to enhance product review and
    evaluation, research, compliance and enforcement, public education
    campaigns, and policy development.
        The Administration for Community Living (ACL) protects seniors and
    persons with disabilities from abuse through investments in Adult
    Protective Services and the Long-Term Care Ombudsman Program. As the
    populations served by ACL continue to grow, the Budget provides $139
    million to protect vulnerable older adults. The Budget also bolsters
    ACL's role as an advocate for older adults and people with
    disabilities.
                      refugees and unaccompanied children
        Amid the COVID-19 pandemic, large numbers of unaccompanied children
    continue to arrive at our Southern border. HHS is committed to
    fulfilling our legal and humanitarian responsibility to care for all
    unaccompanied children (UC) referred to us by Federal partners. The
    fiscal year 2023 Budget includes $6.3 billion in discretionary funding
    for the Office of Refugee Resettlement, including $4.9 billion for the
    unaccompanied children program so that HHS may continue to care for UC
    safely and humanely, in alignment with child welfare best practices.
    The Budget also proposes a mandatory contingency fund to provide
    additional funds if there is a surge in UC referrals, as well as
    mandatory funding to build towards universal UC legal representation.
    HHS is committed to unifying these children with vetted sponsors,
    usually a parent or close relative, as safely and quickly as possible,
    and the Budget includes funding to implement critical programmatic
    reforms and service expansions. The Budget also builds on the nation's
    refugee infrastructure to support resettling of up to 125,000 refugees
    in 2023, and requests authority to use these funds to support the
    successful reunification of families who were cruelly separated under
    the Trump Administration.
                  improving safety and oversight nursing homes
        Building on the President's State of the Union Address, the Budget
    is committed to ensuring nursing homes are safe and providing high
    quality care to vulnerable Americans by increasing funding for nursing
    home health and safety inspections by nearly 25 percent. Additionally,
    by increasing nursing home owners' accountability for minimum quality
    standards, noncompliant facilities can be held financially responsible
    for poor safety and care. The Budget also requests authority to publish
    accreditation surveys for other healthcare facilities, like hospitals,
    rural health clinics, and ambulatory surgical centers, which will
    better inform the public when selecting care locations for loved ones.
    The Administration also supports strengthening home and community-based
    services to ensure people have access to safe options that work for
    them.
                        funding core program operations
        While the service provided by HHS continues to grow, investment in
    the Department's operational needs ensures HHS can carry out its
    mission to enhance and protect the health and well-being of all
    Americans while maximizing our resources. This investment 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 importance and magnitude of HHS' work, ensuring the
    integrity of our spending is a core value and responsibility of HHS.
    The Budget increases discretionary Heath Care Fraud and Abuse Control
    program spending to a total of $899 million to provide oversight of CMS
    health programs, strengthen OIG investigations, and protect
    beneficiaries against healthcare fraud, yielding a return-on-investment
    of $13.6 billion over 10 years. The pandemic has unleashed new
    healthcare fraud risks related to the implementation of billions in new
    Federal spending, as well as multiple provider regulatory and other
    flexibilities. These funds are critical to help HHS root out bad actors
    and ensure program integrity.
                                   conclusion
        I want to thank the Committee for inviting me to discuss the
    President's fiscal year 2023 Budget for HHS. The Budget offers a vision
    for the nation that reinvests in America's health, supports growth and
    prosperity, and meets our commitments to the American people and
    especially to the most vulnerable. I look forward to working with you
    to fulfill that vision. If we step up in this moment, we can lay the
    foundation now.
        These are critical programs and issues that deserve attention and
    adequate funding. Thank you for your partnership in advancing our
    shared goal to improve the health, safety, and well-being of our
    nation.

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

                                    TITLE X

        Secretary Becerra, when Texas passed its highly restrictive
    abortion ban, President Biden promised a whole of Government
    response. And in a statement yesterday, he said the
    Administration will be ready when any ruling is issued. What
    can you tell us about the Administration's plan for a whole of
    Government response to defend the right to abortion?
        Secretary Becerra. Madam Chair, as I mentioned before, we
    are working at HHS through a reproductive healthcare task force
    that we established to make sure that we continue to protect
    the rights of women that exist today. Those rights that exist
    today to have access to care. We have expanded program services
    like Title X, and we will work with all of our partners
    throughout the Federal Government to make sure that every woman
    has the legal right to access the care that she is entitled to.
        Senator Murray. Well, I have been really alarmed that some
    Republicans have made it clear they don't intend to stop at
    abortion. Some saying the case that ruled against birth control
    bans was wrongly decided.
        And they have refused to increase funding for the Title X
    program, which I have been talking about, that provides funding
    for birth control, cancer screening, and lifesaving care. And
    in fact, they voted to undermine that program just last week.
        Now, HHS approved, but had to turn away dozens of highly
    qualified applicants for this program in March as a result of
    that funding. Can you tell us what that means for patients?
        Secretary Becerra. First, I want to make note that because
    Congress was successful in passing its omnibus budget, we are
    going to be able to do far more than what the President's
    budget first proposed, because it was based on a baseline using
    the continuing resolution funding levels.
        So we will do much more working with you to make sure
    adequate funds are available for programs that provide women
    access to the care that they need. We are also going to make
    sure that we speak to all those providers who are out there who
    have an obligation to make sure women are receiving the
    services they are entitled to.
        I yesterday spoke to a number of health plans and
    representatives of various health plans throughout the country
    to make it clear that we intend to enforce the law when it
    comes to women accessing the care that they are entitled to.
        Senator Murray. Can you tell us how the proposed increase
    in HHS will expand access for women of color and low income
    women?
        Secretary Becerra. We are working hard to make sure that we
    are addressing some of the maternal mortality and morbidity
    circumstances that we see in this country, where typically a
    woman in the black community and in our native populations will
    suffer the consequences of lost birth, possibly a loss of life,
    in far greater numbers, probably 3 to 1 compared to in the
    white community.
        And so we are investing in the President's budget close to
    half a billion dollars to increase our services in maternal
    health and mortality. We are also calling on States through the
    American Rescue Plan to increase the number of days that a
    woman is entitled to postpartum care from 60 days under
    Medicare, Medicaid--excuse me, to 365 days under Medicaid.
    COVID-19 Funding
        Senator Murray. Okay. Thank you. On another topic, I am
    really concerned that further delay in passing emergency COVID
    funding could undermine our hard won progress. What are the
    immediate effects if Congress does not provide more funding for
    the COVID-19 response as soon as possible?
        Secretary Becerra. Madam Chair, thank you for that
    question. I have said this publicly many times, we have been
    first in line to receive vaccines, some of the therapeutics,
    the antiviral medications, because we have been at the
    beginning of the negotiations to have access to those therapies
    and drugs.
        Without the money to make the long term commitment going
    forward, we can't assume that we will get first in line. Many
    other countries are already negotiating for access to those
    treatments. And what we need to do is plan ahead. We have a
    stock right now of vaccines and treatments that cover us for
    the next several months.
        But we can't say that if there is a new variant that hits
    or if we need to buy the next generation vaccine that we'll be
    the first in line if we don't have the money.
        Senator Murray. Meaning there is a limited supply, and we
    won't have access to that supply unless we have the funds
    available now?
        Secretary Becerra. Correct.
        Senator Murray. Okay. Parents across the country are
    waiting anxiously for vaccines for young kids. I know FDA is
    working on this, but having safe, effective vaccines is the
    first step, and we need the Administration to be ready to
    distribute enough doses and make it easy for parents to get
    them for their kids. Are you ready for that?
        Secretary Becerra. We are ready and anxious, as anxious as
    you are. As you said, safe and effective are the key words. FDA
    will move when they have the data that reflects if they are
    safe and effective to use for those under 5 years of age. And
    we are already coordinating with a number of providers,
    including pediatricians, to make sure we are making those
    available as quickly as possible.
        Senator Murray. Do we have enough doses available, once it
    is approved?
        Secretary Becerra. We will be able to purchase, because we
    made a reservation of funds to make sure we could purchase. But
    once again, how much, how far, and what the vaccine might look
    like will determine whether or not we have access to the supply
    we need.
        Senator Murray. Thank you very much. Senator Blunt.

                                     ARPA-H

        Senator Blunt. Thank you, Chair. Let's talk about ARPA-H
    for a little bit. This for people who have not been thinking
    about--an idea the President has to take the long experience
    with DARPA, Defense Advanced Research, which is different than
    the way we have done basic health research, and in those
    instances where we can work toward a rapid conclusion and a
    more hands together partnered way to do that, I am for that.
        Chair Murray has supported the approach of trying to get
    there quickly as she and Senator Burr have introduced
    legislation to codify this concept. I really want to ask two
    questions here, and one is, talk a little bit about your
    decision to structurally put ARPA-H under the NIH umbrella but
    directly reporting to you, and then we will come to the
    spending decision later.
        Secretary Becerra. Senator, thank you for the question and
    the support you provided to ARPA-H. ARPA-H at the end of the
    day is like NIH, an agency that takes that research. But how it
    differs from NIH is it wants to be able to launch from the pad
    very quickly. And working in partnership with the private
    sector, those innovators that are out there, the biomedical
    scientists, be able to actually give the American people a
    product quickly.
        And that is why we want ARPA-H to be more nimble, more
    facile, and have the opportunity to break away from the tethers
    of governance that you see at NIH to be able to launch as
    quickly as possible. We believe we are going to be able to do
    that while using the efficiencies at NIH has.
        So, for example, starting up, your human relations office,
    your payroll office, your accounting office, rather than have
    ARPA-H have to start from very scratch, make use of what NIH
    provides, but give them the autonomy to launch the way they
    think fit.
        Senator Blunt. And at ARPA-H, I think is, I have heard that
    discussed while all of those assets would be there, the
    umbrella agency of NIH, the ARPA-H system would not necessarily
    work like the NIH system.
        You would have the ability to bring people in for shorter
    periods of time, understanding that this is a project, we are
    bringing you in to work on it, and at the end of, say, 3 years,
    we expect this project to be done and you will have the ability
    to go on to some other work somewhere else. Is that your
    understanding of this as well, Secretary?
        Secretary Becerra. That is correct. It will not work the
    way NIH works. It will work much closer to what you understand
    the way DARPA works in the Department of Defense.
        Senator Blunt. I do think that NIH showed during COVID with
    RADx and with some of the Warp Speed involvement that even NIH
    had, but particularly gives RADx the ability to do things in a
    different way. But I think looking at how that worked and how
    DARPA works and figuring out how they all work together would
    be a good thing.
        So Senator Murray and I have worked together on this
    committee for 7 years, and have increased the NIH funding by
    more than 50 percent after a decade with no real increase. It
    has been an important goal that we have worked on together. The
    concern at NIH about ARPA-H--or the NIH advocates, not
    necessarily the people working there, but the support groups
    and advocates of NIH, has always been that it would take money
    that otherwise would go to NIH. It appears that is exactly what
    is happening here.
        We did $1 billion for startup money for ARPA-H last year.
    This budget proposes another $4 billion for ARPA-H and zero for
    NIH. I am confident that based on our past, working on this
    topic, zero will not be the number we come up with. But why did
    you submit zero as opposed to an increase in NIH and money for
    ARPA-H as well?
        Secretary Becerra. Appreciate the question and to explain.
    We, when the President asked us to submit our budgets to
    Congress, we had to work with the baseline that we knew that
    was in front of us.
        At that point, Congress had not completed the work on a
    fiscal year 2022 budget, and so we had to operate expecting
    that our baseline would be the continuing resolution, which is
    far lower than what you ultimately passed in the omnibus bill
    for 2022.
        Certainly now, knowing what the omnibus bottom line is for
    NIH, we will work using that bottom line to talk about
    increases for NIH. And we look forward to working with you to
    make sure that NIH continues to receive the robust funding that
    it has always received from Congress.
        Senator Blunt. Thank you, Senator Murray. I will have some
    other questions, but I assume we will have a chance to ask a
    second round of questions.
        Senator Murray. Yes, we will do that. Thank you. Senator
    Manchin.

                                  SUPPLY CHAIN

        Senator Manchin. Secretary, thank you for being here.
    Appreciate it. Thank you for your service. On supply chains, we
    have spoken quite a bit about supply chains, and we learned
    that during the COVID-19 pandemic, how fragile it is and trying
    to make sure that we are able to meet the needs of the people.
        This Administration, Biden Administration, they instituted
    a whole of Government effort to assess what can be done to
    strengthen competitiveness and supply chain resilience,
    including the 100 day reviews. And later this year, I think you
    all will issue your first annual report to provide an update on
    the challenges, developments, and opportunities.
        So the only thing, I know that we are running into these
    timeframes and everything, so I guess what progress has the
    Department made in confronting this supply chain crisis that
    jeopardizes the supply of medications that patients are going
    to rely on and need?
        Secretary Becerra. Senator, I look forward to working with
    you on that. As you know, this Administration has used the
    Defense Production Act on several occasions to try to increase
    and expand our supply chain. Quick example.
        Last year, all the manufacturers of COVID test kits were
    not domestic, and we worked really hard not only to expand the
    number of testing kits that would be available for Americans to
    test themselves against COVID, but we worked really hard to
    make sure those were domestically manufactured.
        And today we have several in America that are domestically
    manufactured, which, by the way, they will begin to shut down
    those lines of production if we don't have the monies to
    guarantee that we will be able to fund test kits moving into
    the future.
        Senator Manchin. You have been able to track manufacturing,
    but people are willing to come back into our manufacturing
    base?
        Secretary Becerra. Absolutely.

                                     LIHEAP

        Senator Manchin. You show them the support, they will be
    there. Okay. The other thing is on LIHEAP, the LIHEAP, Low
    Income and Energy Assistance Program. We are having a hard
    time, and advocates both from back home in West Virginia and
    nationally, challenge in the States facing administering this
    program. They are having trouble getting the people to
    administer the program and getting the money to be
    administered.
        So I guess, quickly, have you all looked into this, and can
    you look into it on LIHEAP, how you can maybe help or make sure
    that money is getting there, or they have the administration
    that they are going to need, the support that they are going to
    need to get this money out, because it just has been very, very
    difficult for a lot of poor people.
        Secretary Becerra. Americans need heat in the winter, and
    they need to be cool in the summer. And we will do everything.
    We have expanded LIHEAP. We will do everything we can, Senator,
    working with you and others to make sure that the resources
    that you all provided get to people who need it.
        Senator Manchin. I think basically just accept--helping
    them with their application approval process. That will help
    tremendously, if you can look into that. The other thing is
    that I had one thing that I wanted to mention to you, and I
    think we have talked about before, I have been trying to
    support and trying to pass the Lifeboat Act.
        And only thing it does, Lifeboat truly is saying that we
    are going to charge manufacturing of opiates one penny per
    milligram. That one penny per milligram goes to treatment
    centers all over America. Every one of us in our States have an
    addiction problem. But we have so few facilities, and the
    Government can only do so much. But I think the manufacturing
    that is a manufacturing fee, it won't be passed on as far as
    cost to the consumer.
        But for--if you are going to put this product on the
    market, you ought to know the damage it does. And right now, we
    see lawsuits all over the country. I would hope you are looking
    into that and see if it is something you all could support. It
    is not onerous at all. It basically directs every penny to
    treatment centers.
        And the final thing I want to ask you about, the $10
    billion that we are stuck on, I cannot believe it. What is it
    going to do? What risk are we really going to be faced if we
    don't get this funding?
        Secretary Becerra. Well, the $10 billion is certainly not
    enough to carry us to the end of the fiscal year. But what it
    does do is it lets us stay at the front of the line to make
    sure we are purchasing the medicines, the treatments, and the
    vaccines that we need moving forward. Without that, again, we
    could lose our place in line.

                                    COVID-19

        Senator Manchin. This is like the different variants, that
    first of all, we thought COVID-19 was over. Then we have been
    told, Dr. Fauci told us, that there are going to be different
    variations. And it is exactly true what he said. And now we
    even have more. But what is the time element? Where are you
    going to be crunched on if politics is being played? Democrats
    and Republicans got to come together for the health of all
    Americans.
        Secretary Becerra. Our scientists are telling us that in
    the fall, winter, we probably will see another surge. How big,
    who knows. But in order to be ready for that fall or winter, we
    have got to start purchasing today, not in the fall or winter.
        Senator Manchin. I just, I know you all have a yeoman's
    task in front of you, and I appreciate the job you are doing.
    And I just want make sure that we can help you and assist in
    any way possible. So communications between the offices have
    been great and I appreciate that. We need a lot more and we are
    going to try to do all we can to make sure we can protect
    Americans.
        Secretary Becerra. Thanks, Senator.
        Senator Manchin. Thank you. Thank you.
        Senator Murray. Thank you. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Chairwoman Murray and
    Ranking Member Blunt, for holding this hearing today. And I
    also want to thank the Secretary for being here and your
    willingness to serve and your willingness to answer these
    questions. On March 11, 2021, President Biden signed the
    American Rescue Plan Act of 2021 into law. Out of the nearly $2
    trillion in this bill, only 6 percent went to vaccines and
    public health.
        Despite the fact that a lot of ARPA funding has yet to be
    disbursed, the Biden Administration continues to press Congress
    for more money. Over the past few months, your Department in
    particular has asked Congress for more funding to ensure
    continuation of critical aspects of the U.S. healthcare
    response to COVID-19.
        Knowing that there would be a continued need for pandemic
    related healthcare, why did HHS divert healthcare related funds
    toward the care of illegal immigrants who were coming here due
    to the Biden Administration's open borders policy?
        Secretary Becerra. Senator, thank you for the question. And
    as you recall, in the midst of the American Rescue Plan,
    America was sinking and the rescue plan was to do more than
    just the healthcare side, it was to make sure that those
    families who had lost their jobs, those business owners who
    were losing their businesses, could survive the pandemic. And
    so that is why so many of the resources went to keep America
    afloat. And today we see that very few Americans are
    unemployed.
        The economy is moving. But I get--to your point on the
    resources, we used resources to deal with COVID in its many
    different facets, including at the border. And so when it came
    to those migrant children, we wanted to make sure that everyone
    was safe, including those children.
        So we used some of the COVID money to make sure for COVID
    related reasons, we kept America safe and including those
    children safe from any particular spread. And so we documented
    the spending on those programs to Congress, and we continue to
    show that the success of keeping COVID from spreading,
    including on the border, was not only important, but kept our
    economy moving.
        Senator Hyde-Smith. I am well aware of the need for that
    funding and all the American children that needed the vaccines
    as well. Knowing these healthcare needs exist, why isn't your
    Department working with the Office of Management and Budget to
    shift undisbursed funds toward the healthcare priorities before
    asking for more money?

                                    COVID-19

        Secretary Becerra. Senator, we are more than willing to go
    through with you and your team the way we have used the money.
    We have allocated all the dollars we have, the discretion to
    move towards the task of dealing with unaccompanied children or
    dealing specifically with COVID, but we are more than willing
    to get into some of the specific if you would like to see how
    we have been able to use the resources you provided.
        Senator Hyde-Smith. And staying on the topic of COVID-19,
    this is incredibly important to me. I have been in touch with
    your Department for months on behalf of a gentleman by the name
    of Cody Flint in Mississippi. He is an agricultural pilot in
    Mississippi. Cody received his first dose of the Pfizer vaccine
    on February the 1st, 2021, and immediately began experiencing
    very adverse side effects, such as headaches, vision, and
    hearing issues, dizziness, loss of balance, and a lot of pain.

                  COUNTERMEASURES INJURY COMPENSATION PROGRAM

        Due to these serious health issues, he has not been able to
    fly as an Ag (Agricultural) pilot since receiving the COVID
    vaccine shot, rendering Cody unable to provide for his family
    as an Ag pilot in Mississippi. For more than a year, Mr. Flint
    has been painstakingly going through the Countermeasures Injury
    Compensation Program, seeking compensation he may be entitled
    to based on his experience.
        I have worked with him to try to navigate this process. And
    I have been stunned not only by your agency's lack of urgency
    in refusing such claims, many claims, but also the lack of the
    transparency in that process. I certainly still advocate for
    the vaccine, and I myself received the vaccine, and I encourage
    others to speak to their doctors about receiving it, however,
    as with any new medical product, some people will have side
    effects.
        The CICP (Countermeasures Injury Compensation Program)
    exists for that very reason, and I am very concerned about the
    amount of time it takes your agency to process claims and the
    lack of clarity given to those folks who were adversely
    affected. Can you tell me what you are going to do to address
    the thousands of claims currently in backlog at HHS?
        And what are you doing to improve the transparency of the
    CICP process so that Americans like Mr. Flint are properly
    compensated in a reasonable time period?
        Secretary Becerra. Senator, well, you have asked a very
    important question not just to Mr. Flint, but to so many
    Americans who did what they should, which is to get vaccinated.
    We are finding that there are a number of Americans who are
    suffering from what we are calling today long COVID, and we are
    doing everything we can to make sure we provide them with the
    support that they need to get through this, who knows how long
    it may be. We are doing research on this as well.
        I will say this, transparency is important. Accountability
    is important. And we want to make sure that those who really do
    have a medical issue to report are the ones who are receiving
    the assistance. We, as you are aware, in some cases, some of
    the COVID money has been used fraudulently by many.
        We want to make sure that no one is trying to game the
    system to get relief for something that doesn't exist, that way
    we can reserve the funds that we have for people like Mr. Flint
    and provide him with some help.
        And so why don't we do this? I am more than willing to have
    my team reach out to you, and we can see about Mr. Flint and
    where he is in his process, because we have heard this story on
    many occasions. We know that millions have been saved because
    of the vaccine, but we also know that many people are still
    suffering, so we look forward to working with you.
        Senator Hyde-Smith. He has totally lost his income and the
    financial burden is just unbelievable, but the frustration of
    trying to just get some answers of when something could be done
    for him for this compensation has been very great. Thank you
    for your help and for answering my questions.
        Senator Murray. Thank you. Senator Reed.

                                     LIHEAP

        Senator Reed. Thank you very much, Madam Chairman. Let me
    go back, Mr. Secretary, to an issue that Senator Manchin
    raised, that is LIHEAP. I am pleased to say that the President
    slightly increased LIHEAP in his budget this year, but the
    reality is that energy prices are just exploding. In the past
    12 months alone, the price of natural gas has increased by 22
    percent and the price of heating oil has increased by 70
    percent.
        So would you support any type of supplemental funding to
    enhance the LIHEAP so that we can deal with this extraordinary
    increase in prices?
        Secretary Becerra. Senator, we will support any effort to
    try to further fund LIHEAP given the circumstances that we are
    in.
        Senator Reed. Thank you very much. Also, let me go back to
    the point you raised, which I am pleased that you are moving
    aggressively. That is the 9-8-8 number. We all understand that
    we were in a mental health crisis in the country. I hear that
    not only from my constituents, but as I visit troops around the
    globe, I hear it from our military personnel also. And we just
    had a terrible incident, you know, multiple suicides at one of
    our Navy carriers. 9-8-8 is a great idea, I think.

                      NATIONAL SUICIDE PREVENTION LIFELINE

        I had something to do with it and that is why I think that
    way. But anyway, it is going to allow someone to call who has a
    suicidal ideation and try to get help. But it has to be
    implemented thoroughly throughout the Nation. In Rhode Island,
    my State has done, I think, a very good job of setting up the
    counseling centers, the technology, and etcetera. But as I
    understand the system, if someone calls in and a State doesn't
    have the infrastructure, they are referred someplace else.
        So you have a not a very good relationship, long distance,
    and also adding more work to States that have enough work
    already. So can you give us sort of a sense of how the Nation
    is doing and are we all going to come online together?
        Secretary Becerra. Thank you, Senator. And I do believe
    your State is doing very well in moving forward. We have a
    patchwork right now of call centers that accept these calls
    from folks who are suffering from mental stress. We are trying
    to turn that into one cohesive network. It is difficult because
    it won't be run by the Federal Government, it will be run by
    the 50 States, the territories, and the Tribal governments.
        But what we are doing is working with them with your
    support. We have so far invested $300 million throughout the
    country with all the States, local governments to try to make
    it work. We will also provide back up call centers to make sure
    that if any particular location is receiving a large volume of
    calls, there will still be someone who answers the phone,
    because the worst thing you can have when someone reaches out,
    instead it goes in the wrong direction, is to get a busy signal
    or be put on hold.
        Senator Reed. No, I completely agree, Mr. Secretary. And,
    you know, there are long term costs to not implementing
    something properly. We understand that. And this is an
    opportunity. We have to get it right. I also understand the
    President has requested nearly $700 million in his budget for
    the National Suicide Prevention Lifeline.
        And I think you will need that money, but I think right now
    we have a few months to get it right. And if you need
    additional help or assistance, please let us know.
        Secretary Becerra. Thank you. We are keeping tabs. We are
    contacting every Governor of every State every month to let
    them know where they stand.
        Senator Reed. Well, thank you, Mr. Secretary. It was a
    pleasure working with you in the House, and it is a pleasure
    working with you in your capacity. Thank you.
        Secretary Becerra. Thank you, Senator.
        Senator Murray. Senator Moran.

                                 ORGAN SHARING

        Senator Moran. Chairwoman, thank you very much. Mr.
    Secretary, good morning. Let me start with a topic that I asked
    you about in your confirmation hearing or in our conversation
    prior to your confirmation hearing, organ transplants. For over
    30 years, HHS has contracted with United Network for Organ
    Sharing, UNOS, yet it is currently under a Congressional
    investigation by the Senate Finance Committee.
        I would tell you my experience is their attitude approach
    to their policy has been very discouraging and detrimental to
    the lives and well-being of those individuals who are hoping to
    be a recipient of an organ transplant. Damaging geographically
    in their outlook and damaging geographically in their policy.
    The contract that UNOS holds with HHS for organ procurement and
    transplantation is up for competition in 2023.
        A recently published request for information on the
    contract, which I joined Senator Grassley and Senator Wyden and
    Young in supporting--this RFI (request for information) is an
    essential step to improving the Nation's organ transplant
    network. Numerous reports have highlighted the best way to
    increase competition for the contract is to divide it up.
        I don't know whether that is the right answer or not, but I
    would love to hear from you what specific steps--I want to know
    that you are aware of these problems and what specific steps
    you intend to take to increase competition for potential organ
    procurement and transplant network contractors.
        Secretary Becerra. Senator, this is an issue where you have
    real people who come to you and tell you about their real life
    circumstances. So we absolutely know about this. We are trying
    to prepare to make sure that in the process of coming up with
    these new contracts, we increase supply, not diminish supply,
    that we make it a more fair distribution of these organs and
    that we make it more transparent.
        And that is in the works. And what I offer to you, because
    I think it is so important across the country, we will work
    with you if you and your team have any particular ideas, if we
    haven't already incorporated them. I am more than willing to
    make sure we take that into consideration.
        Senator Moran. If you would give me a name of a contact,
    you give my staff a name of a contact today, we would be glad
    to follow up. I would love for your team to hear from not only
    me, but from those who are actively engaged in trying to make
    the system work better.
        Secretary Becerra. I will follow up with you at the end of
    the hearing. Whether we meet directly or through our staffs, I
    will make sure that happens.

                        THE NATIONAL STRATEGIC STOCKPILE

        Senator Moran. Xavier, thank you very much. Let me
    highlight a couple of other things. The National Strategic
    Stockpile, Strategic National Stockpile, you request, the
    budget requests $975 million for the national stockpile for
    fiscal year 2023. Ensuring that--and I raised this topic in the
    authorizing committee, and I want to make sure that it is not
    lost between the two committees. I serve on both of them.
        But ensuring that the SNS (Strategic National Stockpile) is
    restocked and maintained to its maximum capacity is important.
    I think it became more important with Russia's invasion of
    Ukraine, and I would ask your commitment to prioritizing fully
    stockpiling the biodefense and pandemic response supplies
    maintained by the SNS.
        Secretary Becerra. You have got my commitment, and I hope
    you will take a look at the President's pandemic preparedness
    plan moving forward. I think you will like what you see.

                              PROVIDER RELIEF FUND

        Senator Moran. Thank you very much. And I will do that.
    Rock Regional Medical Center is a new hospital in the suburbs
    of Wichita. We have been, me and my office have been working
    with the Health Resources and Services Administration for the
    past year flagging Rock Regional, which did not receive a fair
    allocation of provider relief funding.
        It is a new hospital and was treated in a way that--it
    seemed to me that HRSA (Health Resources and Services
    Administration) seemed uncaring about solving this problem, and
    it is not the only hospital in which that is the circumstance.
    And I don't think I am the only member of the Senate who
    believes that. So why is HRSA so unwilling to reconsider their
    methodology for PRF (Provider Relief Fund) funding for new
    hospitals?
        Secretary Becerra. Senator, you are absolutely correct. You
    are not the first and Rock Creek is not the only facility. Here
    is the difficulty. All those funds that were dispersed before
    2021 were done under a formula that we could not change. That
    formula, to your point, relied on looking at past performance.
    If you are a new hospital, it is hard to talk about your past
    performance.
        That did damage a lot of these facilities that were newer.
    The difficulty, as you will understand, is we could not change
    the statutory framework of the provider relief fund and the
    distribution. To undo that would have meant to have to pull
    back all the funds. What we did do was we changed the formula
    with the tranches of dollars that was still existed that we
    could move forward with.
        But we are more than willing to work with you and those
    providers in your State so we can try to address some of that.
    But it is tough because we can't undo what was previously used.
        Senator Moran. You described it--I am always pleased when
    an administration official of any administration says they want
    to follow the Congressional law. That is pleasing to me. It is
    not always the case that I find it to be the case that it
    happens. But I would indicate that we thought this could be
    better addressed in the later phases, and our conclusion was
    that it was not. So I would be glad if you will, again, help me
    get again to somebody who can address this issue.
        Secretary Becerra. And if you will permit me a quick
    response, it is not that we don't want to, it is just that what
    was left with the final phases was so little, and there were
    still so many new incoming requests and some facilities that
    had gotten no money whatsoever. For example, nursing homes had
    been left out in the first tranches. So it is not that we
    didn't want to go back. It is that with what was left, we
    couldn't try to undo the formula requirements of the previous
    Administration.
        Senator Moran. Thank you for your explanation.
        Senator Baldwin [presiding]. I will now recognize myself
    for 5 minutes of questions. Secretary Becerra, thank you so
    much for appearing here today. I am, as are you, prepared to
    talk about the fiscal year 2023 budget, but I did want to
    acknowledge what we saw from the Supreme Court on Monday night.
    If the court is really going to legislate from the bench and
    turn back the clock 50 years on Roe v. Wade, then I think the
    Senate needs to pass the Women's Health Protection Act, an act
    that I have co-led with Senator Blumenthal.
        And frankly, I would say that if we need to eliminate the
    filibuster to get it done, that is what we should do. And I
    encourage strongly my colleagues to support that effort. Now,
    the Biden Administration has worked to expand access to
    comprehensive, affordable coverage through the Affordable Care
    Act.

                                INSURANCE PLANS

        And I support these efforts. But unfortunately, we continue
    to wait for the Administration to address the issue of junk
    insurance plans. I wanted to share the story of Phillip from
    Janesville, Wisconsin. He received a $34,000 bill for an
    emergency room visit and an overnight stay at an area hospital.
    Rather than paying the bill, his junk insurance plan rescinded
    coverage due to an alleged preexisting condition. When Phillip
    wrote to my office, he said he wanted to warn people about the
    dangers of these plans.
        And he shouldn't have to do that. So, Secretary Becerra,
    during the hearing to consider last year's budget request, I
    asked why the Administration hadn't yet taken action to address
    these junk insurance plans. It has been a year. Can you tell me
    when the Administration will take action to address these
    plans?
        Secretary Becerra. Senator, absolutely an appropriate
    question. And we are in the midst of rulemaking. As you know,
    rulemaking could take a little while, but we started that
    process because of what you have explained. It does happen.
    Junk plans are leaving Americans with these tremendously
    expensive bills.
        Fortunately, with your help, the No Surprises Act is now
    law. And so individuals who get these surprise bills will no
    longer have to worry about paying such exorbitant bills. We
    hope that what we find is between the No Surprises Act statute
    and are changed to try to undo these junk insurance plans--that
    we will provide Americans the protections they thought they
    had.

                      NATIONAL SUICIDE PREVENTION LIFELINE

        Senator Baldwin. Yes. Well, please keep me apprised of the
    timeline. We are very anxious to see this addressed in
    rulemaking. I know that you were just asked some questions
    about the 9-8-8 Suicide Prevention and Lifeline Hotline.
        I want to just add that I was very proud to be the co-lead
    on the 9-8-8 bill and very supportive of the additional funding
    in the budget to prepare the States to make this line live. I
    still, though, hear from leaders in Wisconsin who are concerned
    that our State may not be fully prepared for the 9-8-8
    transition.
        So can you tell me a little bit more about the guidance
    that the Department is giving to States when it comes to
    securing the additional funding? And do we need to take more
    action to make sure that there is adequate preparation in the
    States for this transition?
        Secretary Becerra. Senator, the most important thing you
    can do is to continue to advocate that your State build the
    capacity to handle its 9-8-8 response. There are several States
    that have. We are working with every State with the resources
    you have made available to us to work with States, the
    territories, and the Tribal governments.
        But without the States taking control of this, it will be
    very difficult to believe that they will be able to manage the
    calls that they will get. And the last thing any of us want is
    for someone who is reaching out at a time of pain to not have a
    real person respond.
        Senator Baldwin. Can you, as a follow up, make me aware of
    the interactions that you have had with Wisconsin? It is
    troubling to hear these concerns raised by mental health
    leaders. And I want to make sure that our State is accessing
    the Federal funding that is available.
        Secretary Becerra. Senator, I can make sure we give you a
    copy of the letter we sent to every Governor, in this case,
    your Governor, to let them know where they stand in
    implementation.
        Senator Baldwin. I see I have run over my time. We might
    start a second round of questioning now, and I will call on
    Senator Blunt for a second round.
        Senator Blunt. Thank you, Senator. Let's talk about mental
    health for just a little bit. I was pleased in the budget that
    you have shown--asked for a substantial increase in the
    certified community behavioral health clinics, allowing them to
    continue to treat mental health like all other health, and also
    making the current demonstration program permanent and allowing
    all the States and territories to participate.
        So I am pleased to see that. I look forward to seeing how
    far we can go to create a reality of that request. One thing I
    did want to talk to you about with the mental health agency,
    SAMHSA. The budget was released on March 29. Three weeks later,
    we got the first of two notices of a fairly substantial
    reorganization, three reorganizations. One established a new
    Office of Recovery within the Office of the Assistant
    Secretary.
        Another created an Office of 9-8-8, which is the suicide
    helpline number, Behavioral Health Crisis Coordination. A third
    established a new program of prevention initiative. I have
    several concerns here. One is, there is nothing in the budget
    that reflects these agencies being there or so far no direction
    as to where money should come from to fund them.
        Two, I think some of the prevention efforts have become
    more harm reduction efforts than I think that Congress would
    have intended for, or certainly that I would intend for. And
    three, there are even press reports that the Administration is
    thinking about safe injection sites under the guise of
    prevention, even though I believe those sites are against the
    law.
        Now, we did have an update just yesterday, the first update
    of our staff of what that Office of Prevention might do. And we
    asked about some of these controversial things. I think we are
    not at all sure yet that there is enough information out there
    to not be concerned about this or not stay fully engaged.
        One, why would we get that kind of reorganization 3 weeks
    and only 3 weeks after the budget was submitted? And two, how
    do you expect us to incorporate this into the budget that you
    have already asked for?
        Secretary Becerra. Senator, thanks for the chance to
    respond. And as I mentioned to you previously in a
    conversation, we would reach out to your team. We have reached
    out to your team. Let me tell you what my team is explaining to
    me. First, the reorganization does not impact the budget. We
    are going to work with the monies that we have.
        We don't need new authorities because what we are simply
    doing is reflecting the President's priority on behavioral
    health, to really tackle this, and also to focus on trying to
    have a new strategy on drug use. And so what these offices are
    doing is essentially consolidating what exists in our agencies
    to really focus in more directly on these very important
    subjects.
        And so what we could do is we will follow up again with
    your team to give you details. As I said, it doesn't impact the
    budget. And what we can do is explain how the reorganization
    helps us achieve the President's desire to really tackle mental
    health and drug use as directly as we can. We established, for
    example, a coordinating council among all of HHS's agency so
    that we wouldn't wait to learn what each other is doing.
        SAMHSA and the Office of Public Health are coordinating
    that. So we are working immediately to deal with mental health,
    and so we are going to do more of that so we can make the best
    use of our money. But we will follow up.
        Senator Blunt. Well, we need you to do that. And it will
    impact the budget to the extent that we need to know where that
    funding comes from and what new authority--new line items,
    lines need to be created for that reorganization if there need
    to be new items. And we look forward to continuing to work with
    you on that.
        Secretary Becerra. Thank you.
        Senator Blunt. Thank you, Chair.
        Senator Murray [presiding]. Thank you. Senator Baldwin.

                         PERSONAL PROTECTIVE EQUIPMENT

        Senator Baldwin. Thank you. So I am thinking back to the
    first months of our struggles with the COVID-19 pandemic and
    all of the work we were doing with first responders and
    hospitals and others to secure PPE (Personal Protective
    Equipment).
        And in particular, respirator, N95 masks were in
    desperately short supply. And at that time, American companies
    began stepping up and they retooled manufacturing lines to help
    compensate for these weaknesses in the supply chain when there
    was a global demand.
        And working around the clock, they met the need for
    essential products, including N95 respirator masks and other
    PPE. These companies helped save lives, and now they are in
    trouble. I wrote to President Biden earlier this year urging
    him to prioritize long term contracts for the purchase of masks
    made by American workers in American factories with American
    materials.
        So I wonder, Secretary Becerra, as Health and Human
    Services works to replenish the Strategic National Stockpile,
    can you commit to prioritizing American made PPE?
        Secretary Becerra. Senator, absolutely. That is what we
    have done. As I mentioned earlier, we made it possible to
    actually have tests that were manufactured here. But to keep
    those lines of production going domestically, we have to be
    able to commit now, otherwise they are going to start to phase
    those lines down and it would take months for them to try to
    ratchet back up, which could cause us to have to go to foreign
    sources for that supply of tests or masks.
        Senator Baldwin. Are you procuring American made N95 masks
    right now for the national stockpile? Have you been?
        Secretary Becerra. We--and I will get back to you on
    exactly how much of that might be domestic production. But you
    will recall that we put out about 270 million N95 masks to
    Americans free of charge to help people deal with COVID the
    pandemic. We are resupplying the stockpile, and we are doing
    everything we can to make sure that when we do resupply, it is
    with domestic manufactured product.
        Senator Baldwin. Okay. Thank you.
        Senator Murray. Senator Braun.

                             GENDER AFFIRMING CARE

        Senator Braun. Thank you, Madam Chair. So when we have had
    an opportunity to talk, you know, early on I have been a
    proponent of reforming healthcare by making it more
    transparent, more competitive. I think that has largely been
    lost in all the other issues that have come up. Still
    interested in that. But the subject that is really creating
    controversy across the country would be gender affirming care
    for young people, and it is on the HHS website.
        I would like to work through what gender affirming care
    actually means and do it with a couple of subjects in mind,
    drugs and surgeries. Let's start with prescription drugs. I
    don't think these drugs have been proven safe and effective for
    the use you are recommending. That is probably why the FDA has
    not approved puberty blocking and hormone therapy drugs for
    gender transition.
        Any time a physician, you know, prescribes it, they are
    doing it off label. Would you agree that off label
    prescriptions for usages not approved by the FDA are
    potentially dangerous for patients, especially kids?
        Secretary Becerra. Senator, thank you for the question. And
    that is a question that HHS, including FDA, CDC, have been
    tackling quite a bit as a result of the pandemic. What I would
    simply say to you is that the FDA would raise alarms if they
    saw that a particular medicine or a treatment were being
    misused.
        And at this stage, what we know is that for a drug to be
    out there available, it has to be safe and effective as FDA has
    found it. So, what I would simply say with regard to this
    particular subject is, when individuals go in for care, it is
    their physician who is making that decision with them about
    what type of medicine or treatment they should receive.
        Senator Braun. You know, if you use that same logic on what
    we have just navigated through COVID, it seems like there would
    have been a different point of view. And to me, for many
    parents across the country, this has more potentially tragic
    consequences and it seems like it is a double standard.
        Let's look at surgeries that would be even more impactful.
    And I am not going to mention the particulars there. It is
    almost grotesque to mention what could occur. Could you explain
    what irreversible top and bottom sex change surgeries are and
    why that is on the portal as well?
        Secretary Becerra. Senator as you have just indicated,
    there are many different types of procedures that can be
    deployed. What I will say to you is, again, in any case, no
    individual, no patient will proceed forward unless his or her
    doctor has advised of the procedure. And it is considered by
    the FDA and others who have to go ahead and certify a medicine
    or a procedure to be safe and effective.
        Senator Braun. So I will try to distill it into a more
    simple form. In what case would it be appropriate to perform
    irreversible sex change surgery on kids?
        Secretary Becerra. Those decisions are made by that
    individual in consultation with physician and caregivers, and
    no decision would be made without having consulted
    appropriately.
        Senator Braun. You know, I think the Government shouldn't
    be pushing or have it out there on a portal that moves you
    towards irreversible sex change therapy. And I think we just
    need to think about it carefully because we are navigating into
    territory that we have never done before as a government.
        Kids going through this are having a hard time. We should
    be maybe focusing more on mental health and not things that are
    irreversible. And I think leading the HHS, it might be a little
    more important to be a little more definitive rather than
    making it look like, well, a laissez faire approach and
    whatever happens, happens. I think that is out of sync with
    most of America. And it seems to me it would be wise to maybe
    back up a little bit.
        Secretary Becerra. Senator, I hear what you are saying. I
    believe that we should help those have the life affirming care
    that they need. There are many transgender youth who have
    actually gone in the opposite direction, taking their life. If
    we can make a life better for someone in America, we should,
    especially if, in consultation with their physician, they
    approve of those procedures.
        Senator Braun. You think it would be reasonable, my last
    question, in the meantime to maybe take this off the site until
    there is a little more kind of science built into the approach,
    a little more discussion about what may or may not make sense,
    rather than having an out there where it looks like it condones
    the process?
        Secretary Becerra. I would say to you that many of our
    medical experts would tell you that we have explored this
    subject for a long time, and what we find is that we are
    helping improve the lives of many Americans by providing them
    with the care that they have chosen, with the informed consent
    of family, and also with the consent and advice of their own
    physician.
        Senator Braun. Thank you.
        Senator Murray. Thank you. Senator Shaheen.

                               WOMEN'S HEALTHCARE

        Senator Shaheen. Thank you, Madam Chairman. And thank you,
    Mr. Secretary, for being here this morning and for the work
    that you and everyone at the Department of Health and Human
    Services does to promote the healthcare of the people of this
    country.
        I was stunned, as I am sure all of us were, by the news on
    Monday when we saw the draft opinion leaked from the Supreme
    Court that proposed eliminating access to safe and legal
    abortions for women and for healthcare that goes along with
    that. I think it is stunning. And this is a statistic that I
    found incomprehensible, that the United States could become one
    of only 25 countries in the world that would totally ban
    abortion.
        And if this decision is correct and this is what the court
    decides, it would leave up to the States decisions about
    women's reproductive freedom that presents challenges in States
    like mine, New Hampshire, where we have seen funding denied to
    family planning centers on the front lines of these efforts,
    even though it is funding that does not support performing
    abortions.

                                    TITLE X

        But these family planning centers provide healthcare to
    thousands of women in New Hampshire. We appreciated your visit
    to see how Title X is working to keep doors open for family
    planning services for thousands of women in the Granite State.
    So I am very concerned about what is going to happen.
        And I wonder if you could update us on the work of Health
    and Human Services Reproductive Health Care Access Task Force?
        Secretary Becerra. Senator, thank you very much. We are
    going to double down on the effort to make sure that the legal
    rights of all Americans, women, to access the care that they
    are entitled to continue forward.
        Yesterday I had an opportunity to address a number of the
    representatives of many of the insurance plans, health
    insurance plans in America, and made it very clear that we
    intend to continue to enforce the law. We have heard complaints
    that some women are not being provided with access to the care
    that they are entitled to through their insurance plans.
        We will continue to do that. We will continue to support
    the efforts of family planning efforts that are available
    through Title X. We will also make it clear what the law
    requires of anyone who accepts Federal funding through
    Medicare, Medicaid to provide services to all Americans without
    discrimination.
        As I said, we are going to double down to make sure that no
    one goes without the care that they are entitled to.

                          STATE OPIOID RESPONSE GRANTS

        Senator Shaheen. Thank you very much. I appreciate that.
    Another crisis that New Hampshire and so many other States in
    the country are dealing with is substance use disorder
    epidemic. And we have seen how the COVID pandemic has
    exacerbated that. In New Hampshire, we are still in the middle
    of this crisis, and the State opioid response grants have
    really been a vital source of funding for our State to provide
    treatment that people need.
        So as you work to administer those grants this year, will
    you commit to working with me and with other members of New
    Hampshire's delegation to ensure that changes in a State's
    ranking in opioid overdose deaths don't result in large scale
    reductions in funding.
        One of the things that I am--I should preface that with
    saying, one of the things that we have seen in New Hampshire is
    that our overdose deaths have leveled out to some extent
    because we have gotten so good at using Narcan and providing
    Narcan to local police departments and firefighters so that
    they can respond when someone has overdosed, but that doesn't
    mean the underlying problem isn't there.
        Secretary Becerra. Senator, first, thank you for keeping
    this issue of the SOR (State Opioid Response) grants top of
    mind to make sure that no State, no community suffers a cliff
    in the funding that they need to continue to provide service to
    those who are suffering from drug use. We will continue to work
    with you.
        We have provided additional resources. The budget proposes
    $475 million above the previous fiscal Year because we
    understand how important it is. But I have no doubt that you
    will continue to insist that we do this the right way and that
    no one loses the funding they need.

                       AFFORDABLE CARE ACT PREMIUM RELIEF

        Senator Shaheen. Well, thank you. I know that is of
    interest to others on this subcommittee. So thank you very
    much. A final question has to do with the Affordable Care Act
    premium relief, which one of the very positive aspects of the
    American Rescue Plan was the Act's premium tax credits that
    extend for 2 years to help provide coverage for people who
    can't afford the cost of healthcare.
        Those provisions are set to expire at the end of this year.
    Can you talk about what the plans are to ensure that we don't
    see a number of people kicked off of the Affordable Care Act
    insurance because those premium tax credits are expiring?
        Secretary Becerra. Senator, thank you for what you and your
    colleagues did to make that possible. As a result, today, more
    Americans have access to healthcare, they have insurance,
    health insurance, than at any point in our country's history, a
    greater number. And part of that is the 14.5 million Americans
    who receive their coverage through the Affordable Care Act
    marketplace.
        That came because you made it possible for us to avoid the,
    again, the cliff that some families faced when it came to the
    cost of coverage by providing those subsidies and made it very
    affordable. And in some cases for some families so affordable
    that they were finding that they were paying $10 or less per
    month for their monthly premiums.
        And as I always try to say, go try to see a movie in
    America for less than $10 a month, for one movie, not for a
    whole month. And so we will continue to work with you, because
    it has clearly proven itself successful to make sure Americans
    can afford to have their health insurance coverage.
        Senator Shaheen. Can I just ask one follow up----?
        Senator Murray. Yes----
        Senator Shaheen [continuing]. Madam Chair. So when you say
    you will continue to work with us, should we expect a proposal
    coming from the Administration to extend those premium tax
    credits or to look at other ways to provide help to people who
    need help with the cost of health insurance?
        Secretary Becerra. The President has made it very clear, we
    want to see those premium tax credits extended. In the
    President's proposals, Build Back Better proposals, and others,
    we have talked about how we continue to expand access to
    healthcare and reduce costs, and we will continue to work with
    you.
        Senator Shaheen. Thank you. Thank you, Madam Chair.
        Senator Murray. Senator Moran.

                      NATIONAL SUICIDE PREVENTION LIFELINE

        Senator Moran. Thank you, Chairman. Mr. Secretary, in the
    time that I have been here, you have been asked a number of
    times about 9-8-8. Let me just ask a specific question about
    your plans.
        Would you fill in the details on the $700 million request
    for the National Suicide Prevention Hotline with the
    opportunity to explain the reasoning behind that amount and
    what it would be used for?
        Secretary Becerra. Senator, thank you. We are finding that
    because we have had this patchwork, as I have mentioned before,
    of response and we are trying to make it into one unified
    response--so if you today are in D.C. and you are feeling
    stressed, but then you travel into Maryland or West Virginia,
    you don't find that you lose the same access to services that
    you might have had if you were in one of those different
    locations.
        To make that happen so it is seamless, requires a great
    deal of support because the States are accustomed to dealing
    only with the folks in their communities. We are trying to make
    it so that there are--it makes no difference. If you have an
    area code phone from the State of Kansas, but you happen to
    find yourself in my State of California, you are still going to
    get response regardless of where you are. That requires
    resources. Some States have moved to actually provide a
    permanent line of funding for their 9-8-8 services.
        Others have not. We don't want to see anyone fall through
    the cracks. And so we are working hard to provide them with
    services. We put in over $300 million in this current fiscal
    year. The President is requesting more because we know it is
    not just a matter of making sure that the system works, but
    moving forward, we want to make sure that the follow up
    services are available so that you don't just get a voice that
    says we are here to help, but that the services will be there
    to follow within the States.
        Senator Moran. So is the $700 million utilized for the
    technology of the phone call? Or in providing actual services
    once you get somebody on the line?
        Secretary Becerra. More for the services. So for example,
    many States are not able to handle the call volume they get. We
    want to make sure that regardless of where you are, even if a
    State is receiving a high volume or exceeds its capacity, that
    that call will still get answered. So we have backup call
    centers that are set up.
        That is something that we are really supporting because
    States, if they don't have enough in their own State, are
    probably not prepared to fund a callback--or call capacity. So
    we are trying to make sure we have those fallback centers in
    place.
        Senator Moran. Excuse my obtuseness, but that sounds to me
    as if that is the technology of the phone call, the access to
    reaching somebody, not--that is not money to provide the
    psychologist to talk to or the mental health counselor on the
    other end of the line?
        Secretary Becerra. The technology isn't that difficult. We
    are actually working with the FCC (Federal Communications
    Commission) right now to try to make sure that those calls can
    be connected regardless of where the individual is and who the
    responder will be.
        So we are going through those technical aspects, but the
    resources are to make sure there is actually a professional, a
    health professional who will be available to answer those
    calls. Some States, as I said, are more prepared than others.
    That shouldn't be a reason why an individual who is crying out
    for help doesn't get support.
        Senator Moran. Secretary, so if a State is lax in their
    implementation of this legislation, there will be a Federal
    response to the phone call from that State?
        Secretary Becerra. Well, that is the thing. We don't--you
    all did not give us the resources or the authority to
    essentially run the whole lifeline. But what you did give us
    was the capacity to help States lift up their capacity. And so
    we are working very hard right now and for the immediate future
    to make sure that July 16, if someone calls 9-8-8, they get a
    response.
        Some States will be better prepared July 16 than others.
    The funding that we are requesting lets us get everybody up to
    speed.
        Senator Moran. I think the way I would say what you are
    saying is they get a response, and the response is more than
    someone saying, hello.
        Secretary Becerra. Yes.
        Senator Moran. It is the follow on to that.
        Secretary Becerra. So crucial. So crucial.
        Senator Moran. Okay. Thank you. I was one of the original
    sponsors of this bill. I am trying to see and figure out how--I
    guess what you are describing is that the legislation, it
    provides what you are supposed to do, and you are trying to do
    it.
        Secretary Becerra. Yes. And we can provide you with an
    update on where Kansas is because we are providing every
    Governor with an update every month of where they stand so they
    are aware of what they need to do or how well they have done.
        Senator Moran. Okay. Thank you, Madam Chairman.

                                 OPIOID CRISIS

        Senator Murray. Thank you. Secretary Becerra, I want to go
    back to a topic that Senator Shaheen mentioned, and that is
    that our communities are really being hammered by the opioid
    crisis. Just last year, more than 105,000 Americans died from a
    drug overdose. In Washington State, synthetic opioid use is up
    drastically.
        Overdose deaths are now up 66 percent since 2019, and over
    half of those are attributable to fentanyl. This is just
    unacceptable. We really need some urgent action from the
    Administration. Can you talk to us about what your plan is to
    stop the harm being caused by opioids, especially fentanyl?
        Secretary Becerra. Madam Chair, in response to some of
    Senator Blunt's questions, I mentioned that we have reorganized
    within HHS to make it a priority to address drug use and
    address the disorder that is there, especially with opioid.
        So we have come up with a different strategy where we
    forget about the stigma, we forget about the old way of doing
    it. And our strategy now not only relies on prevention and
    treatment, but on harm reduction and follow up services so that
    we don't let people regress.
        And so what we are doing right now is working with local
    communities, because we don't do it at the Federal level, we
    work with local communities, with the resources you all are
    giving us to help beef up their capacity to provide not just
    testing and treatment, but also to help them with harm
    reduction.
        Senator Murray. Well, I am especially alarmed by the rise
    in overdose deaths among adolescents. Fatal overdoses among
    youth nearly doubled in 2020 and have continued to rise since
    then, which appears to be driven by these counterfeit pills
    that are laced with fentanyl.
        Parents in my State want to know, what is the Biden
    Administration doing to protect our kids and prevent young
    people from seeking out illicit drugs and make life saving
    overdose reversal drugs more available?
        Secretary Becerra. Well, Senator, we broke through that
    ceiling that existed that prevented us from supporting local
    successful operations that, for example, let someone know if
    the drug they were about to take was laced with fentanyl.
        The bugaboo back then, the stigma was, oh, you are helping
    someone take drugs. We would rather save a life than judge that
    person who is about to take a drug because they will take the
    drug, whether we try to help them or not.
        And so today, the Federal Government will support those
    local programs that are, for example, providing fentanyl strips
    to people so they can test that drug that they may be about to
    use to find out if it is going to have a harmful----
        Senator Murray. Does that help adolescents?
        Secretary Becerra. That would help anyone who comes in and
    who has access to that service from that local provider.
        Senator Murray. And kids would seek that out?
        Secretary Becerra. Madam Chair, there is--everyone, every
    walk of life, every age as well, who is coming to some of these
    centers. And some of these kids may require some adult
    authorization in order to take certain treatments, but fentanyl
    strips are available for those who are about to inject
    themselves or use a drug that is--could likely kill them.
        Senator Murray. And kids know about this?
        Secretary Becerra. I suspect many adolescents are aware of
    some of the local anti-drug programs that are available. I
    can't tell you I know if they make use of them directly or not.
    And I can't tell you what every State has in terms of laws and
    making some of these services available to those who are
    adolescents. But I do know that those programs are made
    available to those who have drug issues.
        Senator Murray. Okay. Well, let me just change the topic a
    little bit. The pandemic, as you know, has been really hard on
    our kids and it has turned their lives upside down. They have
    lost time at school, time with their friends.
        Some have lost loved ones and they are dealing with a lot
    of stress and anxiety and trauma, and they really need our
    help. But even before the pandemic, I was hearing from parents
    who are frustrated by how hard it is to find mental health
    services for their kids.
        The President's budget would invest heavily in crisis care
    systems, which I agree are important to handle emergency
    situations and prevent tragic outcomes. But let me be clear,
    children should not have to wait until their mental health hits
    this crisis point to be able to get care. Parents are really
    desperate to get help for their children here.
        How would this budget, particularly your proposal, allowing
    States to use 10 percent of their mental health block grant
    funding for prevention and early intervention programs help
    with that?
        Secretary Becerra. Madam Chair, let me point out one
    particular program that I know you and Senator Blunt have
    worked hard on over the course of some time, and that is a
    certified community behavioral health clinics and how we are
    planning to expand access to those.
        We provide about a quarter of a billion dollars for the
    expansion of those services because we know that locally in the
    community, if a family, if a young person has access to those
    services, we get to them a lot sooner and perhaps save a life.
    And so we are going to try to expand that.
        The $51.7 billion, 10 year investment that the President is
    making in mental health services is transformative. If you all
    pass that in the President's budget, we will be able to do far
    more in reaching these families because too many, as you said,
    don't have the access they need.
        Senator Murray. Okay. Thank you very much. That will end
    our hearing today. And I want to thank my fellow committee
    members and Secretary Becerra for a very thoughtful discussion
    about how we can do more to support our communities, and keep
    people safe and healthy, and address the challenges we hear
    about from back home.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due May 13 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 Secretary Xavier Becerra\1\
                  Questions Submitted by Senator Patty Murray
        Question. The fiscal year 2023 President's Budget includes $400
    million for the Title X--Family Planning program, which provides birth
    control, cancer screening, and other lifesaving care. Unfortunately,
    HHS approved but had to turn away dozens of highly qualified applicants
    in March as a result of the flat funding in fiscal year 2022.
    ---------------------------------------------------------------------------
        \1\ Responses are current as of the date of the hearing.
    ---------------------------------------------------------------------------
        What does that mean for patients? How many women will not have
    access to life-saving healthcare services this year as a result of flat
    funding?
        Answer. Title X has not received an increase in service delivery
    funding in the annual appropriations in 8 years. In total, we received
    more than $420 million in requests for the $256 million that was
    published available, meaning that approximately $165 million in
    requests went unfunded. Due to internal budget adjustments, an
    additional $3 million was used to award grants. It means that there
    remains a high need for Title X reproductive health services needed
    across the nation.
        Question. How would HHS use the proposed increase for next year to
    expand access for women of color and low-income women?
        Answer. In fiscal year 2022, all new Title X grantees were awarded
    at a 20-40 percent reduction of their requested amount, which reduced
    the overall projected number of individuals that will be served in year
    one. In many instances, that translated to significantly less than they
    received in fiscal year 2021 because that funding has been redirected
    to cover service areas that were entirely unfunded. Also, existing
    Title X grantees that were approved in the grant review but not funded
    were awarded funds for 1 year to help them serve and transition their
    clients to other locations as they closed out their grants.
        If $400 million were allocated to the Title X program in fiscal
    year 2023, all of the Title X service grantees would be funded at their
    original requested amounts. Additionally, those Title X approved but
    not funded grantees would be fully funded for another year. As a
    result, approximately 3.5 million clients would be served.
        Question. The fiscal year 2023 President's Budget request includes
    $975 million, an increase of $130 million, for the Strategic National
    Stockpile. The request states that the SNS investments would ``make
    meaningful investments across several portfolios necessary to ensure
    readiness for future public health emergencies.'' Among such threats, I
    remain concerned about the perennial danger of another influenza
    pandemic, which infectious disease experts believe is not a matter of
    ``if'' but ``when.''
        Do you share my concern about a flu pandemic, and would you support
    the procurement of available medical countermeasures for the SNS to
    prepare for this possibility?
        Answer. The United States Government has and continues to support
    preparedness for a flu pandemic. Influenza antivirals were originally
    purchased by SNS using funds provided in 2005 under a pandemic
    influenza supplemental. SNS has worked closely with the Food and Drug
    Administration (FDA) to extend the expiration dates of many of the
    influenza antivirals held by the SNS. The most recent extension of
    expiration dates for influenza antivirals held by SNS was granted in
    April 2022.
        Question. The fiscal year 2023 President's Budget for Sexually
    Transmitted Disease (STD) prevention is funded at the same level as
    fiscal year 2022. These funds provide the bulk of the Federal dollars
    going to State departments of public health to help prevent the spread
    of STDs. Recently, the CDC has released data showing that STD rates
    continue to climb and are at a 20-year high. The COVID-19 pandemic
    likely contributed to the spread of STDs, since most of the health
    departments across the country discontinued STD fieldwork because their
    contact tracers were diverted to work on COVID-19.
        What is your plan to ensure that when the next pandemic or other
    public health crisis hits, we will have enough resources to address
    both STDs and any new maladies that may be coming down the pike?
        Answer. CDC's STD Program is utilizing the disease intervention
    specialists (DIS) Workforce American Rescue Plan Act (ARPA) funding
    (fiscal year 2021-fiscal year 2026) for COVID-19 and other infectious
    diseases to directly fund DIS hiring, retention, and support by state
    and local health departments; training and formal certification for
    DIS; and providing DIS with critical tools such as diagnostic tests for
    use in the field. CDC's STD Program will award a total of $1 billion to
    state and local health departments from fiscal year 2021-fiscal year
    2026. fiscal year 2021 and fiscal year 2022 funds ($200 million each
    fiscal year) have been awarded through a supplement to CDC's
    Strengthening STD Prevention and Control for Health Departments
    cooperative agreement, which funds all 50 states and 9 local/
    territorial health departments. These funds can be used to address the
    existing emergencies of COVID-19, STDs, and HIV, as well as emerging
    issues such as monkeypox or other public health crises.
        Question. Given the dramatic rise in STDs, why did the Department
    not ask for a more robust budget to combat STD rates?
        Answer. The Administration, the Department and CDC must assess a
    wide range of funding priorities when developing the President's Budget
    request, within constrained resources. CDC is the only Federal agency
    that directly supports and funds sexually transmitted infection
    prevention and control activities of state, territorial, and local
    health departments. STIs compromise Americans' health and cost
    billions. To address the substantial increases in the rates of STIs,
    CDC will continue to conduct STI surveillance and support states to
    conduct STI prevention and control activities (e.g. contact tracing),
    support training and educational materials for healthcare
    professionals, and studies to translate STI research to practice and to
    improve program delivery. CDC will also continue to support efforts in
    alignment with the HHS STI Federal Action Plan and continue to bridge
    implementation science, public health program management, and STI
    prevention services that are high impact, scalable, cost-effective, and
    sustainable.
        Question. 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--and the horrifying
    reality is that the vast majority of these deaths are preventable. And
    Black women, Tribal women, and women who live in rural areas are at
    much greater risk. I've been constantly pushing for more investments
    here, and it's good to see this budget does the same. But we still
    haven't managed to provide what's needed here.
        What are the gaps in care that HHS won't be able to address this
    year due to Congress' failure to fully fund your department's request.
        Answer. The fiscal year 2023 President's Budget includes $164
    million, an increase of $81 million over the fiscal year 2022 enacted
    level, for the Safe Motherhood and Infant Health Activities at CDC. The
    requested funding level included to expand the Enhancing Reviews and
    Surveillance to Eliminate Maternal Mortality (ERASE MM) Program to all
    50 states, Washington D.C., and territories for organizations
    coordinating and managing Maternal Mortality Review Committees to
    identify, review, and characterize maternal deaths and identify
    prevention opportunities. With the lower funding level in the fiscal
    year 22 omnibus, CDC will be able to fund 38 awards in 39 states which
    falls short of a national ERASE MM program.
        Wide disparities exist in maternal morbidity and mortality, with
    racial and ethnic minority women and women in rural communities at
    higher risk of pregnancy-associated death and complications. The trans-
    NIH Implementing a Maternal health and Pregnancy Outcomes Vision for
    Everyone (IMPROVE) Initiative, launched in 2020, supports research
    focused on reducing preventable causes of maternal deaths and improving
    health for women before, during, and after delivery. IMPROVE also
    focuses on health disparities and populations disproportionately
    affected (African American/Black women, American Indians/Alaska
    Natives, Asian Pacific Islanders, Hispanics/Latinas, and people with
    disabilities). One of the goals in fiscal year (FY) 2023 is to
    establish a national network of Maternal Health Research Centers of
    Excellence (COE). These COEs will conduct research to mitigate
    preventable maternal mortality, decrease severe maternal morbidity, and
    promote health equity by engaging communities, addressing health
    disparities, and including communities that are maternity health
    deserts.
        The fiscal year 2023 budget request dedicates $276 million across
    HRSA to improve maternal health; $202 million above fiscal year 2022
    enacted funding levels. This includes funding for new and existing HRSA
    programs that prioritize reducing maternal mortality and addressing the
    disparity in maternal outcomes for women of color. The initiatives aim
    to:
      --Increase access to equitable, high quality maternity care services
            for all pregnant and postpartum individuals;
      --Expand and diversify the perinatal workforce; and
      --Support strategies that impact maternal health where women live,
            learn, work, and play.
        This investment will help address gaps in care, including patient-
    centered services, care to tribal communities, and direct support to
    rural communities to respond to hospital closures and workforce
    shortages.
        Without the funding requested in the fiscal year 2023 President's
    Budget for these new or expanded programs, HRSA will be unable to
    adequately support these important efforts. These critical investments
    will help transform maternal healthcare to better meet women where they
    are with the services they need, especially women of color and those in
    underserved and rural communities, and to reduce health disparities and
    improve maternal health outcomes.
        The fiscal year 2023 budget addresses gaps in care by expanding and
    diversifying the perinatal workforce with new investments in the doula
    ($20 million) and certified nurse midwife ($25 million) workforces,
    along with funding to create a research network for minority-serving
    institutions to advance maternal health research and practice that
    focuses on addressing health disparities and equity ($10 million).
        The budget also proposes new investments to address social and
    structural determinants of health including:
      --A new program, Addressing Emerging Issues and Social Determinants
            of Maternal Health ($55 million), that will:
        --Support communities in addressing social determinants of maternal
                health for pregnant and postpartum individuals to address
                racial and ethnic disparities;
        --Expand access to behavioral health services;
        --Promote equitable access to care through digital tools; and
        --Support technology-enabled collaborative learning to build
                provider capacity to improve maternal health outcomes.
      --Increased funding for Healthy Start ($145 million, $13 million
            above fiscal year 2022 enacted) to support new programs in
            communities with the highest rates of disparities to address
            factors that contribute to disparities in poor outcomes for
            mothers and their babies, including mothers of color.
        The budget also includes a Pregnancy Medical Home Demonstration
    Project ($25 million) to support integrated healthcare services to
    pregnant women and new mothers; Implicit Bias Training Grants for
    Health Care Providers ($5 million); and a National Academy of Medicine
    Study on incorporating bias recognition in clinical skills testing ($1
    million).
        The budget proposes increases for existing programs that help
    expand access and improve quality of maternal health for women of
    color. These include the State Maternal Health Innovation Grants ($55
    million, $26 million increase from fiscal year 2022 enacted) that
    implement state specific innovative action plans to improve access to
    maternal care services and address workforce needs and the Alliance for
    Innovation on Maternal Health ($15 million, $3 million above fiscal
    year 2022 enacted) to expand the implementation of maternal safety
    bundles.
        To increase access in areas with healthcare shortages, the budget
    increases funding for Rural Maternity and Obstetrics Management
    Strategies ($10 million, $4 million above fiscal year 2022 enacted) to
    expand access to maternal and obstetrics care in rural communities. The
    budget also invests in
        Maternity Care Target Areas ($5 million, $4 million above fiscal
    year 2022 enacted) to help better identify areas in need of provider
    capacity.
        The budget expands access to behavioral healthcare for pregnant and
    postpartum women through increased investments in the Screening and
    Treatment for Maternal Depression program ($10 million proposed for
    reauthorization, $3.5 million above fiscal year 2022 enacted) and the
    Maternal Mental Health Hotline ($7 million, $3 million above fiscal
    year 2022 enacted).
        Finally, the budget also increases funding for the Maternal,
    Infant, and Early Childhood Home Visiting Program (MIECHV) ($467
    million, an increase of $67 million from the fiscal year 2022 enacted
    level of $400 million) to expand the capacity of MIECHV awardees to
    reach more women, families, and communities. Current authorization of
    the MIECHV Program is set to expire at the end of fiscal year 2022.
        The HHS Office on Women's Health initiated an $8 million nationwide
    contract with a healthcare improvement company to improve maternal
    health data and recruited 220 nationally representative hospitals to
    deploy clinical, evidence-based best practices in maternity care. The
    Maternal Morbidity and Mortality Data and Analysis Initiative builds
    upon HHS's maternal health work as outlined in the President's fiscal
    year 2021 Budget. This vital data will inform policy and validate
    evidence-based practice to improve maternal and infant health outcomes.
    OWH would have used additional funds to recruit more hospitals that
    serve Black women, Tribal women, and women who live in rural areas to
    participate in the Maternal Morbidity and Mortality Data and Analysis
    Initiative.
        Question. How will the $470 million requested in the President's
    new budget address the disparities for women of color and women who
    live in rural areas?
        Answer. The fiscal year 2023 President's Budget invests in several
    HRSA programs to address disparities for women of color and women who
    live in rural areas, including:
      --An increase to the Healthy Start program ($145 million, $13.16
            million above fiscal year 2022 enacted) to support new programs
            in communities with the highest rates of disparities, focusing
            on addressing the unique structural, environmental, and
            systemic factors that contribute to disparities in poor
            outcomes for mothers and their babies.
      --New funding to support an Addressing Emerging Issues and Social
            Determinants of Maternal Health program ($55 million) that will
            support community-based investments to improve outcomes
            particularly in areas with high rates of adverse maternal
            health outcomes and/or significant racial and ethnic
            disparities in maternal health outcomes. Efforts may focus on
            addressing social determinants of maternal health for pregnant
            and postpartum individuals; expanding access to behavioral
            health services for women; promoting equitable access to care
            through digital tools; and supporting technology-enabled
            collaborative learning to build provider capacity to improve
            maternal health outcomes.
      --A proposed $10 million in funding for minority-serving institutions
            to support research on health equity and racial disparities in
            maternal health. Institutions may use funds to promote
            diversity within the workforce and advance research into the
            field of maternal minority health to best serve their patient
            populations.
      --An increase in funding for MIECHV ($467 million, an increase of $67
            million from the fiscal year 2022 enacted level of $400
            million) would expand the capacity of MIECHV awardees to reach
            more women, families and communities. Current authorization of
            the MIECHV Program is set to expire at the end of fiscal year
            2022.
        --The MIECHV Program supports voluntary, evidence-based home
                visiting services for pregnant people and parents with
                young children up to kindergarten entry living in
                communities that face greater risks and barriers to
                achieving positive maternal and child health outcomes.
                MIECHV-funded programs currently serve 71,000 families,
                reaching only approximately 15 percent of the more than
                465,000 families who are likely eligible and in need of
                MIECHV services. With the proposed five-year funding
                increase, HRSA anticipates the MIECHV Program could provide
                home visiting services to up to 165,000 additional families
                in over 600 additional communities through targeted
                evidence-based home visiting over the course of 5 years.
        --The MIECHV Program also includes a 3 percent set-aside for grants
                to Tribal organizations to implement home visiting programs
                in American Indian and Alaska Native communities, which
                include geographically rural areas.
      --The budget also expands the Screening and Treatment for Maternal
            Depression and Related Behavioral Disorders (MDRBD) program
            ($10 million, $3.5 million above fiscal year 2022 enacted) to
            expand healthcare providers' capacity to screen, assess, treat,
            and refer pregnant and postpartum individuals for maternal
            depression and related behavioral disorders, including in rural
            areas and medically underserved areas. Current authorization of
            the MDRBD program is set to expire at the end of fiscal year
            2022.
        The fiscal year 2023 President's Budget includes $164 million, an
    increase of $81 million over the fiscal year 2022 enacted level, for
    the Safe Motherhood and Infant Health Activities at CDC. This increase
    would help optimize critical public health infrastructure, improve
    maternal health outcomes, and eliminate persistent racial/ethnic and
    geographic disparities in healthcare outcomes. Investments in state,
    local, and territorial public health infrastructure would dramatically
    improve timely and relevant clinical, non-clinical, and systems level
    data to guide implementation and evaluation of maternal and infant
    health policies and programs. In addition to expanding the ERASE MM
    Program to all 50 states, Washington D.C. and territories, the fiscal
    year 2023 President's Budget includes support for key public health
    infrastructure, including expanding Maternal Mortality Review
    Committees (MMRCs) capacity to acquire detailed and complete data on
    maternal mortality and develop recommendations for prevention. CDC is
    partnering with HHS' Office of Minority Health and others to build a
    health equity framework for maternal mortality review and prevention.
    With this proposed increase, CDC would also modernize the Pregnancy
    Risk Assessment Monitoring System (PRAMS) to test and implement
    strategies for rapid-data collection and dissemination, including
    facility-based data collections; establishing individual, facility, and
    community level data linkages); improve response rates and
    representative samples; and develop a queryable data system. PRAMS
    collects jurisdiction-specific, population-based data on maternal
    attitudes and experiences before, during, and shortly after pregnancy
    and are used to better understand emerging issues in the field of
    reproductive health. CDC would also support significant expansion of
    the Hear Her Campaign, which is an effort to prevent pregnancy-related
    deaths by sharing potentially life-saving messages about urgent warning
    signs. Finally, CDC would promote diverse and representative community
    engagement in MMRCs and Perinatal Quality Collaboratives (PQCs).
        OWH initiatives aim to address disparities and advance health
    equity for women across the life course for women of color and women
    who live in rural areas. The President's new budget will allow OWH to
    continue ongoing initiatives, such as our Breastfeeding Education and
    Promotion Campaign for African American Mothers and Families. An
    increase in the budget would also allow OWH to increase the funding
    amount for the Reducing Maternal Deaths due to Substance Use Disorder
    grant opportunity.
        Question. The President's budget includes increased funding to end
    HIV in the U.S. as well as an increased focus on PrEP for medications
    that prevent HIV. These drugs, which can be a daily oral regimen or
    now, long acting injectables, are underutilized in the communities that
    need them most, such as Black and Latino gay men, and Black women,
    particularly in the South. The budget proposes a new $9.8 billion
    mandatory spending PrEP delivery program that largely focuses on bulk
    purchasing of generic drugs.
        Please provide detail to support how HHS calculated the $9.8
    billion figure over 10 years.
        How will the $9.8 billion be allocated for different services and
    distributed to communities throughout the country? Please provide
    detail on what is needed to cover the costs of the drug, as well as
    community outreach, and provider education and training programs.
        Answer. The new mandatory Pre-Exposure Prophylaxis Delivery Program
    to End the HIV Epidemic in the United States (``PrEP Delivery
    Program'') is designed to expand access to PrEP and essential
    wraparound services for uninsured and underinsured individuals at high
    risk of HIV infections across the United States.
        This national program would create a financing and delivery system
    for PrEP. Currently, there is a patchwork of PrEP access programs for
    uninsured individuals; this comprehensive new program is a key pillar
    of the Administration's efforts to meet the commitments laid out in the
    National HIV/AIDS Strategy for the United States 2022-2025 to reduce
    HIV infections by 75 percent by 2025.
        The PrEP Delivery Program will guarantee access to PrEP at no cost;
    eliminate costs for essential associated services; and establish a
    network of providers in underserved communities that provide culturally
    and linguistically appropriate services. It will create an efficient,
    systematic approach to drug acquisition and distribution and also
    provide the critical wrap-around services that make it possible for
    individuals to successfully participate in the ongoing intervention.
        The Department will purchase PrEP medications in bulk directly from
    manufacturers, leveraging its large purchasing power to obtain the
    lowest possible price, creating a long-term, sustainable model for
    purchasing medication. The PrEP Delivery Program will expand PrEP
    access at clinical settings through on-site dispensing and lab services
    for those without healthcare coverage.
        Additionally, the PrEP Delivery Program will establish and support
    PrEP programs for state, tribal, and local public health departments,
    community-based organizations (CBOs), and healthcare facilities that
    serve the highest risk populations, such as the CDC's health department
    and CBO grantees, tribal-servicing organizations, STI clinics,
    community health centers, Title X clinics, substance use disorder
    treatment programs, mobile prevention units, homeless shelters, and
    domestic violence shelters. These organizations will administer the
    program for clients and work to implement PrEP education campaigns,
    medication support services, and provide outreach and education to
    increase utilization of PEP and PrEP among individuals at risk of HIV
    infection.
        Question. Nationwide, we're facing a child care crisis. Parents are
    struggling to find or afford child care, and too many can't get the
    early education or pre-k that would help their children thrive. At the
    same time, early educators are making poverty wages and can't make ends
    meet, and are leaving the field to get higher pay elsewhere, which is
    creating real problems in Head Start classrooms, where programs cannot
    find enough staff to fully operate.
        A cost-of-living adjustment is critical in the Head Start Program
    to allow programs to keep up with inflation, but may not adequately
    address the issues programs are having recruiting and retaining highly-
    qualified educators. How does the proposed budget address the child
    care and early educator shortages we are seeing nationwide?
        Answer. Head Start programs across the nation are facing workforce
    challenges and this instability prevents classrooms from being fully
    staffed. Low wages have been a key driver for turnover among the early
    childhood education workforce. With that in mind, the fiscal year 2023
    President's Budget includes a request for funding to provide a cost-of-
    living adjustment and allow programs to keep pace with inflation. While
    this does not help make wages to be more competitive, it does help
    preserve their real value.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        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 these emotional scars can harm the
    developing brain, change the way a child sees the world, and 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 substance use disorder--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. We have
    now secured $17 million over the past 3 years for this work. We also
    created the Interagency Task Force on Trauma-Informed Care that brings
    our Federal agencies around the table to promote trauma ``best
    practices'' in every grant program, we were pleased to secure $1
    million in fiscal year 2022 for this effort. And in fiscal year 2022,
    we provided $7 million for the first time to stand up a trauma and
    mental health support program in schools, under Project AWARE (Sec.
    7134 of the SUPPORT Act).
        Now, the 2023 budget proposes a $250 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 needed to grapple with our gun violence
    epidemic--including street outreach efforts, and trauma programming in
    schools.
        Under a program called the HEAL Initiative that I launched with the
    ten largest hospitals serving Chicago, as hospitals stitch up their
    physical wounds, they also pair victims of violence with counselors to
    address their trauma to prevent retaliations--otherwise nearly half of
    those gunshot victims would wind up back in the hospital within 5
    years. They are also improving data-sharing across hospitals and
    getting into the community to delivery violence prevention and
    intervention services.
        Secretary Becerra, can you explain how this new community-violence
    proposal can support programs like those in Chicago, and how you
    envision these various Federal trauma and violence prevention programs
    working together?
        Answer. SAMHSA leads the Interagency Task Force for Trauma-Informed
    Care. The Task Force is comprised of 21 agencies and has been
    identifying, evaluating, and making recommendations regarding best
    practices for children and families who have experienced trauma or are
    at risk of experiencing trauma and ways Federal agencies can better
    coordinate responses to families affected by substance use disorders
    and trauma. The Task Force developed a National Strategy for Trauma-
    informed Care grounded in four pillars: best practices, research, data,
    and Federal coordination. The fiscal year (FY) 2023 budget request will
    help support SAMHSA in leading the Task Force; collecting data and
    identifying and evaluating trauma-informed resources for practice;
    making recommendations to the general public and to Federal agencies
    through an Internet website; ongoing solicitation of input from
    stakeholders to inform the work; and coordinating Federal agencies in
    their integration of trauma-informed principles and interventions into
    their ongoing work.
        The ACEs work is a critical priority at CDC. People who experience
    ACEs are more likely to have physical, mental and behavioral health
    challenges, including future experiences with violence. We understand
    even more now that protective factors, including but not limited to
    growing up in communities with access to nurturing and safe childcare
    and strong partnerships with businesses, healthcare, government, and
    other sectors, help establish safe and stable environments across
    generations. Through our program Preventing ACEs: Data to Action (PACE:
    D2A), we currently fund six states to build a state-level surveillance
    infrastructure that ensures enhances the capacity to collect, analyze,
    and use ACEs data to inform ACEs prevention activities and to support
    implementation of ACEs primary prevention strategies selected from the
    best available evidence.
        CDC will continue to work to better understand both protective and
    risk factors as well as primary prevention strategies and contribute to
    the evidence base for community violence prevention work. In addition,
    there is a great need at the state and local level for resources to
    support this critical work. The fiscal year 2023 President's Budget
    includes a request for an additional $8 million in funding to further
    support states in ACEs prevention.
        The $250 million investment proposed for community violence
    intervention in the fiscal year 2023 President's Budget has been
    designed to stem the rise of violence in cities across the country
    through prioritizing evidence based-prevention strategies, research,
    and data to inform action. With these funds, CDC would support up to 75
    cities and communities disproportionately impacted by homicides to
    establish a collaborative, community driven approach to reduce
    community violence. CDC would also expand our research and evaluation
    investments to further build the evidence base for preventing violence
    in communities experiencing the greatest burden, and to reduce the
    racial, ethnic, and economic inequities that characterize such violence
    across our country.
        Hospital-community partnerships, such as the Chicago Hospital
    Engagement, Action and Leadership (HEAL) Initiative that you mentioned,
    represent one type of strategy to prevent and reduce community violence
    and could be supported under the proposed community violence
    initiative. Rigorous evaluation will be an important component of CDC's
    community-violence prevention work to help us identify the most
    effective programs for reducing community violence and re-injury.
        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 hospital-
    community partnerships, can create safer, healthier, and more resilient
    communities. For more information about these upstream approaches, we
    would recommend CDC's A Comprehensive Technical Package for the
    Prevention of Youth Violence and Associated Risk Behaviors.
        Question. Too often in our country, new moms and infants--
    especially women and babies of color--are dying from preventable health
    problems. Nationwide, more than 800 women die every year as a result of
    pregnancy--more than 70,000 others have near-fatal complications. And
    it's getting worse--we saw a 15 percent increase in maternal deaths in
    2020 compared with 2019.
        In Illinois, more than 70 women die every year due to pregnancy-
    related complications--70 percent of these deaths are preventable.
        Not only are we losing new moms, we also are losing their babies.
    Annually, more than 23,000 babies die in the U.S., many due to
    preventable factors, such as pre-term birth and low birth weight.
        I introduced a bill--the MOMMA's Act--to expand Medicaid coverage
    to new moms for a year post-partum, versus 60 days. A version of my
    bill was included in the American Rescue Plan, and Illinois was the
    first state to offer this expanded Medicaid coverage.
        How many states have now expanded their Medicaid programs for new
    moms, and how do you think this change will improve health outcomes for
    new moms and babies?
        Answer. CMS has taken a series of actions to further advance the
    safety and quality of maternal care. CMS is encouraging hospitals to
    implement evidence-based patient safety practices for managing
    obstetric emergencies along with interventions to address other key
    contributors to maternal health disparities.
        CMS encourages states to take advantage of the American Rescue
    Plan's option to provide 12 months of postpartum coverage to pregnant
    individuals who are enrolled in Medicaid or CHIP beginning April 1,
    2022. Even before this option became available, in 2021, CMS approved
    section 1115 demonstrations in Georgia, Illinois, New Jersey, and
    Virginia to extend Medicaid and CHIP postpartum coverage beyond the
    required 60-day postpartum period.
        On April 1, 2022, Louisiana became the first state to use the ARP
    option to extend Medicaid postpartum coverage to 12 months, covering an
    estimated 14,000 pregnant and postpartum individuals. Two weeks later,
    Michigan received CMS approval to extend postpartum coverage to 12
    months for an estimated 16,000 pregnant and postpartum individuals. CMS
    continues working with other state partners to extend coverage for 12
    months after pregnancy, which has also been proposed in several other
    states, including Indiana, Maine, Minnesota, New Mexico, Pennsylvania,
    West Virginia, North Carolina, South Carolina, Tennessee, Washington,
    and Connecticut, as well as the District of Columbia. As a result of
    these efforts, as many as 720,000 pregnant and postpartum individuals
    across the United States, annually, could be guaranteed Medicaid and
    CHIP coverage for 12 months after pregnancy.
        Question. A large majority of Americans take dietary supplements
    daily--from calcium chews, to multi-vitamins, to fish oil. Yet, there
    is very little oversight or transparency into these products--we do not
    even know how many supplements are on the market today, with guesses
    ranging anywhere from 50,000 to 80,000.
        We don't know because FDA doesn't currently have the authority to
    require dietary supplement companies to register their products, nor
    are they required to submit ingredient lists, allergen statements,
    health claims, or even the copies of the labels for these products.
        Senator Braun and I introduced the bipartisan Dietary Supplement
    Listing Act to change all of that. Our bill--which is supported by
    dietary supplement companies, as well as consumer and physician
    groups--would require companies to provide basic, vital information
    about their products.
        Mandatory listing of dietary supplements was a new authority that
    President Biden--and President Trump--requested in their budgets. Can
    you tell the Committee why you think this issue is so important?
        Answer. The dietary supplement industry has grown ten times the
    size it was when the Dietary Supplement Health and Education Act
    (DSHEA) was enacted in 1994. Under DSHEA, FDA does not approve dietary
    supplement products, and generally does not review and approve label
    claims before dietary supplements are introduced to consumers. As a
    result, FDA has no systematic way to know when new dietary supplements
    are introduced or what they contain; therefore dangerous and otherwise
    unlawful products that contain undeclared or otherwise improper
    ingredients continue to be marketed.
        The fiscal year 2023 President's Budget includes a legislative
    proposal--similar to proposals offered in other recent budgets--for a
    mandatory listing requirement for dietary supplements. Under this
    proposal, FDA is seeking to modernize DSHEA to strengthen and clarify
    FDA's authorities relating to products marketed as ``dietary
    supplements.'' These new authorities would allow FDA to know when new
    products are introduced and enhance FDA's ability to quickly identify
    and act more effectively against dangerous or otherwise illegal
    products.
        Question. Last year, the President signed into law the Accelerating
    Access to Critical Therapies for ALS Act (ACT for ALS)--legislation
    spear-headed by Senators Coons and Murkowski. I was pleased to
    cosponsor this important legislation, which will fund essential
    research into fast-progressing terminal diseases like ALS, and expand
    access to promising investigational new therapies.
        This issue is personal to me. My friend, and constituent, Brian
    Wallach is a 41-year-old man living with ALS. He, and his wife Sandra,
    took Brian's terminal diagnosis and turned it into hope-- starting I Am
    ALS, an organization that advocates for real, tangible results in the
    fight against ALS.
        Secretary Becerra, last year, you joined a Zoom with Brian and
    Sandra to celebrate ACT for ALS becoming law. Can you talk about the
    importance of engagement, input, and collaboration from the ALS patient
    leadership community as HHS, NIH, and FDA work to urgently implement
    this law?
        Answer. The National Institutes of Health (NIH) agrees that
    engagement, input, and collaboration with the ALS community will be
    crucial for implementing the law. To that end, the U.S. Food and Drug
    Administration (FDA) and NIH held a listening session with leaders in
    the patient community on March 25 to discuss Access to Critical
    Therapies (ACT) for ALS implementation. Additionally, NIH plans to
    include people affected by ALS on the review panel for expanded access
    grant applications, and the request for applications for this program
    strongly encourages applicants to establish relationships with patient
    groups and solicit their input on recruitment, the clinical
    meaningfulness of the question under study, the relevance of the
    proposed clinical outcomes, and approaches to minimizing the burden on
    study participants.
        Question. Please also clarify what resources you need from Congress
    to get this law implemented quickly and efficiently.
        Answer. Fiscal Year (FY) 2022 appropriations for NIH included $25
    million for ACT for ALS implementation. These funds should be
    sufficient for NIH to support the expanded access grant program in
    section 2 of ACT for ALS for fiscal year 2022 and to initiate the
    Public Private Partnership in section 3 of the statute this fiscal
    year.
        Question. Secretary Becerra, the budget proposes $848 billion for
    Medicare. One of the greatest drivers of outlays by the Medicare
    program is the cost of chronic conditions. By some estimates, 10
    percent of Medicare spending is attributable to smoking and its health
    harms. So it would seem that the Department would want to be doing
    everything it can to prevent tobacco use, especially among youth.
        While I was pleased to see FDA finally act to ban menthol
    cigarettes and all flavors in cigars, I remain concerned that JUUL e-
    cigarette products--which fueled the youth vaping epidemic in our
    country--remain on the market EIGHT months past a court- ordered
    deadline for FDA to act.
        For years, FDA refused to act in the face of mounting evidence that
    millions of children were becoming addicted to nicotine because of
    JUUL--or JUUL knock-off--products. Mango, cool mint, fruit medley--
    these were the flavors JUUL used to hook our children. And, today,
    despite millions of other products being ordered off the market, JUUL
    remains on store shelves--despite not having authorization from FDA.
        One could argue that the FDA's actions to regulate virtually every
    vaping product except for JUUL is tantamount to clearing the market so
    that JUUL can sell its products without competition. In fact, these
    products are only on the market today because FDA is exercising
    enforcement discretion. They can and should take JUUL off the market
    TODAY.
        Secretary Becerra, why is the FDA now 8 months past the court
    order?
        Answer. FDA's review of premarket tobacco product applications
    (PMTAs) for electronic nicotine delivery systems (ENDS) continues to be
    a high priority for the Department of Health and Human Services and for
    FDA, and FDA is committed to completing its review of premarket
    applications as soon as possible. FDA has made significant progress on
    the entire body of submissions, taking action on 99 percent of the
    applications for about 6.7 million products received by the September
    9, 2020 deadline. As the Agency has described publicly, FDA has
    dedicated resources to the review of applications from companies whose
    products account for the largest share of the ENDS market, including
    JUUL. These PMTAs tend to be voluminous and complex and have required
    additional review time. The Agency has issued decisions for products
    from four of the five brands that held more than 95 percent of the ENDS
    market in the summer of 2020, when applications were due. But we have
    more work to do, including completing review of all of the applications
    from the larger market share companies. FDA continues to work
    expeditiously on the remaining applications and is issuing decisions on
    a rolling basis. The Department and FDA continue to work steadfastly to
    transform the ENDS market to one where all products have undergone
    thorough scientific review.
        Question. Because we are 8 months past the September 9th court-
    permitted window, all e-cigarettes that have not been authorized yet
    remain on the market currently are only allowed to do so because of
    FDA's enforcement discretion. Why not restore the statutory burden of
    proof as envisioned in the Tobacco Control Act for manufacturers to
    prove to FDA that their products are appropriate for the protection of
    public health, by removing all yet-unauthorized products from the
    market UNTIL their PMTAs are adjudicated?
        Answer. All new tobacco products on the market without the
    statutorily required marketing authorization are marketed unlawfully
    and are subject to enforcement by FDA. FDA continues to make
    enforcement decisions on a case-by-case basis according to its
    enforcement priorities and individual circumstances.
        FDA is committed to working as quickly as possible to transition
    the current marketplace for deemed new tobacco products to one in which
    all products available for sale have undergone a careful, science-based
    review by FDA and met the statutory standard. It is imperative that we
    get it right.
        It is also important to note that FDA does not possess independent
    litigation authority. FDA works closely with the Department of Justice
    (DOJ), without whose support neither injunctive actions nor seizures
    can occur. FDA regularly consults DOJ with respect to potential
    enforcement actions, including in relation to unauthorized tobacco
    products that are the subject of pending applications. Although the
    Agency does not discuss the substance of its internal deliberations
    with the dedicated attorneys at DOJ, their legal analysis and expert
    legal judgment greatly inform FDA's enforcement decisionmaking.
        Question. Do you believe that JUUL products--which have been proven
    to hook kids on nicotine--benefit the public health?
        Answer. At this time, FDA has not authorized any JUUL tobacco
    products for marketing.
        As you know, premarket tobacco product applications (PMTAs) must
    provide scientific data to FDA that demonstrate that permitting the
    product to be marketed would be appropriate for the protection of the
    public health (APPH). As set forth in Section 910(c)(4) of the Federal
    Food, Drug, and Cosmetic Act, the finding as to whether the marketing
    of each tobacco product for which an application has been submitted is
    APPH shall be determined with respect to the risks and benefits to the
    population as a whole, including users and nonusers of the tobacco
    product.
        FDA continues to work expeditiously on the remaining PMTA
    applications and is issuing decisions on a rolling basis. We will keep
    your office apprised of any updates and would be happy to offer
    briefing or discussion as those decisions are made.
        Question. I recently met with the Illinois Health and Hospital
    Association, who shared that their top concern is workforce shortages.
    But this is not a new problem caused by the pandemic. Even before
    COVID, our nation faced a shortfall of 120,000 doctors and a quarter-
    million nurses.
        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
    averaging 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. And less than 10 percent of doctors are Black
    or Latino, which can lead 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 Corps.
        It will help surge tens of thousands of new clinicians into under-
    served areas, and already has built the healthcare pipeline by
    quadrupling the number of scholarship recipients.
        Secretary Becerra, your budget proposes a significant increase to
    the National Health Service Corps. Can you talk about the importance of
    this program in addressing our workforce needs, our preparedness, and
    health disparities?
        Answer. For the past 50 years, the National Health Service Corps
    (NHSC) has been a dedicated resource for building healthy communities
    by mobilizing a primary care workforce to serve in the nation's high-
    need areas. The NHSC does this by providing scholarships and loan
    repayment for clinicians who commit to practice in underserved
    communities. NHSC-approved sites provide care to individuals regardless
    of their ability to pay. Currently, there are approximately 20,000
    medical, dental, and behavioral healthcare clinicians, the largest
    cohort ever, providing quality care to more than 21 million Americans
    in rural, urban, and tribal communities. The increase to the number of
    clinicians providing care is the result of the $800 million
    appropriated for the NHSC in American Rescue Plan (ARP) Act in fiscal
    year 2021, $700 million of which is for the NHSC Scholarship Program
    (SP), Loan Repayment Programs (LRPs), and Students to Service (S2S).
    These funds enabled the NHSC to award all qualified applicants; the
    remainder of these funds will be fully obligated in fiscal year 2022.
        In recent years, the NHSC has demonstrated the ability to be agile
    and address the emerging heath needs across the U.S. States and
    Territories. This includes, but is not limited to, supporting a
    workforce dedicated to addressing the Zika epidemic (2016), combatting
    the nation's substance use disorder crisis (2018-present), and
    expanding access to care during the height of the COVID-19 pandemic
    (2021-present). Further, NHSC appropriations have been dedicated to
    deliver healthcare services in Indian Health Service facilities,
    Tribally-Operated 638 Health Programs, and Urban Indian Health Programs
    (ITUs). With this directed funding, the NHSC has awarded all eligible
    clinicians serving in ITUs who applied to the NHSC Loan Repayment
    Programs (LRPs).
        Through the NHSC Substance Use Disorder (SUD) Workforce loan
    repayment program and Rural Community loan repayment program, HRSA is
    working to support the SUD workforce needs of underserved communities
    by helping to recruit and retain health professionals to improve access
    to quality opioid and evidence-based SUD treatment in rural and
    underserved areas nationwide, and to prevent overdose deaths. As of
    September 30, 2021, there are more than 44,000 clinicians in the NHSC
    providing substance use disorder treatment.
        Additionally, ensuring greater racial and ethnic diversity of the
    healthcare workforce is essential for increasing access to culturally
    competent care for all patients, improving opportunities and
    representation of all groups within the health professions, and meeting
    the overall needs of our diverse population, particularly in the most
    underserved areas.\2\ Many racial and ethnic minority groups are
    underrepresented nationally within the major health professions,\3\ and
    the share of racial and ethnic minority NHSC providers exceeded their
    share in the national workforce:
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        \2\ Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the
    healthcare workforce. Health Aff (Millwood). 2002 Sep-Oct; 21(5): 90-
    102 (http://content.healthaffairs.org/content/21/5/90.full).
        \3\ U.S. Department of Health and Human Services, Health Resources
    and Services Administration, National Center for Health Workforce
    Analysis. Sex, Race, and Ethnic Diversity of U.S. Health Occupations
    (2010-2012), Rockville, Maryland; 2014 (https://bhw.hrsa.gov/sites/
    default/files/bhw/nchwa/diversityushealthoccupations.pdf).
    ---------------------------------------------------------------------------
    Primary Care
      --Black or African American physicians represented 14.9 percent of
            the NHSC LRP and Scholarship Program (SP) participants,
            exceeding their 5.0 percent share in the national physician
            workforce.\4\
    ---------------------------------------------------------------------------
        \4\ Association of American Medical Colleges, Diversity in
    Medicine: Facts and Figures, 2019. (https://www.aamc.org/data-reports/
    workforce/interactive-data/figure-18-percentage-all-active-physicians-
    race/ethnicity-2018).
    ---------------------------------------------------------------------------
      --Hispanic or Latino physicians represented 12.9 percent of the NHSC
            LRP and SP participants, exceeding their 5.8 percent share in
            the national physician workforce.\5\
    ---------------------------------------------------------------------------
        \5\ Ibid.
    ---------------------------------------------------------------------------
      --American Indian and Alaska Native physicians represented 1.6
            percent of the NHSC LRP and SP participants, exceeding their
            0.3 percent share in the national physician workforce.\6\
    ---------------------------------------------------------------------------
        \6\ Ibid.
    ---------------------------------------------------------------------------
      --Black or African American nurse practitioners represented 15.7
            percent of the NHSC LRP and SP participants, exceeding their
            9.1 percent share in the national healthcare workforce averages
            of nurse practitioners.\7\
    ---------------------------------------------------------------------------
        \7\ U.S. Department of Labor, Bureau of Labor Statistics Labor
    Force Characteristics by Race and Ethnicity, 2020, November 2021,
    Report 1095.
    ---------------------------------------------------------------------------
      --Hispanic or Latino nurse practitioners represented 9.1 percent of
            the NHSC LRP and SP participants, exceeding their 6.3 percent
            share in national healthcare workforce averages of nurse
            practitioners.\8\
    ---------------------------------------------------------------------------
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Mental and Behavioral Health
      --Asian health services psychologists represented 5.8 percent of the
            NHSC LRP participants, exceeding their 4.1 percent share in the
            national healthcare workforce averages of health services
            psychologists.\9\
    ---------------------------------------------------------------------------
        \9\ Ibid.
    ---------------------------------------------------------------------------
      --Hispanic or Latino health services psychologists represented 20
            percent of the NHSC LRP participants, exceeding their 3.5
            percent share in the national healthcare workforce averages of
            health services psychologists.\10\
    ---------------------------------------------------------------------------
        \10\ Ibid.
    ---------------------------------------------------------------------------
    Oral Health
      --Black or African American dentists represented 13 percent of the
            NHSC LRP and SP participants, exceeding their 1.4 percent share
            in the national healthcare workforce averages of dentists.\11\
    ---------------------------------------------------------------------------
        \11\ Ibid.
    ---------------------------------------------------------------------------
      --Hispanic or Latino dental hygienists represented 20 percent of the
            NHSC LRP participants, exceeding their 10.5 percent share in
            the national healthcare workforce averages of dental
            hygienists.\12\
    ---------------------------------------------------------------------------
        \12\ Ibid.
    ---------------------------------------------------------------------------
        Based on self-reports of the 2,523 NHSC scholars (i.e., those in
    school, pursuing post-graduate training, or awaiting placement in an
    NHSC-approved service site), 22 percent are Black or African American,
    16.8 percent are Asian or Pacific Islander, 2.3 percent are American
    Indian or Alaska Native, and 14.1 percent of NHSC scholars self-
    reported as Hispanic or Latino. Black or African American NHSC scholars
    exceeded national student enrollment averages in dentistry, medicine,
    physician assistant, and nursing disciplines.\13\ Hispanic or Latino
    NHSC scholars exceeded student enrollment averages in dentistry,
    representing 15.7 percent of the Corps' dental participants, compared
    to their 9.0 percent share of the national student enrollment.\14\
    American Indian and Alaska Native NHSC scholars exceed national student
    enrollment averages in dentistry, medicine, physician assistant, and
    nursing disciplines.\15\
    ---------------------------------------------------------------------------
        \13\ American Dental Association, 2018-2019 Survey on Dental
    Education: Academic Programs, Enrollments, and Graduates. Association
    of American Medical Colleges Total U.S. Medical School Enrollment,
    2020-2021. American Association of Colleges of Nursing, 2021. 35th
    Physician Assistant Education Association Annual Report, 2019.
        \14\ Ibid.
        \15\ Ibid.
    ---------------------------------------------------------------------------
                                     ______

                  Questions Submitted by Senator Brian Schatz
        Question. I am concerned we are facing a cliff for digital health
    when the public health emergency ends. Last month you said that when it
    comes to telehealth we cannot let the ``old way of business get in the
    way''. I agree, and so do 61 of my colleagues who have cosponsored my
    CONNECT for Health Act. HHS's current authority to expand Medicare's
    coverage of telehealth expires 151 days after the public health
    emergency ends. Unless Congress acts to ensure permanent expansion of
    Medicare coverage authorities, we will go back to the dark ages with
    very limited access to telehealth. During the pandemic, you also waived
    requirements for other communication technology-based services that CMS
    could amend without additional authorities needed from Congress.
    Finally, CMS provided robust guidance to states to increase access to
    telehealth for individuals in Medicaid and CHIP during the pandemic.
        What are the factors you are considering for when this public
    health emergency could be declared over?
        What is CMS's plan regarding the pandemic flexibilities granted for
    communication technology-based services, such as remote physiologic
    monitoring, remote therapeutic monitoring, and virtual check-ins?
        How is HHS continuing your work with states beyond the public
    health emergency to ensure that individuals enrolled in Medicaid and
    CHIP have the same access to telehealth services as those with
    commercial insurance?
        Answer. During the COVID-19 public health emergency, telehealth has
    been a reliable resource, allowing healthcare providers to reach
    patients directly in their homes to ensure access to care and
    continuity of services. The Biden-Harris Administration is committed to
    supporting a temporary extension of broader telehealth access under
    Medicare beyond the declared COVID-19 Public Health Emergency (PHE) in
    order to study its impact on utilization of services and access to
    care. Telehealth, including audio-only telehealth, can greatly expand
    access to services for individuals who may not have access to broadband
    or technology to support 2-way audio-video. This is particularly true
    in rural and underserved areas, and among older populations.
        The Administration is also expanding access to mental health and
    beneficiary-centered care under Medicare through greater use of
    telehealth and other telecommunications technologies to provide
    behavioral healthcare, among other services. Medicare beneficiaries can
    access care directly in their homes thanks to recent statutory
    amendments (CAA, 2021), and using audio-only technology where
    appropriate based on the patient's needs thanks to changes in
    regulations, including in CMS's CY 2022 Physician Fee Schedule (PFS)
    final rule, that allow payment for certain behavioral health services
    via audio-only telephone calls.
        In addition, the President's fiscal year 2023 Budget includes a
    proposal to remove statutory limits on the list of practitioners that
    are authorized to receive direct Medicare payment for their mental
    health services, which would expand access to mental health services in
    Medicare, especially in rural and underserved areas with fewer mental
    health professionals or in communities more likely to receive care from
    the referenced practitioners.
        CMS has released numerous resources to help states identify
    opportunities for increasing the use of telehealth services within
    Medicaid and CHIP. For example, CMS developed Medicaid & CHIP
    Telehealth toolkit to help states accelerate adoption of broader
    telehealth coverage policies in Medicaid and CHIP during the COVID-19
    PHE. This toolkit provides states with statutory and regulatory
    infrastructure issues to consider as they evaluate the need to expand
    their telehealth capabilities and coverage policies. The toolkit also
    includes a compilation of frequently asked questions and other
    resources available to states. CMS also released a supplement to the
    toolkit to provide additional support to state Medicaid and CHIP
    agencies in their adoption and implementation of telehealth as they
    begin to plan beyond PHE flexibilities. States may use this
    supplemental toolkit to help think through how they will explain and
    clarify which policies are temporary or permanent, when flexibilities
    will expire, which services can be accessed through telehealth, which
    providers may deliver those services, the modality they may use to
    deliver telehealth services, and the circumstances under which
    telehealth can be reimbursed. Several state profiles are included in
    this toolkit.
        Question. Healthcare workforce shortages are at critical levels in
    many parts of the country. In addition to workforce training and
    retention programs, state licensure portability can be an important
    strategy to increase access to care. As states have begun rescinding
    licensure waivers, providers are confronting a state patchwork that
    impacts some from effectively practicing across state lines.
        Keeping patient safety in mind, what authority do you need to
    enhance licensure portability and reciprocity and address regulatory
    restrictions for providers?
        Answer. HRSA's Office for the Advancement of Telehealth supports
    the Licensure Portability Grant Program under the authority of Section
    330L of the Public Health Service Act. States establish their licensure
    requirements for healthcare providers. However, the Licensure
    Portability Grant Program assists providers with cross-state licensure
    by providing funding to work with state licensure boards to create
    multi-state licensure compacts. Through this program, HRSA provides
    support to the Federation of State Medical Boards (FSMB) and the
    Association of State and Provincial Psychology Boards (ASPPB). The FSMB
    created the Interstate Medical Licensure Compact (IMLC), which offers a
    voluntary, expedited pathway to licensure for qualified physicians to
    practice in multiple states, including physicians participating in
    Medicare and Medicaid. The ASPPB created the Psychology
    Interjurisdictional Compact (PSYPACT) to facilitate telehealth and
    temporary in-person, face-to-face practice of psychology across
    jurisdictional boundaries.
        Question. Please list and describe the state policies that HHS
    helped to enact and/or implement through its Licensure Portability
    Program.
        Answer. The purpose of the Licensure Portability Grant Program is
    to provide support for state professional licensing boards to carry out
    programs under which licensing boards of various states cooperate to
    develop and implement state laws and related policies that will reduce
    statutory and regulatory barriers to telemedicine, such as creating
    multi-state licensure compacts. Since states establish their licensure
    requirements, HHS does not have the authority to change state policies.
        Question. What resources would be needed to ramp up HHS's efforts
    to support state licensure portability?
        Answer. The two grantees supported through the Licensure
    Portability Program, the FSMB and ASPPB, have developed several tools
    to facilitate access to inter-state telehealth services. These include
    the Interstate Medical Licensure Compact (36 states, Guam, and the
    District of Columbia), the Provider Bridge (www.ProviderBridge.org),
    the Psychology Inter- jurisdictional Compact, also known as PSYPACT (33
    states), and the Licensure Project (www.LicensureProject.org).
    Together, these tools support a range of clinicians, including
    physicians, physician assistants, nurses, occupational therapists,
    physical therapists, psychologists, and social workers. Resources could
    be used to continue the use of tools such as www.ProviderBridge.org and
    www.LicensureProject.org, expand on efforts to get more states to join
    the compacts, and support new grantees through the Licensure
    Portability Program, which would expand the types of healthcare
    disciplines that are included in the Licensure Portability Program.
        HHS is committed to continuing to work within the confines of the
    law to strengthen the healthcare workforce and connect skilled
    providers with communities in need including through the use of
    telehealth. Medicare defers to state law with regard to licensure
    issues.
        Question. Remote patient monitoring (RPM) allows providers to track
    patients' health metrics and empowers individuals to effectively manage
    their conditions at home. These tools can improve access to care and
    health outcomes. Through its Physician Fee Schedule rulemaking, CMS has
    eliminated some barriers to coverage and payment for RPM services.
    However, some policies may not adequately address the 77 percent of
    older adults with at least two chronic conditions who are
    disproportionately low-income and from minority communities, and could
    benefit from multiple technologies.
        How is HHS enabling the use of technology, such as remote
    physiologic monitoring and remote therapeutic monitoring, for Medicare
    beneficiaries who have comorbid chronic health conditions, e.g.,
    diabetes, hypertension, obesity, depression?
        Answer. CMS is committed to ensuring our beneficiaries receive
    high-quality, coordinated care that helps them manage their health.
    Care coordination and tools such as telehealth and other virtual
    services can be particularly beneficial for those with one or more
    chronic health conditions. The COVID-19 public health emergency (PHE)
    has highlighted that telehealth and other communications technologies
    can be a reliable resource that allows healthcare providers to reach
    patients directly in their homes in order to ensure access to care and
    continuity of services.
        In recent years, we have engaged in efforts to update and improve
    care management and coordination services within the physician fee
    schedule including chronic care management services, which involve
    patients with at least two chronic conditions. We also established
    payment for remote therapeutic monitoring services which can be used to
    monitor a variety of chronic and acute health conditions.
        The Biden-Harris Administration is also committed to supporting a
    temporary extension of broader telehealth access under Medicare beyond
    the COVID-19 Public Health Emergency declaration in order to study its
    impact on utilization of services and access to care. Telehealth,
    including audio-only telehealth, can greatly increase access to
    services for individuals who may not have sufficient bandwidth or
    technology to support 2-way audio-video, particularly in underserved
    areas and among older populations.
        Question. The Native Hawaiian Health Care Improvement Act (NHHCIA)
    was enacted in furtherance of the Federal trust responsibility of the
    U.S. government to provide resources to raise the health status of
    Native Hawaiians. By statute, Papa Ola Lokahi is identified as the
    single administrative entity responsible for carrying out specific
    functions. In this capacity, Papa Ola Lokahi must utilize its community
    expertise to administer the program and work with the five mandated
    Native Hawaiian healthcare systems to ensure delivery of culturally
    appropriate care that improves the health status of Native Hawaiians.
    The NHHCIA does not list among the Secretary's responsibilities the
    role of identifying a grantee through a competitive application or
    evaluation process. Instead, the Secretary is obligated to execute a
    grant or contract with Papa Ola Lokahi and to evaluate its performance.
        How is HHS applying its special obligations under Federal trust
    responsibility to administer the NHHCIA grants?
        Answer. In fiscal year 2021, HRSA released a Notice of Funding
    Opportunity to make available appropriated funding authorized by the
    Native Hawaiian Health Care Improvement Act for a service grant to Papa
    Ola Lokahi for activities described in the NHHCIA, including
    coordination of healthcare programs and services provided to Native
    Hawaiians, and service grants to 5 certified community-based Native
    Hawaiian Health Care Systems (NHHCS) to provide a full range of
    services identified by the legislation and tailored to fit the needs of
    their respective island communities.
        Question. How is HHS applying culturally appropriate standards
    aligned with the specific goals of the NHHCIA to hold Papa Ola Lokahi
    and the Native Hawaiian healthcare systems accountable for raising the
    health status of Native Hawaiians?
        Answer. The most recent Notice of Funding Opportunity (NOFO)
    identifies that funding is intended to improve the provision of
    comprehensive disease prevention, health promotion, and primary
    healthcare services for Native Hawaiians. The requirements outlined in
    the NOFO hold Papa Ola Lokahi and the Native Hawaiian healthcare
    systems accountable for reporting the following: progress towards goals
    that align with the NHHCIA, strategies used to overcome challenges
    encountered in meeting those goals, and changes in the needs of the
    target population and service area. Clinical quality measures focus on
    progress made by NHHCS towards health needs pertinent to the target
    population and are aligned with standardized measures in HRSA's Uniform
    Data System for the Health Center Program. HRSA monitors POL and the
    five NHHCS through annual progress reports, regular monitoring calls,
    the annual submission of performance data, as well as operational site
    visits. HRSA continues to ensure that this oversight is culturally
    appropriate.
        Question. How is HRSA collaborating with and leveraging the Indian
    Health Service's expertise in the Federal trust relationship to
    administer the NHHCIA and evaluate grant performance?
        Answer. HRSA collaborates with IHS on reporting data methods and
    effective community engagement. HRSA also continues to explore new ways
    to improve the administration and evaluation of this grant funding.
        Question. If the final Supreme Court decision for Dobbs v. Jackson
    Women's Health Organization results in the same legal decision as the
    leaked draft opinion, Americans will lose their constitutional abortion
    rights protections. After Texas passed its six-week abortion ban,
    President Biden stated his administration would take a ``whole-of-
    government approach'' to abortion rights. During your opening testimony
    you noted HHS would ``double down on our authorities''. I appreciate
    this commitment, and greater action is needed by HHS to meet this
    moment. In a major step last December, the FDA revised its Risk and
    Evaluation Mitigation Strategy (REMS) for mifepristone, removing the
    in-person dispensing requirement. This decision was consistent with the
    legal action Dr. Graham Chelius of Kauai took against HHS when he
    recognized that his patients had to fly to Oahu to obtain a drug safer
    than Tylenol or Viagra. While I applaud FDA for its revised REMS, I am
    concerned that it retained unnecessary requirements.
        What is FDA's rationale for maintaining its Patient Agreement Form
    requirement when in 2016, FDA staff recommended removal of this
    requirement stating it is duplicative of information and counseling
    provided to patients under standard informed consent practices and
    professional guidelines?
        Answer. As part of FDA's 2021 review of the Mifepristone REMS
    Program, which involved a detailed analysis of a significant amount of
    data, FDA concluded that the Patient Agreement Form remains necessary
    to assure the safe use of mifepristone for medical termination of early
    pregnancy. This form documents that the prescriber has counseled the
    patient on the use of mifepristone, what the serious risks are, and
    what to do if the patient experiences an adverse event. FDA's review of
    the published literature suggests that the removal of the in-person
    dispensing requirement may result in an increase in the number of
    providers becoming certified prescribers. The Patient Agreement Form is
    an important part of standardizing the medication information on the
    use of mifepristone that prescribers communicate to their patients, and
    provides the information in a brief and highly understandable format.
        Question. FDA justifies mifepristone's provider certification
    requirement by noting medical professionals' lack of familiarity and
    experience with medication abortion. Simultaneously, it is within your
    authority to strengthen the workforce and increase training for
    providers. What is HHS's plan to increase the number of providers with
    the necessary skills to deliver appropriate care?
        Answer. Last January, the Secretary launched an HHS-wide Task Force
    on Reproductive Healthcare Access to protect and bolster access to
    sexual and reproductive healthcare. This includes looking to ways to
    expand access to safe and legal abortion care, permissible under the
    law, and includes working to increase information and engagement with
    patients and providers to help ensure care. We are continuing to
    evaluate and look at our authorities and programs and services and will
    continue to keep you apprised of our thinking on this critical issue.
        Question. Is FDA considering modifying its REMS for mifepristone,
    including its requirement that drug manufacturers must certify
    prescribing clinicians and pharmacists, and the rule that patients must
    sign an agreement that they understand drug risks?
        Answer. To determine whether a modification to the Mifepristone
    REMS Program is warranted, in 2021 FDA conducted a comprehensive review
    of the published literature, other relevant safety data (including
    adverse event data), and information provided by advocacy groups,
    individuals, and the applicants. Based on this review, FDA concluded
    that mifepristone will remain safe and effective for medical
    termination of early pregnancy if the in-person dispensing requirement
    is removed, provided all the other requirements of the REMS are met,
    and pharmacy certification is added.
        Accordingly, on December 16, 2021, FDA sent REMS Modification
    Notification letters to the applicants, notifying them that a
    modification is necessary and must include removal of the in- person
    dispensing requirement and the addition of pharmacy certification.
    Following receipt of these letters, the applicants prepare proposed
    REMS modifications and submit them to FDA. Once those submissions are
    approved, the REMS modifications will be effective.
        Question. Is the administration considering challenging state laws
    that contradict the mifepristone REMS?
        Answer. Last January, the Secretary launched an HHS-wide Task Force
    on Reproductive Healthcare Access to protect and bolster access to
    sexual and reproductive healthcare. This includes looking to ways to
    expand access to safe and legal abortion care, permissible under the
    law, and includes working to increase information and engagement with
    patients and providers to help ensure care. We are continuing to
    evaluate and look at our authorities and programs and services and will
    continue to keep you apprised of our thinking on this critical issue.
        Question. Does HHS have a plan to increase awareness of medication
    abortion--including its safety and efficacy--particularly among
    communities whose access to care is limited? Can you please describe
    this plan? What resources are needed to execute?
        Answer. Last January, the Secretary launched an HHS-wide Task Force
    on Reproductive Healthcare Access to protect and bolster access to
    sexual and reproductive healthcare. This includes looking to ways to
    expand access to safe and legal abortion care, permissible under the
    law, and includes working to increase information and engagement with
    patients and providers to help ensure care. We are continuing to
    evaluate and look at our authorities and programs and services and will
    continue to keep you apprised of our thinking on this critical issue
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. One of the most pressing issues West Virginia faces is
    shortages across the healthcare sector. Nurses, specialists, you name
    it, we likely don't have enough of them. As we continue to address the
    COVID-19 pandemic, hospital capacity remains a big issue, especially in
    rural areas of the state that already faced significant access to care
    issues. In West Virginia, there are about 7,000 licensed hospital beds,
    but only enough staff to operate 5,000 of them. That is why Senator
    Manchin pushed to include $8.5 billion in the American Rescue Plan
    specifically to assist rural healthcare providers, including with
    staffing expenses.
        What can the Department do to help ensure places like West Virginia
    can offer healthcare professionals the resources and tools they need to
    continue providing care?
        Answer. HRSA is focused on workforce needs in rural areas generally
    and hospital capacity in rural areas specifically. In fiscal year 2022,
    HRSA will be awarding new programs under the Public Health Workforce
    Training Network Program to expand the public health capacity by
    supporting healthcare job development to help to address workforce
    shortages in rural areas. Additionally, several of HRSA's rural
    community-based programs offer non-categorical funding that allows
    applicants to propose and build a program in response to an area of
    need. HRSA has funded many programs that focus on workforce development
    through the Rural Health Network Development, Rural Health Care
    Coordination, Rural Health Care Services Outreach, and Delta States
    Rural Development Network grant programs. The fiscal year 2023
    President's Budget also supports a new pilot program to enable Rural
    Health Clinics (RHCs) to strengthen their workforce and bring critical
    services to rural communities. The request will fund approximately 18
    Rural Health Clinics.
        HRSA supports education and training to West Virginians through
    grant programs focusing on training primary care providers, nurses,
    preventive medicine and addiction specialist physicians, and physician
    assistants. These healthcare providers are training in hospitals and
    community-based organizations to provide care to rural and medically
    underserved communities. In addition, trainings support community-based
    collaboration, technology, medically underserved communities, oral
    health, minority health, geriatric health, behavioral health focused on
    substance use disorder and primary care integration. Course delivery
    modes include: classroom-based, self-paced distance learning, real-
    time/live distance learning, online webinars, and hybrid trainings with
    workshops and clinical rotations.
        HRSA will continue to provide resources and tools to assist the
    heath care workforce provide quality care. Demonstrated efforts are
    shown through the following grant programs:
      --The National Health Service Corps (NHSC) increases access to care
            in underserved areas by supporting qualified healthcare
            providers dedicated to working in underserved communities. The
            NHSC received supplemental funds through the American Rescue
            Plan Act to support the nation's COVID-19 response and to help
            address primary care provider need. In fiscal year 2021, there
            were 242 NHSC clinicians serving in West Virginia.\16,17\
    ---------------------------------------------------------------------------
        \16\ Bureau of Health Workforce Clinician dashboards. (n.d.).
    Retrieved June 9, 2022, from https://data.hrsa.gov/topics/health-
    workforce/clinician-dashboards.
        \17\ Bureau of Health Workforce Clinician dashboards. (n.d.).
    Retrieved June 9, 2022, from https://data.hrsa.gov/topics/health-
    workforce/clinician-dashboards.
    ---------------------------------------------------------------------------
      --The Primary Care Training and Enhancement--Physician Assistant
            Rural Training (PCTE-PAR) Program develops and implements
            longitudinal clinical rotations in primary care in rural areas.
            The program also supports the training and development of
            preceptors in rural areas. In fiscal year (FY) 2022, West
            Virginia University and Marshall University were awarded PCTE-
            PAR Program grants.
      --The Nurse Corps Program received supplemental funds through the
            American Rescue Plan Act to support our Nation's COVID-19
            response and to help address nursing staffing. In fiscal year
            2021, Nurse Corps awarded three nursing scholarships in West
            Virginia and 14 Nurse Corps loan repayment awards.
      --The Behavioral Health Workforce Education and Training (BHWET)
            Program aims to increase the supply of behavioral health
            professionals while also improving distribution of a quality
            behavioral health workforce.
        In fiscal year 2021, West Virginia University was awarded a BHWET
    Program for Professionals grant. The purpose of their proposed Rural
    Integrated Behavioral Health Training (RIBHT) program is to prepare
    Master of Social Work students for behavioral health practice, with a
    focus on integrated and rural service delivery.
        Marshall University was also awarded a BHWET Program for
    Professionals grant between AY 2017-2021. The primary focus of the
    project is to increase the number of training slots that provide
    experience in integrated behavioral health within the primary care
    setting for trainees from programs that have previously not offered
    such training opportunities. These programs include the Master's
    program in Psychology with Clinical and School emphasis, the Masters in
    Counseling, and the Psychiatry residency program. Specific attention is
    given to understanding the unique needs of rural and underserved
    populations in West Virginia and Appalachia in general and how those
    needs may impact both behavioral and physical health.
        Question. Last month, the Administration released its National Drug
    Control Strategy. This strategy lays out the steps the Administration,
    in coordination with Federal agency staff across the government, will
    take to address the drug epidemic, which Senator Manchin has said time
    and time again continues to grow in West Virginia and across the
    nation. Prevention and early intervention are listed in the National
    Drug Control Strategy as a priority, as they should be. In 2020, the
    Substance Abuse and Mental Health Services Administration issued its
    annual report on substance use. The report found that 158,000 people
    ages 12 to 17 started using prescription pain relievers for the first
    time in 2020. While this a decline from previous years, youth substance
    use needs our full attention before we lose the next generation of
    leaders to the drug epidemic.
        What efforts are underway at HHS to address substance use by our
    youngest and most vulnerable populations?
        Answer. SAMHSA oversees grant programs that utilize evidence-based
    programs and promising practices to address substance use by youth ages
    12 to 17, among other efforts.
        For instance, SAMHSA's Enhancement and Expansion of Treatment and
    Recovery for Adolescents, Transitional Aged Youth, and their Families
    (Youth and Family TREE) grant program supports substance use disorder
    (SUD) treatment specifically for youth, young adults, and their
    families with these conditions. Many of SAMHSA's programs include
    elements that address youth and young adult SUD issues.
        The Screening, Brief Intervention, and Referral to Treatment
    (SBIRT) program aims to implement screening, brief intervention, and
    referral to treatment services for individuals of varying age groups
    and across different settings. The program includes a focus on
    screening for underage drinking, opioid use, and other substance use
    among youth and young adults in primary care and other health settings
    that serve this population (e.g., pediatric healthcare providers,
    Children's Hospitals, federally Qualified Health Centers (FQHCs).
        Grants to Expand Substance Misuse Treatment Capacity in Family,
    Juvenile, and Adult Treatment Drug Court programs support courts that
    employ the treatment drug court model to provide SUD treatment
    (including recovery support services, screening, assessment, case
    management, and program coordination) to youth and young adults
    involved in the court system or their parents who are at risk of having
    dependency petitions filed against them.
        The Sober Truth on Preventing Underage Drinking Act (STOP Act)
    program works to prevent and reduce alcohol use among youth and young
    adults ages 12-20 in communities throughout the United States. STOP Act
    grant recipients serve as a catalyst for increased citizen
    participation and greater collaboration among all sectors and
    organizations of a community to foster a long-term commitment to
    reducing alcohol use among youth. Grant recipients disseminate timely
    information to communities regarding state-of-art practices and
    initiative that have proven to be effective in prevention and reducing
    alcohol use among youth. By being deeply rooted in the community, grant
    recipients utilize town halls to gain feedback from communities and
    utilize that feedback to implement change and enhance local community
    initiatives and strategies.
        The Strategic Prevention Framework--Partnership for Success (SPF-
    PFS) program works to prevent the onset and reduce the progression of
    substance use and its related problems while strengthening prevention
    capacity and infrastructure at the community and state level. Utilizing
    a data-driven approach, grant recipients identify communities of high
    need and at-risk populations of focus, including youths. Grant
    recipients utilize community coalition building strategies to advance
    substance use prevention efforts across the community and develop
    prevention messaging and other prevention strategies to ensure the
    dissemination of these messages and strategies.
        Additionally, SAMHSA has state level programs that also include
    services for youth. SAMHSA's State Opioid Response (SOR) program
    provides resources to states and territories, to continue and enhance
    the development of comprehensive strategies focused upon preventing,
    intervening in, and promoting recovery from issues related to opioid
    use, and increasingly stimulant use. The Tribal Opioid Response (TOR)
    program provides dedicated resources to perform these activities in
    Tribal communities. Both programs aim to address the overdose crisis by
    increasing access to the three FDA-approved medications for the
    treatment of OUD, reducing unmet treatment need, and reducing opioid-
    related overdose deaths through the provision of prevention, harm
    reduction, treatment, and recovery support for OUD (including
    prescription opioids, heroin and illicit fentanyl and fentanyl analogs)
    and stimulant use disorder as so elected by states.
        A key component of SOR/TOR grantees' substance use prevention
    strategy is the implementation of Evidence Based Practices (EBPs). For
    prevention, EBPs are approaches and strategies shown to be effective in
    reducing the impact of social and population-based substance use
    concerns.
        Examples of EBPs that SOR grantees are implementing include Botvin
    Life Skills Training; Strengthening Families Program for Parents and
    Youth ages 10-14; Project Success; and Sources of Strength, Positive
    Action. All of these strategies focus on preventing the initiation of
    substance use for at-risk youth. SOR grantees also use funds to support
    interventions through Teen Courts, Recovery High Schools, Peer Mentor
    Programs, and Clubhouses. Between fiscal year 20 and fiscal year 2021,
    approximately 7 percent of individuals receiving treatment and recovery
    support services with SOR funds were under the age of 24 at the time-
    of-service delivery.
        The Substance Abuse Prevention and Treatment Block Grant (SABG)
    Program provides funds to all 50 states, the District of Columbia,
    Puerto Rico, the U.S. Virgin Islands, 6 Pacific jurisdictions, and 1
    tribal entity to prevent SUD, provide treatment and promote recovery
    for those with SUD. Under the SABG program, grantees have the
    discretion to identify adolescents with SUDs and/or mental health
    disorders and children/youth at risk for behavioral health disorders as
    priority populations. Between fiscal year 2018-fiscal year 2021, the
    SABG program served 330,192 clients ages 17 and under and 729,024
    clients ages 18-24.
        In addition to directly supporting services for youth and young
    adults across the SUD intervention, treatment, and recovery support
    continuum, SAMHSA believes that education of the workforce and young
    people themselves is needed to have an impact in this area. SAMHSA has
    taken concrete steps to educate providers and those who use substances
    on the harms of opioid use (prescription and synthetic). SAMHSA
    supports a broad range of training and technical assistance resources
    that reach the specialty behavioral health treatment community, general
    healthcare professionals including students, and the general public.
    Providing education on the impact of using opioids empowers these
    audiences to educate individuals (youth and adults) on the risks and
    harms of using opioids. In addition, reaching youth and young adults
    with evidence-based information on avoiding exposure to harmful
    substances puts knowledge directly into the hands of those who may be
    at highest risk and their peers. This work is augmented through cross-
    agency collaboration. SAMHSA representatives regularly meet with other
    agencies to foster synergy in the expansion or improvement of SUD
    treatment, and how public education might be augmented.
        The National Institute on Drug Abuse (NIDA), part of the NIH,
    supports research to understand and address substance use and its
    consequences across the lifespan, including among vulnerable children
    and adolescents. Research findings indicate that substance use and
    other drug-related harms are more likely to occur in the presence of
    specific risk factors, such as adverse social determinants of health,
    and less likely to occur among certain protective factors, like healthy
    family and peer relationships and financial stability. Prospective,
    longitudinal studies like the HEALthy Brain and Child Development
    (HBCD) \18\ and the Adolescent Brain Cognitive Development (ABCD) \19\
    studies will help us better understand the specific brain, cognitive,
    social, and emotional factors that underlie healthy and unhealthy
    development from the prenatal period through young adulthood. These
    studies will contribute immeasurably to future substance use prevention
    strategies.
    ---------------------------------------------------------------------------
        \18\ https://heal.nih.gov/research/infants-and-children/healthy-
    brain.
        \19\ https://heal.nih.gov/research/infants-and-children/healthy-
    brain.
    ---------------------------------------------------------------------------
        Because most opioid and other substance misuse begins during
    adolescence and young adulthood, this is a critical period for
    prevention. Older adolescents and young adults are at the highest risk
    for initiation of opioid use, opioid misuse, opioid use disorder (OUD),
    and death from overdose, and there is a need for evidence-based
    interventions to prevent OUD. With funding from the Helping to End
    Addiction Long-term Initiative (NIH HEAL Initiative), NIDA leads
    studies on effective strategies to identify and reach at-risk
    individuals in various settings, such as schools, healthcare, justice,
    and child welfare systems. For example, one study is testing a video
    game opioid use prevention intervention for older teens in school-based
    health centers (UH3DA050251-03).\20\ Another study utilizes a
    convenient smartphone application to engage high-risk youth in a
    mindfulness-based intervention to help them reduce or quit their
    substance use (UH3DA050189-03).\21\ Other NIDA-supported studies are
    aimed at improving the uptake and reach of existing evidence-based
    prevention interventions across settings, developing tailored
    approaches for diverse populations, and improving our understanding of
    the mechanisms of action for effective prevention approaches. NIDA also
    supports research to expand effective screening approaches for pregnant
    and postpartum women and school-age children in healthcare settings
    (NOT-OD-22-106 \22\ and NOT-OD-22-107) \23\ and, through its NIDAMED
    initiative, translates research findings into evidence-based resources
    and tools for clinicians to screen for problematic substance use
    (Screening for Substance Use in the Pediatric/Adolescent Medicine
    Setting).\24\
    ---------------------------------------------------------------------------
        \20\ https://reporter.nih.gov/search/q7GOLosA3kSsoyk3nLnCtQ/
    project-details/10408897.
        \21\ https://reporter.nih.gov/search/q16mokkSqkSYJFFKEUseMA/
    project-details/10441666.
        \22\ https://grants.nih.gov/grants/guide/notice-files/NOT-OD-22-
    106.html.
        \23\ https://grants.nih.gov/grants/guide/notice-files/NOT-OD-22-
    107.html.
        \24\ https://nida.nih.gov/nidamed-medical-health-professionals/
    science-to-medicine/screening-substance-use/in-pediatric-adolescent-
    medicine-setting.
    ---------------------------------------------------------------------------
        Finally, monitoring real-world substance exposure among youth is
    also critical for informing prevention efforts. NIDA's Monitoring the
    Future study, an annual survey of substance-related behaviors,
    attitudes, and values of Americans from adolescence through adulthood,
    and the Population Assessment of Tobacco Health (PATH) Study, a
    national longitudinal study of tobacco and health, are helping us to
    better understand the landscape of adolescent substance use to better
    target interventions to prevent and reduce youth substance use.
        Question. The 340B Drug Pricing Program is essential for providing
    access to safe and affordable medications for West Virginians. Senator
    Manchin has consistently advocated for the Department of Health and
    Human Services to safeguard this essential program and ensure that
    pharmaceutical companies cannot blatantly disregard the statutes they
    agreed to. We are hearing about practices that undercut this program by
    pharmacy benefit managers, or PBMs, known as white bagging or brown
    bagging, which puts patients' safety at risk and can dramatically raise
    the out-of-pocket costs for patients. This can also force patients to
    forgo treatment all together, all so PBMs can receive rebates from the
    manufacturers.
        What is the Department doing to clamp down on these practices?
        Are you monitoring this issue?
        How can we as legislators help our constituents who are falling
    victim to these bad practices?
        Answer. We are aware of the practices of pharmacy benefit managers
    under the 340B Drug Pricing Program (340B Program) that you reference.
    While there is no statutory provision in the 340B statute prohibiting
    the pharmacy benefit management programs from utilizing this approach,
    these practices are counter to the intent of the Program, which allows
    safety net providers to stretch scarce Federal resources and ensure
    that the safety net has access to discounted drugs for its patients. By
    pursuing this policy, pharmacy benefit management programs may make it
    cost prohibitive for certain covered entities to participate in the
    340B Program and reduce services to their patients. We look forward to
    working with you on this issue and to continue to support the important
    work of the 340B program.
        Question. Each year, the Secretary of Labor is required to submit a
    report regarding compliance with mental health parity laws. Mental
    health parity laws generally prohibit restrictions on mental health
    services that are more restrictive than those for all medical and
    surgical benefits. Secretary Becerra, in January, your Department,
    along with the Department of Labor and the Department of Treasury,
    released a report showing that health insurers for the most part are
    failing to deliver parity for mental health and substance use disorder
    benefits to beneficiaries. Senator Manchin's office has heard from
    several constituents who work in the mental health and substance use
    disorder workforce that mental health parity laws are simply not being
    followed. What's worse, mental health parity laws are not really being
    enforced. The bad actors aren't seeing any consequences for their
    actions, which are limiting patient access to mental health and
    substance use disorder services.
        What is the Department doing to ensure mental health parity laws
    are being enforced?
        Answer. Although SAMHSA has no direct enforcement role in the
    implementation of Mental Health Parity and Addiction Equity Act
    (MHPAEA), it has been a valued collaborator, partner, and leader on
    parity. SAMHSA has actively supported MHPAEA implementation by working
    closely with other agencies such as the Centers for Medicare & Medicaid
    Services and Departments of Labor and Treasury, as well as the Office
    of National Drug Control Policy. For instance, in partnership with the
    Department of Labor, the HHS and SAMHSA developed new, free
    informational resources that inform Americans of their rights under law
    on coverage for mental health benefits. The following resources are
    available on SAMHSA's website:
      --``Know Your Rights: Parity for Mental Health and Substance Use
            Disorder Benefits,'' an updated trifold pamphlet explaining
            mental health parity, detailing what it means to the consumer,
            and listing the protections the parity law provides.
      --``Understanding Parity: A Guide to Resources for Families and
            Caregivers,'' which provides an overview of parity geared
            toward parents, family members or caregivers with information
            and tools to help them obtain behavioral health services for
            children or family members in their care.
      --``The Essential Aspects of Parity: A Training Tool for
            Policymakers,'' which provides state regulators and behavioral
            health staff an overview of mental health and substance use
            disorder parity and how to implement and comply with the
            Federal parity law regarding employee-sponsored health plans
            and group and individual health insurance.
        We are committed to working with our Federal and state partners to
    ensure that health plans and insurance companies are accountable for
    delivering comprehensive care that includes protections on mental
    health and substance use disorder parity. Non-compliance, both
    intentional and unintentional, is a widespread problem, and additional
    investments are needed to conduct enforcement activities on an
    appropriate scale. While CMS has some enforcement authority, states are
    the primary enforcers of mental health parity for health insurance
    issuers in the small group and individual markets.
        In the 2022 MHPAEA Report to Congress, the Departments of HHS,
    Labor, and the Treasury (the Departments) highlighted their recent
    emphasis on greater Mental Health Parity and Addiction Equity Act
    (MHPAEA) enforcement and discussed the significant resources dedicated
    to supporting these efforts. The Departments provided examples,
    including how the Departments requested comparative analyses of plans'
    and issuers' nonquantitative treatment limitations (NQTLs), which is a
    process provided by the Consolidated Appropriations Act, 2021, and the
    impact of the corrections.
        In addition, HHS, together with the Departments of Labor and the
    Treasury, intends to release additional rulemaking on the MHPAEA. There
    have been a number of changes related to MHPAEA since issuance of the
    final regulations, including the 21st Century Cures Act, the Substance
    Use-Disorder Prevention that Promotes Opioid Recovery and Treatment
    (SUPPORT) for Patients and Communities Act, and the Consolidated
    Appropriations Act, 2021. This rule would propose amendments to the
    2013 final rules (78 FR 68239) and incorporate examples and
    modifications to account for this legislation and previously issued
    guidance.
                                     ______

                    Questions Submitted by Senator Roy Blunt
    Title 42
        Question. Has the Department of Health and Human Services been
    asked to provide or provided any vaccines to the Department of Homeland
    Security for efforts to vaccinate illegal immigrants at the Southern
    border?
        If yes, how many?
        Answer. No.
        Question. If no, where is DHS procuring vaccines from and is it
    from manufacturers directly? And if it is, is it part of a HHS
    contract?
        Answer. HHS defers to the Department of Homeland Security for
    information on their procurements.
        Question. On March 30, 2022, DHS released a Fact Sheet entitled DHS
    Preparations for a Potential Increase in Migration. It states that
    ``DHS has also been providing the COVID-19 vaccines to noncitizens in
    ICE custody since summer 2021.'' It goes on to state that ``Beginning
    March 28, 2022, DHS expanded those efforts to cover migrants in CBP
    custody, so as to further safeguard public health and ensure the safety
    of border communities, the workforce, and migrants.'' What role is HHS
    playing in this decision?
        Has HHS provided any funding to support the mass vaccination of
    illegal immigrants either in CBP or ICE custody?
        Answer. HHS has allocated $48 million from CDC ARP funding via
    Interagency Agreement with DHS to support certain vaccine related
    services (e.g., vaccine event adverse reporting, inventory,
    coordination with state/local Federal agencies) associated with DHS/
    CBP's migrant vaccination programs.
        Question. How many Public Health Service Corps members are
    currently deployed to the Southern border?
        Answer. Operation Artemis consisted of 71 unique missions, with a
    total of 938 separate deployments occurring to support. A total of 805
    unique officers deployed, with some officers deploying multiple times
    to meet the 938 deployments.
        Question. What are the costs associated with their deployment?
        Answer. The average cost per officer to support a deployment is
    $8000, totaling an estimated $7,504,000 to include officer travel, per
    diem, rental vehicles, and miscellaneous expenses.
        Question. What is their role and/or what mission are they
    supporting?
        Answer.
      --USPHS deployed a flag officer, RADM Richard Childs, as the officer
            in charge of Operation Artemis, due to the significance of the
            operation and to ensure dedicated leadership personnel.
      --Officers provided administrative support, facility and engineering
            support, and clinical support on these deployments. Clinical
            support included: COVID-testing, nursing case management, COVID
            vaccination administration, general clinical evaluation and
            care, pharmacological management, infectious disease support,
            behavioral health management, and clinical coordination of
            services across multiple agencies for unaccompanied children
            and their families.
      --Some of the roles in which officers were deployed to support these
            missions included: Incident Commander, Site Lead, Chief Medical
            Officer, Chief Nurse Officer, Safety Officer, Force Health
            Protection, Nurse/Medical/Quality Control/Engineering/Pharmacy/
            Mental Health Officers to name the most common.
        Question. Are they providing vaccinations to illegal immigrants in
    DHS custody?
        Answer. Officers did provide vaccinations to unaccompanied children
    to prevent the spread of COVID-19 and other communicable diseases.
        Question. What is the policy for treating illegal immigrants in the
    Department of Homeland Security's custody with COVID-19 therapeutics if
    they test positive while in custody and what is HHS' role in this
    activity?
        Answer. CDC does not provide treatment or therapeutics for COVID-
    19. CDC provides technical assistance and guidance to the Department of
    Homeland Security to implement COVID-19 mitigation procedures in DHS
    facilities. For more information regarding implementation of these
    procedures, please contact DHS.
    Aduhelm Decision
        Question. In the last 7 years, this Subcommittee has written bills
    that have more than quintupled funding for Alzheimer's research. That
    is how critical of an issue it is to address. FDA has finally approved
    a drug to treat mild-to-moderate Alzheimer's disease last year. But
    last month, CMS made a historic decision to limit coverage only to
    those participating in an NIH or FDA trial. And, interestingly, CMS
    made a distinction between drugs approved through FDA's traditional
    drug approval process and those that receive accelerated approval. I
    don't believe that this distinction has ever been applied to a FDA-
    approved treatment before.
        I recognize that there is a lot of controversy around Aduhelm, its
    data, its price, and potentially its approval. But putting that aside,
    I am concerned that CMS, and ultimately HHS, has made a critical error
    by making a coverage decision that affects not only
        Aduhelm, but all other monoclonal antibody treatments coming down
    the pike. Further, the decision calls into question FDA's entire
    accelerated approval process and by doing so, clearly undermines the
    scientific decisions made by FDA. Can you address what this CMS
    decision means for the future of FDA's accelerated approval process?
        Answer. The agency is committed to using expedited programs to
    bring medicines to underserved populations with serious conditions and
    unmet medical need when the science supports the decision within the
    statutory authorities given to FDA by Congress. Our decision regarding
    Aduhelm exemplifies that commitment. It is important to distinguish
    between FDA's and CMS' role. The standard for Medicare coverage is not
    the same as the standards for FDA approval of a drug. Our role is to
    determine if drug is safe and effective. The agency cannot speak for
    CMS. We continue to see sponsors pursue accelerated approval.
        Ensuring the availability of innovative interventions for people is
    a shared priority for both the Centers for Medicare & Medicaid Services
    (CMS) and the U.S. Food and Drug Administration (FDA). Underpinning
    both agencies' work is the unwavering commitment to use reliable data
    to ensure that effective treatments are made available to patients. The
    FDA's decision to approve a new medical product is based on a careful
    evaluation of the available data and a determination that the medical
    product is safe and effective for its intended use. CMS can conduct its
    own independent review to determine whether an item or service should
    be covered nationally by Medicare, including examining whether it is
    reasonable and necessary for use in the Medicare population.
        The final National Coverage Determination (NCD) ensures access to
    and coverage for Aduhelm and other drugs in the antiamyloid monoclonal
    antibody class that receive accelerated approval. The decision also
    supports innovation and certainty of coverage by creating a long-term
    coverage pathway for new drugs in this class that obtain FDA
    traditional approval, without requiring a new NCD.
        The work of both agencies is critical to ensure that medical
    products are available to people across the country. We recognize the
    impact these decisions have on people with serious and life-threatening
    conditions and their loved ones. We share a common goal of wanting to
    advance the development and availability of innovative medical
    products. The agencies remain committed to using our distinct set of
    authorities to ensure the continued availability of medical products
    that meet our respective standards to care for the people we serve.
        In issuing this NCD, HHS is not making any statement about coverage
    of accelerated approval drugs. This decision is specific to the
    antiamyloid monoclonal antibody class of drugs. HHS looks forward to
    continuing our work on the innovative Cancer Moonshot initiative. All
    Americans are invited to share perspectives and ideas, and
    organizations, companies, and institutions to share actions they plan
    to take as part of this mission at whitehouse.gov/cancermoonshot.
        Question. How does the decision on Aduhelm affect other Alzheimer's
    monoclonal antibody therapies that are under development?
        Answer. NIH notes that the decisions issued by the FDA and Centers
    for Medicare & Medicaid Services (CMS) are regulatory decisions, and
    NIH defers to these agencies on such matters.
    Supply Chain
        Question. What is the Department's plan for investing in supply
    chain resiliency for active pharmaceutical ingredients (API),
    particularly those for essential medicines?
        Answer. The HHS Office of the Assistant Secretary for Preparedness
    and Response (ASPR) made a $354 million investment in Phlow, a
    consortium of organizations that will expand domestic manufacturing of
    raw materials and active pharmaceutical ingredients for drugs. This
    effort includes support for continuous manufacturing. The efforts will
    target drugs on the FDA drug shortage list that have become even more
    critical during the COVID-19 response. I will be happy to keep you and
    your staff informed of activities related to this initiative.
        Question. Is the Administration leveraging existing manufacturers
    and their ability to expand US capacity in the short term (i.e., within
    1-2 years)?
        Answer. With our initial award to PHLOW, we immediately began
    supporting efforts to enhance domestic capacity immediately.
        In addition, we have been supporting efforts to strengthen the
    overall domestic manufacturing base to ensure we are better positioned
    and prepared for whatever comes next. Within HHS/ASPR, we are working
    to institutionalize efforts to support domestic manufacturing efforts.
    Specifically, we are integrating and organizing supply chain
    situational awareness and industrial analysis, domestic industrial base
    expansion, and supply chain logistics. Bringing these pieces together
    will strengthen our industry partnerships and support our work to
    establish and maintain resilient supply chains. A new office within
    ASPR will pull together several lines of effort across--PPE, Durable
    Medical Equipment, Testing and Diagnostics, API, etc. While the new
    office won't necessarily manage every program within that space--SNS,
    BARDA and H-CORE will continue in key roles--the new office will be a
    driving force in ensuring coordination of ASPR's efforts to expand the
    industrial base and solidify the nation's supply chains.
        Question. How much funding has been obligated or committed for this
    activity?
        Answer. Specific to the Phlow contract, an initial award of $354
    million was issued. Phlow is a consortium of organizations that will
    expand domestic manufacturing of raw materials and active
    pharmaceutical ingredients for drugs.
        Question. Does the current investment include a plan for warm based
    manufacturing capabilities and a vendor managed model that would allow
    for these newly manufactured APIs to support the underlying healthcare
    marketplace both during and outside of public health emergencies?
        Answer. Current investments are focused on generating highly
    distributed continuous manufacturing capacities for APIs and finished
    drug products allowing the U.S. to build resilient supply chains for
    drug substances and drug products, both during and outside of public
    health emergencies.
    COVID-19 Education Campaign
        Question. The HHS congressional justification references a
    commitment to use local broadcasters and local newspapers for the
    COVID-19 education campaign, but does not provide additional details on
    how the Department will do so. What steps will the Department take to
    ensure that local broadcasters and newspapers, especially in small and
    rural communities, play a role in the ongoing educational campaign on
    COVID-19?
        Answer. Since onset, the Campaign has committed to using local
    broadcasters and local newspapers to supplement broad-reaching national
    outreach. Doing so has allowed for consistent surround-sound presence
    to adults across America, with a layer of focused messaging directed to
    the critical audiences. How the campaign has executed local media buys
    to reach Americans where they live and from the channels they trust
    most:
        The Campaign greatly prioritizes placing paid advertising via local
    media outlets, and specifically on local television, local cable, local
    radio, local newspapers and local websites. These run consistently in
    20+ markets per month (in some months up to 100 markets) directed to
    different Campaign audiences.
        These local buys run as a supplement to the Campaign's foundation
    of national ads on broadcast and cable television (and sometimes
    national radio).
        Importantly, national, and local media outlets that are at least 50
    percent owned by Minorities are prioritized, provided they provide
    efficient outreach and are qualitatively suitable for Campaign
    messages.
        As one example, the Campaign designed a hyper-local campaign to
    reach Black and Hispanic residents of Milwaukee, WI with an invitation
    to visit a regional Community Vaccine Clinic. The four-week buy
    included ads on:
      --Radio: WJMR-FM (Urban Adult Contemporary), WNOV-AM/FM (Urban/Talk/
            Community) WKKV-FM-(Urban Contemporary) WJYI-FM-(Contemporary
            Christian/Christian preaching), WDDW-AM/FM (Regional Mexican)
            and WJTI-FM (Regional Mexican)
      --Print: Milwaukee Community Journal, Milwaukee Courier, Milwaukee
            Times, Journal Sentinel Community NOW papers (targeted to
            specific zip codes), Urban Milwaukee, El Conquistador, Hispanic
            Reflections, Spanish Journal, La Comunidad News.
      --OOH: Hyper-local poster boards within highly populated B/AA and
            Hispanic communities and zip codes. Highly visible billboards
            on heavy traveled roads and highways. Mobile targeted ads, geo-
            targeted around vaccine clinic(s). DOOH (malls, office
            buildings, gas stations, fitness centers, etc.)
      --Digital: Urbanmilwaukee.com, sherpardexpress.com, Onmilwaukee.com,
            bizjournal.com, milwaukeens.com for programmatic placements.
            Site direct partners i.e. Nextdoor.
      --Social: Facebook, Instagram, Twitter (geotargeted to Milwaukee
            metro area)
      --SEM: Google, Bing, Yahoo, Duck Duck Go (geotargeted to Milwaukee
            metro area)
        In order to continue to ensure that local broadcasters and
    newspapers, especially in small and rural communities, play a role in
    the ongoing educational campaign on COVID-19, it is critical to keep
    Campaign messages in very local programming (including news, regional
    entertainment and sports):
        The campaign has made a dedicated effort to invest paid media
    dollars in media channels that are located in and trusted by rural
    populations. The ``We Can Do This'' campaign has had a dedicated rural
    audience effort with tailored creative and media buys across efforts to
    increase first doses for ``movable middle'' adults, parents with
    unvaccinated children, and encouraging booster doses.
        In addressing rural audiences, the campaign has focused on the more
    than 46 million Americans who live in ``micropolitan'' or ``noncore''
    counties according to the National Center for Health Statistics 2013
    Urban-Rural classification scheme. On a monthly basis, the campaign has
    identified heavy-up markets for additional local media purchases, and
    concentrations of population in the media market that reside in rural
    counties has been a factor when determining audiences.
    Percentage of the paid budget spent on local paid--ideally compared to
            industry benchmarks
      --Of the Campaign's entire budget, approximately 70 percent is
            allocated to the placement of paid advertising. More than half
            of these dollars (51 percent) are directed locally in one of
            two ways, either through direct purchase of space with
            community media outlets or through national channels' reach
            into specific locations.
        In addition to collaborating with thousands of local media outlets
    to run paid advertising, we have also engaged in partnerships and
    relationships with community-based organizations. Many of the
    organizations with whom we work allow us to affect hyper-local, highly
    vulnerable populations who may not otherwise be reached with critical
    information about how, where, and why to get vaccinated. For example,
    we're working with:
      --National PTA activating 34 local PTAs in priority markets to host
            events and conduct outreach to parents of children eligible to
            get vaccinated. Since the start of the partnership, PTA has
            conducted a total of 86 pop-up vaccine clinics and vaccinated
            (first shot or booster) 2,050 people.
      --The Cobb Institute of the National Medical Association has been
            hosting a series of ``Stay Well Community Health Fair and
            Vaccine'' events in priority markets targeted at reaching Black
            and African American families. Since the start of the
            partnership, they have hosted sixteen events, 1,475 individuals
            have been vaccinated or been given booster shots at these
            events.
      --Eighteen Asian American, Native Hawaiian, and Pacific Islander
            organizations across the country to conduct in-person and
            digital outreach. From November 2021 to June 2022, we reached
            over 3,000,000 people. Some of the organizations include, The
            Asian American Pacific Community Health Organization, Asian and
            Pacific Islander Vote, and The National Association of Pasifika
            Organizations.
      --In partnership with Copa Univision, we attended a community sport
            event in Dallas, TX on June 4-5, to share COVID-19 information
            with over 800 Latino families participating at the amateur
            soccer event. The Campaign will participate in three other Copa
            Univision events in Houston, Chicago, and New York.
      --National Day Laborer Organizing Network (NDLON) has been reaching
            migrant workers and farm workers with key information about
            vaccines through in-person events and radio. The organizations
            will also share new videos produced in five different
            indigenous languages.
      --Vaccine Hunters distributed 2,274 Campaign materials at six
            canvassing sites and hosted 48 vaccination clinics in Maryland
            to reach Spanish-speaking Latino people. The organization has
            already vaccinated 2,426 people.
      --Working with the National Diaper Bank and Alliance for Period
            Supplies to distribute campaign information among 200 local
            banks across the country. These will include fact sheets,
            drafted press release, postcards, and other materials in diaper
            and period supply boxes.
      --The United Methodist Health Ministry Fun posted seven video
            testimonials reaching an online audience of more than 200,000
            and hosted a webinar for 82 Kansas faith-based, healthcare and
            childcare providers as well as published an op-ed in Topeka
            reaching more than 31,000 print and 500,000 online subscribers.
      --The National Rural Education Association created three video
            testimonials with teachers from Missouri, Iowa and Northern
            California reaching more than 50,000 online viewers; shared
            information with 300 educators in Victoria, TX at a state
            conference; published a podcast with a pediatrician from West
            Virginia with 3,400 downloads; and published a social media
            toolkit and newsletter for their national network of rural
            educators and state directors with a reach of more than
            100,000.
        Question. Please provide details on obligations to date to local
    broadcasters and newspapers for education campaigns from both the
    COVID-19 supplemental funds and the American Rescue Plan, broken out by
    bill, year, and agency.
        Answer.

                        Fiscal Year 2020

    Local Radio.............................................      $8,512,770
                                                             ---------------
        Fiscal Year 2020 Total..............................      $8,512,770

    Fiscal Year 2020--Funding Source

        IAA with the CDC funded by CARES Act appropriation
         to CDC, Public Law 116-136, 134 Stat. 281, 554-55.

                        Fiscal Year 2021

    Local Newspapers........................................     $11,136,940
    Local Radio.............................................    $14, 526,430
    Local Television........................................      $4,428,756
                                                             ---------------
        Fiscal Year 2021 Total..............................     $30,092,126

    Fiscal Year 2021--Funding Source

        CARES Act appropriation to CDC, Public Law 116-136,
         134 Stat. 281, 554-55.

        American Rescue Plan (ARP) Public Law 117-002.

                        Fiscal Year 2022

    Local Newspapers........................................      $7,482,218
    Local Radio.............................................     $14,916,933
    Local Television........................................     $11,082,786
                                                             ---------------
        Fiscal Year 2022 Total..............................     $33,481,938

    Fiscal Year 2022--Funding source

        CARES Act appropriation to CDC, CARES Act, div. B,
         title VIII, Public Law 116-136, 134 Stat. 281, 554-
         55.

        American Rescue Plan (ARP) Public Law 117-002.

    HRSA Poison Control
        Question. I remain concerned that the Department has failed to
    address the issue of misdirected calls to poison control centers, as
    required under the Poison Center Enhancement Act that passed in 2019 as
    part of the fiscal year 2020 appropriations bill. It is my
    understanding that poison centers in 12 states and the District of
    Columbia have more than 10 percent of their calls misrouted to the
    wrong poison center. Critical medical treatment can be delayed when
    this occurs.
        The Poison Center Enhancement Act requires the Secretary of HHS to
    coordinate with the FCC within 18 months of enactment to ensure calls
    are routed to the proper poison center based on the location of the
    caller to the ``extent technically and economically feasible.'' From
    what I can tell little progress has been made on this issue. Please
    provide an update on this issue, as well as a plan of action to
    improve, if not solve, this growing problem.
        Answer. HRSA recognizes the importance of proper routing of the
    Poison Help Line calls.
        HRSA is engaging with our internal and external partners to
    identify technologically feasible solutions to address the longstanding
    issue associated with caller's area codes versus geographical location
    being used for call routing. We are currently engaged with Verizon (the
    toll-free vendor), an industry technology solutions organization
    (ATIS), the American Association of Poison Control Center (AAPCC), and
    FCC to identify potential technology-based solutions to the call
    routing issue. Verizon has submitted a formal issue statement to ATIS
    to initiate an industry review of potential methods to improve the
    routing information wireless providers over 4G mobile networks; this
    issue statement was accepted by ATIS and is currently under review.
    HRSA also conducted individual calls with several vendors to further
    stimulate telecommunication contractors to propose solutions.
        We are committed to continuing to work with industry on a solution
    to this important issue.
    COVID-19 Commercialization
        Question. Products are able to go into the commercial market once
    they receive FDA approval. For COVID-19 related products that have FDA
    approval, like COVID-19 vaccines for adults, when will the Department
    transition from being the sole purchaser of these products?
        Answer. To date in the COVID-19 response, HHS has supported efforts
    to ensure that vaccines are available to all states and communities. As
    of April 1, 2022, HHS has procured approximately 2 billion doses of
    vaccine and 10.4 million therapeutics and has provided these resources
    to states and territories at no cost. As Congress has not provided the
    resources requested for these efforts, the Department is thinking
    through courses of action to manage the transition away from Federal
    acquisition. There are a number of potential issues that need to be
    considered related to licensure, access, and coverage, which may
    require possible statutory or regulatory changes to resolve. Additional
    funding is required to ensure that there is a smooth transition and
    that challenges are addressed as we move forward with shifting vaccines
    to the commercial market.
    COVID-19 Tests
        Question. What is the Department's funding plan for COVID-19
    testing manufacturers?
        Answer. The Administration has been working closely with domestic
    suppliers and manufacturers since the very beginning. From its first
    days in office, the Administration has used the Defense Production Act
    (DPA), industrial mobilization, and advance market commitments to
    accelerate production of tests. The Administration has also invested
    billions of dollars in industrial base expansion and procurement of a
    large quantity of tests from a variety of domestic manufacturers,
    including Abbott, Quidel, Orasure, and others, as part of the
    COVIDTest.Gov initiative, and other testing initiatives. We also
    continue to find ways to maximize any level of support we can provide,
    including through existing contracts for tests for Long-Term Care
    Facilities, federally Qualified Health Centers, other Community Health
    Centers, food banks, and schools. However, as we have been saying for
    the past months, we need the additional requested funding to provide
    ongoing support and avoid further production cuts and job layoffs
    during this time. Without additional funding, there are risks that we
    will not have the testing capacity we need during a future surge.
        Question. Earlier this year, the Department purchased 1 billion at-
    home tests to be distributed to Americans. The majority of those tests
    were purchased from Chinese manufacturers. Should a spike in cases
    cause the Department to purchase additional at-home tests, is there a
    plan in place to make these purchases from domestic manufacturers?
        Why were domestic manufacturers not used for the 1 billion at-home
    tests the Administration purchased in January 2022?
        Answer. When the Administration began offering COVID-19 tests, at
    no cost, to any person who requested such tests, the intention was to
    increase the number of tests available without impacting the supply of
    tests in the commercial market and without impairing existing state/
    territorial contracts for the procurement of tests. However, from
    November 2021 to February 2022, we saw a strained domestic
    manufacturing and supply chain for COVID-19 tests due to an increase in
    cases. During this timeframe, domestic capacity was not large enough to
    produce the number of tests required to achieve this initiative. To
    avoid further straining the domestic market and to further increase
    access to free tests for the American public, the Administration made
    the decision to purchase tests from international manufacturers for the
    larger test initiative. Since the market has stabilized, the
    Administration has once again shifted to purchasing domestic tests. Our
    goal is to continue to prioritize the purchase of tests domestically,
    but we must continue to provide stability and predictability to the
    domestic market.
        Question. As of May 4, testing companies have not received
    additional volume commitments, but have been provided guidance from the
    Department to ramp up to maximum capacity. Will these domestic
    manufacturers receive a concrete order from the Department?
        Answer. As we have been saying for the past months, we need the
    additional requested funding to be able to provide ongoing support to
    domestic manufacturers in order to avoid production cuts and job
    layoffs. We have already heard from companies that they have reduced
    their production capacity by as much as 85 percent compared with
    maximum production capacity and laid off thousands of workers. We need
    the additional requested funding from Congress to avoid further
    reductions and ensure we have sufficient testing supply and capacity in
    the event of another surge.
        Question. What is the Department's plan for warm-basing domestic
    testing manufacturing?
        Answer. The ability of manufacturers to continue to produce at high
    levels requires a commitment by the Federal government. Tests purchased
    by consumers on the retail market tend to ebb and flow as cases rise
    and fall. Given this, the Federal Government serves as the only real
    backstop that can guarantee purchases for domestic manufacturers. The
    Administration will continue to emphasize the need for Congress to
    provide the requested funding for these purposes. Our inability to fund
    warm basing within domestic testing manufacturing risks us not having
    the testing capacity we need in the event of a fall or winter surge.
    988 and Behavioral Health Crisis Services
        Question. The Substance Abuse and Mental Health Services
    Administration (SAMHSA) submitted the ``Report to Congress on 988
    Resources'' (Report to Congress), which was required by the National
    Suicide Hotline Designation Act of 2020, more than 8 months after it
    was due. The new three-digit lifeline is set to launch in July this
    year, and the budget requests an increase of nearly $600 million for
    fiscal year 2023. SAMHSA has known about the July 2022 launch date for
    some time, yet SAMHSA's delay puts Congress in a difficult position to
    provide a fivefold increase or else appear to shortchange this critical
    effort. Further, the fiscal year 2023 funding will not be available for
    988 for months after the launch, and that is a best case scenario.
        While the Report to Congress outlines projected annual resources to
    sustain 988, the fiscal year 2023 budget does not provide any detail as
    to how SAMHSA would allocate $696.9 million. While appreciated, the
    Report to Congress is not a budget document. Please provide a breakout
    of funding for the fiscal year 2023 request and a detailed description
    of each activity for the 988 and Behavioral Health Crisis Services,
    along with the allocation method for each activity.
        Answer. First, it is important to note that July 2022 and the
    transition to 988 and the impacts on volume are as yet unknown. SAMHSA
    is projecting resource needs based upon the best available current
    data, and will continue to provide ongoing assessments to respond to
    potential alternate scenarios. These ongoing assessments may alter
    projected resource needs outlined below.
        The fiscal year 2023 Budget Request for 988 and Behavioral Health
    Crisis Services is $696.9 million. The budget proposes an historic
    investment in the 988 program to ensure there is sufficient funding to
    support crisis response. The proposed funding will play an essential
    role in advancing the crisis system to meet the once-in-a lifetime
    opportunity of 988 by:
        Increasing crisis center capacity ($545 million): This funding will
    enhance local capacity through partnerships in behavioral health crisis
    response--Local center capacity is critical to ensuring that
    individuals in crisis receive responses that are tailored to the
    service system where they are located and that services across the
    continuum are linked and coordinated. We expect the greatest resource
    needs in supporting 988 response across the national crisis back up
    centers (Federal) and local crisis centers (combined Federal and non-
    Federal). SAMHSA's budget projections are based on volume expectations
    at an $82 cost per contact and volume estimates that project 7.6
    million contacts in fiscal year 2023. Given current estimates of local
    capacity and non-Federal funding sources to support local response,
    SAMHSA expects a Federal resource need of $545 million. This funding
    shores up our crisis centers around the country to ensure that they
    have the ready workforce available to staff and answer calls, chats and
    texts for help and strengthens partnerships that decrease law
    enforcement response to individuals in crisis.
        Strengthening network operations ($117 million): As the network
    continues to scale, additional funding will be required for the
    Lifeline administrator and centralized network functions, including
    data and telephony infrastructure; standards, training, and quality
    improvement; evaluation and oversight.
        Funding will also be required to sustain and expand technology to
    promote access for marginalized populations. The fiscal year 2023
    investment further increases the capacity and performance of these key
    network infrastructure components and functions to the standard
    required for the projected contacts anticipated in fiscal year 2023 and
    support collaborative efforts with partner organizations to improve
    local routing of contacts.
        Sustaining the 988 & Behavioral Health Crisis Coordination Office
    ($10 million): The 988 transition will require continued extensive
    coordination at the Federal, state, and local levels. Coordination
    activities led at a Federal level include technical assistance to
    states, and crisis centers; strategic planning, performance management,
    evaluation, and oversight; and formal partnerships, convenings, and
    cross-entity coordination.
        Supporting public awareness with targeted 988 national messaging
    ($25 million): The 988 code will provide a universal, easy-to-remember,
    three-digit phone number and connect people in crisis with life- saving
    resources. As 988 is implemented, SAMHSA anticipates the need and
    additional costs to educate the public on services covered by 988, and
    the differences between 988 and 911. This funding would permit
    continuation of focused work on populations known to be at high risk of
    suicide, building upon formative research processes that were launched
    in fiscal year 22. This funding is not for a larger scale public
    awareness campaign, but is targeted, foundational work needed to
    educate the public and local communities on the function of 988.
        Question. The Report to Congress indicates that $560 million would
    be needed to strengthen local crisis call center capacity from Federal
    and non-Federal funding. How does the budget request account for non-
    Federal resources? Please provide an estimate and description of non-
    Federal resources.
        Answer. SAMHSA is working with its partners to track state-level
    legislative and non-legislative activity aimed at supporting local
    crisis capacity. To date, only four states have passed legislation with
    corresponding 988 state cell phone fees, including Colorado, Nevada,
    Washington, and Virginia. Other states have passed appropriation
    legislation not connected to cell phone fees, some have ordered
    commissions without any specific funding allocation, and many states
    have either legislation in progress or no current plans for legislative
    activity. Some states have also looked to Medicaid and payer
    reimbursement to support crisis center development though this is in
    very early stages in most areas. SAMHSA expects that it will take time
    for most states to develop sustainable and comprehensive mechanisms to
    support 988.
    Organ Procurement and Transplantation Accountability
        Question. The HHS budget documents appear to be sending a mixed
    message with regard to the Administration's position on holding Organ
    Procurement Organizations (OPOs) accountable for poor performance. The
    fiscal year 2023 HHS Budget in Brief document includes a section called
    ``Remove Restrictions on the Certification of New Entities as Organ
    Procurement Organizations and Increase Enforcement Flexibility,'' which
    proposes flexibility to recertify poor performing OPOs that lose
    certification because of failure to meet certain criteria. This
    narrative runs counter to the Final rule ``Organ Procurement
    Organizations Conditions for Coverage: Revisions to the Outcome Measure
    Requirements for Organ Procurement Organizations'' (42 CFR Part 486),
    which will bring much needed standardization to how OPOs measure
    performance and ensure all OPOs are performing at high quality
    standards. What is intended by this budget narrative and why is it
    proposed in light of the Final rule 42 CFR Part 486?
        What is the status of implementation of 42 CFR Part 486 and what
    guidance has CMS provided to OPOs regarding its implementation?
        Answer. Organ procurement organizations (OPOs) are vital partners
    in the procurement, distribution, and transplantation of human organs
    in a safe and equitable manner for all potential transplant recipients.
    The role of OPOs is critical to ensuring that the maximum possible
    number of transplantable human organs is available to individuals with
    organ failure who are on a waiting list for an organ transplant. HHS is
    dedicated to improving health equity and access in the organ
    procurement and transplantation system, including by holding OPOs
    accountable for their performance.
        In December 2020, CMS published ``Medicare and Medicaid Programs;
    Organ Procurement Organizations Conditions for Coverage: Revisions to
    the Outcome Measure Requirements for Organ Procurement Organizations''.
    This rule finalized new outcome measures OPOs are required to meet for
    re-certification and was published with the intention of increasing
    donation and organ transplantation rates by replacing the previous
    outcome measures with new transparent, reliable, and objective outcome
    measures that are used to make better certification decisions and
    incentivize better performance. At the end of the re-certification
    cycle, each OPO will be assigned a tier ranking based on its
    performance for both the donation rate and transplantation rate
    measures, as well as the re-certification survey. The highest
    performing OPOs will be assigned in Tier 1 which means the donation and
    transplantation rates of the top 25 percent of OPOs, and automatically
    recertified for another 4 years. OPOs with rates that are below the top
    25 percent will be in either Tier 2 or 3. Tier 2 OPOs are not
    automatically recertified but they will have to compete to retain their
    donation service area (DSA). Tier 3 OPOs are the lowest performing OPOs
    and will be decertified and lose their service area. CMS believes that
    increasing competition between the OPOs will incentivize them to
    maximize their performance and consequently increase the number of
    organs available for transplantation.
        OPOs will be held accountable for the new measures for
    recertification purposes in 2026. While CMS will conduct activities for
    OPO recertification in 2026, the timeline for OPOs to implement needed
    improvements occurs much earlier than 2026. OPOs will be notified of
    their performance on the new outcome measures at the end of each 12-
    month period of the 4-year recertification cycle, which starts in 2022.
    OPOs will be accountable to this requirement when they receive their
    first results in the next re-certification period. The target data for
    this first report is spring of 2023. By identifying the performance of
    OPOs annually, poor performing OPOs can appropriately change and adopt
    effective practices that improve their performance in donation and make
    more organs available for transplantation.
        The President's fiscal year 2023 Budget includes a proposal that
    would certify new entities as organ procurement organizations and
    recertify certain organ procurement organizations that do not meet the
    criteria for recertification based on outcome measure performance, but
    which have shown significant improvement during a re-certification
    cycle. The proposal will provide the flexibility CMS needs to avoid
    organ procurement disruptions due to the certification status of
    certain organ procurement organizations and provide these organizations
    with an incentivize to maximize performance even if they do not believe
    they could satisfy the outcome requirements at the next
    recertification.
        Question. I was pleased to see HRSA released a Request for
    Information regarding the Organ Procurement and Transplantation Network
    (OPTN), seeking ways to improve and strengthen the OPTN ahead of the
    fiscal year 2023 Request for Proposal. Throughout the last 4 years, the
    OPTN contractor United Network for Organ Sharing (UNOS) has been
    exposed for its regional bias and inability to effectively improve the
    organ procurement and transplantation system. For example, records that
    UNOS fought vigorously to keep hidden from the public reveal UNOS
    colluded against certain regions of the country when it issued the
    liver allocation policy in December 2018. Further the National
    Academies of Science, Engineering, and Medicine (NASEM) revealed an
    astounding number of organs continue to unused, and NASEM made several
    recommendations related to the OPTN contract and HHS oversight to
    improve accountability, improve policymaking, and modernize the
    transplantation network. How is HHS planning to update the OPTN
    contract to hold the contractor accountable for system improvements?
        Will HHS break up the OPTN contract to separate the policymaking
    functions from the IT functions?
        Answer. HRSA recognizes that the Organ Procurement and
    Transplantation Network (OPTN) contract is critical to the oversight
    and accountability of the organ donation and transplantation system and
    intends to be appropriately deliberative about decisions impacting the
    effectiveness and efficiency of the system. As you note, HRSA issued a
    Request for Information (RFI) to solicit feedback about opportunities
    to strengthen the OPTN. In particular, the RFI sought feedback on the
    ways to address many of the National Academies of Science, Engineering,
    and Medicine findings and recommendations in its report titled
    Realizing the Promise of Equity in the Organ Transplantation System.
    HRSA released the RFI to better support HRSA's efforts to increase
    accountability in OPTN operations, modernize performance of the OPTN IT
    system and related tools, and improve engagement with donors and
    patients. It specifically focuses on opportunities to strengthen
    equity, access, and transparency in the organ donation, allocation,
    procurement, and transplantation process. In addition, it also sought
    stakeholder input on the governance, finance, IT, data collection,
    policy, and operational components of the OPTN. HRSA is appreciative of
    the response to the RFI and is actively reviewing this important
    feedback to inform the development of the next contracting cycle. We
    look forward to continuing to engage with Congress as we develop the
    next contracting cycle and continue to identify strategies for
    modernization and accountability across the organ procurement and
    transplantation system.
    Provider Relief Fund (PRF)
        Question. Hospitals and providers that opened their doors in 2020
    and 2021 have not had equitable access to the PRF, despite experiencing
    some of the same challenges during the COVID-19 pandemic as established
    healthcare providers. What has the Administration done to ensure
    equitable access to the PRF dollars Congress provided for this subset
    of providers?
        Answer. As part of the Administration's ongoing commitment to
    equity, and to support providers with the most need, HHS included new
    elements in Phase 4 of the Provider Relief Fund (PRF). Rather than
    paying the same percentage of losses for all providers as in Phase 3,
    PRF Phase 4 reimburses smaller providers for their operating revenues
    net expenses at a higher rate compared to larger providers. That means,
    new providers who just opened their doors and have $10 million or less
    in annual patient care revenues in 2020 would receive 45 percent of
    their adjusted quarterly losses, compared to 25 percent or 10 percent
    for medium and large providers.
        In addition, HHS allocated approximately 25 percent of the $17
    billion allocation to Phase 4 Bonus payments based on the amount and
    type of services to Medicare, Medicaid, and Children's Health Insurance
    Program (CHIP) patients. HHS used a similar methodology for the $8.5
    billion in ARP Rural payments, making payments based on the amount and
    type of services provided to Medicare, Medicaid, and CHIP patients who
    live in rural areas, as defined by the Federal Office of Rural Health
    Policy. Bonus payments relied on claims submitted from January 1, 2019
    through September 30, 2020 in order to capture both pre-pandemic care,
    as well as care delivered during the pandemic. This allowed providers
    that opened their doors in the first three quarters of CY 2020 to be
    eligible for additional funds.
        Question. How many hospitals and healthcare providers opened their
    doors in 2020, 2021, or 2022? Can HHS please provide a breakout by
    provider type, year, and an estimate of the emergency relief funding
    that these providers have requested and received from the PRF?
        Answer. Attached, please find the Phase 3 and Phase 4/ARP Rural
    payments to new provider in 2020 by self-selected provider type.
        Please note, new providers in 2021 and 2022 were not eligible for
    PRF or ARP Rural payments. Furthermore, the application portals for
    Phase 3 and Phase 4/ARP Rural did not collect providers' emergency
    funding requests. The data attached are Quarterly Losses, which are
    calculated based on changes in operating revenues and expenses pre-
    pandemic and COVID-19, as reported by applicants. For new providers
    where there is no comparable pre-pandemic time period, the revenue loss
    was estimated using the revenues reported by the provider and the
    average loss rate for that category of provider.

    Substance Use Harm Reduction
        Question. Thank you for your prompt response to my letter in
    February on HHS' harm reduction grant. As many in Congress were, I was
    concerned that HHS was on the precipice of providing Federal funding to
    purchase crack pipes. After the controversy that funding announcement
    stirred up, what did HHS do to ensure these grants will not go toward
    purchasing illegal drug paraphernalia, like syringes and crack pipes?
        Answer. In the Notices of Award, SAMHSA included terms and
    conditions explicitly restricting funds from directly or indirectly
    purchasing or promoting the use of drug paraphrenia, including pipes/
    pipettes in safer smoking kits. Syringes to prevent and control the
    spread of infectious disease are allowed for purchase. Harm reduction
    programs that use Federal funding must adhere to Federal, state, and
    local laws, regulations, and other requirements related to such
    programs or services. A comprehensive program monitoring and oversight
    plan is being implemented to ensure that funds are not misused. Please
    see the Notice of Funding Opportunity for more information: https://
    www.samhsa.gov/sites/default/files/grants/pdf/fy22-harm-reduction-
    nofo.pdf.
        Question. Drug overdose trends are a cause for alarm. In my time as
    the lead Republican on this Subcommittee, we have increased funding by
    $4 billion toward addressing the opioid crisis, which suffered a
    setback during the pandemic. There's no doubt we need to continue to
    address this crisis. I'm concerned, however, with the push to expand
    overdose prevention activities and similar harm reduction activities at
    the expense of primary prevention activities. Since 2019, in a
    bipartisan manner, this Subcommittee has explicitly funded harm
    reduction activities through the Center for Substance Abuse Treatment.
    This was done to not undercut programs that are focused on primary
    prevention of substance use and to ensure people who suffer an overdose
    have access to treatment, yet SAMHSA has blatantly ignored
    Congressional intent. This willful disregard for Congressional intent
    is inexcusable and a cause for concern. Why did SAMHSA continue to fund
    the administration of ``Grants to Prevent Prescription Drug/Opioid
    Overdose,'' ``First Responder Training for Opioid Overdose Reversal
    Drugs,'' and ``Improving Access to Overdose Treatment'' out of the
    Center for Substance Abuse Prevention, after Congress specifically
    moved the programs to the Center for Substance Abuse Treatment in 2019?
        Will you work with us to make sure both the administration and
    funding for harm reduction activities align with congressional intent?
        Answer. Since 2019 and up to the present time, SAMHSA has followed
    Congressional guidance and funded PDOA, FRT, and IAOT out of CSAT.
    However, in recognition that the most effective harm reduction
    strategies are implemented across the *behavioral health continuum,
    CSAP subject matter experts have been heavily involved in the
    administration of these programs. This management approach has not been
    implemented at the expense of SAMHSA's primary prevention efforts but
    have enhanced the effectiveness of behavioral health services and
    interventions across the continuum of care.
        Unfortunately, traditional primary prevention programs are not
    always effective in preventing substance misuse and/or overdose deaths.
    CSAP programs that expand beyond primary prevention utilize data that
    targets trends and themes associated with overdose deaths and increased
    substance use. Including indicated and selective prevention activities
    such as psychosocial supports in CSAP programs is critical to
    connecting at risk individuals to support services and treatment
    services that are funded by CSAT. Funding multiple types of prevention
    programs that utilize evidence-based approaches saves lives.
    SAMHSA's Behavioral Health Continuum:
        Promotion: These strategies are designed to create environments and
    conditions that support behavioral health and the ability of
    individuals to withstand challenges. Promotion strategies also
    reinforce the entire continuum of behavioral health services.
        Prevention: Delivered prior to the onset of a disorder, these
    interventions are intended to prevent or reduce the risk of developing
    a behavioral health problem, such as underage alcohol use, prescription
    drug misuse, and illicit drug use.
        Treatment: These services are for people diagnosed with a substance
    use or other behavioral health disorder.
        Maintenance: These services support individuals' success and
    include long-term treatment, continuing care, and recovery support.
        Question. It has been reported that the Biden Administration is
    considering support for safe injection sites. These sites allow drug
    users to consume illicit drugs under medical supervision and are
    against the law. The Associated Press reported in February that the
    Department of Justice is ``talking to regulators about `appropriate
    guardrails''' for such sites. What is the status of these discussions
    and is HHS or SAMHSA involved?
        What are the ``appropriate guardrails'' that are under discussion?
        Answer. SAMHSA is not involved in safe injection sites. Given the
    legal status, we have and continue to refrain from involvement.
    Unaccompanied Children
        Question. In fiscal year 2021, the Department had the largest
    number of referrals of unaccompanied children ever. It spent almost $7
    billion on the program, including almost $4 billion transferred from
    funding that was supposed to be spent on COVID-19 activities. fiscal
    year 2022 referrals to date are almost 40 percent higher than they were
    at this time in fiscal year 2021, and Congress has provided $8 billion
    to care for unaccompanied children this fiscal year. However, for
    fiscal year 2023, the Administration only requested $4.9 billion in
    discretionary funding for the program. Why do you think the Department
    will be able to cut $3.1 billion in costs when referrals of UACs and
    program costs have gone up the past 2 years?
        Answer. The Administration requested a $4.9 billion discretionary
    appropriation for fiscal year 2023 as well as two mandatory
    appropriations. With the funding provided by the discretionary
    appropriation, ACF will continue to effectively care for children
    referred by the Department of Homeland Security (DHS), ensure
    facilities meet FSA standards, and work to expand post-release services
    to all children released from ORR care. The Budget also proposes
    mandatory appropriations for a contingency fund, recognizing the
    unpredictable fluctuations in program needs, and a fund for UC legal
    representation. Additionally, the number of permanent shelter beds will
    increase, reducing the amount of funding needed for more expensive
    temporary shelter beds. Approximately 75 percent of budget costs go
    directly to care for unaccompanied children (UC) in ORR shelters. Other
    services for UC such as medical care and family unification services,
    including background checks, make up approximately 20 percent of the
    budget. Administrative expenses to carry out the program total
    approximately 5 percent of the budget. The UC program will keep the
    appropriations committees apprised of changes to program costs as
    needed.
        Question. As I mentioned in my opening statement, I'm concerned
    about the impact of the termination of the Title 42 Order. Even though
    unaccompanied children have been exempted from the order since January
    2021, the Department of Homeland Security is projecting a large
    increase in illegal border crossings which will likely include
    unaccompanied children. What are your plans to handle a surge in UACs?
    Can the program support a surge at the level requested in the
    President's budget?
        If not, why wouldn't you provide Congress with a budget request
    that reflects the actual costs of the program?
        Answer. ORR will continue to care for children referred by DHS and
    ensure their safety and well-being. However, this program's costs are
    inherently unpredictable and challenging to budget for with any degree
    of certainty. Despite this uncertainty, we have an obligation to
    provide appropriate services to all unaccompanied Children.
        HHS's mission is to care for UC until they are safely released to a
    vetted sponsor or leave ORR custody following an immigration judge's
    order of removal, turn 18 years of age, or obtain legal immigration
    status in the United States. The number of children referred by DHS in
    ORR care can fluctuate, which is why ORR continuously reviews capacity
    needs throughout the year.
        These estimates are based on historic data and DHS predictions and
    consider several factors such as UC referral numbers, trends,
    projections, and COVID-19 infection rates and impact on staffing and
    bed availability. These estimates further inform program costs in real-
    time and impact budget numbers accordingly.
        Because of the inherent uncertainty in the UC program, it is
    extremely challenging to fund it through the conventional annual
    appropriations process. For this reason, the 2023 Budget would
    establish a mandatory contingency fund, which would provide additional
    resources when there are unexpected surges in the number of
    unaccompanied children requiring care.
        HHS/ORR continuously plans for increases in migration. This
    includes projecting influx capacity needs, expanding bed capacity,
    adding more beds through entering into cooperative agreements with
    existing grantees, and adding new grantees to ORR's network of
    facilities. Associated program costs are included in the current budget
    proposal before the committee. ACF maintains regular dialogue with the
    appropriations committees and will continue to keep
        Members and staff apprised of changes in funding needs.
        Question. The budget proposes, again, a contingency fund for the
    UAC program. This has never been an effective way to manage the
    program, as witnessed in an fiscal year 2017 CR when the Democrats
    forced the inclusion of $200 million in funding for a contingency fund,
    its threshold trigger was set too high, and that funding was wasted.
    Knowing that, why would the Department propose a contingency fund
    again? It appears that it is simply a budget gimmick.
        Answer. We do not view the contingency fund as a gimmick. Instead,
    we view it as a reasonable way to deal with the inherent uncertainty in
    the UC program, allowing the program to have a reliable source of
    funding to activate new shelter capacity to handle unexpectedly high UC
    referrals.
        ACF analyzed the previous iteration of the contingency fund and
    designed this proposal accordingly to be more effective and
    operational. We concur that the threshold trigger in the fiscal year
    2017 CR was set too high. ORR took that miscalculation into account and
    designed the current proposal to be more efficient. Specifically, the
    fund would pay out $27 million for each increment of 500 referrals
    above a threshold of 7,500 UC referrals per a month, which is a
    historically high level of monthly referrals.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
        Question. Review Choice Demonstration for Inpatient Rehabilitation
    Facility services
        The inpatient rehabilitation facility review choice demonstration,
    or IRF RCD, is slated to begin in Alabama at some point, perhaps later
    this year. What steps has HHS/CMS taken to identify qualified auditors
    who have experience caring for IRF patients, given the increased
    auditing that will occur under IRF RCD? We have about 20 rehabilitation
    hospitals and hospital-based inpatient rehabilitation units in Alabama,
    and this IRF RCD program is going to be a big challenge for them. Will
    HHS/CMS commit to collaborate with them so that the RCD doesn't become
    an overwhelming burden of paperwork and claim denials? If so, what
    actions will the Department and agency take to minimize the
    administrative burden and promote access to care?
        Answer. The proposed Inpatient Rehabilitation Facility (IRF) Review
    Choice Demonstration (RCD) would allow the agency to better understand
    the scope and causes of improper payments and work with IRFs to reduce
    documentation errors. This would allow CMS to focus on the prevention
    of improper or fraudulent IRF claims and assist in developing improved
    procedures for the identification, investigation, and prosecution of
    Medicare fraud occurring among IRFs providing services to Medicare
    beneficiaries. Additionally, the proposed IRF RCD would offer IRFs
    provisional assurance of payment and would reduce the burden of audits
    and associated appeals while protecting beneficiary access to care in a
    timely manner.
        This proposed demonstration would not create new clinical
    documentation requirements; rather, it would only require submission of
    the same information providers are currently required to maintain. IRFs
    would have flexibility as they can choose their path to demonstrate
    compliance with Medicare requirements. IRFs would initially select, for
    the first 6 months, between two review choices: 100 percent pre-claim
    review or 100 percent post payment review. Providers who select pre-
    claim review may resolve any documentation issues and resubmit their
    requests an unlimited number of times prior to submitting the claim for
    payment. IRFs that have a high pre-claim review affirmation rate or
    post payment review claim approval rate would have additional options
    from which to choose, including relief from most reviews which will
    offer providers the flexibility to choose a review option that would
    work for them based on their resources and financial needs. No matter
    which choice is selected, beneficiary access to treatment will not be
    delayed.
        To ensure consistency in operations and to eliminate potential
    contractor variation in medical review, we will ensure there is
    vigorous oversight of demonstration operations, including quality
    assurance and accuracy reviews of Medicare Administrative Contractor
    (MAC) review decisions to ensure they are reviewing in accordance with
    CMS policies. The MAC reviewers will undergo training to ensure
    consistency before beginning the reviews. The MACs involved in the
    demonstration regularly perform Medicare reviews on behalf of CMS and
    will be following all applicable statutes and regulations that are in
    effect when the demonstration is implemented. Both the MAC and CMS will
    monitor the reviewers' accuracy throughout the demonstration. In
    addition, CMS medical staff will conduct reviews on a selection of pre-
    claim review requests and claims to ensure the MAC decisions are
    accurate and consistent across reviewers.
                                     ______

                   Questions Submitted by Senator Jerry Moran
        Question. Mr. Secretary, Congress has provided bipartisan support
    to help extend the reach of state and Federal programs to serve more
    families and improve the overall quality of care. I was pleased to
    support significant funding increases for the Child Care Development
    Block Grant and Head Start in particular in the fiscal year 2022
    omnibus. I am also a cosponsor of the Child Care and Development Block
    Grant Reauthorization Act of 2022, which would build on the bipartisan
    Child Care and Development Block Grant program to provide greater
    support to working families to afford child care.
        Can you please speak to how additional funding for CCDBG will help
    low- and middle-income families be able to continue to access and
    afford high- quality child care?
        Answer. In fiscal year 2020, the CCDF program served 1.49 million
    children and 900,300 families despite minimal or even inadequate
    funding. The number of children served has steadily declined over the
    last decade from a high of 1.7 million children in fiscal year 2010.
    Only about 15 percent of federally eligible children receive child care
    subsidies. Moreover, almost all states establish child care provider
    payment rates that fail to reimburse providers for the full cost of
    quality child care, which reduces parent choice, inhibits supply, and
    contributes to high staff turnover and low wages. In turn, states are
    forced to limit eligibility, enforce waitlists, charge unaffordable
    family co-payments, and establish payment rates that fail to reimburse
    providers for the full cost of quality child care. CCDF needs
    significantly more resources to ensure that additional families have
    access to child care, improvethe quality of care, increase wages, and
    strengthen the child care sector.
        Question. During the Senate Appropriations Subcommittee hearing on
    May 4th, you committed to fully stocking the biodefense and pandemic
    response supplies maintained by the Strategic National Stockpile. It is
    also imperative that the Stockpile is maintained with products
    manufactured in the U.S. and not depend on China as we did when COVID-
    19 first arose. I'm troubled to learn that HHS has cancelled 3
    contracts to manufacture gowns for the Strategic National Stockpile in
    the past 6 months. We've also been told there are currently zero
    sterile surgical gowns in the Stockpile. However, your fiscal year 2023
    budget does note that you have a target of 265M gowns and that
    procurements are in process.
        Can you confirm for me specifically how many sterile surgical gowns
    are currently in the Strategic National Stockpile and what are your
    plans to procure additional U.S.-made sterile surgical gowns to meet
    your stated targets?
        Answer. The SNS currently holds approximately 60 million deployable
    isolation gowns.
        While SNS has made progress in building its inventory of gowns,
    holding more than 12 times the amount held at the beginning of the
    COVID-19 response, the progress has been exclusively to the inventory
    of isolation gowns rather than surgical gowns. SNS currently holds
    fewer than 1000 surgical gowns. SNS previously signaled its intention
    to procure domestically manufactured surgical gowns to help close the
    gap between current holdings and the COVID-19 target of 265 million
    gowns.
                                     ______

                  Questions Submitted by Senator John Kennedy
        Question. Secretary Becerra committed to ``robust enforcement''
    during his confirmation hearing before the Senate HELP Committee (2/23/
    21) to become the Secretary of the Health and Human Services
    Department. Despite this commitment and widespread non- compliance, HHS
    has failed to meaningfully enforce the hospital price transparency
    rule.
        A recent national survey found an overwhelming bipartisan majority,
    87 percent of Americans, support the requirement for hospitals to post
    prices, and nearly 79 percent want critical measures like transparency
    in coverage to be implemented immediately without further delay.
        A comprehensive study published February 2022 by Patient Rights
    Advocate, reviewed 1,000 hospitals nationwide and found only 14.3
    percent of hospitals are compliant with the HHS rule that went into
    effect over 1 year ago.
        Mr. Secretary, first can you tell the Committee how many hospitals,
    as of today's hearing, have received warning letters and/or corrective
    action plans for non-compliance?
        Of the letters that went out to non-compliant hospitals, can you
    please tell me how many responded?
        Mr. Secretary, can you also tell me how many hospitals, who again
    have had over 15 months to comply, have been issued a civil monetary
    penalty?
        When do you expect to issue your first civil monetary penalty for
    non- compliance?
        Can you commit to this committee, Congress, and the American people
    that your Department will immediately post both compliant and non-
    compliant hospitals on your website and begin issuing fines to non-
    compliant hospitals?
        Answer. CMS is committed to ensuring consumers have the information
    they need to make fully informed decisions regarding their healthcare.
    Hospital price transparency helps Americans know what a hospital
    charges for the items and services they furnish.
        The hospital price transparency final rule was published in
    November 2019 and became effective January 1, 2021. The final rule
    implements section 2718(e) of the Public Health Service Act (as added
    by the Affordable Care Act) and requires each hospital, for each year,
    to establish, update, and make public a list of the hospital's standard
    charges for items and services provided by the hospital. The final rule
    superseded guidance issued by CMS in 2015 and 2019. The rule requires
    hospitals to make public five types of 'standard charges:' gross
    (chargemaster) charges, discounted cash prices, payer-specific
    negotiated charges, and the minimum and maximum de-identified
    negotiated charges.
        The final rule also specified methods by which CMS may monitor
    hospitals' compliance with the requirements, including evaluating
    complaints made to CMS, reviewing analyses sent by third parties
    regarding hospital noncompliance, and auditing hospitals' websites.
    Should CMS conclude a hospital is noncompliant with one or more of the
    requirements to make public standard charges, CMS may take any of the
    following actions, which generally, but not necessarily, will occur in
    the following order:
        (a) Provide a written warning notice to the hospital of the
    specific violation(s).
        (b) Request a corrective action plan from the hospital if its
    noncompliance constitutes a material violation of one or more
    requirements.
        (c) Impose a civil monetary penalty not in excess of $300 per day
    on the hospital and publicize the penalty on a CMS website if the
    hospital fails to respond to CMS's request to submit a corrective
    action plan or comply with the requirements of a corrective action
    plan.
        We expect hospitals to comply with these requirements and are
    enforcing these rules to make sure Americans have information regarding
    what the hospital will charge for their healthcare in advance. Prior to
    the effective date, CMS developed a dedicated hospital price
    transparency website found here: https://www.cms.gov/hospital-price-
    transparency. This website includes resources to help hospitals comply
    with the rule in addition to a method for consumers to contact CMS and
    submit specific complaints related to hospital noncompliance.
        In January 2021, we began proactive audits of hospital websites as
    well as review of complaints submitted to CMS via the hospital price
    transparency website. In April 2021, we issued the first set of warning
    letters to noncompliant hospitals. These letters list specific areas of
    deficiencies identified through CMS compliance review and request
    hospital action to remedy the deficiencies. We intend to continue to
    send warning letters on a rolling basis as we identify noncompliant
    hospitals through our proactive audits and review of complaints.
    Hospitals that fail to submit a corrective action plan or comply with
    the requirements of a corrective action plan will be subject to a civil
    monetary penalty. In the event CMS issues a civil monetary penalty
    (CMP), CMS will identify the hospital and display the hospital's name
    on a CMS website.
        In November 2021, in the Hospital Outpatient Prospective Payment
    System and Ambulatory Surgical Center Payment System Final Rule (CMS-
    1753FC), CMS increased the civil monetary penalties that will apply to
    noncompliant hospitals. The final rule set a minimum CMP of $300/day
    for smaller hospitals with a bed count of 30 or fewer, and a penalty of
    $10/bed/day for hospitals with a bed count greater than 30, not to
    exceed a maximum daily dollar amount of $5,500. Under this approach,
    for a full calendar year of noncompliance, the minimum total penalty
    amount would be $109,500 per hospital, and the maximum total penalty
    amount would be $2,007,500 per hospital. This approach to scaling the
    CMP amount retains the original penalty amount for small hospitals,
    increases the penalty amount for larger hospitals, and affirms the
    Administration's commitment to enforcement and public access to pricing
    information. The revised CMP policy took effect January 1, 2022.
        Question. I understand that implementing a monumental law, such as
    the No Surprises Act, takes time. To that extent, I am grateful that
    the Federal Independent Dispute Resolution (IDR) portal was officially
    opened in April. However, I am concerned as I have heard from providers
    who have thousands of claims ineligible for the IDR process. Once the
    Federal Portal was opened, providers were given 15 business days to
    submit all claims to IDR where the 30-business day, post Open
    Negotiation limit had expired. However, this extension does not apply
    to claims where no Open Negotiation was initiated. This is worrisome as
    I have heard from providers who did not submit claims for Open
    Negotiation, as the portal was not open to file for IDR within the
    required 4 days.
        Would the Department of Health and Human Services (HHS) be willing
    to open a 30-day window for reconsideration of all claims between
    January 1, 2022 and April 14, 2022, allowing providers to initiate Open
    Negotiations now that the Federal IDR portal has been established?
        Answer. The Federal Independent Dispute Resolution (IDR) system
    went live on April 15, 2022, and CMS has posted operational guidance
    for providers and plans on the CMS No Surprises Act website. As
    described in regulations and operational guidance, a 30-day open
    negotiation period may begin after a provider or facility receives a
    payment or denial notice from a health plan or issuer for applicable
    out-of-network services. At the end of the 30-day open negotiation
    period, if the health plan or issuer and provider or facility haven't
    agreed on a payment amount, either party can submit the item(s) or
    service(s) for review in the IDR process. If the disputing parties
    experience extenuating circumstances during the IDR process that
    prohibit them from complying with deadlines to submit information, they
    may email the Departments at: FederalIDRQuestions@cms.hhs.gov and
    include the IDR dispute reference number, if known, to receive a
    Request for Extension Due to Extenuating Circumstances form and
    instructions for next steps. Consumers, providers, facilities, plans,
    issuers, and FEHB carriers with questions about the No Surprises Act
    can call the No Surprises Help Desk at 1-800-985-3059.
        Question. According to the No Surprises Act Interim Final Rules,
    insurers must provide an email and physical address to submit Open
    Negotiations. However, I have heard from many providers that insurers
    are inhibiting the flow of claims information by creating unnecessary
    steps for providers who wish to exchange information on claims and
    submit open negotiations, such as by withholding the required contact
    information, withholding information on payment remittances, or by
    requiring providers to register with various websites.
        Will there be proper oversight to ensure these obstructive
    practices are not occurring, and that proper transparency, as required
    by law, is taking effect? What will the Administration to do prohibit
    these burdensome hurdles impacting Open Negotiations?
        Answer. HHS--together with our colleagues at the Department of
    Labor, Department of the Treasury, and Office of Personnel Management--
    has been working to implement the No Surprises Act (NSA) and ensure
    that consumers receive the benefits of the protections included in the
    law by Congress. We have released regulations and guidance for
    providers, group health plans, health insurance issuers, and FEHB
    carriers that explain the requirements related to the processing of
    claims and the open negotiation process. We will continue to work to
    provide additional training and technical assistance to help
    stakeholders understand their obligations and comply with key
    requirements of the NSA.
        We are committed to ensuring compliance with the requirements of
    the NSA and its implementing regulations. If you are hearing from
    providers or plans about issues regarding compliance with the
    requirements of the NSA, they should submit a complaint to the No
    Surprises Help Desk at https://www.cms.gov/nosurprises/consumers/
    complaints-about-medical-billing or by calling 1-800-985-3059.
        Question. It was clear that the No Surprises Act was intended to
    force providers and insurers to move in-network, avoiding the IDR
    process altogether, creating a smoother process for all parties
    involved. I am concerned, because in reality, everything I was afraid
    of happening, is. I have heard from various providers that insurers are
    using the No Surprises Act as leverage to cut in-network provider
    contracts in half during negotiations. Others who have established the
    necessary amount of contracts to establish a ``Median In-Network'' rate
    are sending providers notices stating their networks are ``closed'' to
    additional providers.
        How is HHS addressing the issue of narrowing of networks and these
    predatory practices?
        Answer. Under CMS's Notice of Benefit and Payment Parameters for
    2023 Final Rule, CMS finalized regulatory changes in the individual and
    small group health insurance markets and establishes parameters and
    requirements issuers need to design plans and set rates for the 2023
    plan year. The rule also includes regulatory standards to help states,
    the Marketplaces, and health insurance companies in the individual and
    small group markets better serve consumers.
        Under the final rule, CMS finalized changes to ensure that patients
    have access to the right provider, at the right time, in an accessible
    location. The rule requires qualified health plans (QHPs) on the
    federally-facilitated Marketplaces (FFMs) to ensure that certain
    classes of providers are available within required time and distance
    parameters. For example, a QHP on the FFMs will be required to ensure
    that its provider network includes a primary care provider within ten
    minutes and five miles for enrollees in a large metro county. The rule
    also sets a standard, starting in the 2024 plan year, requiring QHPs on
    the FFMs to ensure that providers meet minimum appointment wait time
    standards. For example, QHPs will be required to ensure that routine
    primary care appointments are available within 15 business days of an
    enrollee's request. Additionally, HHS will review additional
    specialties for time (i.e., the time it takes the enrollee to get an
    appointment) and distance (i.e., the distance between the provider and
    enrollee)--including emergency medicine, outpatient clinical behavioral
    health, pediatric primary care, and urgent care. OB/GYN parameters will
    also be aligned with the parameters for primary care.
        Additionally, Section 109 of Title I of Division BB of the
    Consolidated Appropriations Act, 2021, requires HHS, in consultation
    with the Federal Trade Commission and the Attorney General, to conduct
    a study of the effects of the No Surprises Act on market concentration,
    healthcare costs, and access. The first report is due no later than
    January 1, 2023, and four additional reports shall study the effects of
    the Act in the four subsequent years.
        Question. I understand that medical procedures account for 96
    percent of all human exposure to man- made radiation. This can result
    in severe burns, cataracts, cognitive dysfunction, immunosuppression,
    and even cancer--in patients and clinicians. While the CDC embraces the
    guiding principle for radiation safety of ``as low as reasonably
    achievable,'' or ``ALARA'', it is not aligned with current medical
    procedures; increased use of high- radiation procedures like
    fluoroscopy to place stents; extensive clinical data on the dangers of
    radiation exposure and need for utilizing better precautions; and the
    latest shielding technologies that can prevent this excessive,
    avoidable radiation exposure.
        How can we address this with appropriate guidance communicated
    effectively to providers to prevent harm to them and their patients,
    especially regarding simple changes like appropriate radiation
    shielding?
        Answer. Keeping in mind the diagnostic and potentially life-saving
    value that these procedures provide to the public, the principles of
    justification and optimization are essential to the practice of
    radiation medicine. Are the diagnostic procedures indicated or
    warranted (justification), and if so, are the procedures of high
    quality to gain the needed diagnostic information with minimal dose
    (optimization)? CDC sponsored the National Council on Radiation
    Protection and Measurements (NCRP) to conduct the most recent estimate
    of radiation doses to the U.S. population. This NCRP study provided an
    update to the earlier estimate in 2009 that indicated the sharp
    increase in average dose to the U.S. population due to the evolving
    technology and use of these diagnostic tools.
                                     ______

                   Questions Submitted by Senator Hyde-Smith
        Question. Local pharmacies and pharmacists have long been a trusted
    and vital part of our local healthcare community. 9 in 10 Americans
    live within 5 miles of a pharmacy, and many of those Americans have
    come to rely on their pharmacy during the pandemic to provide vital
    access to COVID-related services, including testing, vaccinations, and
    treatments. Pharmacists were central to combating COVID-19, providing
    more than 245 million vaccine doses and millions of tests across
    20,000+ pharmacies nationwide. However, CMS treats pharmacists
    differently than other healthcare professionals when it comes to
    providing these services, and, ultimately, CMS does not have the
    necessary payment structure to appropriately reimburse pharmacists for
    these services.
        Secretary Becerra, can you please elaborate on the efforts CMS has
    taken to expand pharmacist provider status/reimbursement during the
    COVID-19 PHE, and clarify which flexibilities granted to pharmacists
    can and will be extended beyond the PHE? Specifically, how will
    pharmacists receive reimbursement for COVID-19 tests and vaccine
    administration after the PHE?
        Answer. Pharmacists are essential parts of our healthcare system
    and are playing an important role in the response to the COVID-19
    public health emergency. Pharmacists may perform certain tests if they
    are enrolled in Medicare as a laboratory, in accordance with a
    pharmacist's scope of practice and state law. In addition, pharmacists
    can enroll as mass immunizers and bill Medicare for administering Part
    B vaccines.
        We have explicitly clarified that pharmacists fall within the
    regulatory definition of auxiliary personnel under our regulations. As
    such, pharmacists may provide services incident to the professional
    services and under the appropriate level of supervision of the billing
    physician or practitioner, if payment for the services is not made
    under the Medicare Part D benefit. This includes providing the services
    incident to the services of the billing physician or practitioner and
    in accordance with the pharmacist's state scope of practice and
    applicable state law.
        Question. 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
    $3.5 million, despite the tremendous cost of CKD to society, Medicare,
    and Medicaid. We must increase awareness and early detection of kidney
    disease via a national kidney disease awareness public health
    initiative, which the CKD Initiative at CDC is poised to do with proper
    funding and community partnership.
        Please comment on efforts to expand the Chronic Kidney Disease
    Initiative to meet this awareness and early detection need.
        Answer. The Chronic Kidney Disease (CKD) Initiative currently
    conducts several activities to promote kidney health, including
    collaborating with partners to support and enhance the CKD Surveillance
    System. This system tracks kidney disease and its risk factors over
    time and monitors progress in prevention, detection, and management.
        The CKD initiative works to:
      --Increase public awareness of CKD, its risk factors, and
            complications through scientific publications, provider
            resources, featured articles, and other educational resources.
      --Promote early diagnosis and treatment of CKD by
        --Encouraging providers to use the CKD e-phenotype to detect CKD in
                people early on, help manage CKD, and help reduce CKD-
                related complications such as heart disease and kidney
                failure.
        --Publishing on the state-level awareness of CKD in the U.S.
        --Sharing information for the public on prevention and risk
                management, and how to take care of your kidneys.
      --Conduct surveillance, epidemiology, health outcomes, and economic
            studies in partnership with other offices at CDC, other
            government agencies, universities, and national organizations.
        CDC is committed to the CKD Initiative, and its important work has
    been highlighted in HHS' Advancing American Kidney Health Initiative.
    In the fiscal year 2022 Omnibus, the CKD Initiative received an
    increase of $1 million dollars from fiscal year 2021 funding (total of
    $3.5 million). While continuing the current work of the CKD Initiative,
    CDC is using the funding increase to:
      --Study the effects of youth-onset type 2 diabetes on kidney
            structure, function, and complications to identify novel and
            specific targets for CKD prevention and treatment.
      --Update the CKD cost effectiveness studies to include new data,
            treatments, and numerous advances in our understanding of CKD
            and its causes, progression, and treatment.
      --Expand the analytical capacity of the CKD Surveillance System,
            including analysis of large datasets and incorporating new
            indicators of the social determinants of health and CKD
            morbidity at the national, state, and county levels.
      --Examine trends in incidence of end stage kidney disease, diabetes
            complications, and impact on high-risk populations.
        Question. There have been recent positive changes to clinical
    practice in the diagnosis of kidney disease, namely the adoption of new
    equations for estimating GFR that do not include race as a modifier.
        What else is NIDDK doing to elevate kidney-specific research and
    interventions to eliminate racial and ethnic disparities in kidney
    care? Specifically, can you comment on investments in research
    initiatives that bridge existing deficits in CKD management and
    treatments to reduce incidence and progression, increase the number of
    CKD clinical trials related to kidney disease (including efforts to
    enhance participation of under- represented populations), identify
    strategies to improve the delivery of evidenced-base care in under-
    represented populations, and address issues related to kidney patients'
    quality of life?
        Answer. Addressing disparities in kidney disease outcomes is a
    major research priority for the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK). Recognizing that new approaches
    are needed, the Institute held a workshop in February 2022 aimed at
    helping design interventions to address structural racism in kidney
    health disparities. An important outcome of this effort is a
    forthcoming initiative, recently approved by the NIDDK's Advisory
    Council, inviting clinical trials to develop and implement these and
    other interventions in hopes of providing new, evidence-based solutions
    to overcome disparities in chronic kidney disease and end stage renal
    disease (also known as ESRD or kidney failure) care and outcomes.
        The NIDDK is also determined to improve care and reduce disparities
    in management of advanced kidney disease. For example, ESRD
    disproportionately affects African Americans and can severely affect
    quality of life, particularly for the roughly half of ESRD patients who
    experience severe pain. The Hemodialysis Pain Reduction Effort (HOPE)
    clinical trial is exploring non-opioid methods of pain management and
    improving quality of life, with a focus on heavily affected
    communities. The trial is engaging participants as partners in the
    research process and study management to strengthen the science--
    efforts that have also helped accelerate recruitment of new
    participants.
        A variation in the APOL1 gene that is more common in people of
    African descent than in other populations is one factor accounting for
    kidney disease disparities among African Americans. However, it is not
    yet well understood how APOL1 variation might affect outcomes for
    kidney donors or recipients. The APOL1 Long-term Kidney Transplantation
    Outcomes Consortium is currently addressing these vital questions,
    while employing a ground-breaking patient-engagement effort that served
    as a model for HOPE and other studies. Another factor that worsens
    disparities in outcomes for people with ESRD is the relative lack of
    access to transplanted kidneys for communities of color. The NIDDK and
    the Patient Centered Outcomes Research Institute are therefore working
    together to fund the System Interventions to Achieve Early and
    Equitable Transplants (STEPS) Study, an intervention designed to
    improve access to transplantation for African Americans through
    healthcare system change.
        Question. Studies indicate that we could have over one million
    people in kidney failure and need a transplant by 2030. Yet, each year,
    thousands of recovered kidneys go un-transplanted, while every day, 12
    people die waiting for a kidney transplant. Recently there has been
    additional scrutiny into our organ procurement and transplantation
    system, yet no major policy proposals have been announced to improve
    this appalling failure of care. Organ Procurement Organizations are the
    sole stakeholders in the transplant ecosystem responsible for
    recovering and transporting deceased organs without legitimate
    oversight and accountability to ensure quality assurance and
    performance improvement. Transplant centers desperately need financial
    incentives to accept less than perfect kidneys and care for complex
    transplant patients. People of color and underserved communities face
    numerous hurdles in being referred for a transplant evaluation.
        What is HHS planning to do to reduce organ discards, improve
    transplantation, and minimize racial and ethnic disparities in
    transplantation access?
        Answer. Organ procurement organizations (OPOs) are vital partners
    in the procurement, distribution, and transplantation of human organs
    in a safe and equitable manner for all potential transplant recipients.
    The role of OPOs is critical to ensuring that the maximum possible
    number of transplantable human organs is available to individuals with
    organ failure who are on a waiting list for an organ transplant. HHS is
    dedicated to improving health equity and access in the organ
    procurement and transplantation system, including by holding OPOs
    accountable for their performance.
        In December 2020, CMS published ``Medicare and Medicaid Programs;
    Organ Procurement Organizations Conditions for Coverage: Revisions to
    the Outcome Measure Requirements for Organ Procurement Organizations''.
    This rule finalized new outcome measures OPOs are required to meet for
    re-certification and was published with the intention of increasing
    donation and organ transplantation rates by replacing the previous
    outcome measures with new transparent, reliable, and objective outcome
    measures that are used to make better certification decisions and
    incentivize better performance. The revised measure will encourage OPOs
    to pursue all potential donors, even those who are only able to donate
    one organ. CMS estimates that if every OPO were to meet or exceed this
    measure, we could have approximately 5,600 more organs per year to
    transplant.
        HRSA is committed to an equitable and timely organ donation and
    transplant system. This spring, HRSA issued a Request for Information
    (RFI) to solicit feedback about opportunities to strengthen the Organ
    Procurement and Transplantation Network (OPTN). In particular, the RFI
    sought feedback on the ways to address many of the National Academies
    of Science, Engineering, and Medicine findings and recommendations in
    its report titled Realizing the Promise of Equity in the Organ
    Transplantation System. HRSA released the RFI to better support HRSA's
    efforts to increase accountability in OPTN operations, modernize
    performance of the OPTN IT system and related tools, and improve
    engagement with donors and patients. It specifically focuses on
    opportunities to strengthen equity, access, and transparency. HRSA is
    appreciative of the response to the RFI and is actively reviewing this
    important feedback to inform the development of the next contracting
    cycle. We look forward to continuing to engage with Congress as we
    develop the next contracting cycle and continue to identify strategies
    for modernization and accountability across the organ procurement and
    transplantation system. In addition, HRSA is collaboratively working
    with its CMS colleagues on an End Stage Renal Disease Treatment
    Learning Collaborative (ETCLC) project designed to capture and share
    best practices and processes to increase transplants and reduce
    discards. The ETCLC focuses on kidney transplants, which make up
    approximately 85 percent of the total waiting list. Improvements in
    this area will have a broad impact on the system. HRSA is committed to
    the critical work of continuously improving the organ donation and
    transplantation system, and looks forward to continuing to work with
    you on this issue.
                                     ______

                  Questions Submitted by Senator Patrick Leahy
        Question. Due to a long-standing Federal policy known as the
    `institutes of mental disease' (IMD) exclusion, states are prohibited
    from claiming Federal Medicaid funds for in-patient mental health
    services delivered to eligible individuals residing in hospitals or
    institutions of more than 16 beds. While the exclusion was originally
    intended to ensure that maintained primary financial responsibility for
    inpatient psychiatric care and reduce the Federal cost share, it has no
    clinical rationale and inhibits access to critical services for
    Medicaid beneficiaries. This includes individuals suffering from
    substance use disorders, which has hit an all-time high during the
    COVID-19 pandemic. Many states such as Vermont are facing a critical
    shortage to appropriate and timely mental healthcare that results from
    a lack of funding for in-patient psychiatric beds.
        What would be the fiscal cost over 10 years to repealing the IMD
    exclusion?
        How can Congress work with the agency to overcome the barriers
    caused by the IMD exclusion and increase access to much needed in-
    patient mental health treatment?
        Concurrently, how will the President's budget be used to
    incentivize and help states develop and provide community-based
    services for individuals suffering from mental health disorders?
        Answer. The Biden-Harris Administration is committed to expanding
    access to affordable care, including inpatient psychiatric and
    substance use disorder care when appropriate. While the Medicaid
    statute prohibits states from receiving Federal financial participation
    for services delivered to most individuals residing in an IMD, CMS has
    worked within the confines of the law to provide states with
    flexibility to increase access to these services. For example, CMS has
    approved Medicaid section 1115 demonstrations that allow state Medicaid
    programs to pay for services provided to adults with serious mental
    illness/serious emotional disturbance or substance use disorder who are
    short-term residents in an institution for mental disease (IMD).
    Similarly, managed care organizations (MCOs) are permitted to reimburse
    up to 15 days per month of treatment in IMDs as an in-lieu of service--
    that is, a service that is not included under the state plan, but is a
    clinically appropriate, cost-effective substitution for a similar,
    covered service.
        When appropriate, the Biden-Harris Administration also supports
    strengthening home and community-based services (HCBS) as an
    alternative to institutionalized care, in order to ensure that people
    have access to safe options that work for them. People are happier and
    healthier when they live in their community, and living in one's own
    home and community usually costs less than care in an institution. The
    department is working hand-in-hand with states to ensure they have the
    time and support they need to strengthen their home care systems. HHS
    recognizes the importance of HCBS which allow millions of Medicaid
    beneficiaries to receive services in their own home or community rather
    than institutions or other isolated settings. HHS looks forward to
    working with Congress to improve this access.
        Question. The COVID-19 pandemic has exacerbated a youth mental
    health crisis in our country. A recent NIH-funded study revealed that
    since the start of the pandemic, there has been an increase in the
    number of suicides among youth 10-to-19 years of age. In the past year,
    nearly 200 Vermont children have sought care for mental health related
    issues at emergency rooms. Many of these children had to wait an
    average of over 24 hours before they were seen for care. Rural states
    like Vermont also face significant barriers to meeting the demand for
    mental healthcare, the most prevalent being the shortage of behavioral
    healthcare clinicians. I strongly support proposed investments in
    school-based mental healthcare, early childhood intervention, community
    mental health centers, and the 988 suicide prevention and crisis
    support line to start to address these issues.
        How will the agency use the proposed investments for youth mental
    health to ensure that rural areas can adequately train, recruit and
    retain behavioral healthcare providers that are pediatric specialists?
        Answer. SAMHSA oversees multiple grant programs that support
    training pediatric behavioral healthcare providers.
        SAMHSA's Infant and Early Childhood Mental Health grant program
    helps to address the national shortage of mental health professionals
    with infant and early childhood expertise by training early childhood
    providers and clinicians to identify and treat behavioral health
    disorders of early childhood. In fiscal year 2021, grantees trained
    4,003 clinicians and early childhood providers on evidence-based mental
    health treatments for infants and young children. The Mental Health
    Awareness Training grant program trains individuals, including primary
    care and specialty healthcare providers, how to respond to individuals
    with mental disorders appropriately and safely. The Certified Community
    Behavioral Health Clinic Improvement and Advancement grant program
    includes a staff training requirement as part of the overarching goal
    of enhancing and improving community behavioral health systems.
        SAMHSA also supports technical assistance centers that provide,
    among other things, training to pediatric healthcare providers. These
    centers include the Suicide Prevention Resource Center, National Child
    Traumatic Stress Network, and Mental Health Technology Transfer Center
    Network.
        To strengthen the mental health and substance use disorder
    workforce, the fiscal year 2023 budget provides an investment of $397
    million for HRSA's Behavioral Health Workforce Development Programs,
    which is $235 million above fiscal year 2022 enacted level. This
    funding will increase training of new behavioral health providers,
    including a track for health support workers such as peer support
    specialists and community health workers and place an emphasis on team-
    based care. In order to promote inclusive and equitable behavioral
    healthcare for youth, this investment will support a special focus on
    the knowledge and understanding of children, adolescents, and youth at
    risk for a mental health disorder, Serious Emotional Disturbance, or
    substance use disorder. The Behavioral Health Workforce Development
    Programs includes $225.8 for Behavioral Health Workforce Education and
    Training (BHWET) Programs. In fiscal year 2023, the BHWET Programs seek
    to establish and expand field placements, internships, and experiential
    sites for behavioral health professionals and paraprofessionals to
    train, especially among children- and youth-focused community-based
    partners who are able to conduct trainings in school-based settings. A
    special focus is placed on the knowledge and understanding of children,
    adolescents, and transitional-aged youth at risk for a mental health
    disorder, Serious Emotional Disturbance (SED), and/or substance use
    disorder.
        The Budget also includes increases in Primary Care Training and
    Enhancement and Nurse Education, Practice and Retention to expand
    behavioral health services into primary care.
        In fiscal year 2022, HRSA received $5 million for a pediatric
    specialty loan repayment program under which participants will be
    employed full-time for a specified period, of not less than 2 years, in
    providing pediatric medical subspecialty, pediatric surgical specialty,
    or child and adolescent mental and behavioral healthcare, including
    substance use disorder prevention and treatment services. Program
    participants will be required to work in, or for a provider serving, a
    health professional shortage area or medically underserved area, or to
    serve a medically underserved population.
        The fiscal year 2023 President's Budget proposes $10 million for
    the Pediatric Mental Health Care Access (PMHCA) program, which has
    played an important role in helping to increase access to specialized
    mental health providers and build provider capacity for children in
    rural areas. The PMHCA program promotes behavioral health integration
    in pediatric primary care through new or expanded statewide or regional
    pediatric mental healthcare telehealth programs. These networks of
    specialized pediatric mental healthcare teams provide tele-
    consultation, training, technical assistance, and care coordination to
    assist pediatric primary care providers.
        Through the PMHCA Program, pediatric primary care providers are
    able to diagnose, treat and refer children to the care they need for
    behavioral health concerns. Telehealth technologies promote long-
    distance clinical healthcare, clinical consultation, and patient and
    provider education, helping address challenges in accessing behavioral
    health clinicians who treat behavioral concerns in children and
    adolescents.
        The number of primary care providers enrolled in the PMHCA Program
    increased from 1,963 in fiscal year 2019 to 4,511 in fiscal year 2020.
    Authorization for the PMHCA program expires at the conclusion of fiscal
    year 2022.
        In addition, the fiscal year 2023 President's Budget includes $57.3
    million, a $3 million increase over fiscal year 2022 enacted, for
    HRSA's Autism and other Developmental Disorders program. Among other
    programs, this investment supports the Developmental-Behavioral
    Pediatrics Training Program (DBP) that trains Fellows in developmental
    behavioral pediatrics to address the broad range of behavioral,
    psychosocial, and developmental concerns that pediatric primary care
    providers see. The program also supports practitioners' ability to
    provide proven interventions to children's behavioral and developmental
    concerns, including for individuals with autism spectrum disorder and
    other developmental disabilities. In fiscal year 2020, the DBP Training
    Program trained over 1,400 DBP Fellows, medical students and pediatric
    residents. DBP graduate survey results show that 5 years following
    completion of the program, 100 percent of DBP Fellows demonstrated
    leadership, worked in an interdisciplinary manner, and worked with
    maternal and child health populations, including those considered to be
    underserved. The proposed fiscal year 2023 increase will help support
    the DBP program, as well as the Leadership Education in
    Neurodevelopmental and Other Related Disabilities (LEND) Training
    program to address unmet needs and disparities in evaluation,
    diagnosis, and treatment. For DBP, funding will allow expansion of the
    DBP program including increased fellowship opportunities for existing
    awardees.
        Finally, the fiscal year 2023 President's Budget supports the Child
    and Adolescent Health Promotion Services Program, referred to as the
    Bright Futures Program. This program supports quality health promotion
    and preventive services for all children, adolescents, and young adults
    through evidence-driven, strengths-based clinical guidance. This
    includes the Periodicity Schedule of the Bright Futures Recommendations
    for Pediatric Preventive Health Care (``Periodicity Schedule''), which
    includes preventive services that group health plans and health
    insurance issuers must cover without cost sharing. The Periodicity
    Schedule recommends several mental and behavioral health screenings be
    conducted during well visits. This program serves providers across the
    country, including those in Health Provider Shortage Areas (HPSA),
    Medically Underserved Areas (MUA), and providers who serve patients
    from historically marginalized backgrounds.
        Question. Vermont, like many other states, is currently facing a
    severe nursing shortage. The State has forecasted 6,244 vaccines within
    the nursing professions within the next 2 years, largely caused by an
    aging workforce and mental burnout that has been accelerated by the
    COVID-19 pandemic. There is also an inadequate number of nursing
    educators to train the next generation of nurses.
        How can HHS help states to build and bolster resilient nursing
    pipelines and nurse training programs?
        Answer. CDC makes essential workforce and training resources
    accessible across the globe through the Department of Health and Human
    Services, CDC, and state and local health departments. CDC's
    fellowships are a pathway for training and recruiting the next
    generation of public health leaders, including nurses.
        With short-term ARP funds, CDC is working with the Corporation for
    National and Community Service (CNCS) to place members onsite at public
    health departments to help meet current staffing needs for the COVID
    response. This is one component of a longer-term program to support
    ongoing public health staffing needs and future surge staffing needs
    for emergencies. While meeting immediate staffing needs, the Public
    Health AmeriCorps, established jointly between CNCS and CDC will also
    include a goal of creating a pathway of entry level, future public
    health professionals, including nurses. The joint venture between
    AmeriCorps and the CDC received 122 applications representing community
    organizations from 41 of 50 states. Funding decisions and notices of
    awards from AmeriCorps were released in April 2022. For more
    information: https://americorps.gov/newsroom/press-release/americorps-
    cdc-award-more-60-million-public-health-americorps-programs-part.
        CDC is providing $3 billion in grants to state, territorial, and
    local jurisdictions. CDC plans has posted the notice of funding
    opportunity, and awards will be made in 2023. Funding will support
    hiring, retention and training of public health workers, particularly
    from the communities they are intended to serve, and will permit the
    funding of a broad range of public health workers, including nurses and
    public health nurses and other community health professionals.
        The nursing pipeline is supported and enhanced through HRSA
    programs:
      --The Nurse Corps Scholarship and Loan Repayment Programs assist in
            the recruitment and retention of nurses while reducing the
            financial barrier to nursing for all levels of professional
            nursing students and increase the pipeline of nurses by
            supporting nurses and nursing students committed to working in
            communities with high need. Additionally, the Nurse Corps
            program supports nurse faculty who will train the next
            generation of nurses. In fiscal year 2023, HRSA anticipates
            funding scholarship and loan repayment awards.
      --Another challenge for advancing and growing the nursing field is
            recruitment and training of nurse faculty. To address this
            issue, in fiscal year 2023, HRSA will also support the Nurse
            Faculty Loan Program (NFLP), which provides funding to
            accredited schools of nursing to establish and operate a
            student loan fund and provide loans to students enrolled in
            advanced education nursing degree programs who are committed to
            becoming nurse faculty. In exchange for completion of up to 4
            years of post-graduation full-time nurse faculty employment in
            an accredited school of nursing, the program authorizes
            cancelation of up to 85 percent of the student loan.
      --An additional area of focus in our nursing work is recruiting and
            training nurses who are underrepresented in the nursing
            profession. The Nursing Workforce Diversity (NWD) Program
            supports nurse training for individuals from disadvantaged
            backgrounds (including racial and ethnic minorities
            underrepresented among registered nurses).
      --The fiscal year 2023 Budget Request also would support the Advanced
            Nurse Education Program at $105.6 million, $20 million above
            the fiscal year 2022 enacted level. The Budget includes an
            increase of $20 million for grants to grow and diversify the
            maternal and perinatal health nursing workforce by increasing
            and diversifying the number of Certified Nurse Midwives with a
            focus on practitioners working in rural and underserved
            communities.
      --The Scholarships for Disadvantaged Students (SDS) Program dedicates
            16 percent of its total budget to providing scholarships to
            educate and train bachelor and graduate-level nurses and nurse
            midwives from disadvantaged backgrounds to address nursing
            shortages in rural and underserved communities. The SDS Program
            currently funds 25 bachelor and graduate-level nursing schools
            across the United States and its territories.

                              SUBCOMMITTEE RECESS

        Senator Murray. The committee will next meet in Dirksen
    138, Wednesday, May 17, at 10 a.m. for a hearing on the Biden
    Administration's budget request for the National Institutes of
    Health. The committee is adjourned.
        [Whereupon, at 11:10 a.m., Wednesday, May 4, the
    subcommittee was recessed, to reconvene at 10 a.m., Wednesday,
    May 17.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2023

                                  ----------

                             TUESDAY, MAY 17, 2022

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:02 a.m. in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Durbin, Reed, Baldwin, Blunt,
    Moran, Kennedy, Braun, and Rubio.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF LAWRENCE TABAK, D.D.S., PH.D., ACTING
                DIRECTOR
    ACCOMPANIED BY:
            ANTHONY FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY
                AND INFECTIOUS DISEASES
            GARY GIBBONS, M.D., DIRECTOR, NATIONAL HEART, LUNG, AND BLOOD
                INSTITUTE
            JOSHUA GORDON, M.D., PH.D., DIRECTOR, NATIONAL INSTITUTE OF
                MENTAL HEALTH
            RICHARD HODES, M.D., DIRECTOR, NATIONAL INSTITUTE ON AGING
            NORA VOLKOW, M.D., DIRECTOR, NATIONAL INSTITUTE ON DRUG ABUSE

                   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 2023 budget request for the
    National Institutes of Health.
        Senator Blunt and I will each have an opening statement.
    Then I will introduce our witnesses. And after their testimony,
    Senators will each have 5 minutes for a round of questions.
        While we were unable to have this hearing fully open to the
    public, or media for in-person attendance, live video is
    available on our committee website. If you are in need of
    accommodations, including closed captioning, you can reach out
    to the Committee or the Office of Congressional Accessibility
    Services.
        Every day across my Home State of Washington, researchers
    at the Fred Hutch Center, University of Washington, Washington
    State University, Seattle Children's hospital, and so many
    other world-class institutions are working around the clock and
    making ground-breaking discoveries.
        Discoveries that don't just drive innovation and economic
    growth, but also bring families, cures, and treatments, and
    hope for the future, discoveries that saves lives, discoveries
    that don't just drive innovation and economic growth, but also
    bring families cures, and treatments, and hope for the future.
        I am pleased to say this budget request shows the
    administration understands the tremendous importance of
    supporting our Nation's biomedical research community, and
    continuing our tradition of global leadership here, especially
    as in the past few years, have been such a stark reminder of
    how the investments we make in research today pay off down the
    road.
        The rapid development of safe, effective COVID vaccines was
    made possible by research into mRNA vaccines we funded, in
    response to Ebola and other viruses, and by a biomedical
    research enterprise that has been built over decades.
        And today, thanks to the vaccines and therapeutics that NIH
    (National Institutes of Health) researched to help develop,
    COVID deaths and hospitalizations are the lowest we have seen
    in 2 years. However, we are not out of the woods yet when it
    comes to this pandemic. There is still the threat of new, more
    deadly variants, especially right now when caseloads are
    inching up again, but our communities' resources have largely
    been spent down.
        We need to defend the hard-won progress we have made, and
    that means passing emergency COVID funding, so our communities
    have the tests, and treatments, and vaccines, and tools they
    need to keep families safe.
        This is really urgent. So I am going to keep fighting to
    make sure we get it done. And in addition to providing our
    communities the resources they need to fight this pandemic, I
    hope we are able to come together this year, as we have so many
    times in the past, to continue providing our researchers what
    they need to help us to fight COVID-19, and so many other
    challenges.
        Challenges like: Developing better tests, making next-
    generation vaccines that are effective against all COVID
    variants, and understanding long COVID, and how we support the
    millions of people who are living with it; and challenges like
    the mental health crisis this pandemic has made so much worse,
    especially for young people, or overdose deaths which have been
    skyrocketing due to the rise of fentanyl.
        Recently, our Nation lost a record 107,000 people to
    overdose deaths in a single year, and in Washington State,
    opioid deaths increased by two-thirds in 2021. This crisis is
    tearing a hole in so many communities, so many families, it is
    truly heartbreaking, and we have to pull out all the stops to
    get this under control.
        That is why I am working on bipartisan legislation to
    strengthen programs that help our first responders, healthcare
    professionals, and others on the front lines. And why I want to
    make sure we continue investing in research here like this
    budget proposes.
        Of course the measure of success against any disease is not
    how much we invest to fight it; it is how much we are helping
    patients. For example, when it comes to Alzheimer's disease,
    that is exactly what we need to be focused on, for patients
    fighting this disease the stakes are intensely personal. They
    are fighting to hold onto cherished memories with loved ones,
    and a feeling of control over their daily lives, and the weight
    of that fight falls on their family members, friends, and
    caregivers.
        With so much at stake in their lives, these families
    deserve to know the research projects they are depending on are
    being thoughtfully designed and prioritized for meaningful
    outcomes and results. This is really important for me,
    especially when we have increased funding for Alzheimer's
    research six-fold since 2015; when the 2025 target date that is
    established in the National Alzheimer Project Act is just
    around the corner, and when there are so many other terrible
    diseases families are desperate for NIH to put more resources
    into as well.
        Another important undertaking is the launch of the Advanced
    Research Projects Authority for Health, which aims to break the
    mold for how cutting-edge research is conducted, speed up the
    discovery and development of medical treatments, and support
    projects that have the potential to transform medicine.
        I worked hard to provide resources to establish ARPA-H
    (Advanced Research Projects Agency for Health) in our
    bipartisan funding bill earlier this year, and I am working
    hard right now to pass the Prevent Pandemics Act to set it up
    for long-term success.
        That requires striking a balance to ensure ARPA-H can
    complement NIH's expertise while still operating independently
    to nimbly seize opportunities to accelerate innovation and
    breakthroughs.
        I am focused on getting that balance right, so I will be
    asking more about why so much of the NIH budget increase,
    requested by the administration, goes towards ARPA-H when it is
    yet to bring on a staff and what that means for the other NIH
    institutes and centers.
        Of course at the end of the day, innovation isn't 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 this work is to our families, we
    can't afford to have this agency's potential limited, or its
    success threatened by bias, discrimination, or harassment in
    the workplace.
        We have to do more to address harassment in the biomedical
    research community, as well as address the fact that the number
    of researches of color is too low, and even clinical trials
    often fail to be adequately representative.
        These are real problems with real consequences for
    research, and I have been pressing for progress on this for
    years. So I have been glad to see NIH working to examine
    barriers to diversity among its researchers, address how its
    practices have reimbursed structural biases and discrimination,
    and implementing a new policy, as secured in this committee
    that requires those that receive NIH grants to notify the
    agency when a Principal Investigator is removed, even
    temporarily, for sexual harassment or bullying.
        But more work remains to be done to remove racism,
    discrimination, and harassment from research. And I will
    continue to follow our progress here.
        Finally, before I turn over to Senator Blunt, I just want
    to take a moment to note that this will be the last NIH hearing
    we have with him, and to say how grateful I am, Senator Blunt,
    for all the work with you on this issue over the years.
        It has been really great to have a partner across the aisle
    who really understands why these investments are so important
    to families, in Washington State, Missouri, across the country,
    and who is really willing to sit down and work in a bipartisan
    way to make sure we are delivering for folks back home.
        So thank you so much, Senator Blunt. And I will turn it
    over to you.

                         STATEMENT OF SENATOR ROY BLUNT

        Senator Blunt. Well, thank you, Chair. I appreciate the
    work we have done together. As you said, this is in my, in all
    likelihood, last NIH hearing. And as I have started to look
    back on the time I have spent in the Senate, one of the things
    I think will have the most long-term impact is what we have
    done together for NIH research.
        You have been a great partner in that effort. We have
    worked closely with Chairman DeLauro, and Congressman Cole, in
    the House, who chaired that subcommittee, and they both chaired
    the committee during the 8 years we have been doing this work
    together. The entire committee, of course, was involved, but I
    would particularly like to mention Senator Durbin and former
    Senator Alexander, who were right there at the beginning of
    trying to see what we could do to change a trajectory that,
    really, was not good.
        And of course, Dr. Tabak, thank you for you, and the
    directors being here with us today; and I think all of you
    would remember when I became chairman nearly 8 years ago, NIH
    funding was stagnant, and had been for about a decade, but over
    the past 7 years, working together, we have increased that
    funding by nearly 50 percent.
        It was a period of time that, looking back, the NIH, not
    only could count on sustained funding, but also having a
    substantial increase every year. And I am hopeful and confident
    that Senator Murray's continued partnership in that commitment
    will let us do that again this year. And I hope we are able to,
    successfully, work together and have a bill before the end of
    the year.
        I am disappointed that this budget request reduces funding
    for 12 of the 27 institutes, including the National Cancer
    Institute, and the National Institute of Allergy and Infectious
    Diseases. The latter, of course, was demonstrated over and over
    again how important it was during COVID. There are very few
    increases, frankly, that are proposed in this request, the
    increase in CURES is coincidental, and that this fiscal year
    2023 year has that number already built in.
        The only significant increase, as the Chair has pointed
    out, at NIH this year, would be an increase of $4 billion for
    ARPA-H. Now, I am a supporter of ARPA-H, I am a supporter of
    the Secretary's decision to have it associated with NIH. But a
    $4 billion increase for ARPA-H, and no increase for NIH would
    really verify the worst concerns that people have had, about
    ARPA-H as a competitor to our ongoing research, as opposed to
    finding a way where the government can and should be willing to
    take on more financial risks, to become a real partner in
    targeted research outcomes, that have a specific short-term
    goal in mind, and to help us reach that goal. That doesn't mean
    we should jeopardize research challenges as big as cancer, and
    Alzheimer's disease, or as small as hearing aids, as we look to
    build, frankly, on the goal of doing more of what we were able
    to do in the pandemic.
        I was also surprised that the budget request failed to take
    more of the lessons learned from the pandemic into
    consideration, instead of embracing more high-risk, high-reward
    science, and focusing on projects with instant impact which
    proves so successful with programs like RADx (Rapid
    Acceleration of Diagnostics), it appears that the budget got
    bogged down with political priorities that don't quite fit the
    agency's long-standing mission.
        This is clearly illustrated with a request for a new Center
    for Sexual Orientation and Gender Identity, yet virtually no
    additional money for the Cancer Moonshot. NIH is clearly in a
    period of transition. If there is one lesson to be learned from
    the COVID-19 pandemic, it is that our Nation's success depends
    on medical research infrastructure, across the country,
    supported by NIH.
        Now is not the time to abandon that goal, now is the time,
    in fact, to make it even stronger. And I hope the original, or
    the eventual budget that we propose to our colleagues in the
    Senate, and to the whole Congress, will reflect that
    determination, to make NIH stronger across the board rather,
    than the way this budget proposal looks at NIH.
        And Chair, thank you for your comments. And thank you for
    the chance to speak, and for holding this hearing.
        [The statement follows:]
                    Prepared Statement of Senator Roy Blunt
        Good morning. Thank you, Dr. Tabek and the other Institute
    Directors, for being here today.
        This is my last NIH hearing. As I've started to look back on my
    Senate career, one of my proudest accomplishments is realigning the
    priorities within the Labor/HHS bill to focus on medical research.
        When I became Chairman nearly 8 years ago, NIH funding was
    stagnant. And it had been that way for nearly a decade. But over the
    past 7 years, NIH funding has increased nearly 50 percent, and NIH
    could count on sustained funding and a substantial increase each year.
    I am hopeful, with Senator Murray's continued partnership and
    commitment, we will continue this legacy in my last Labor/HHS bill this
    year.
        I am disappointed, however, that Dr. Tabek has to defend a budget
    that is nearly indefensible. This is a budget request that reduces
    funding for 12 of the 27 Institutes, including the National Cancer
    Institute and the National Institute of Allergy and Infectious
    Diseases, the latter of which demonstrated its importance during the
    COVID pandemic. The very few and modest increases that are proposed in
    the budget request were likely only accomplished because CURES funding
    significantly increases in fiscal year 2023--a mere coincidence that
    was not determined by the Administration.
        The only significant increase NIH receives this year in the budget
    request is an increase of $4 billion for ARPA-H. I am a supporter of
    ARPA-H and particularly the Secretary's decision to house it within
    NIH. ARPA-H has the ability to translate what we learned during COVID--
    that the government can and should be willing to take more financial
    risks to become a real partner in research outcomes--and expand that
    model to other research challenges as big as cancer and Alzheimer's
    disease to as small as hearing aids.
        However, no matter how much I support the goal of ARPA-H, it cannot
    be the sole focus of NIH's budget request. And it cannot displace other
    scientific priorities or be funded at the expense of other critical
    research efforts.
        I am also surprised that the budget request failed to take more of
    the lessons learned during the pandemic into consideration to move the
    agency forward. Instead of embracing more high-risk, high-reward
    science and focusing on projects with instant impact, which proved so
    successful with programs like RADx, it appears that the budget got
    bogged down with political priorities that don't quite fit the agency's
    longstanding mission. This is clearly illustrated with a request for a
    new Center for Sexual Orientation and Gender Identity, yet virtually no
    additional funding for the Cancer Moonshot.
        NIH is clearly in a period of transition. The long-time Director
    has left and we are coming out of a pandemic that has been nearly the
    sole focus of the agency for the past two-and-a-half years. I hope NIH
    takes this opportunity to review its current mission and consider
    whether it aligns with where you want it to be and where you want it to
    go.
        If there is one lesson learned from the COVID-19 pandemic, it is
    that our nation's success depends on the medical research
    infrastructure across this country supported by NIH. Now is not the
    time to abandon it. Now is the time to make it even stronger.
        Thank you.

        Senator Murray. Thank you. I will now introduce our
    witnesses. We have Dr. Lawrence Tabak, he is the Acting
    Director of the National Institutes of Health; Dr. Anthony
    Fauci is the Director of the National Institute of Allergy and
    Infectious Diseases; Dr. Gary Gibbons is the Director of the
    National Heart, Lung, and Blood Institute; Dr. Joshua Gordon is
    the Director of the National Institute of Mental Health; and
    Dr. Nora Volkow is the Director of the National Institute on
    Drug Abuse.
        Welcome to all of you, and thank you for being here today.
        Acting Director Tabak, you may deliver your opening
    remarks.

                    SUMMARY STATEMENT OF DR. LAWRENCE TABAK

        Dr. Tabak. Thank you, Chair Murray, Ranking Member Blunt,
    and distinguished subcommittee members. I am honored to be here
    today with my colleagues representing the NIH. This is a time
    for NIH and the entire biomedical research community to
    reexamine all of our efforts. During the COVID-19 pandemic, we
    were driven by the urgency of the moment.
        NIH must learn from this experience, and seize the
    opportunity to define a new normal. As acting director, I am
    committed to new strategies, new voices, and a renewed focus on
    the future.
        Now is the time to reflect on what worked and did not work
    to address COVID and to shape new strategies. Your sustained
    investment in NIH research set the stage for the new mRNA
    technology, and immunogen design that were key to the
    development of safe and effective vaccines in an unprecedented
    timeline. Since these vaccines became available, it is
    estimated more than two million American lives were saved, and
    more than 17 million hospitalizations were averted.
        Now we need continued support for a wide range of
    biomedical fields, including the behavioral and social
    sciences, to identify and successfully implement better ways of
    responding to the short- and long-term health effects of COVID-
    19, to prepare for future pandemics, and to ensure equitable
    protection of our diverse population.
        And it is not just about vaccines. Our Rapid Acceleration
    of Diagnostics, our RADx Initiative, fueled the development of
    many new approaches for COVID-19 testing that are being used in
    the communities.
        To help ensure that such benefits were shared with of those
    disproportionately affected by the pandemic, we initiated
    efforts like RADx Underserved Populations, and the NIH
    Community Engagement Alliance. These experiences, along with
    other NIH-led efforts focus on COVID treatment development,
    demonstrate the extraordinary value of public-private
    partnerships.
        The NIH can build upon the momentum of the COVID response,
    and apply it to other challenges through the Advanced Research
    Projects Agency for Health, ARPA-H. Thanks to your inclusion of
    key authorities, and funding in the Omnibus, NIH is beginning
    to frame the basic administrative infrastructure for ARPA-H.
    This is a key first step in creating a permanent home for the
    strategic partnerships that are so urgently needed to address
    cancer, diabetes, Alzheimer's, and many other diseases.
        But we can't stop there. In addition to new strategies,
    biomedical research needs new voices. A growing body of
    evidence demonstrates that inclusion of diverse perspectives
    yields better outcomes. In the clinical setting medical teams
    provide--diverse medical teams provide more accurate diagnoses
    and improve health for patients while building trust.
        We do better science when we have a diversity of
    scientists, from different backgrounds and communities,
    scientific fields in various career stages. NIH continues to
    prioritize, fund and empower early-stage investigators so they
    can succeed as independent researchers.
        In 2021, we reached an all-time high of early-stage
    investigators, funded 1,513. The passion and commitment of our
    scientists is matched by the voices of people living with a
    wide range of diseases and conditions. Conversations with
    patients and their advocates are sometimes difficult, but those
    are often the discussions that teach us the most.
        From the AIDS (Acquired Immunodeficiency Syndrome) advocacy
    groups of the 1980s, to today's groups for autism, ME/CFS
    (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome), long
    COVID, and many others, these voices have refused to be
    ignored, and ultimately, all of us benefit.
        This is a moment for renewed focus on the future. I spent a
    lot of time encouraging early-stage scientists, but I also like
    to think about the importance of engaging elementary school-
    aged children, like those my wife has taught, for over 40
    years.
        During the pandemic, exposure to the importance of science
    has become a big part of many of their lives. Past pandemics
    have inspired young people to become scientists, but the images
    they saw were usually of older men who looked pretty much like
    me. Hopefully, today's kids are seeing more scientists who look
    like them.
        Still, we need to do better. Our Nation needs all the
    bright minds we can find, and I hope you will continue to work
    with the NIH to make this happen.
        Thank you for your time. And my colleagues and I welcome
    your questions.
        [The statement follows:]
             Prepared Statement of Lawrence A. Tabak, D.D.S., Ph.D.
        Good morning, Chair Murray, Ranking Member Blunt, and distinguished
    Members of the Subcommittee. I am Lawrence A. Tabak, D.D.S., Ph.D, the
    Acting Director of the National Institutes of Health (NIH). It is an
    honor to appear before you today.
        I am grateful for the committee's long-standing support for NIH.
    Whether it is cancer immunotherapy or sickle cell therapies or COVID-19
    vaccines, NIH's successes would not have been possible without the
    investment made by this committee.
        The fiscal year 2023 President's Budget will support science that
    helps tackle many critical national challenges: from initiatives to
    address health disparities, fight the rising tide of addiction, and
    transform nutrition science. The budget will also build upon the
    initial investment in the new Advanced Research Projects Agency for
    Health (ARPA-H).
                  advanced research projects agency for health
        The President's Request proposes $5 billion to fully operationalize
    ARPA-H \1\ in fiscal year 2023. This new agency will be a key component
    to drive transformational innovation in health research and we are
    grateful for your support. At the direction of the Secretary, we are
    working to create an ARPA-H that is free to innovate and take risks, an
    ARPA-H that leverages NIH infrastructure, and an ARPA-H that has
    unfettered and frequent access to all of the brightest minds across all
    research fields--from biomedicine to sociology to mathematics. In
    alignment with the DARPA model, ARPA-H will recruit term limited,
    visionary program managers who will use its catalytic platform to take
    on critical challenges in conjunction with traditional and
    nontraditional partners across academia, government, and industry.
    ARPA-H will use directive approaches that will provide quick funding
    decisions to support projects that are results- and use-driven and
    time-limited, and identify emergent opportunities through advanced
    systematic horizon scans of academic and industry efforts.
    ---------------------------------------------------------------------------
        \1\ 1 https://www.nih.gov/arpa-h.
    ---------------------------------------------------------------------------
        ARPA-H projects would be bounded in time, typically a few years
    with longer periods allowed for efforts that are highly complex, and
    with the understanding that a significant fraction of projects will not
    reach their goals, a necessary outcome when conducting ambitious,
    innovative research. To determine which bold questions should be
    undertaken and to evaluate proposed programs and projects, ARPA-H would
    adopt approaches similar to those utilized by DARPA, such as the
    ``Heilmeier Catechism,'' \2\ a set of principles that assesses the
    challenge, approach, relevance, risk, duration, and metrics of success.
    It will be critical for ARPA-H to engage with the broader biomedical
    community, including patients and their caregivers, researchers,
    industry, community groups, and others, to understand the full range of
    problems and the practical considerations that need to be addressed for
    all groups and populations.
    ---------------------------------------------------------------------------
        \2\ https://www.darpa.mil/work-with-us/heilmeier-catechism.
    ---------------------------------------------------------------------------
                                cancer moonshot
        The President's Cancer Moonshot\SM\ \3\ aims to accelerate progress
    in cancer research and make additional therapies available to more
    patients. Established in 2016, the Beau Biden Cancer Moonshot was a
    bold action on behalf of cancer patients. The President's Budget
    includes $216 million to the National Cancer Institute for Cancer
    Moonshot.
    ---------------------------------------------------------------------------
        \3\ https://www.cancer.gov/research/key-initiatives/moonshot-
    cancer-initiative.
    ---------------------------------------------------------------------------
        Prominent, ongoing Moonshot priorities include immunotherapy,
    childhood cancer, cancer prevention and early detection, and cancer
    implementation science. For example, several Moonshot initiatives focus
    on rare pediatric cancers, including research on the fusion of genes
    that yield novel ``fusion oncoproteins'' that drive some childhood
    cancers. Additionally, Federal agencies, led by NIH, will develop a
    focused program to expeditiously study and evaluate multicancer
    detection tests, as we did for COVID-19 diagnostics, which could help
    detect cancers early, when there may be other, more effective,
    treatment options for patients. Finally, implementation science strives
    to maximize the use of proven cancer prevention and early detection
    strategies and to incorporate them into standards of care, which is an
    urgent need among underserved, rural, and minority populations.
                               health disparities
        A key area where NIH hopes to build upon investments made by this
    committee in fiscal year 2022 is in the agency-wide effort to reduce
    health disparities. In the wake of a pandemic that disproportionately
    affected communities of color, this year's President's Budget will
    enlist most of our Institutes and Centers (ICs) in developing and
    testing interventions to reduce health disparities that have been
    appropriately tailored to the breadth of clinical and community
    services found in diverse settings and contexts.
        Importantly, the health disparities research agenda will be aided
    and informed by the NIH UNITE Initiative,\4\ composed of actively
    engaged representatives from across all 27 NIH ICs and the Office of
    the Director. This initiative was launched with the goal of identifying
    and addressing structural racism within the NIH-supported and the
    greater biomedical research community through development and
    implementation of new policies, procedures, and practices. To gain a
    better understanding of stakeholders' concerns, NIH issued a public
    Request for Information in March 2021, which captured over 1,100
    responses from researchers, external partners, and members of the
    public. Responses will inform efforts to improve the culture and
    advance structural change in biomedical research.
    ---------------------------------------------------------------------------
        \4\ https://www.nih.gov/ending-structural-racism/unite.
    ---------------------------------------------------------------------------
        NIH has recently launched several more initiatives to improve the
    health of racial and ethnic minorities and other populations who
    experience health disparities. One of the funding opportunities will
    commit $60 million over the next 5 years to support transformative
    research to address health disparities and advance health equity.\5\
    NIH will also commit $30 million from 25 Institutes, Centers, and
    offices to support observational research that will define the role of
    structural racism and discrimination (SDR) in causing and sustaining
    health disparities, and intervention research that will address SDR to
    improve minority health or reduce health disparities.\6\ Finally, NIH
    will provide approximately $24 million for the Transformative Research
    to Address Health Disparities and Advance Health Equity at Minority
    Serving Institutions initiative, which is designed to support research
    projects with the strongest potential to have a profound effect on
    health disparities research.\7\
    ---------------------------------------------------------------------------
        \5\ https://grants.nih.gov/grants/guide/rfa-files/RFA-RM-21-
    021.html;
    https://grants.nih.gov/grants/guide/rfa-files/RFA-RM-21-022.html.
        \6\ https://grants.nih.gov/grants/guide/rfa-files/RFA-MD-21-
    004.html.
        \7\ https://grants.nih.gov/grants/guide/rfa-files/RFA-RM-21-
    022.html.
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                                 mental health
        With the fiscal year 2023 President's Budget Request, NIH intends
    to direct increased attention towards mental health. Mental illnesses
    are the fifth leading cause of disability in the United States,
    accounting for 6.6 percent of all disability-adjusted life years in
    2019. In addition, suicide rates for youth have risen over the past 2
    decades in the United States; in 2019, an estimated 6,488 youth ages 10
    to 24 died by suicide. Despite advances in the treatment of depression
    and other serious mental illnesses, there remain few evidence-based
    interventions that rapidly reduce suicide risk within healthcare
    settings. NIH is supporting research projects that focus on testing the
    safety, efficacy, and feasibility of several of the newest
    antidepressant interventions--intravenous ketamine and intranasal
    esketamine (medications known to rapidly reduce depressive symptoms in
    hours or days) as well as transcranial magnetic stimulation (TMS; a
    noninvasive treatment that uses magnets to activate specific parts of
    the brain)--to rapidly reduce suicidal thoughts and behaviors in adults
    and adolescents.\8,9\
    ---------------------------------------------------------------------------
        \8\ https://www.fda.gov/news-events/press-announcements/fda-
    approves-new-nasal-spray-medication-treatment-resistant-depression-
    available-only-certified.
        \9\ https://www.nimh.nih.gov/news/research-highlights/2021/nimh-
    addresses-critical-need-for-rapid-acting-interventions-for-severe-
    suicide-risk.
    ---------------------------------------------------------------------------
        In response to the pandemic, which exacerbated mental illness
    throughout the country, NIH launched a project to support research
    focused on the social, behavioral, and economic impacts of COVID-19,
    which supports research on the secondary effects of the pandemic, such
    as financial hardship, reduced access to healthcare, and school
    closures.\10\ The fiscal year 2023 President's Budget requests $2.2
    billion for the National Institute of Mental Health (NIMH), that
    includes targeted increases of $25 million to expand research on the
    impact of the COVID-19 pandemic on mental health, $5 million to
    undertake studies of the impact of social media on mental health, and
    $5 million to inform mental health treatment approaches, service
    delivery, and system transformation in support of the Administration's
    mental health initiatives.
    ---------------------------------------------------------------------------
        \10\ https://covid19.nih.gov/news-and-stories/covid19-ripple-
    effects.
    ---------------------------------------------------------------------------
                        maternal morbidity and mortality
        Even during a global pandemic, NIH has continued to focus on other
    long-standing yet urgent public health needs. The Centers for Disease
    Control and Prevention estimates 700 women die each year in the United
    States of pregnancy-related deaths, 60 percent of which are
    preventable, and over 50,000 experience severe pregnancy-related
    morbidity each year.
        To address this alarming trend, NIH established the Maternal
    Morbidity and Mortality Task Force,\11\ an NIH-wide collaboration. The
    Task Force coordinates the Implementing a Maternal health and Pregnancy
    Outcomes Vision for Everyone (IMPROVE) Initiative,\12\ which invests in
    studies to promote an integrated understanding of biological,
    behavioral, sociocultural, and structural factors that contribute to
    maternal morbidity and mortality and engages communities in the
    development of solutions to address the needs of pregnant and
    postpartum individuals. IMPROVE plans to launch a national network of
    Maternal Health Research Centers of Excellence that will incorporate
    local community needs and perspectives to expand and complement
    existing research efforts by developing, implement and evaluating
    community tailored interventions to address health disparities in
    severe maternal morbidity (SMM) and maternal mortality (MM). Through
    this strategy, IMPROVE will build an evidence-based approach to
    reducing SMM/MM and its associated health disparities. To support this
    key initiative, the fiscal year 2023 President's Budget requests $30
    million for IMPROVE. In addition, the request also includes $3 million
    for the Eunice Kennedy Shriver National Institute of Child Health and
    Human Development to support research on mitigating the effects of
    COVID-19 on pregnancies, lactation, and post-partum health with a focus
    on individuals from racial and ethnic minority groups.
    ---------------------------------------------------------------------------
        \11\ https://www.nih.gov/research-training/medical-research-
    initiatives/improve-initiative/trans-nih.
        \12\ https://www.nih.gov/research-training/medical-research-
    initiatives/improve-initiative.
    ---------------------------------------------------------------------------
                           opioids and pain research
        Since early in the pandemic, studies have found increases in the
    use of many kinds of illicit drugs, including fentanyl, cocaine,
    heroin, methamphetamine, and cannabis. The NIH Helping to End Addiction
    Longterm (HEAL) Initiative,\13\ launched in 2018, is a cross-agency
    program spanning basic, translational, and clinical research on opioid
    and stimulant misuse and addiction, and pain. HEAL Initiative funds are
    being used to accelerate the development and availability of longer-
    acting formulations of existing opioid use disorder (OUD) therapies
    (e.g., buporenorphine and methadone) and novel immunotherapies (e.g.,
    vaccines) that could block the effect of opioids in the brain to help
    people with OUD and decrease the incidence of overdose.
    ---------------------------------------------------------------------------
        \13\ https://heal.nih.gov/.
    ---------------------------------------------------------------------------
        The HEAL Initiative is building the Integrative Management of
    chronic Pain and OUD for Whole Recovery (IMPOWR) network \14\ to
    develop effective treatment interventions for people who experience
    both chronic pain and OUD. The IMPOWR network consists of clinical
    research centers that collaborate to develop effective interventions,
    best models of care for delivery of services, and sustainable
    implementation strategies for a variety of patients with co-occurring
    chronic pain and OUD or opioid misuse, with an emphasis on highly
    vulnerable groups.
    ---------------------------------------------------------------------------
        \14\ https://heal.nih.gov/research/clinical-research/integrative-
    management-chronic-pain.
    ---------------------------------------------------------------------------
        In 2020, this committee directed NIH to expand HEAL to address
    methamphetamine use and we are making progress toward this goal. For
    example, NIH-funded research on immunotherapies for stimulant use
    disorders led to the development of a monoclonal antibody called IXT-
    m200 that targets methamphetamine.\15\ This treatment has received Fast
    Track designation from the Food and Drug Administration and is now
    being studied in emergency department settings in people with
    methamphetamine overdose.\16\ It is the first novel, investigational
    treatment for methamphetamine addiction ever to advance in the
    medication development process to a Phase 2 clinical trial. In order to
    continue to respond to these evolving challenges, the fiscal year 2023
    President's Budget includes total funding of $2.6 billion in this
    research area across NIH's ICs.
    ---------------------------------------------------------------------------
        \15\ https://nida.nih.gov/news-events/nida-notes/2020/02/part-2-
    immunotherapies-new-tool-to-treat-methamphetamine-addiction.
        \16\ http://intervexion.com/2016/01/intervexion-therapeutics-
    announces-fast-track-designation-of-ixt-m200-for-treatment-of-
    methamphetamine-addiction/.
    ---------------------------------------------------------------------------
        Importantly, NIH seeks to involve many more of our ICs in this
    initiative, particularly with respect to research addressing pain. The
    fiscal year 2023 President's Budget Request will expand research into
    effective therapies that don't involve the brain or the central nervous
    system by involving researchers from many Institutes and Centers like
    the National Institute on Dental and Craniofacial Research (NIDCR),\17\
    which I led for a decade prior to becoming the Principal Deputy
    Director of NIH. As a dentist, I know that there is no group of
    clinicians who have more to contribute or more to gain from identifying
    better pain management approaches. For example, researchers have
    identified clinical signs and symptoms that can help predict whether
    temporomandibular disorder pain will linger and turn into chronic pain.
    Research at the National Center on Complementary and Integrative Health
    \18\ proposes to investigate the role of the brain in pain processing
    and control, and how factors such as emotion, attention, environment,
    and genetics affect pain perception.
    ---------------------------------------------------------------------------
        \17\ https://www.nidcr.nih.gov/.
        \18\ https://www.nccih.nih.gov/.
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                               nutrition research
        The complexity of human nutrition, combined with the impact of diet
    on chronic diseases that were a contributing factor to the excess
    deaths of the pandemic, demands that cutting-edge data science and
    system science methods be employed to move nutrition science into the
    21st century. To reflect the high priority NIH places on innovative,
    multidisciplinary nutrition research, in 2021 the NIH Director moved
    the Office of Nutrition Research (ONR) \19\ to the Office of the
    Director. Dedicated funding is critical to ensure that the ONR can
    operate effectively as a cross-cutting NIH entity and to accomplish the
    goals of the plan. The fiscal year 2023 President's Budget requests
    $97.2 million for the NIH Office of the Director to support ONR.\20\
    ---------------------------------------------------------------------------
        \19\ https://dpcpsi.nih.gov/onr.
        \20\ https://officeofbudget.od.nih.gov/pdfs/fiscalyear23/ics/27%20-
    OD%20FY%202023%20CJ%20
    Chapter.pdf.
    ---------------------------------------------------------------------------
        Within this amount, one new collaborative project proposed is
    Reducing Nutrition Health Disparities through Food Insecurity and
    Neighborhood Food Environment Research. This research will use
    precision regional implementation science and pragmatic research
    approaches to test strategies to ensure food security and access to
    healthy food, which are intended to prevent disparities in a variety of
    diet-related diseases and conditions, such as cardiovascular disease,
    obesity, diabetes, and cancer. Elucidating the role of these social
    conditions on diet and nutritional status could help address and
    prevent diet-related health disparities and promote health equity.
        This kind of population and system science will be an important
    complement to the Nutrition for Precision Health program \21\ (awarded
    in January 2022 to recruit 10,000 diverse participants to study how a
    person's nutritional status, metabolism, microbiome, genetics, and
    environment affect health) and the $50 million Artificial Intelligence
    for Chronic Disease initiative (first funded in fiscal year 2021, the
    initiative leverages machine learning and data science tools to
    untangle the complex underlying causes of chronic diseases and look for
    early treatments).
    ---------------------------------------------------------------------------
        \21\ https://commonfund.nih.gov/
    nutritionforprecisionhealth#::text=The%20goal%20of%20the
    %20NIH,prevention%20and%20treatment%20of%20disease.
    ---------------------------------------------------------------------------
                          nih buildings and facilities
        NIH strives to ensure that its facilities are safe and enable
    scientists to discover new diagnostics, therapies, and cures. As part
    of this effort, the President's Budget proposes $300 million for NIH's
    Buildings and Facilities appropriation. These funds are meant to begin
    addressing the backlog of life and safety repairs that totaled over $1
    billion in the 2019 report by the National Academies of Science,
    Engineering and Medicine on the condition of NIH's facilities on the
    Bethesda Campus. A key aspect of NIH's strategy is to sustain the
    condition of existing facilities to prevent premature deterioration and
    the curtailment of research, including the physical plant, building
    structures, utility systems, roads, and grounds at all NIH sites. These
    projects will help to ensure the continued efficient and effective
    performance of NIH's real property assets to meet ongoing and projected
    research requirements and to offset the deterioration and obsolescence
    caused by age and use.
        The President's Budget request also proposes a modification to the
    language governing repairs, which is intended to move NIH's property
    stewardship beyond maintenance and repairs to more proactive efforts
    like the modernization at NIH's research hospital, replacement of
    obsolete, temporary, and fragmented research facilities, improvement of
    facilities that advance computational and data science, and improvement
    of the energy and water efficiency of buildings. To achieve this will
    take time, so NIH looks to leverage prioritization processes currently
    in place to focus on the projects that are of the most need to our
    organization.
                                   conclusion
        A healthier nation is a more productive nation and a vibrant
    research community is a pillar of an economically sound nation. With
    your support, NIH looks forward in fiscal year 2023 to continue the
    tradition of catalyzing major break throughs over decades, bettering
    the human condition through rigorous and innovative science. My
    colleagues and I look forward to answering your questions.

        Senator Murray. Thank you very much. And I realized it as I
    was going through the list of panelists in front of us, I
    skipped Dr. Richard Hodes, is the Director of National
    Institute on Aging. Welcome to you as well.
        We will now begin a round of 5-minute questions of our
    witnesses, and I ask my colleagues to please keep track of the
    clock and stay within your 5 minutes.

                                 DRUG OVERDOSE

        Dr. Volkow, I want to start with you. As I mentioned in my
    opening remarks, across the country overdose deaths continue to
    rise dramatically. Last year they spiked in my home State of
    Washington by 30 percent, and much like the rest of the
    country, were really driven by fentanyl.
        This is really a national crisis, so we have got to be
    using every tool that we have to support our communities,
    including fentanyl strips, which Secretary Becerra mentioned at
    his hearing here a few weeks ago. The research I have seen
    indicates that those strips which are used to detect fentanyl
    in drugs, are an effective overdose prevention tool, but they
    require several steps to use them, including chipping off some
    of the pill to be able to test it.
        Can you tell us what the research shows about the
    effectiveness of those test strips? And really, are they easy
    to use? Can you talk a little bit about that?
        Dr. Volkow. Thanks very much for that question. And indeed
    the fentanyl test strips have been tested for sensitivity and
    specificity, and the data shows, actually, high sensitivity,
    and there are only a few fentanyl analogs that are not
    detected.
        Having said that, the fentanyl test strips were developed
    for testing drug use in urine, so for patients that are being
    monitored; and so now this is a new application, and as a
    result of that there can be problems on how it is implemented.
        Overall, patients that have used the fentanyl test strips
    report positive outcomes, and actually in terms of identifying
    drugs that may put them at higher risk. The research is now
    ongoing to try to determine what are the optimal guidelines on
    how to use them, number one; but number two, if the results
    were positive, what is it that an individual should do in case
    that they still want to consume them.
        As you know there are still multiple problems in terms of
    making these fentanyl tests available throughout the United
    States, and there is interest on actually determining and
    getting approvals for some of these tests by the Food and Drug
    Administration, so they can be utilized in healthcare settings,
    which is not possible at this moment.

                              OVERDOSE PREVENTION

        Senator Murray. Well, are there overdose prevention
    strategies that you and HHS (Department of Health and Human
    Services) hope to roll out in the coming months? Talk to me a
    little bit about what we are doing in terms of prevention.
        Dr. Volkow. Prevention strategies that have been shown to
    be widely effective is perhaps one of the most important ones,
    is widespread distribution of Naloxone, and that becomes
    actually, in some instances, a challenge if the Naloxone is not
    available for those that use them.
        Another harm-reduction practice that has generated a lot of
    attention, is the extent to which, because the drug supply is
    so extremely dangerous these days, in which safe injection
    sites could be viable for patients that otherwise may be at
    high risk of overdosing. And while the data is still
    preliminary in the United States, in other countries they have
    shown that in certain settings they can be quite effective. So
    there is interest on evaluating them.
        There is also interest in the community to test other
    products that may serve as harm reduction, for example, the use
    of kratom, which is sold as tea, and that contains a drug--a
    molecule that has the effects that are similar to those of
    buporenorphine, but could be utilized also for decreasing
    withdrawal or depression. So these are more novel, and we don't
    have sufficient data, but those are things that are being
    discussed.

                              ALZHEIMER'S DISEASE

        Senator Murray. Okay. Thank you.
        Dr. Hodes, it is said that science is a marathon, not a
    sprint. However, Congress has really approached investing in
    research to treat and cure Alzheimer's disease and related
    dementias, with really a sense of urgency. We have poured
    resources into this research, $17 billion since 2015 to really
    supercharge the discovery process with a goal of finding a
    treatment or cure by 2025.
        And I am concerned that NIH isn't positioned to meet that
    deadline. Given the sheer scale of Federal investment, what is
    NIH doing to deliver meaningful and measurable outcomes that
    assess its progress towards finding effective treatments?
        Dr. Hodes. Thank you for that critical question. And let me
    answer it very briefly in terms of process, and then with some
    examples of meaningful accomplishments during this time. As you
    know, we have counted on critical input from the national and
    global research communities, advocates, et cetera, with our
    annual summits, all of which feed into a careful identification
    of milestones, that is the goals and targets which are
    necessary to meet our most important needs.
        I want to take a moment just to thank the staff of this
    committee for the interactions we have had over the past year
    to help us focusing these milestones into meaningful,
    quantifiable outcomes, and making them transparent and
    available.
        To touch on just some of the examples of the important
    advances, I would point starting with our clinical trials. So
    for example, in pharmacological trials, there are currently
    eight studies targeting amyloid, or not, which are Phase 3, in
    their latest stages capable of identifying definitive, positive
    outcomes, meaningful outcomes, clinically which are due over
    the next years to reveal their answers.
        There are some 62 early-phase clinical trials, and a
    variety of targets, three-fourths of them not amyloid, and
    these are the results of basic science, which has found more
    and more potential targets. So the clinical trials, or
    investment in them, are critically important, and you alluded
    as well, to the burden on the families, and those living with
    dementia, that is also an area of clinical research, clinical
    trials, And we now are funding a large number of trials
    studying interventions for care and care providing, which will
    be producing their results.
        The National Academy has identified two of those generated
    with NIH funds that are ready for dissemination, being
    disseminated with further evidence. Happy to elaborate as time
    allows, but these are some of the examples of accomplishments,
    and of our important process to continue being accountable to
    ourselves, to you, and to the public for making the best use of
    these very critical funds to accomplish the highest of the
    priorities.
        Senator Murray. Well, thank you. And I think transparency
    is really important. The deadline is around the corner, and we
    have put out a lot of money for this, and need to know, as
    Congress, how those investments are going.
        So I look forward to working with you. And Senator Blunt
    will look forward to working with you on that as well.
        Senator Blunt. Thank you, Chair.

                          UNDIAGNOSED DISEASE NETWORK

        Dr. Tabak, during the time you were Deputy Director, the
    seven hearings we had with Dr. Collins, who was the Director at
    the time, I think every single time he talked about the
    importance of NIH bringing hope to millions. I want to talk a
    little bit about the proposed ending of funding for the
    Undiagnosed Diseases Network.
        We have one of those in St. Louis; Chair Murray has one in
    Seattle. I had somebody reach out to me a couple of weeks ago,
    Michele Herndon, from Affton, Missouri. She was concerned
    because her son, Mitchell, who had suffered from a series of
    health issues that doctors couldn't diagnose, had benefitted
    from one of the centers.
        In fact, by late-high school, he was in a wheelchair, his
    hearing was gone, and his eyesight was gone. They were losing
    hope, but after they sought treatment at the Undiagnosed
    Disease Network in St. Louis, they found a neurological
    condition so rare, that it didn't even have a name.
        In fact, Mitchell lost his battle. The condition he had now
    carries his name, the Mitchell syndrome. But Michele and her
    family were comforted by the fact that they finally knew what
    this long struggle had been about. This year's budget cuts the
    Undiagnosed Diseases Network, and closes all l2 of its clinical
    sites.
        She was concerned about that. I am too. I think there is
    some discussion where they may graduate in some way to where
    they continue to exist. I think it would be a problem to walk
    away from that. Not everybody can come to NIH in Bethesda. And
    if you don't have the site within some reasonable distance of
    where you are, you are unlikely to get this service. Do you
    want to talk about why that decision was made to stop funding
    these 12 sites?
        Dr. Tabak. We certainly agree that the diagnostic services
    provided by the Undiagnosed Diseases Network are extremely
    valuable to patients and to their families. The challenge that
    we face is there does come a point where the diagnoses become a
    part of standard care, versus a research question, but finding
    that right balance is something that we continue to work
    through.
        All the cases that are enrolled presently will continue to
    undergo comprehensive evaluation. We will establish a Data
    Management and Coordinating Center to draw upon the experience
    of all of the centers that are participating in this program.
    But really, we would like to work with you, going forward, to
    come up, perhaps, with a better solution in the mid- and long-
    term.
        Senator Blunt. Good. Well, let us continue to work on that.
    I mean, really you can't have standard care if you are still
    discovering things that needs to be looked at as an option.
    Mitchell syndrome is Mitchell syndrome only because he was the
    first, and may be the only diagnosed person so far, that ever
    had that. And that is going to fall outside of standard care
    definition, I think. So let us continue to work on that.

                                      RADX

        Is Dr. Gordon available? Let me ask him, on RADx, Dr.
    Gordon, in the mental health area, and in the RADx example of,
    again, NIH itself, partnering directly with others to try to
    find a rapid solution. Do you think that a Shark Tank RADx kind
    of option would be a possibility, as you look for biomarkers in
    mental health?
        Dr. Gordon. I think that is a great idea, Senator Blunt. I
    appreciate your support of that initiative, and NIMH (National
    Institute of Mental Health) as well. We have funded a number of
    small businesses, as well as a number of academics, who have
    come up with really wonderful ideas for biomarkers that can
    help guide clinical decisionmaking. Something that we
    desperately need in psychiatry to help speed treatments and
    make sure the people who need treatment, get the right
    treatment from the get-go.
        And one of the ideas for it, we have been thinking about is
    using the RADx example where you had, essentially, a
    competition between a number of different companies in RADx, it
    was for tests for COVID. But the idea is to apply something
    like that to the biomarker space for mental health.
        And we think now is the right time to do that, and so we
    are talking with our colleagues at NIBIB (National Institute of
    Biomedical Imaging and Bioengineering), who ran the RADx
    competition, and trying to figure out how we can do that for
    biomarkers for mental health.
        Senator Blunt. Very good. I would encourage that. I think
    every single home test for COVID comes out of the RADx
    experience, and again, if you have got people that have ideas
    that can come to you, and see which of those you should partner
    with; I think that would be a great step in the right
    direction.
        Thank you, Chair.
        Senator Murray. Senator Reed.
        Senator Reed. Thank you, Madam Chairman.

                                    SUICIDE

        Dr. Gordon, we are in the midst of a significant spike in
    suicides, particularly among children, which is very
    disturbing, and we know some of that is a result of the
    pandemic, but I am just interested in what research at NIH is
    pursuing this issue, to recognize warning signs. How is that
    research being operationalized, and put out to practitioners,
    particularly, and to families? And then the other point would
    be, we have a new national hotline, 988, are you in any way,
    sort of trying to coordinate, or work with that, or study that?
        Dr. Gordon. The answer to both those questions is, yes, we
    are deeply involved in making sure that our research informs
    practitioners both in the clinic and at the State level when we
    are talking about 988.
        Let us talk about youth suicide first. NIMH has funded a
    number of research programs in identifying individuals at risk,
    particularly the young, and in getting to evidence-based care.
    One quick example, the NIMH Intramural Program developed a
    screening questionnaire called the ASQ (Ask Suicide-Screening
    Questions) that has been disseminated to primary care
    practices, and pediatric emergency rooms throughout the
    country, and really it is being used nationwide.
        We also have funded a number of research projects, looking
    at school-based identification and prevention measures as well,
    and we do our best to make sure that they are out there.
        We also work with Federal partners, like the Substance
    Abuse and Mental Health Services Administration, or SAMHSA, and
    there we are working with them, especially around the 988,
    looking, to try to make sure that States that are implementing
    the follow-ups to 988, are aware of evidence-based approaches
    to mental health crises.
        For example, the proper utilization of mobile crisis teams
    that are trained in responding to individuals in mental health
    crises is one evidence-based approach that has been proven over
    and over again to work. So yes, and we continue to work in both
    of those areas. Thank you.
        Senator Reed. All right. Thank you, Dr. Gordon.

                                LONG HAUL COVID

        Dr. Fauci, the issue of long-haul COVID has been dominating
    the news lately. Can you describe how NIH is tracking these
    cases? Are there common elements to them? Are there treatments
    showing any promise? Where are we in the process of tackling?
        Dr. Fauci. Yes. Thank you very much for that question,
    Senator. I will begin the answer, and then I will hand it over
    to Dr. Gibbons, who is also very much involved in this.
        Senator Reed. Thank you.
        Dr. Fauci. As you well know, this is a real phenomenon, and
    the epidemiology of it is still being worked out, I mean, the
    range of people anywhere from 5 percent to up to 30 percent of
    people have the persistence of symptoms that are not thoroughly
    explainable by any pathogenic process that we have been able to
    identify.
        We put together large cohorts that are now being followed,
    both to understand the actual prevalence, incidence, as well as
    the pathogenesis.
        With regards to treatment, Senator, it is very difficult to
    do any treatment for it when you don't know exactly what the
    pathogenic mechanisms are, and that is the reason why we are
    putting so much effort into trying to find out just what is
    going on. Is it immune activation? Is it persistence of virus?
    Not necessarily replication competent virus, but maybe
    particles of virus such as the nucleotides.
        But let me hand it over to Dr. Gibbons who could also tell
    you a bit about that.
        Senator Reed. Thank you.
        Dr. Gibbons. You know, I only add to Dr. Fauci's comments,
    that we are indeed setting up the recovery--researching COVID
    to enhance recovery effort. It is moving with a great sense of
    urgency given the suffering of the patients with long COVID.
    There are a number of elements that have launched effectively.
    One is to create an electronic health record, a base set of
    cohorts. They are derived from 60 million records of patients
    across the country.
        A diverse body of patients, of which, between four and five
    million have COVID, and that provides an opportunity to track
    those individuals electronically, and digitally, and
    longitudinally, to see who develops long COVID, who does not,
    that can inform, as Dr. Fauci mentioned, our understanding of
    the prevalence, as well as the risk factors, as well as the
    long-term effects, chronically.
        It is already starting to show preliminary evidence that is
    suggestive of--potentially the ability of vaccination to
    prevent the development of long COVID. Similarly, they were
    seeing signals that are telling us that the severity on the
    acute COVID has bearing on your susceptibility to develop long
    COVID.
        Similarly, we are seeing trends towards, who is most
    affected. And again it is identifying people of color, African-
    Americans and Latinos as a high-prevalence group, developing
    long COVID that really hasn't come to the fore as much; and so
    we are learning as we go and develop this program. Thank you.

                           CHILDHOOD CANCER STAR ACT

        Senator Reed. Thank you very much. Just a final point, if I
    may. We have to reauthorize the STAR (Childhood Cancer
    Survivorship, Treatment, Access, and Research) Act. It is the
    best thing we have done in a long time, with respect to
    childhood cancer.
        And I think you would agree, Dr. Tabak? Just a nod of the
    head is sufficient.
        Dr. Tabak. Yes.
        Senator Reed. Thank you. Thank you, Madam Chair.
        Senator Murray. Senator Kennedy.
        Senator Kennedy. Thank you, Madam Chair.
        Dr. Tabak, what the National Institutes of Health has done,
    and continues to do is nothing short of extraordinary, I mean,
    it is really breathtaking. And I want to thank you and your
    colleagues for doing that.
        We have all been to pandemic school for the last several
    years, and I want to use the few minutes I have to explore what
    we have learned.

                         COVID RELATED SCHOOL CLOSURES

        Dr. Fauci, whether you asked for it or not, you have sort
    of been the government's face on the response to the pandemic.
    Looking back, and I recognize that hindsight is crystal clear,
    but looking back, do you think it was worth it, do you think
    the benefits were greater than the costs of closing down our
    elementary and secondary schools?
        Dr. Fauci. I think it is difficult to give a definitive
    answer to that. I know in the very beginning when we had really
    no other protection prior to vaccinations that were available
    to contain, somewhat, the spread of the virus. One of the
    things that was felt to be important would be to protect
    children as well as the rest of the population.
        Right now we have felt, more than just recently, that it is
    very important to keep the children in school for the simple
    reason that we know of the deleterious effects, both
    psychologically, mentally, and developmentally in children, to
    keep them out of school. But you have to have a delicate
    balance between protecting the children from getting infected,
    and perhaps bringing the----
        Senator Kennedy. Did we strike the proper balance?
        Dr. Fauci. You know, I believe that we have. It is very
    tough to tell. I think only time will tell whether that is the
    case, because there is indication that has been deleterious
    effects on children, but we believe from a public health
    standpoint, that at the time it was the right decision.
        Senator Kennedy. Well, can I ask you this Doctor. And I
    realize, I am not asking--I am not saying, or offering judgment
    of what was done at the time. I am asking what we have learned.
    Let us suppose we have a substantial increase in prevalence of
    the coronavirus next week, God forbid.
        Dr. Fauci. Right.
        Senator Kennedy. Would CDC (Centers for Disease Control and
    Prevention) recommend shutting down the elementary and
    secondary schools?
        Dr. Fauci. It is very difficult for me to speak for the
    CDC, but knowing the fact that we----
        Senator Kennedy. Would you recommend it?
        Dr. Fauci. Right now, I would do everything we can to keep
    the children in school, and not shut down the school. And that
    has always been my strong recommendation, to the extent
    possible, not to keep the children out of school.
        Senator Kennedy. But yet we did shut down.
        Dr. Fauci. But to keep them safely in school, by getting
    children that are available to be vaccinated, vaccinated.
        Senator Kennedy. Right.
        Dr. Fauci. To get the children who are eligible to be
    boosted, vaccinated, and to surround the children with teachers
    and personnel in the schools who are vaccinated. That is the
    best way to protect the children while keeping them in school.
        Senator Kennedy. Okay. Let me ask you this. In hindsight,
    knowing what you know now, had you known it then, did we do the
    right thing in shutting down society? Would we have been better
    off saying: No, we are going to protect the vulnerable, the
    elderly, the people who are immunocompromised, and we are going
    to isolate them but have the rest of American society,
    churches, businesses, universities, schools go on about their
    business, while at the same time providing them guidance about
    how to protect themselves?
        Dr. Fauci. Well, it is a complicated question, I will try
    and give as simple an answer as possible. I think there is a
    misperception about who the vulnerable are. There are many,
    many more vulnerables in society, and there is a misperception
    that the only vulnerables----
        Senator Kennedy. Yes. But I am about to run out of time.
    Let us assume we can agree on a definition.
        Dr. Fauci. I don't think you can. I think that society is
    very heterogeneous, and it isn't a question of shutting down
    completely, Senator, because we never shut down completely. If
    you do shut down a society you do it for a purpose, and the
    purpose is, at that period of time when you are protecting
    people from interaction, that you get as many people vaccinated
    as you possibly can.
        Senator Kennedy. Let me stop you at that.
        Dr. Fauci. To shut down----
        Senator Kennedy. I am going to run out of time. Let me ask
    you one last question.
        Dr. Fauci. Sure.
        Senator Kennedy. What would you do differently today?
        Dr. Fauci. Right now I would hope that we would get many
    more people vaccinated.
        Senator Kennedy. No. But what would you do when you did it,
    in hindsight, if you knew then what you know today?
        Dr. Fauci. It depends on when we got the vaccine. Do you
    mean before the availability of vaccine? Before the
    availability of vaccine, when we had no other situation, I
    would try to protect people by making sure that they masked,
    and kept themselves separated from this congregate, indoor
    settings, that is what I would do, in the absence of a vaccine.
        But right now I think it is important, looking forward, we
    still only have 66 percent of the total population vaccinated,
    and less than half of those are boosted. I think we can
    approach what we are likely going to be seeing, and are seeing
    now, with an increase in surges, with the possibility of a
    surge in the fall and winter.
        One of the real things we can all do as a Nation, is pull
    together and try to get our people vaccinated, and those who
    are eligible to be boosted, boosted. That would solve a lot of
    the problems that you are referring to.
        Senator Kennedy. Okay. Thank you. Thank you all.
        Senator Murray. Thank you. Senator Baldwin.
        Senator Baldwin. Thank you, Madam Chair.

                            SUBSTANCE ABUSE EPIDEMIC

        Welcome, Dr. Tabak. I am posing the first question to you
    for an update on research efforts to better respond to the
    substance-use epidemic, by way of context. As you well know,
    the substance-use epidemic continues to ravage communities
    across Wisconsin, and across the United States, and an
    increasingly dangerous role is played by synthetic opioids,
    such as fentanyl, as well as psychostimulants, like
    methamphetamine.
        So I believe it is vital that we invest in sustained
    research into substance-use disorders to prevent deaths, treat
    patients, and make our communities safer. If you could describe
    recent research efforts, including what is happening with the
    HEAL Initiative, the Helping to End Addiction Long-Term
    Initiative, I would appreciate that.
        Dr. Tabak. If I may, to turn to Dr. Volkow, who is our
    expert in this field.
        Senator Baldwin. Absolutely.
        Dr. Volkow. Thanks very much for the question. And our
    research is actually going from the basic to help develop
    medications with new targets, to help develop formulations that
    can be--actually lead to better outcomes. To epidemiology
    research to understand the changing face of the overdose
    crisis, which now, as you are mentioning, is no longer just
    limited by our overdoses from prescription opioids, but
    encompasses overdoses from fentanyl, methamphetamine, and
    cocaine, to the implementation research that can help us
    determine what are the optimal models of care that we can
    deploy in community, and to take advantage of infrastructure.
        So for example, research is ongoing to determine how the
    health care system can be involved in the prevention and
    treatment of substance-use disorders, and how can we bring
    treatments to justice settings, like prisons, and jails, and
    upon release, and maximize the possibility of these individuals
    to get healthcare, to the involvement of community, so that we
    can actually integrate the effort between healthcare, justice,
    and communities.
        Through the HEAL Initiative, we have been able to
    accelerate significantly. Also, another area that has been
    neglected, overall, which is the need to better treatments for
    the management of severe pain, and if we do not address the
    need of patients suffering from severe pain, we keep them as
    very, very vulnerable, to seeking out much more dangerous
    drugs, out in the illicit market.
        And finally, we need to also ask ourselves: What is it in
    the United States that is making Americans so vulnerable to the
    use of these drugs? And that is relevant to prevention, because
    if we do not understand it, then we cannot do interventions to
    actually protect those that because of circumstances alien to
    them, are actually at much higher risk to taking drugs, and
    ultimately develop addiction or overdosing.
        Senator Baldwin. I appreciate your response.

                             INVESTMENT IN RESEARCH

        Dr. Fauci, the U.S. was able to bring a COVID-19 vaccine to
    the public in really record time. And I am grateful for the
    work of so many that made that possible; including several who
    are in this room.
        Unfortunately, the next pandemic, driven by an unknown
    disease X will come. And I believe we can't wait. We should
    invest in the development of novel antivirals, and vaccines,
    and diagnostics for unknown threats from priority viral
    families, now, so that we are better prepared in the future.
        Can you explain how the investments we have made over time
    at NIH and across the Federal Government, made the COVID-19
    vaccines and medical countermeasures possible? And how would
    sustained investments to develop responses to viral families of
    concern make us better prepared?
        Dr. Fauci. All right. Thank you very much for that
    question, Senator. Yes, it is very, very clear that the
    investment in basic and clinical biomedical research for at
    least a few decades, and maybe more, prior to the realization
    that we are dealing with a new, historic pandemic, allowed us
    to do something that was completely unprecedented.
        Two examples of that are the work that was done on what we
    call vaccine platforms, the mRNA vaccine which was fundamental,
    basic research, on how to get the mRNA molecule to actually
    serve as a platform for vaccine.
        Work at the NIH, in our own campus, as well as NIH-funded
    investigators throughout the world, also worked on what is
    called immunogen design to do work that led to the ability to
    stabilize the optimal immunogen, in this case it was the spike
    protein, which allowed us to go from the realization of a new
    pathogen, on January 9-10, 2020, getting into Phase 1 trial, in
    65 days and 11 months data, having a safe and effective
    vaccine.
        We did that because of the investment you are referring to.
    Right now, looking forward, we have what is called a Prototype
    Pandemic Preparedness Plan, which means you do just what I
    believe you are alluding to. You develop a number of families.
    There are about 20 families that are the high risk, of those
    there are about 7 families of viruses that if you do the
    fundamental work of looking at the commonalities among them,
    and develop diagnostic tests, assays, immune correlates, and do
    that now.
        And if we don't get the resources now, Congress has been
    very generous to us up to now, but if we don't get the
    resources we need, we are not going to be able to do the kind
    of preparedness, not only for vaccine, but also for targeted
    development of antivirals, which we did so successfully with
    HIV (human immunodeficiency virus), and did quite successfully
    right now.
        But we have programs that are not going to get off the
    ground unless we get funding. So fundamental basic, and
    clinical research are the core of everything that is going to
    protect us in the future. Thank you.
        Senator Murray. Senator Braun.

                             FUTURE COVID LOCKDOWNS

        Senator Braun. Thank you, Madam Chair. So I am going to
    have two questions, and I would like Dr. Tabak and Dr. Fauci to
    answer each of the two questions. I am going to start with this
    one.
        So in navigating through the entirety of what we did to
    fight COVID, clearly, the most expensive feature of the
    navigation would have been lockdowns. We did that out of
    uncertainty, we had no idea, you know, how that was going to
    work.
        Even in the business I ran, you had early dust ups, where
    you would get a case and clear out a warehouse. And we quickly
    understood you do not throw caution to the wind, and you take
    the basic information that we all had to deal with, and you
    took it seriously, you put protocols in.
        Let us look at lockdowns. It costed us trillions of
    dollars, and we are paying for that now, with super-high
    inflation. You know, I think I am interested in, when Johns
    Hopkins comes out with a study that said basically that didn't
    have any impact on mortality, and I don't know that that study
    addressed what mortality might have been impacted, in terms of
    deferring other healthcare. Can we take lockdowns off the table
    in terms of what we do in the future? Dr. Tabak, and then Dr.
    Fauci.
        Dr. Tabak. I can't say, because I don't know what that
    future holds for us. If you have a pathogen that is very
    virulent, very infectious----
        Senator Braun. Let us assume it is in the same modality as
    what we have been navigating through over the last couple 3
    years.
        Dr. Tabak. I think the initial presentation of the virus
    was one that was devastating. It killed a lot of people.
        Senator Braun. What about the study that Johns Hopkins did,
    because we are always saying, pay attention to the science?
        Dr. Tabak. I am not familiar with that study, sir.
        Senator Braun. Dr. Fauci.
        Dr. Fauci. Senator that is a very good question. If you are
    going to lock down, you have got to use it temporarily for a
    reason to prepare you to be able to un-lock down, and get the
    public prepared for that.
        Right now, looking forward, I don't see the need of
    lockdown in the future unless something really, very, very
    unusual happens. And the reason is, that what we really need to
    do, is we need to get our population vaccinated, and we need to
    get them boosted. That would completely obviate the need to
    lock anything down.
        So right now if you ask me the question, looking forward,
    do I see, even if we do get a new variant, I think the
    vaccinations that we have, have enough cross-reactivity and our
    ability, with proper resources, to make variant-specific
    boosts, I don't see lockdown in the future. Lockdown is a
    temporary thing, to get you to be able to move quickly to save
    lives.
        Senator Braun. That is good to hear, because in that kind
    of moment of uncertainty, I don't think we could afford to do
    it again. I hope the Biden administration is listening to that.

                                VACCINE MANDATES

        The other question; and I led the effort on it; is when we
    took this and distilled it down to, you either get a vaccine or
    you lose your job. And thank goodness, we did marshal
    bipartisan support that said that didn't make sense, Supreme
    Court used that as a cue, you know, in terms of what they did
    to abrogate that.
        So in the future, will we heed what the Supreme Court said,
    and that you wouldn't calculate, even though don't disagree
    that vaccines are an important tool, along with therapeutics,
    and preventative? Would you push to do the same thing that we
    almost did, that would have been the second calamity to occur?
    In terms of what it would have cost the economy, and probably
    not benefit from a result that would have been measurable?
        Dr. Tabak, and then Dr. Fauci.
        Dr. Tabak. As you know the vaccination is the single most
    effective preventive measure, and so to the extent that the law
    allows, you would want to continue to act----
        Senator Braun. But would you recommend that we go down that
    path again, down to 100 employees in a business, to where you
    said, either get it, or lose your job.
        Dr. Tabak. That is a policy call, sir. I don't make those
    calls.
        Senator Braun. Dr. Fauci.
        Dr. Fauci. Again, it is a policy call. I would hope that we
    would marshal everybody, you know, both sides of the aisle, to
    get out there and encourage everybody to get vaccinated, and if
    they did, we wouldn't even have to address that question. I
    don't like mandating things. I don't like punishing people for
    not doing something.
        But I would hope that they would realize, if you look at
    the data, and you just made an appropriate statement, Senator,
    a moment ago, about following the science; if you look at the
    data, of the differences in vaccinated versus unvaccinated
    people, and hospitalizations, and death, it is striking what it
    is.
        So as a public health person, I would say why don't we all
    pull together to get people vaccinated. We won't have to worry
    about, essentially, putting what appears to be and is in fact a
    penalty if you don't.
        Senator Braun. And I think the key to that navigation is to
    pay attention to the data, and the science, not the political
    science.
        Dr. Fauci. Right, exactly.
        Senator Braun. Thank you.
        Dr. Fauci. Thank you.
        Senator Murray. Thank you. Senator Rubio.
        Senator Rubio. Thank you. Thank you all, for being here.

                            GENDER TRANSFORMING CARE

        Dr. Tabak, let me start with this question. You know, we
    have recently seen that the--not just the Biden administration,
    but the Biden administration, and others in the policy realm,
    have been actively promoting and supporting the use of things
    like, puberty blockers, and hormone therapy for young boys and
    girls. I want to sort of limit my question to minors, for what
    they have termed gender transforming care.
        That is not an FDA-approved use of puberty blockers and
    hormone therapy I don't believe in any people, but especially
    in minors. So as the NIH is America's medical research agency,
    what work have we done at NIH, what work has been done to
    determine if this non-FDA-approved use of these medicines, this
    off-label use of these medicines is appropriate for minors
    seeking gender transforming care?
        Dr. Tabak. So NIH funds a small number of observational
    studies to gather the data on the effects of treatments that
    transgender youth and their parents have chosen. And there are
    also a small number of studies that describe the health issues
    and risks, including HIV that are unique to these transgender
    youth. But all of the research in this space is observational.
    We do no interventional work.
        Senator Rubio. I guess, my question is before--one thing is
    a decision made by an adult, right, and especially given the
    irreversible nature of some of these treatments, isn't there
    some wisdom in the notion that before policymakers are out
    there promoting the off-label use of medications that lead to
    permanent changes, that there be some more research done on its
    impact, you know, 5, 10, 15, 20 years from now?
        Dr. Tabak. So as you know, transgender youth are more
    vulnerable to depression, anxiety, engaging in self harm, and
    so it is important that we examine and evaluate the potential
    effects of these treatments.
        Researchers are observing longer term psychological impact
    of these protocols, and so by looking at individuals,
    transgender youth, with and without histories of puberty
    suppression, we will be able to better answer the types of
    questions that you are posing.
        Senator Rubio. Yes. I guess my--that is my point. My point
    is, we don't know what its long-term implications are when we
    weight the costs and the benefits. The FDA (Food and Drug
    Administration) hasn't approved this, and yet we have
    policymakers promoting it. And I think that is an important
    point.
        I mean, clearly, we don't want anybody harming themselves,
    and things of this nature, but we don't know what--these policy
    decisions are being made on the basis of observational
    guidance, and by your own admission, without any sort of long-
    term trajectory on its holistic impact.

                           COVID TRAVEL RESTRICTIONS

        Dr. Fauci, I am running into something that is pretty
    interesting. I believe the United States is the only major
    Western country that now requires its citizens to test negative
    for COVID before they can get on an airplane and reenter the
    country. I believe that is accurate.
        And on the other hand, we are hearing now that, for
    example, Title 42, which is a COVID-era policy should be lifted
    because we have reached the point now where COVID is
    manageable, or at a level where we no longer need Title 42. And
    we obviously know we have a problem in our southern border
    where every day people are entering the country, illegally, and
    many are not even being tested for COVID. And even if they are,
    they are being allowed to stay, and most certainly would under
    Title 42.
        I don't understand. How do we tell American citizens, if
    you test positive, even if it is a dead virus that has been in
    your system for 10 days, because you can test positive days
    after you are no longer infectious, and you can't enter your
    own country? But people--if you arrive illegally, whether you
    test positive or not, if you say the magic words for ``asylum''
    you get to stay in the country.
        And this is a real-life scenario. I know people that are
    abroad, they test positive, they are not sick; maybe they were
    sick a week ago. And they can't afford to continue to pay for
    hotel rooms, and staying overseas until they can finally score
    a negative test.
        Has the time come for us to lift this, in your view; you
    know, having been so integral in our COVID response? Are we at
    a point now where American citizens should be allowed to return
    to their country without testing negative?
        Dr. Fauci. You know, I am not--thank you for the question.
    It is an important question. I don't have the answer to that. I
    mean, we work with our CDC colleagues to continue to examine
    the feasibility of that, and the desirability of that. I think
    the idea of having an immigration issue mixed with a public
    health issue for the general population; I think those probably
    should be separated.
        Senator Rubio. Well, except they are interrelated, because
    they both involve groups of people entering the United States.
    One group is citizens of the country entering legally, the
    other group, frankly, are people that are not entering legally.
    The group that is not entering legally, even if they test
    positive, if they are even tested, get to stay; the American
    citizen can't reenter their own country until they produce a
    negative test.
        And my point is, if we have reached the point in COVID,
    where we no longer need Title 42 as a COVID restriction for
    illegal entry, why do we still need travel restrictions for
    American citizens for legal entry into their own country? That
    is the genesis of the question. That is where I think the link
    is the--it sort of seems to be at odds with it.
        Dr. Fauci. Yes.
        Senator Rubio. All right. Thank you.

                            UNIVERSAL COVID VACCINE

        Senator Murray. Thank you. Dr. Fauci, you talked a little
    about this. But I wanted to go back through it again. I am
    really pushing for Congress to pass additional emergency COVID
    funding to make sure that our communities have the tests, and
    the treatments, and vaccines they need to keep their families
    safe.
        And I understand your Institute is supporting research on
    the development of these next-generation vaccines that could
    protect against multiple variants. What can you tell us about
    the progress of that research? And what does NIH need to see it
    to completion?
        Dr. Fauci. Well, thank you for that question. Well, the
    progress has been substantial. To get what we call
    ``universal'', and that is probably too broad a term, is to get
    a vaccine that works against multiple variants of SARS-CoV-2 is
    the first step
        And that would be something where you get a vaccine that
    either is directed against the common component of all of the
    variants, or has each of the components of the variants, for
    example, in a nanoparticle with a mosaic or multiple components
    to it.
        We have studies that are, right now, gone from preclinical,
    namely, in an animal model, into a human study, and the results
    actually look very promising. The next step would be to get a
    vaccine that not only is against all variants of SARS-CoV-2,
    but against all of those group of variants, including, what we
    call, sarbecoviruses, which overlap with the viruses that we
    see in many bats, which almost certainly are the original
    source of these viruses, that have jumped species and gone into
    humans.
        The work is going along very, very well. We are getting a
    number of investigators, both people who have been established
    in the field, and new investigators, but we can't continue it,
    Madam Chair, without additional resources.
        And that is really one of the things that is very, very
    difficult for us, because the scientific opportunity is there,
    and we really feel that we do have this, not only as an
    aspirational goal, but we will be able to get to that goal of
    getting a vaccine that would protect us against both known and
    unknown variants. So we are excited about the science of it,
    but we can't continue without additional resources.

                          INTERAGENCY WORK WITH BARDA

        Senator Murray. To have resources, right. And how is your
    Institute working with BARDA (Biomedical Advanced Research and
    Development Authority) to accelerate innovation in the next-
    generation vaccine development, particularly for COVID-19
    vaccines?
        Dr. Fauci. Well, we have had a long-standing collaboration
    and cooperation with BARDA now for quite a long period of time.
    And the way that works is that we do the fundamental, basic
    research, and proof of concept, and very often get involved,
    not only in the preclinical, but in the early trials, whereas,
    BARDA partners with a pharmaceutical company to do the advanced
    development of these concepts.
        So it is a partnership that has really worked very, very
    well, and hopefully we will be able to continue that, again
    with the need for new resources.
        Senator Murray. Okay. Thank you.
        Dr. Gordon, I want to come back to you. You have had
    several questions about mental illness, not surprising. It is a
    huge issue for America today. And I know that despite the best
    efforts of researchers, like yourself, in the past 30 years, we
    have seen dramatic increases in mortality, morbidity, and
    healthcare costs related to mental illness; and that is
    actually before factoring in the effects of this pandemic, and
    the opioid crisis.

                         MENTAL HEALTH DIAGNOSIS ISSUES

        And on top of it all, diagnosis is really difficult. And
    medications don't always work, and can have awful side effects.
    So I know Senator Blunt asked you about using RADx, as one
    possible approach, but what are the greatest barriers to
    accurate diagnosis?
        Dr. Gordon. Well, frankly, one of the greatest barriers to
    accurate diagnosis, Senator, is that our diagnoses are not
    terribly good, in terms of describing what is going on in the
    brain. And so we need a better individualized approach, not
    just to diagnosis, but really being able to make informed
    clinical decisions in cooperation with our patients.
        Well, the clinical issue really isn't, does this individual
    have depression, or schizophrenia, or bipolar disorder,
    although those diagnoses can be sometimes hard to differentiate
    in the individual patients.
        The bigger clinical question is: For this patient with
    depression, are they going to benefit most from a medication,
    or which type of medication? Or are they going to benefit most
    from psychotherapy, or a brain stimulation treatment?
        We have a number of different research projects that are
    aimed at trying to make those kinds of clinical decisions with
    the aid of technology, with the aid of increased attention to
    details in the patients' behaviors, and cognitions. And that
    approach I think is going to take advantage of things like big
    data. So we need to collect lots and lots of information
    about--well characterized patients.
        And then we need to make careful experiments to try to
    determine when that information helps us describe that patient
    better. So it is really about precision medicine in psychiatry,
    moving it forward in a number of different fronts, from grants,
    to academic organizations. And as I mentioned also before,
    small business grants that are really paying off. So we should
    see some progress, hopefully in the future, near future.
        Senator Murray. So I assume it is fair to assume that
    solving this diagnosis puzzle, will really open doors for
    better treatments?
        Dr. Gordon. It would open doors to transforming how we
    decide with our patients what treatments to use. It would
    really change psychiatry. Right now, as a psychiatrist, if I
    want to help someone with depression, our only discussion is
    about which side effects they don't want. And so we try to
    avoid one medication or another. As opposed to which
    medication, or which treatment that I have to offer is going to
    work better for them. So yeah, it would really transform
    things.
        Senator Murray. Okay. Thank you. Senator Blunt.
        Senator Blunt. Thank you, Chair.

                                    ADUHELM

        Dr. Hodes, I have been watching the FDA decision on
    Aduhelm, the Biogen drug, as well as the CMS (Centers for
    Medicare & Medicaid Services) handling of that. I think that
    decision is going to have some pretty long-term consequences,
    particularly the CMS decision, and other companies will be
    following. Biogen has already made some pretty dramatic
    decisions, based on the CMS view that only the people in a
    trial could benefit from the emergency approval, by FDA.
        Would you talk a little bit about both of those things?
    First the FDA approval process, what merit do you see in that
    emergency approval process? And then, what concerns do you have
    or not have about CMS then deciding that it would only be
    available to a few people?
        Dr. Hodes. Thank you for the question. Well, of course FDA
    and CMS have their regulatory responsibilities, and we defer to
    those. But we do work very closely particularly on the science
    involved in these implications; so as many, or all of you may
    know, the decision by FDA was what was called an accelerated
    approval of Aducanumab, Aduhelm, based on its ability to clear
    amyloid from the brain, and by brain scans.
        Without compelling evidence of clinical effectiveness, and
    that was the rub. And in fact, the FDA decision required that
    the sponsors, Biogen, Eisai, then conduct a randomized,
    controlled trial to look if--to determine if there was, in
    fact, clinical outcome.
        It was in that setting that CMS said that for widespread
    coverage it would require randomized, controlled clinical
    trial. It made the distinction, though, about the future of
    such drugs. Any drug that received an approval based on
    clinical outcome, based on FDA decision and judgment, would
    have broader coverage without requirement for another
    randomized clinical trial.
        But any in which there was no demonstrated evidence of
    effectiveness on clinical outcomes, would require that kind of
    outcome before they went further. Again, those are regulatory
    decisions.
        Senator Blunt. So it sounds like, to me, the FDA decision
    was really a CMS; or at least just the decision to continue the
    trial. That may not have been what FDA thought it was doing,
    but that is what CMS decided it was doing?
        Dr. Hodes. No. FDA, again, by requiring that--for
    maintenance even of the accelerated approval, that a clinical
    trial, a randomized trial, be carried out, was also saying
    there needed to be a continuation.
        You asked, importantly I think, what the impact of this
    will be on other studies, other agents. There are currently
    three companies, Roche, Lilly, and Eisai--Biogen, which have
    ongoing clinical trials of other antibodies to amyloid, they
    have all received a breakthrough designation last year from the
    FDA. They are all expected to produce their results in the next
    few months. So above all, I think we all share hope and
    optimism that will see effective clinical outcomes there.
        For NIH, I think the implications are clear. We need to
    support the most rigorous and continuing research toward
    amyloid and other targets, the kind of research that will give
    clear-cut, definitive answers about clinically important
    outcomes. And that is certainly our part in this consortium.

                      VACCINE AND THERAPEUTIC DEVELOPMENT

        Senator Blunt. Well, Dr. Fauci, while we are talking about
    the accelerated approvals, or not, during COVID, obviously
    NIAID (National Institute of Allergy and Infectious Diseases)
    shepherded both successful vaccines and therapeutics, through
    the approval process during the pandemic. I am concerned that
    once the pandemic is officially behind us that both vaccine and
    therapeutic research and development will be subjected to
    normal development processes that, in what we have learned in
    the last year-and-a-half may not be the structure that we
    should use. Would you talk about that a little bit?
        Dr. Fauci. Senator, are you referring to the fact that we
    should not slow down the acceleration of approvals when we are
    out of the pandemic phase?
        Senator Blunt. I am asking that, or if there should be some
    ``new normal'' approval process, now that we have had, I think
    two vaccines, and 20 treatments developed through those
    partnerships?
        Dr. Fauci. Yes. I am not sure I understand the question. It
    is my fault. Are you saying that, should we continue the normal
    standard of approval, which would take much longer than the
    emergency-use authorization? Is that the question you are
    asking?
        Senator Blunt. That is the question.
        Dr. Fauci. Yes. Yes, I think we should go through the
    normal approvals, and if we are in an emergency situation
    again, we absolutely should use the EUA (Emergency Use
    Authorization) approach which has fared us very well. But when
    we get behind us the outbreak, I think the normal approval
    process, which is pretty much expedited pretty well by the FDA,
    should continue.
        Senator Blunt. All right. Thank you, Chairman.
        Senator Murray. Senator Kennedy.

                               TITLE 42 RECISSION

        Senator Kennedy. Thank you, Madam Chair. Did the Biden
    administration ask any of you whether it was safe to rescind
    Title 42?
        Dr. Tabak. We have had no discussions about that, sir.
        Senator Kennedy. You haven't done?
        Dr. Tabak. I have not. No.
        Senator Kennedy. How about you, Dr. Fauci?
        Dr. Fauci. No. I have not.
        Senator Kennedy. How about you, Dr. Gibbons?
        Dr. Gibbons. No, No, sir.
        Senator Kennedy. How about you, Dr. Gordon?
        Dr. Gordon. No.
        Senator Kennedy. Dr. Hodes?
        Dr. Hodes. No, sir.
        Senator Kennedy. Dr. Volkow?
        Dr. Volkow. No.
        Senator Kennedy. Well, the Biden administration says it is
    safe, that under the science it is okay. Who did the
    administration rely on, to suggest that rescinding Title 42 is
    in the interest of public safety?
        Dr. Fauci. That was a CDC decision. The Title 42 is a CDC
    decision.
        Senator Kennedy. Do you agree with it, Dr. Fauci?
        Dr. Fauci. Well, I think that the immigration policy should
    be separated from the public health----
        Senator Kennedy. No. And I don't want to get you involved
    in immigration policy; but people are people, physiology is
    physiology.
        Dr. Fauci. Right.
        Senator Kennedy. And one is the susceptibility of the virus
    has nothing to do with their country of origin or immigration
    status.
        Dr. Fauci. Right.
        Senator Kennedy. And what I am asking you, purely from a
    public safety standpoint.
        Dr. Fauci. Right. Yes.
        Senator Kennedy. Is it safe to rescind Title 42?
        Dr. Fauci. I think given the level of infection at the
    time, which is right now, that I think that the CDC decision
    was a reasonable decision.
        Senator Kennedy. Does anybody disagree with that? Do you
    all agree with that? Let me get you, of record.
        Dr. Gibbons?
        Dr. Gibbons. Yes. I concur with Dr. Fauci on that.
        Senator Kennedy. Dr. Gordon?
        Dr. Gordon. I don't have the expertise to concur or not
    concur.
        Senator Kennedy. Okay. Dr. Hodes?
        Dr. Hodes. I would also say I don't have the expertise to
    weigh on this.
        Senator Kennedy. Dr. Volkow?
        Dr. Volkow. I don't have the expertise.
        Senator Kennedy. Okay. All right; thank you very much.
        Senator Murray. Senator Moran.

                               ARPA-H PRIORITIES

        Senator Moran. Thank you, Chairman Murray. I don't have the
    benefit of knowing what has been asked and answered. So I will
    ask questions. Recently the ARPA-H proposal would initially
    focus--this is for Dr. Tabak--would initially focus on three
    diseases: cancer, Alzheimer's, and diabetes, and be housed
    under NIH.
        Congress and NIH already invest significantly into research
    and development to these three diseases. How can NIH conduct
    proper oversight to ensure NIH, through its current work, isn't
    simply being replicated?
        Dr. Tabak. I think those three diseases are meant to be
    illustrative and not restrictive. In terms of the larger issues
    that you raise, as you know, NIH does a rather extensive
    portfolio analyses, and the expectation would be that there
    will be a crosstalk between the new agency, and the NIH to
    avoid, as you put, you know, the potential for duplication.

                         ALZHEIMER'S DISEASE TREATMENTS

        Senator Moran. This is again for you, Dr. Tabak. In recent
    National Coverage Determination, CMS indicated it would support
    FDA and NIH, by covering drugs for Medicare beneficiaries,
    participating in randomized, controlled trials. I would
    interpret that to mean that there is a path to coverage through
    NIH studies for participants qualifying trials, related in the
    FDA-approved Alzheimer's disease treatments. Is that an
    assessment that--and I am not--if that is an accurate
    assessment? Or how would you elaborate?
        Dr. Tabak. If I may turn to Dr. Hodes, who is the expert in
    that space.
        Senator Moran. Dr. Hodes.
        Dr. Hodes. I think that is a very accurate statement. Thank
    you.
        Senator Moran. Good. And that is a good development, right?
    Dr. Hodes shook his head, yes.
        Dr. Hodes. Yes, sir.

                              NCI BUDGET REDUCTION

        Senator Moran. Let me talk a moment, in the absence of Dr.
    Sharpless, I will let you all direct who should answer my
    question. The NIH 2023 budget request suggests $199 million cut
    to the NCI (National Cancer Institute), a 2.9 percent cut from
    the current fiscal year. I assume that that will be explained
    as those dollars being picked up in ARPA-H. What is the
    rationale for the significant funding pivot to ARPA-H at the
    expense of NCI?
        Dr. Tabak. So at the time the budget was prepared, the only
    baseline that the administration had to work with was a
    continuing resolution level. We are fortunate that the
    Congress, in the Omnibus, provided us with substantially more
    resources than were in the continuing resolution. And we
    certainly look forward to working with you as the 2023
    appropriations process works through.
        Senator Moran. So there is room--there is no particular
    insistence that that is the right ratio between the funding of
    one ARPA-H, and the normal appropriations process for NCI?
        Dr. Tabak. I think it is more than a reflection of using a
    baseline that was available at the time.
        Senator Moran. Well, the $16.9 billion increase for NCI in
    fiscal year 2022, allowed the NCI to increase the funding
    allocated toward competitive cancer grants. It is one of the
    reasons we continue to advocate for higher NCI funding, is to
    improve NCI's ability to award those competitive cancer grants.
        In recent years NCI could only fund about one in eight
    research grant applications. Dr. Sharpless indicated, in front
    of the subcommittee, that that was a great concern to him, as
    it is to me. If NCI funding is not boosted above the fiscal
    year 2022 levels, can competitive grants be prioritized and
    expanded?
        Dr. Tabak. It would be very difficult to do that in the
    absence of additional funding.
        Senator Moran. Doctor, thank you, both of you. Thank you
    all.

                          AUTOIMMUNE DISEASE RESEARCH

        Senator Murray. Dr. Tabak, last week the National Academy
    has issued its review of NIH's autoimmune research portfolio,
    and the authors found that much of the work that that agency
    does in this area is really extraordinary. But that NIH doesn't
    do the best job coordinating, or setting priorities, or
    focusing on innovation, or evaluating its autoimmune research
    portfolio.
        The authors' findings really echo an earlier 2010 National
    Academy Study on women's health research, and to address these
    problems, they recommended the creation of an Office of
    Autoimmune Disease Research within the Office of the Director,
    to facilitate collaboration and coordination.
        Given the importance of this research for communities
    across the country, it is critical that NIH does the best
    possible job facilitating it. Do you have concerns with
    establishing this office?
        Dr. Tabak. Senator, the report, as you know, was released
    last week, and we are still reviewing the specifics of it. In
    reviewing the top line messages, among the things they suggest
    that we do, develop an agency-wide strategic plan, make sure
    that investments that we make align with those strategic plans,
    coordinate both within and outside the agency, do evaluation,
    do reports to the Congress.
        At first glance, I think these are things that we could
    probably do without the creation of a new office, but I
    certainly, you know, would be willing to work with you, and
    other members of the committee, going forward, as we sort
    through the specifics of the report, and get a better
    understanding of the rationale behind their specific
    recommendation.
        Senator Murray. Okay. I would like to work more with you on
    that. I think this is extremely important. I want to make sure
    we are addressing it in the correct way, and I want to talk to
    you more about that.
        Dr. Tabak. Thank you.
        Senator Murray. Senator Blunt.

                           EARLY STAGE INVESTIGATORS

        Senator Blunt. Thanks Chair. I think my last question today
    will start with Dr. Tabak, but anybody that wants to talk about
    it. One of the things we were most concerned about 8 years ago
    was the fact that young researchers were leaving the field.
    That the pool of money, not only wasn't increasing, but it was
    about 22 percent less in the research buying power, than it had
    been.
        What are we doing right now to keep young researchers in
    the field, and try to see that they get their first grant, and
    that there is not an obstacle based on numbers of first grants
    to getting that second grant?
        Why don't you start, Dr. Tabak? And if anybody else wants
    to talk about what you are doing to keep young researchers
    engaged I would be pleased to hear that.
        Dr. Tabak. We have prioritized the funding of early-stage
    investigators; back in 2013 we only supported 600 such
    individuals, last fiscal year, 1,513. That has come as a result
    of the Institute and Center leadership prioritizing
    applications from these individuals. We have also created
    certain mechanisms that would incentivize and enable early-
    stage investigators.
        So for example, we have the so-called Katz Early Stage
    Investigator Award, in which no preliminary data is accepted.
    This is important, it basically liberates a new investigator
    from his or her post-doctoral or graduate school experience,
    and they are able to think, you know, as boldly as possible in
    preparing an application.
        We also have the NIH Director's New Innovator Award Program
    which is attracting early-stage investigators from very broad
    biomedical fields. And so when you take these things together,
    I think we are making good progress in ensuring the entree into
    the system of biomedical research.
        But let me turn to my colleagues to see if anybody else
    wishes to comment.
        Dr. Gibbons. If I might add to Dr. Tabak's comments. There
    are two areas for the NHLBI (National Heart, Lung, and Blood
    Institute) that we are particularly focusing on. As evident in
    these hearings, a critical element is the translation of basic
    science understanding into clinical science and clinical
    medicine, and clinician scientists are critical to making those
    transitional leaps that are so important to public health.
        And this is an area, quite frankly, where there is a
    paucity of early-stage investigators, in a critical pipeline.
    And so we have special awards for them to get their first RO1,
    in particular, to launch their careers as early-stage clinical
    investigators.
        I would also add the diversity of that early-stage
    investigator pool is critical, and recognizing the supportive
    efforts to expand that diversity is, again, another high
    priority which we have programs, specifically, designed to do
    that, like our PRIDE Program. Over.
        Senator Blunt. Anybody else?
        Dr. Hodes. I had to reinforce the points made. And note
    that we also try to track outcomes of our programs, including
    training, career development. So for example, with the expanded
    research around Alzheimer's and related dementia's research,
    since 2015 through the present, fully a third of the
    investigators awarded have been new and early-stage
    investigators who have had no prior, major NIH research. And we
    think this is an important reflection of our ability to
    recruit. And now we will see about retaining them into the
    research workforce.
        Dr. Volkow. And I was just going to make a comment, because
    Dr. Tabak alluded to it, and an area that is crucial is to
    ensure that we get the brightest interested in science; so
    going after younger kids, and teaching them, and giving the
    opportunity to see what science is all about, is a way that you
    can ensure that you will have the throughput then, to get
    investigators.
        Senator Blunt. Thank you, Chair.
        Senator Murray. Thank you. Senator Moran.
        Senator Moran. I will just take this moment, Chairman
    Murray, to thank you and Senator Blunt, for your leadership,
    and the success that we have had in numerous years, now in a
    row, in the support for the National Institutes of Health.
        I have been a ranking member of this committee with Senator
    Harkin. You both have been ranking members, and chairmen and
    woman of this committee during a period of time in which we
    were capable, in a bipartisan way, of increasing the investment
    in fighting the diseases and afflictions that Americans and
    people around the globe suffer from.
        And not knowing what our committee schedule is into the
    future, this may be the last time we have Senator Blunt here
    with the NIH crew. And I take this moment to thank him, in
    particular, for his efforts that have been recognized around
    the country, and certainly in our home States of Kansas and
    Missouri, of making a tremendous difference in the efforts to
    find the cures and the treatments to reduce the afflictions
    that we face in the world, of our well-being, of our health.
        And so to you, to Senator Blunt, particularly today, thank
    you for that leadership. I am pleased that the world is in a
    better position, and that Americans have a greater chance of
    fighting these diseases, and there is a lot more hope than
    there used to be.
        Senator Murray. Thank you. Thank you for those comments. I
    think we all agree.
        That will end our hearing today. And I want to thank my
    fellow committee members for a thoughtful conversation.
        I want to thank Doctors Tabak, Fauci, Gibbons, Gordon,
    Hodes, and Volkow. Thank you all for joining us today to share
    your expertise.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due May 27, at 5:00 p.m.; the
    hearing record will 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. Lawrence Tabak
                  Questions Submitted by Senator Patty Murray
        Question. The budget request concentrates most of its proposed
    spending increase in ARPA-H, even though that agency has yet to hire
    anyone. If Congress funded ARPA-H at $5 billion as the budget proposes,
    what impact would that have on N-I-H's 27 institutes and centers? While
    Congress's work on the ARPA-H authorization continues, there's broad
    agreement that it should not be based in Bethesda with the rest of NIH
    and that its staff should be recruited from outside the agency. Given
    the transformative role ARPA-H is supposed to play by supporting high-
    risk, high-reward research, I believe NIH should rely on outside
    expertise to recruit the right staff to stand up the agency.
        Who is handling ARPA-H's hiring? Is it NIH or an outside firm?
        When does NIH expect to have a permanent director on-board?
        Answer. HHS is in the process of standing up ARPA-H and developing
    plans for its operations and functions, including recruiting an
    innovative group of people to help launch the important work of the
    agency. HHS is bringing onboard staff in key support functions--
    acquisitions, budget/finance, and strategic resources. Program managers
    will be recruited after an inaugural director is on board. The
    Secretary is also seeking to identify an interim leader prior to the
    appointment of an inaugural Director. Ideally, this acting deputy
    director would have considerable experience in government--specifically
    familiarity with the ``ARPA'' model, broad technical and management
    experience across several disciplines, and a proven record innovating
    around experimental platforms and tools to facilitate discovery,
    quantification, and validation of fundamental measures in science.
        Meanwhile, the White House is currently looking for candidates for
    President Biden to appoint as an ARPA-H Director who will be
    responsible for administration and operation of ARPA-H and who will
    report to Secretary Becerra. The ideal candidate would be an
    extraordinary leader with a vision and proven track record for driving
    transformative change in health and biomedicine, a strong private
    sector background, and experience in academia or government, as well as
    a proven ability to build partnerships.
        Question. Congress provided significant funding for research into
    long-COVID with the goal of understanding this complex condition and
    developing potential treatments.
        When does NIH expect to exhaust its existing balances of long-COVID
    funding and what steps would it take if faced with a shortfall?
        Answer. Funds for the Researching COVID to Enhance Recovery
    (RECOVER) initiative are being used to implement the necessary in-depth
    and national scale approach to understanding, preventing, and treating
    the post-acute sequelae of SARS-CoV-2 infection (PASC), including Long
    COVID. The National Institutes of Health (NIH) has either obligated or
    has planned/outyear RECOVER activities for all of the $1.15 billion
    funding provided by Congress. Working on an accelerated schedule, NIH
    has obligated approximately $674.5 million as of May 17, 2022. The
    balance will be utilized in planned obligations to cover fiscal year
    2022 and outyear spending for RECOVER studies.
        Our understanding of the complexity and broad range of conditions
    encompassed in PASC has evolved substantially since the time of the
    original appropriation, and it is clear that we need to further
    accelerate and expand our existing efforts and capacity to test a wider
    range of interventions and develop assays for the diagnosis and
    monitoring of patients with PASC.
                                     ______

                    Questions Submitted by Senator Roy Blunt
    ARPA-H
        Question. I am a supporter of ARPA-H. At last year's NIH hearing I
    spent the majority of my statement highlighting that ARPA-H is the
    right idea at the right time because, as we learned so well during
    COVID-19, NIH can take a larger, more involved role in public-private
    partnerships without overstepping the bounds of the role private
    industry should play. Since that time, Congress has passed an Omnibus
    appropriations bill that included $1 billion to establish ARPA-H. In
    addition, the HHS Secretary has established ARPA-H at NIH, but with
    direct reporting to the Secretary's office. Dr. Tabak, can you explain
    why it is important to have ARPA-H under the NIH umbrella, and
    specifically how this will help get ARPA-H established and working on
    research programs faster?
        Answer. On April 15, 2022, Secretary Becerra transferred ARPA-H to
    the NIH as notified in the Federal Register published April 20, 2022.
    The Secretary indicated that, following presidential appointment, the
    ARPA-H director will report directly to the Secretary and be delegated
    all the necessary authorities to administer ARPA-H.
        The Secretary's decision to transfer ARPA-H to NIH is critical to
    accelerating ARPA-H's establishment and reducing the use of funding for
    redundant functions using critical infrastructure provided by NIH.
    Broadly, ARPA-H's mission aligns with NIH's, in that both agencies
    strive to improve health through research. Through close collaboration
    between ARPA-H and NIH, along with other Federal, and public or private
    entities, ARPA-H will ensure it reaches all people with better health
    solutions faster. ARPA-H benefits from drawing closely upon NIH's role
    as a global leader in biomedical research, including its knowledge,
    expertise, and ongoing activities. Setting up ARPA-H within NIH will
    avoid unnecessary duplication of scientific and administrative effort.
    As a part of NIH, ARPA-H is benefitting from and leveraging the use of
    several electronic systems to quickly establish its functional areas,
    provide for a more seamless start up, and avoid building functionality
    from scratch that already exists
        Question. ARPA-H is in the process of being stood up. Can you
    provide the Committee with additional details on:
        What qualifications you are looking for in a Director?
        Answer. President Biden will appoint an inaugural Director with the
    requisite experience to lead this new agency. An ideal candidate would
    be an extraordinary leader with a proven track record and vision for
    driving transformative change in health and biomedicine, a strong
    private sector background, and experience in academia or government. In
    addition, the candidate should have a proven ability to build
    partnerships.
        Question. When do you expect a Director to be in place?
        Answer. The White House manages the search, nomination, and
    announcement, of all presidential appointees.
        Question. How many program managers are you looking to hire?
        Answer. ARPA-H will recruit and hire program managers based on the
    organization's priorities and the funding available. Decisions will be
    made when the inaugural ARPA-H Director is appointed.
        Question. What are the qualifications for the location for an ARPA-
    H headquarters and when will that decision be announced?
        Answer. HHS is in the process of standing up the new agency and is
    developing plans for its operations and functions. Currently, no
    commitments as to the physical location of ARPA-H have been made.
        Question. Will there be an official location search similar to how
    locations for other agencies outside of Washington, DC were chosen?
    Like the recently relocated National Institute of Food and Agriculture?
        Answer. Currently, no commitments as to the physical location of
    ARPA-H have been made. We will continue to engage in a thoughtful
    process.
        Question. When do you expect scientific programs to begin?
        Answer. Scientific programs are expected to begin after the
    appointment of an inaugural director and the recruitment and hiring of
    the first program managers.
        Question. How will ARPA-H be structured to ensure that biomedical
    researchers at universities have an opportunity to be program managers
    when typical sabbaticals from research institutions last 2 years, which
    is less than the typical three year program manager term?
        Answer. Program managers are expected to be appointed for a single
    three-year term with the possibility of a single renewal, but shorter
    terms could be negotiated. In a circumstance where a program manager's
    home institution recalled the researcher prior to the end of an
    appointment, ARPA-H would anticipate working with the institution for a
    mutually agreeable solution.
        Question. Will ARPA-H encourage researchers to publish outcomes of
    their ARPA-H research in medical publications? This is currently
    atypical at DARPA.
        Answer. DARPA and ARPA-H operate in two different ecosystems. DARPA
    funds performers to benefit the Department of Defense in execution of
    its mission. ARPA-H's goal is for new technologies, capabilities, and
    platforms to benefit everyone and improve everyone's health potential.
    Where appropriate, ARPA-H performers will be encouraged to publish
    their findings or otherwise make them widely available.
        Question. Will ARPA-H run clinical trials? If so, what will be the
    process to test/approve treatments or vaccines with FDA?
        Answer. Scientific programs are expected to begin after the
    appointment of an inaugural director and the recruitment and hiring of
    the first program managers. A potential area of focus is to improve
    clinical trials to speed the generation of research results and recruit
    more inclusive trial participants so that those results are more
    representative of the patient population. ARPA-H will seek
    opportunities to work closely with other Federal agencies and the
    private sector on these issues.
        Question. More specifically, how do you envision the partnership
    between ARPA-H and FDA?
        Answer. See Answer above.
        Question. How do you ensure the FDA approval process does not
    hinder the urgency ARPA-H will need?
        Answer. Operating within the Federal Government, ARPA-H anticipates
    the benefit of forming close relationships, collaborations, and
    agreements with other Federal agencies, either formal or informal. In
    either case, the intent remains the same--to work closely with other
    Federal agencies to engage them early in the program development
    process and collaborate to promote synergistic goals.
        Question. Are you concerned that FDA will hinder the fast moving
    nature of the agency because of their slow approval process?
        Answer. ARPA-H anticipates partnering with the FDA through
    collaborative integration and involvement of FDA staff, where
    appropriate, in relevant programs from their inception. These
    collaborations would be developed to be mutually beneficial from ARPA-
    H's and FDA's perspective.
        Question. Will ARPA-H have an advisory board? If so, who will
    comprise it? If not, why not?
        Answer. This would be decided by the inaugural Director.
    Universal Flu Vaccine
        Question. In response to the COVID-19 pandemic, the US was able to
    work through public-private partnerships to develop several vaccines
    within less than a year. While this was a much needed triumph, I
    assume, Dr. Fauci, it also greatly increases expectations that we can
    develop vaccines for other diseases using the mRNA model or the
    processes used for developing a COVID vaccine. What did you learn from
    COVID-19 vaccine research and development that can now be applied to
    the development of other vaccines, particularly a universal flu
    vaccine?
        Answer. The development of vaccines for COVID-19 was greatly
    accelerated by the development of vaccine platform technologies as well
    as advances in structural biology that allowed for the stabilization of
    the SARS-CoV-2 spike protein and its incorporation into the mRNA
    vaccine platform. Research advances that have supported the development
    of COVID-19 vaccines, including current efforts to develop the next
    generation of COVID-19 vaccines, will support ongoing efforts to
    develop universal influenza vaccines by further validating and
    advancing the vaccine platforms and technologies on which they are
    based. For example, advances in mRNA vaccine platforms, including the
    successful development of mRNA-based COVID-19 vaccines, have shown the
    utility of this vaccine platform, especially in situations where rapid
    development of vaccines is crucial or where traditional vaccine
    technologies have not yet proven successful. Several mRNA-based vaccine
    candidates for seasonal influenza are currently undergoing clinical
    testing. The National Institute of Allergy and Infectious Diseases
    (NIAID) also is sponsoring clinical studies of three novel mRNA-based
    HIV vaccines. Evaluation and development of the mRNA vaccine platform
    across a number of diverse virus families will further aid our efforts
    to develop tools and resources for responding to the next pandemic
    threat.
        NIAID also will build on the advances made for COVID-19 vaccines
    using other vaccine platforms, many of which are already in use for the
    development of universal influenza vaccines. NIAID Vaccine Research
    Center investigators have created a nanoparticle-based pan-coronavirus
    vaccine candidate designed to elicit antibodies targeted to the spike
    protein of multiple different coronaviruses. This mosaic nanoparticle-
    based approach--based on the universal influenza vaccine concept known
    as FluMos--is currently undergoing preclinical testing in an animal
    model. Separately, NIAID-supported scientists provided proof of
    principle that self-assembling mosaic nanoparticles displaying receptor
    binding domains of multiple coronaviruses in the Sarbecovirus subgroup
    (including SARS-CoV-2) can induce protection in mice when challenged
    with another Sarbecovirus. These advances in nanoparticle vaccine
    technology will help inform similar strategies for development of a
    universal influenza vaccine. In addition, NIAID intramural
    investigators are evaluating inactivated whole virus vaccine candidates
    for a broadly protective beta-coronavirus vaccine based on related
    efforts to develop a universal influenza vaccine. Development and
    testing of this approach for beta-coronaviruses will provide valuable
    insights into the development of broadly protective inactivated whole
    virus vaccines for influenza and other viral families. NIAID also is
    supporting studies through its vaccine adjuvant program to compare
    different classes of adjuvants and identify the most efficacious
    vaccine formulations. The identification of vaccine adjuvants that
    promote cross-protective and durable immunity in vulnerable populations
    would complement ongoing efforts to develop universal influenza
    vaccines as well as vaccines for other pandemic threats.
        In late 2021, NIAID announced four awards to fund
    multidisciplinary, collaborative teams to conduct research on pan-
    coronavirus vaccine candidates and help accelerate pan-coronavirus
    vaccine development. The teams will incorporate advances in coronavirus
    biology and immunology; immunogen design; and innovative vaccine and
    adjuvant technologies to discover, design, and develop vaccine
    candidates to protect against multiple SARS-CoV-2 variants and other
    coronaviruses. NIAID expects that these efforts not only will advance
    the development of pan-coronavirus vaccines, but also will complement
    similar activities undertaken by NIAID intra- and extramural
    researchers, including at the Collaborative Influenza Vaccine
    Innovation Centers (CIVICs) and the NIAID-supported Vaccine and
    Treatment Evaluation Units (VTEUs) to develop universal influenza
    vaccines. In addition, NIAID-supported research to better understand
    the immune response to SARS-CoV-2 infection and vaccination, including
    the role of antibodies and T cells, will further advance our
    understanding of the human immune system and may provide valuable
    insights into new strategies for developing and evaluating broadly
    protective vaccines for other pandemic threats, including influenza.
    Long COVID
        Question. Dr. Tabak, there are a lot of unknowns about long COVID--
    what the causes are, why it affects only some, even what the defined
    set of symptoms are--and that opens up a lot of research avenues. But
    there is also a sense of urgency that should not be lost and NIH must
    stay focused on finding ways to help those who suffer, which could be
    as many as 30 percent of the population that has had COVID-19.
        At the end of 2020, Congress provided $1.15 billion for research on
    long COVID. Using this funding, NIH started the RECOVER program, which
    in the intervening months has received a lot of criticism. Concerns
    have been raised about NIH's lack of urgency and whether it is focused
    too much on open-ended research questions as opposed to testing
    treatments and moving therapeutics to clinical trials. Can you address
    these concerns and specifically highlight why NIH chose to create a
    large observational study as opposed to focusing on testing
    therapeutics and other possible treatments?
        Answer. Researching COVID to Enhance Recovery (RECOVER) program's
    national longitudinal observation study is enrolling thousands of
    diverse participants including adult, pregnant, and pediatric
    populations from over 200 sites across the country, to fully understand
    the incidence, prevalence, clinical signs, and symptoms of the various
    forms of post-acute sequelae of SARS-CoV-2 infection (PASC) and risk
    factors for their development. Of note, RECOVER is particularly
    attentive to ensuring inclusion of those typically underrepresented in
    biomedical research and those from the populations disproportionately
    affected by COVID-19. The clinical data and specimens from this study
    are necessary to provide the robust evidence base for development of
    diagnostics, clinical monitoring strategies, as well as therapeutics.
    Moreover, the data collected through this study will inform an
    understanding of and strategies to address ethnic and racial
    disparities in PASC, impact on pre-existing conditions, and mental
    health effects.
        Key data and findings from RECOVER's observational study have
    ensured that NIH is now better poised to test currently available
    treatments and agents to address symptomatology while simultaneously
    continuing efforts to fully understanding the full spectrum of
    diagnosis for the pathobiology of PASC--efforts that have not occurred
    in research of other post-viral conditions. For example, with knowledge
    gained through the observational study and other elements of RECOVER,
    potential clinical trial interventions could explore pathways to
    determine if there are viral responses that might generate some sort of
    reaction (e.g., pro-inflammatory) that can be treated or to determine
    if there are other types of disorders producing metabolic aspects that
    can be therapeutic targets.
        Clinical trials to identify safe and effective treatments as well
    as preventive strategies for PASC are a priority for NIH. NIH is
    addressing symptoms/symptom clusters and underlying mechanisms of
    pathobiology of PASC by establishing a dedicated Clinical Trials Data
    Coordinating Center to implement and manage multiple interventions, as
    well as issuing a solicitation for well-designed clinical trials
    testing a range of interventions. Clinical trial development is being
    informed through a consultative process with engagement of patient,
    practitioner, and research communities regarding symptoms/symptom
    clusters, outcome measures, and interventions. The first trials are
    anticipated to be launched by Fall of 2022.
        The RECOVER initiative is also leveraging real-world data derived
    from the electronic health records (EHRs) of over 60 million adult and
    pediatric patients accessible through the National COVID Cohort
    Collaborative (N3C), the PEDSnet consortium, and the National Patient-
    Centered Clinical Research Network (PCORnet).\1,2,3\ RECOVER electronic
    health records (EHR) to better define PASC in all its forms, to
    discover and understand factors that influence the likelihood of
    developing PASC in adults and children, to understand PASC treatment
    strategies as quickly as possible, and to identify high priority
    approaches to address PASC in the populations most affected. While this
    work is ongoing, the RECOVER EHR studies have recently completed their
    initial set of analyses at national scale and are publishing results on
    several key clinical and public health issues including: PASC cardiac
    complications; \4\ development of new onset diabetes as part of PASC;
    impact of COVID-19 vaccination and viral variants on PASC;
    manifestations of PASC in children and adolescents; and racial, ethnic,
    and socioeconomic disparities in PASC.
    ---------------------------------------------------------------------------
        \1\ https://ncats.nih.gov/n3c.
        \2\ https://pedsnet.org/.
        \3\ https://pcornet.org/network/.
        \4\ https://www.cdc.gov/mmwr/volumes/71/wr/mm7114e1.htm.
    ---------------------------------------------------------------------------
        The RECOVER pathobiology studies being launched soon will identify
    mechanisms underpinning clinical phenotypes and symptomatic
    manifestations and understand the pathology in multiple organ/systems
    that has led or will lead to clinically significant health problems.
    Analyses of clinical data and biospecimens from the longitudinal
    studies will contribute to our understanding of the cause(s) of PASC,
    help identify biomarkers, enable risk stratification, contribute to the
    development of new therapeutic targets, and will help inform the design
    of PASC clinical trials.
        A systematic and standardized autopsy study at scale is underway
    now to comprehensively identify the effects of SARS-CoV-2 infection on
    organs/tissues throughout the body for the purpose of understanding the
    pathobiology of PASC and informing development of diagnostics, clinical
    monitoring, and potential treatment and prevention strategies.
    Osteopathic Medicine
        Question. Dr. Tabak, Colleges of Osteopathic Medicine educate
    nearly a quarter of U.S. physicians, but only compromise a small
    portion of NIH grants and are underrepresented on NIH study sections
    and advisory boards. How will NIH work with Colleges of Osteopathic
    Medicine to increase their representation on NIH panels and through
    funding opportunities?
        Answer. The National Institutes of Health (NIH) is dedicated to
    strengthening and diversifying the biomedical research workforce. This
    includes fostering opportunities for physician-scientists with
    osteopathic medical degrees, a group of researchers NIH recognizes as
    being underrepresented in the biomedical workforce. As part of this
    effort, NIH continues to address recommendations described in a 2014
    report focused on the physician-scientist workforce from the NIH
    Advisory Committee to the Director.\5\ As the report notes and NIH
    agrees with, ``findings which lead to advances in practice are driven
    largely by the work of investigators with a variety of degrees
    [including D.O.s], of whom those with clinical training contribute
    essential knowledge and skills.''
    ---------------------------------------------------------------------------
        \5\ acd.od.nih.gov/documents/reports/PSW_Report_ACD_06042014.pdf.
    ---------------------------------------------------------------------------
        Physicians with a Doctor of Osteopathic Medicine (D.O.) degree
    represent an important component of the medical community. They
    straddle the complementary, integrative health, and allopathic medical
    communities and have historically been connected to the National Center
    for Complementary and Integrative Health (NCCIH), one of NIH's
    Institutes and Centers (ICs), through the practice of osteopathic
    manipulation. Osteopathic manipulation is a full-body system of hands-
    on techniques to alleviate pain, restore function, and promote health
    and wellbeing. This promising intervention is of interest to NCCIH, and
    the Center makes every effort to ensure that D.O.s have representation
    on its advisory council. NCCIH currently has two members with a D.O.
    degree on its 18-member council.\6\
    ---------------------------------------------------------------------------
        \6\ www.nccih.nih.gov/about/naccih-member-roster.
    ---------------------------------------------------------------------------
        NCCIH along with other NIH ICs has specific opportunities for
    clinician-scientists, which includes D.O.s, who conduct research across
    a wide range of complementary and integrative health approaches.
    Examples of such programs include, but are not limited to:
      --Mentored Clinical Scientist Research Career Development Awards.\7\
    ---------------------------------------------------------------------------
        \7\ researchtraining.nih.gov/programs/career-development/K08.
    ---------------------------------------------------------------------------
      --K12 career development award program.\8\
    ---------------------------------------------------------------------------
        \8\ researchtraining.nih.gov/programs/career-development/k12.
    ---------------------------------------------------------------------------
      --Academic Research Enhancement Award (AREA) program.\9\
    ---------------------------------------------------------------------------
        \9\ grants.nih.gov/grants/funding/r15.htm.
    ---------------------------------------------------------------------------
    Act for ALS
        Question. Last year, Congress passed a bill I cosponsored, ACT for
    ALS, that establishes a grant program to address neurodegenerative
    diseases, and specifically ALS. The fiscal year 2022 Omnibus passed in
    March provided $25 million to establish the program. Dr. Tabak, I know
    NIH had concerns about this bill when it was passed. Can you discuss
    the concerns and the challenges to this research so we can address them
    moving forward?
        Answer. The National Institutes of Health (NIH) strongly supports
    investing in the unique and specific research needs of the Amyotrophic
    lateral sclerosis (ALS) community. ALS and other rare and fatal
    neurodegenerative diseases inflict immense suffering on people living
    with these diseases and their families, and there is an urgent need to
    develop effective therapies and cures. NIH is enthusiastic about
    partnering with others to catalyze new approaches capable of bringing
    us closer to developing effective interventions to prevent, diagnose,
    mitigate, treat, or cure ALS.
        NIH is supportive of the ACT for ALS provisions that have the main
    intent of broadly enhancing research and development for ALS and other
    rare neurodegenerative diseases, including the HHS Public-Private
    Partnership for Rare Neurodegenerative Diseases, and the U.S. Food and
    Drug Administration (FDA) action plan and grant program for research on
    ALS and other rare neurodegenerative diseases. NIH has major
    capabilities in administering grant programs in ALS research. NIH's
    primary concerns with the legislation have been with the grant program
    for research utilizing data from expanded access to investigational
    therapies for ALS authorized in section 2 of the legislation. NIH's
    concerns continue to be that (1) the creation of the expanded access
    grant program fails to place appropriate focus on the real and
    pernicious challenges impeding the development of effective ALS
    therapies, namely, the desperate need for a real understanding of
    disease mechanisms to allow for the development of effective
    treatments; (2) supplying investigational therapies, especially those
    unproven to have tangible improvements for patients, is beyond the NIH
    mission to advance our fundamental knowledge to improve health; (3)
    programs supplying investigational drugs have the potential to drive
    patients away from enrolling in placebo-controlled trials that are
    desperately needed to actually produce new and effective treatments for
    ALS patients; and (4) few small businesses would qualify for the
    program as defined by the statute, thus limiting the diversity of the
    investigational drugs that could be in the grant program. The final
    amended legislation addressed some of NIH's concerns by requiring
    entities to conduct research enrolling patients ineligible for other
    ALS clinical trials. However, NIH's principal concerns still hold true,
    and we strongly emphasize that investments in mechanistic disease
    research and therapy development are critical for the breakthroughs
    needed to develop transformative therapies for ALS.
        Regarding the research component of the expanded access provision
    in the ACT for ALS, we remain concerned that the expanded access data
    obtained from persons with ALS on whom there is no research-grade data
    preceding an intervention, and for whom there is not a matched control
    group (gender, age, time from onset, rapid vs. slow course, etc.) with
    which to compare is unlikely to yield valuable scientific information.
    Even in instances where some reliable data would be gleaned, the
    information is unlikely to be transformative or rapidly accelerate ALS
    research. Except for an investigational drug that is so potent that it
    stops progression, any other finding would be impossible to ascribe to
    anything other than chance. As section 2 of the ACT for ALS Act
    specifies that investigational drugs in the expanded access grant
    program are confined to those in phase 3 clinical trials, a highly
    potent therapy would be first identified in the randomized controlled
    phase 3 trial. As of the date of the hearing, NIH has begun
    implementing the expanded access grant program. A request for
    applications was published on May 12, 2022.\10\
    ---------------------------------------------------------------------------
        \10\ grants.nih.gov/grants/guide/rfa-files/RFA-NS-22-071.html.
    ---------------------------------------------------------------------------
        NIH places a high priority on research that will lead to the
    development of interventions for ALS and has increased funding for ALS
    research from $52 million in fiscal year (FY) 2016 to $120 million in
    fiscal year 2021. This increase is primarily due to the rise in
    research on Alzheimer's disease and related dementias, which supports
    research on those mechanisms and conditions that cause both dementia
    and ALS, rather than reflecting an increase in research on ALS alone.
    In addition to a broad array of research projects to understand the
    genetic and environmental causes of ALS and to elucidate the cellular
    and molecular mechanisms by which the disease progresses, in fall of
    2021 NIH funded four exciting projects \11\ through the Accelerating
    Leading-edge Science in ALS (ALS2) initiative, part of the NIH Common
    Fund's Transformative Research Awards, which aims to dramatically
    advance our understanding of what triggers ALS and what drives the
    rapid progression of this disease. NIH is also supporting several large
    natural history and biomarkers studies to improve our understanding of
    the disease process and to identify biomarkers that will predict when
    people at risk for ALS might get the disease, which would allow them to
    begin treatment early, perhaps even before symptoms appear. NIH-
    supported preclinical research projects are testing a range of
    therapeutic targets and agents, including gene therapies and small
    molecule drugs, in experimental models of ALS, including animals or
    cells/tissues, to treat inherited and sporadic forms of ALS. Several
    promising industry-funded clinical trials are based upon NIH-supported
    basic and preclinical research findings.
    ---------------------------------------------------------------------------
        \11\ www.ninds.nih.gov/news-events/directors-messages/all-
    directors-messages/spurring-innovative-research-toward-als-cures-
    through-accelerating-leading-edge-science-als-als2.
    ---------------------------------------------------------------------------
        NIH is preparing for the future of ALS research by initiating a
    strategic planning process to identify the highest priorities for
    research that will lead to the discovery of effective interventions for
    the diagnosis, treatment, management, prevention, or cure of ALS. The
    process is engaging researchers, clinicians, advocates, people affected
    by ALS, multiple NIH institutes, and other Federal agencies, and has
    multiple opportunities for the general public to contribute to the
    process. Draft priorities will be presented for public comment at a
    public workshop on October 26-27, 2022.\12\
    ---------------------------------------------------------------------------
        \12\ www.ninds.nih.gov/about-ninds/strategic-plans-evaluations/
    strategic-plans/amyotrophic-lateral-sclerosis-als.
    ---------------------------------------------------------------------------
                                     ______

                Questions Submitted by Senator Richard C. Shelby
        Question. Dr. Tabak, the fiscal year 2023 budget request does not
    continue its support for the Undiagnosed Diseases Network as it
    graduates from the Common Fund. The University of Alabama at Birmingham
    runs the Undiagnosed Diseases Network in partnership with Harvard and
    it has been a valuable resource to which to refer challenging cases and
    also is a network of strong collaborators to help researchers tackle
    those cases. More than that, it is a national resource for Americans
    who have an undiagnosed disease or disorder with no other place to
    turn.
        Why is there not a plan in place to retain the Network and its
    clinical sites around the country?
        Answer. The Undiagnosed Disease Network (UDN) was always planned
    for 10 years--the maximum period of support for Common Fund programs.
    In Phase II of the program (starting in 2018), the UDN was tasked with
    developing a framework to continue its mission after expiration of
    Common Fund support, ensuring sustained clinical utility for decades to
    come. For the final year of the program, the National Institutes of
    Health (NIH) will provide supplements and extensions to the UDN
    extramural clinical sites, Coordinating Center, and some Cores to
    ensure that all participants accepted by the end of the ninth year are
    evaluated as the program transitions to a larger, self-sustained
    network. Some sites have committed to continue enrollment during this
    period, and NIH is exploring means to enable other sites to continue to
    enroll new patients as well. The intramural Undiagnosed Disease
    Program, housed within the NIH Clinical Center and currently supported
    as a UDN clinical site, will continue to receive support and oversight
    from multiple NIH Institutes and Centers (ICs).
        Multiple NIH ICs released a notice of intent to publish a funding
    announcement to support a Data Management and Coordinating Center to
    provide infrastructure and research support for a new network of
    clinical sites. Clinical sites with the appropriate infrastructure,
    expertise, and resources needed to conduct the clinical evaluation and
    DNA sequencing of participants enrolled at their sites can apply for
    designation as a Diagnostic Center of Excellence. Diagnostic Centers of
    Excellence will have access to resources of the Data Management and
    Coordinating Center.
        NIH is committed to the successful transition of UDN and welcomes
    the opportunity to work with Congress to identify the best path
    forward. NIH's long-term vision is to see an expanded Network continue
    to make important scientific discoveries while improving clinical
    practice for undiagnosed patients--regardless of geographic location or
    socioeconomic status.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. I am pleased to be the lead sponsor along with Senator
    Reed of the Childhood Cancer STAR Act. As we know, cancer remains the
    most common cause of death by disease among children in the United
    States. By the age of 50, more than 99 percent of the children who
    survived their initial cancer diagnosis will have had a chronic health
    problem, and 96 percent have experienced a severe or life-threatening
    condition caused by the toxicity of the treatment that initially saved
    their life. Thanks to the STAR Act, the NCI has supported new research
    into improving the quality of life of childhood cancer survivors.
        Could you advise the Committee on how much of the $30 million
    Congress has provided for the STAR Act each year has been invested in
    this research and how many new research projects you have been able to
    support with the STAR Act fund?
        Answer. The National Cancer Institute (NCI) appreciates your and
    Senator Reed's leadership, and the Subcommittee's continued support for
    childhood cancer research, including support for the Childhood Cancer
    STAR Act. Each year, the Subcommittee has appropriated $2 million of
    the $30 million authorization to support the Centers for Disease
    Control and Prevention (CDC) in their implementation of STAR Act
    provisions focusing on enhancing CDC cancer registry efforts (Section
    102 of the Act). NCI has used the remaining $28 million of STAR Act
    funding to support new biobanking research efforts (Section 101) and to
    continue to conduct and support survivorship research projects (Section
    202), as well as evidence reviews focused on childhood cancer
    survivorship (Section 203) in partnership with the Agency for
    Healthcare Research and Quality (AHRQ). These initiatives are supported
    through a variety of mechanisms, including but not limited to new
    research grants. Efforts in each of NCI's three areas are summarized
    below.
    1. Biobanking Projects:
        NCI is committed to making progress for children and adolescents
    and young adults (AYAs) with cancer, survivors, and their families, and
    biobanking efforts have long been a part of this mission. In accordance
    with the goals of the STAR Act, NCI provided supplemental funding to
    the Children's Oncology Group (COG) Biobank in 2019 to support
    immediate enhancements. NCI subsequently funded six supplemental
    projects, which are listed below, starting in 2020 to bolster and
    expand the current programs. The supplements included projects to
    increase collection of diagnostic, relapse, and autopsy specimens, as
    well as specimens from childhood cancer survivors enrolled in NCI's
    Childhood Cancer Survivor Study (CCSS). Pediatric cancers are
    classified as rare cancers, and these efforts will increase sample
    availability to researchers and clinicians in an effort to advance
    research and improve patient outcomes, especially for children with the
    rarest cancer subtypes.
      --Rare Tumor Populations Biobanking (COG): For rare cancers for which
            COG does not have open clinical trials, tumor tissue collection
            options are limited. This program expanded in fiscal year (FY)
            2021 and supports tumor tissue and blood collection for
            specific groups of patients for which current tumor tissue
            collection is lacking or inadequate, with priority for tumor
            types with high risk of treatment failure. This initiative also
            collaborates closely with the Childhood Cancer Data Initiative
            (CCDI) to analyze tumor tissue to obtain a clinically relevant
            molecular profiling through the CCDI Molecular Characterization
            Protocol. The data helps this Protocol support characterization
            of tumors for rare cancers, with an initial emphasis on Central
            Nervous System (CNS) tumors as well as soft tissue sarcomas.
      --Tumor Specimens from Patients at Relapse (COG): 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. One area of focus is the collection of
            relapse specimens from children with rhabdomyosarcoma.
      --Rapid Autopsy Specimen Collection (COG): NCI and COG continue to
            work with patient organizations to support rapid autopsy
            collection of tumor samples from children and AYAs who have
            died of their disease. Foundations and families within the
            pediatric brain tumor community have been leaders in such
            programs, and we hope 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
            help other families.
      --Pediatric MATCH Diagnostic Specimen Collection (COG): This effort
            collects diagnostic samples for children and AYAs who have
            already submitted samples at relapse through NCI's Pediatric
            MATCH Trial and enables molecular characterization to identify
            the changes in gene mutations and gene expression that occur
            between diagnosis and relapse. This in-depth characterization
            aims to inform development of more relevant treatments.
      --Biobanking I--Specimen Collection of Subsequent Cancers (CCSS): The
            development of subsequent malignant neoplasms (SMN) is
            associated with significant morbidity and mortality for
            survivors of childhood cancer. The CCSS has prioritized
            collection of SMN somatic tissue specimens (tissue blocks,
            scrolls, slides) from survivors with confirmed cases of
            subsequent malignancies. The results help design treatment
            protocols and interventions that will result in an increase in
            survival, while minimizing harmful late effects. This research
            is also used to develop and expand programs for early detection
            and prevention of late effects in children and adolescent
            cancer survivors.
      --Biobanking II--Specimen Collection to Study Chronic Health
            Conditions (CCSS): This project will enhance the CCSS as a
            resource for future biologic and genetic evaluations to better
            understand the causes of chronic health conditions in survivors
            of childhood cancer.
        Many of the STAR Act supplement projects are still collecting
    samples and have contributed to many new NCI research projects.
    Childhood cancer researchers have requested and used biospecimens from
    STAR Act funded supplement projects for 11 new research projects, with
    10 of these projects supported by NCI (in addition to the STAR Act
    investments described here) and one supported by the Cancer Prevention
    and Research Institute of Texas. Biospecimens will continue to be
    available for researchers in the coming years with continued support.
    Along with increasing the number of greatly needed samples, these
    projects also address other concerns and barriers to biobanking and
    provide opportunities to mitigate these challenges. Through
    implementation of the STAR Act biobanking provisions, NCI continues to
    support progress towards better understanding pediatric cancers.
    Additional details about each of these biobanking projects will be
    provided to Senators Capito and Reed, and their colleagues, in the
    biobanking report required in Section 101 of the STAR Act, which is
    anticipated to be transmitted to Congress in June 2022.
    2. Survivorship Research Grants:
        NCI also continues to conduct and support childhood and AYA cancer
    survivorship research that advances additional goals of the STAR Act.
    NCI issued a new request for applications (RFA) in March 2020, titled
    ``Research to Reduce Morbidity and Improve Care for Pediatric, and
    Adolescent and Young Adult (AYA) Cancer Survivors'' (RFA-CA-20-027/
    028), which builds upon a previous RFA, ``Improving Outcomes for
    Pediatric, Adolescent and Young Adult Cancer Survivors'' (RFA-CA-19-
    033), to continue to address survivorship research areas emphasized in
    the STAR Act.
        NCI funded seven projects in response to RFA-CA-19-033 in fiscal
    year 2020, and 10 projects in response to RFA-CA-20-027/028 in fiscal
    year 2021. An additional final round of awards is expected to be
    finalized in the coming weeks. Commitments for these 5-year awards will
    extend to fiscal year 2026, pending availability of appropriations.
    Projects supported through the first two rounds of awards in fiscal
    year 2020 and fiscal year 2021 are described in more detail in the
    tables below.
        These efforts aim to improve care and health-related quality of
    life for childhood and AYA cancer survivors, through mechanistic,
    observational, and intervention research projects that focus on six key
    domains: (1) disparities in survivor outcomes; (2) barriers to follow-
    up care; (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.

    rrrrrrrrrrrrrrrrrrrrrrrr
    RFA-CA-19-033:           Tumor Types              Late/Long Term
     Improving outcomes for                            Effect(s)
     Pediatric, Adolescent,
     and Young Adult Cancer
     Survivors

    rrrrrrrrrrrrrrrrrrrrrrrr
    Project Title,
     Principal
     Investigator,
     Institution, Grant
     Type

    Using Information        All                      Disease and treatment-
     Technology to Improve                             related symptoms
     Outcomes for Children
     Living with Cancer
     \13\
    PI: Dr. Jin-Shei Lai
     (Northwestern
     University at
     Chicago), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    A Randomized Trial of a  All                      Sedentary behavior
     Mobile Health and
     Social Media Physical
     Activity Intervention
     Among AYA Childhood
     Cancer Survivors \14\
    PI: Dr. Nina Kadan-
     Lottick (Yale
     University), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Utility of Memantine in  Primary brain tumors     Cognitive dysfunction
     Preventing Cognitive                              after cranial
     Dysfunction in                                    radiotherapy
     Children Receiving
     Cranial Radiotherapy
     \15\
    PI: Dr. Nadia Laack
     (Mayo Clinic), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    A web-based patient-     Breast cancer            Symptoms, unmet needs,
     reported symptom                                  concerns
     monitoring and self-
     management portal for
     AYA breast cancer
     survivors \16\
    PI: Dr. Ann Partridge
     (Dana-Farber), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Telehealth based         All                      Reduced exercise
     exercise intervention                             capacity, impaired
     to improve functional                             physical dysfunction
     capacity in survivors
     of childhood cancer
     with significantly
     limited exercise
     tolerance \17\
    PI: Dr. Kirsten Ness
     (St. Jude), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    An Interactive           All                      Emotional distress;
     Survivorship Program                              adherence
     to Improve Healthcare
     Resources [INSPIRE]
     for Adolescent and
     Young Adult (AYA)
     Cancer Survivors \18\
    PI: Dr. Karen Syrjala
     (Fred Hutchinson), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Implementation of a      All                      Elevated risk of HPV-
     Provider-Focused                                  related complications
     Intervention for                                  and malignancies
     Maximizing HPV Vaccine
     Uptake in Young Cancer
     Survivors receiving
     Follow-Up Care in
     Pediatric Oncology
     Practices: A Cluster-
     Randomized Trial \19\
    PI: Dr. Wendy Landier
     (University of
     Alabama), U01

    rrrrrrrrrrrrrrrrrrrrrrrr
    RFA-CA-20-027/028:       Target Population        Topic Area
     Research to Reduce
     Morbidity and Improve
     Care for Pediatric,
     and Adolescent and
     Young Adult (AYA)
     Cancer Survivors

    rrrrrrrrrrrrrrrrrrrrrrrr
    Project Title,
     Principal
     Investigator,
     Institution, Grant
     Type

    Predicting and           African American,        Cardiotoxicity
     Preventing               doxorubicin-treated
     Chemotherapy-Induced     childhood cancer
     Cardiotoxicity in        survivors \20\
     African American
     Children
    PI: Drs. Paul W
     Burridge and Yadav
     Sapkota (Northwestern
     University at
     Chicago), R01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Bridging Information     Childhood cancer         Follow-up care
     Divides and Gaps to      survivors and primary
     Ensure Survivorship:     care providers
     The BRIDGES Randomized
     Controlled Trial of a
     Multilevel
     Intervention to
     Improve Adherence to
     Childhood Cancer
     Survivorship \21\
    PI: Dr. Nina S Kadan-
     Lottick (Yale
     University), R01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Social Genomic           Non-Hodgkin's lymphoma   Social determinants of
     Mechanisms of Health     and Hodgkin's lymphoma   health
     Disparities Among        survivors
     Adolescent and Young
     Adult (AYA) Cancer
     Survivors \22\
    PI: Dr. Bradley Jay
     Zebrack (University of
     Michigan at Ann
     Arbor), R01

    rrrrrrrrrrrrrrrrrrrrrrrr
    SALSA--Study of Active   Childhood cancer         Cardiovascular disease
     Lifestyle Activation     survivors
     \23\
    PI: Dr. Eric Jessen
     Chow (Fred Hutchinson
     Cancer Research
     Center), R01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Individual, Cultural,    Asian and Asian          Follow-up care
     and Area-Based Factors   American childhood
     Associated with          cancer survivors
     Survivorship Care
     Among Asian/Asian
     American Childhood
     Cancer Survivors \24\
    PI: Drs. Kimberly Ann
     Miller and Joel E
     Milam (University of
     Sothern California),
     R01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Optimization of a        Childhood and AYA        Quality of life
     mHealth Physical         cancer survivors
     Activity Promotion
     Intervention with
     Mindful Awareness for
     Adolescent and Young
     Adult Cancer Survivors
     \25\
    PI: Drs. Siobhan Marie
     Phillips and David
     Victorson
     (Northwestern
     University at
     Chicago), R01

    rrrrrrrrrrrrrrrrrrrrrrrr
    Pilot Test of an         Rural AYA cancer         Alcohol consumption
     mHealth Intervention     survivors
     for Reducing Alcohol
     Use Among Rural
     Adolescent and Young
     Adult Cancer Survivors
     \26\
    PI: Drs. Carolyn
     Lauckner and Laurie
     Mclouth (University of
     Kentucky), R21

    rrrrrrrrrrrrrrrrrrrrrrrr
    Treatment-Specific       Childhood cancer         Risk for chronic
     Genetic Risk Scores      survivors                conditions
     for Late Effects
     Prediction in
     Childhood, Adolescent,
     and Young Adult Cancer
     Survivors \27\
    PI: Drs. Cindy Im and
     Yan Yuan (University
     of Alberta), R21

    rrrrrrrrrrrrrrrrrrrrrrrr
    Remote Monitoring of     Anthracycline-exposed,   Cardiac dysfunction
     Cardiac Function in      long-term childhood
     Childhood Cancer         cancer survivors \28\
     Survivors
    PI: Dr. Saro Armenian
     (Beckman Research
     Institute/City of
     Hope), R21

    rrrrrrrrrrrrrrrrrrrrrrrr
    Caregiving for Young     Latino AYA cancer        Caregiving
     Adults with Cancer in    survivors and their
     Latino Families:         families and providers
     Understanding
     Healthcare Engagement
     and Family Wellbeing
     \29\
    PI: Dr. Michael A Hoyt
     (University of
     California-Irvine),
     R21
    ------------------------

    \13\ reporter.nih.gov/search/owLPDXpgCU-iBbBTXwB1Qg/project-details/
      10247641
    \14\ reporter.nih.gov/search/WCYrRYv2jUyxTU5KGqHtRA/project-details/
      10464453.
    \15\ reporter.nih.gov/search/hhFq_KIhjUK_3mrhwe8Izw/project-details/
      10020353.
    \16\ reporter.nih.gov/search/6iqMWmTbbk2QCUxdJKPfVw/project-details/
      10079364.
    \17\ reporter.nih.gov/search/vD2lwK9vOkCEXKq0gt1xlA/project-details/
      10075046.
    \18\ reporter.nih.gov/search/ouCqFYfadUaDvFDHKRpQvQ/project-details/
      10080015.
    \19\ reporter.nih.gov/search/JL5OOraCfUSRsLG_1qNHJg/project-details/
      10076219.
    \20\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10275329.
    \21\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10274932.
    \22\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10272690.
    \23\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10285925.
    \24\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10275095.
    \25\ reporter.nih.gov/search/SzDDxi0b_UWciL8xp_2iEw/project-details/
      10278744.
    \26\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10273171.
    \27\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10273416.
    \28\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10274206.
    \29\ reporter.nih.gov/search/tuBqAK_RUkKcGDcJFdrNqg/project-details/
      10269806.
    rrrrrrrrrrrrrrrrrrrrrrrr

    3. Childhood Cancer Survivorship Evidence Reviews, with AHRQ:
        NCI entered into an Inter-Agency Agreement with AHRQ to support its
    work to implement Section 203 of the STAR Act, focused on identifying
    best practices in survivorship care, through AHRQ Evidence Reviews on
    Childhood Cancer Survivorship. A summary of the progress is provided
    below.
    4. Disparities and Barriers to Pediatric Cancer Survivorship Care: \30\
    ---------------------------------------------------------------------------
        \30\ effectivehealthcare.ahrq.gov/products/pediatric-cancer-
    survivorship/research.
    ---------------------------------------------------------------------------
        This report was posted on the AHRQ website for public comment in
    October 2020, with simultaneous peer review. The final report was
    published in March 2021. The NCI used the findings of the report to
    provide funding through 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 (supported by NCI in addition
    to STAR Act investments). 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.
    5. Models of Care That Include Primary Care for Adult Survivors of
            Childhood Cancer: \31\
    ---------------------------------------------------------------------------
        \31\ effectivehealthcare.ahrq.gov/products/childhood-cancer-
    survivorship-care/research.
    ---------------------------------------------------------------------------
        This report was posted on the AHRQ website in June 2021 for public
    comment, with simultaneous peer review. The report was published in
    February 2022. NCI and AHRQ are widely disseminating this report to
    raise awareness of the role that primary care providers play in the
    care of adult survivors of childhood cancers. 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.
    6. Transitions of Care from Pediatric to Adult Services for Children
            with Special Healthcare Needs: \32\
    ---------------------------------------------------------------------------
        \32\ effectivehealthcare.ahrq.gov/products/transitions-care-
    pediatric-adult/protocol.
    ---------------------------------------------------------------------------
        The systematic review is anticipated to be posted on AHRQ's website
    in May of 2022. Similar to the other two reports, 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 Patrick Leahy
        Question. The COVID-19 pandemic has adversely affected clinical
    cancer care and profoundly impeded progress in the provision of
    essential clinical trials for cancer patients, with rural populations
    particularly hard hit. Vermont is currently one of seven states
    eligible for the NIH Institutional Development Award (IDeA) that does
    not have an NCI-designated facility. Therefore, Vermont has faced
    reduced access to cancer clinical trials relative to more urban areas.
    Because access to clinical trials directly correlates with improved
    quality of cancer care, this reduced access leads to poorer outcomes
    for Vermonters diagnosed with or at risk for developing cancer. Many of
    these IDeA states that lack NCI-designated centers have medical schools
    that would be capable of conducting clinical trials.
        How will the NIH better support cancer care and clinician
    investigator training in predominately rural IDeA states that lack an
    NCI-designated cancer center?
        Answer. The National Cancer Institute (NCI) leads, conducts, and
    supports cancer research across the nation and is committed to helping
    all people live longer, healthier lives. Ensuring equitable access to
    cancer care and clinical trials across the country is a top priority
    for NCI. This objective was also recently reaffirmed as one of the
    goals identified in the next phase of the Cancer MoonshotSM, which
    includes NCI efforts to continue to support and enhance enrollment of
    underrepresented populations to cancer clinical trials, as well as
    cancer control research in persistent poverty areas.\33\ In addition,
    NCI and the National Institute of General Medical Sciences (NIGMS) have
    recently issued several funding opportunity announcements (FOAs),
    discussed in more detail below, focused on promoting cancer research in
    rural communities, including communities in Institutional Development
    Award (IDeA) states and those that are not home to an NCI-designated
    cancer center.
    ---------------------------------------------------------------------------
        \33\ www.whitehouse.gov/ostp/news-updates/2022/03/17/fact-sheet-
    white-house-announces-initial-steps-for-reignited-cancer-moonshot/.
    ---------------------------------------------------------------------------
        NCI-designated cancer centers are a cornerstone of the NCI's cancer
    research efforts across the country, and many centers have large
    catchment areas that cross state lines. For example, the Dartmouth
    Cancer Center includes the entire states of Vermont and New Hampshire
    as part of its service area.\34\ Greatly extending the reach of the
    NCI-designated cancer centers are several key extramural networks that
    support the majority of NCI-supported clinical trials: the National
    Clinical Trials Network (NCTN), the Experimental Therapeutics Clinical
    Trials Network (ETCTN), and the NCI Community Oncology Research Program
    (NCORP). The NCTN primarily conducts later-phase cancer treatment and
    imaging trials, while ETCTN conducts early phase cancer treatment
    trials. Research groups within these networks hold annual meeting
    sessions on topics related to underrepresented populations, and each of
    these groups has a patient advocate committee to provide input on
    developing and conducting trials. The ETCTN also recently launched the
    Create Access to Targeted Cancer Therapy for Underserved Populations
    (CATCH-UP.2020) program to enhance access via clinical trials to
    targeted cancer therapy for minority/underserved populations.\35\
    ---------------------------------------------------------------------------
        \34\ gis.cancer.gov/ncicatchment/.
        \35\ ctep.cancer.gov/initiativesPrograms/etctn_catch-up2020.htm.
    ---------------------------------------------------------------------------
        The NCORP includes 25 states with large rural populations \36\ and
    expands the reach of the NCTN, bringing cancer research to people in
    their own communities. NCORP provides infrastructure for conducting
    studies on cancer control and prevention, cancer care delivery
    research, and screening, treatment, and quality of life evaluations
    embedded in treatment trials. The NCORP includes seven research bases
    and 46 community sites across the United States, including 14 minority/
    underserved community sites, and this locally based infrastructure
    includes approximately 1,000 component and subcomponent sites (e.g.,
    hospitals, cancer centers, oncology clinics) through which patients can
    enroll in NCTN and NCORP clinical trials.
    ---------------------------------------------------------------------------
        \36\ ncorp.cancer.gov/news/2019-08-19.html.
    ---------------------------------------------------------------------------
        Even in IDeA states without NCI-designated cancer centers or NCORP
    grantees (such as Vermont, Rhode Island and West Virginia), NCI has
    active trial sites reaching rural patients. These sites are not
    required to have an NCORP grant or be associated with a designated
    cancer center to become a ``member site'' for an NCTN/NCORP group. Many
    academic sites are members even if they are not a designated cancer
    center, and community sites are eligible to be full members. These full
    member sites also have affiliated sites throughout the state or region
    where patients can be enrolled. In Vermont, for example, there are
    approximately 55 NCI-supported trials open to patients with a treatment
    site within the state,\37\ and more than 230 Vermont patients enrolled
    in either NCORP or NTCN trials over the past 5 years. The top
    enrollment site was the University of Vermont Medical Center/College of
    Medicine in Burlington.
    ---------------------------------------------------------------------------
        \37\ clinicaltrials.gov/ct2/
    results?cond=cancer&term=&cntry=US&state=US%3AVT&city=&dist=
    &Search=Search&recrs=a&type=Intr&fund=0.
    ---------------------------------------------------------------------------
        Clinicians from these NCTN/NCORP member sites can fully participate
    in the NCTN/NCORP groups, contribute to scientific development, and
    develop expertise in clinical investigations. Dozens of these
    investigators enrolled patients to NCTN and NCORP trials over the past
    5 years, including more than 30 investigators with enrollments in
    Vermont and more than 60 investigators with enrollments in West
    Virginia. Investigator involvement in these NCI-sponsored programs
    provides critical opportunities for rural patients and produces
    valuable research findings. For example, Dr. Robert Ward of Rhode
    Island Hospital is a co-author on research showing that improved
    screening methods for women with dense breasts are needed because of
    their increased risk of breast cancer and of failed early diagnosis by
    screening mammography,\38\ work that was funded by an NCORP breast
    cancer screening study.
    ---------------------------------------------------------------------------
        \38\ doi.org/10.1001/jama.2020.0572.
    ---------------------------------------------------------------------------
        NIGMS-supported research is also benefitting cancer patients in
    rural communities through IDeA Networks for Clinical and Translational
    Research (IDeA-CTR),\39\ such as the Northern New England Clinical and
    Translational Research (NNE-CTR) Network,\40\ which includes
    participating and collaborating healthcare, educational and research
    institutions in Maine, Vermont, and New Hampshire. The IDeA-CTR awards
    support state-wide or multi-state regional networks of clinical and
    translational research, which build research infrastructure, develop
    investigators, and support research activities that address health
    conditions prevalent in populations of IDeA states. Since cancer
    affects individuals nationwide as well as in IDeA states, all 12 IDeA-
    CTRs invest in cancer research by supporting pilot research projects.
    These projects include mechanistic, translational, clinical, and
    prevention studies.
    ---------------------------------------------------------------------------
        \39\ grants.nih.gov/grants/guide/pa-files/PAR-14-303.html.
        \40\ reporter.nih.gov/project-details/10205083.
    ---------------------------------------------------------------------------
        Recognizing that more research is needed to identify the best
    strategies for providing care to rural populations, NCI and NIGMS are
    currently providing funding for projects selected through three
    targeted FOAs:
        1. Improving the Reach and Quality of Care in Rural Populations:
    \41\ This funding opportunity focused on strategies for delivering and
    improving the quality of cancer care in rural areas among low-income
    and/or underserved populations. Over the two funding rounds, nine
    research projects were funded, including research focusing on financial
    toxicity and navigation, survivorship, telehealth, community-based
    patient navigation for cancer screening, palliative care, and symptom
    management.
    ---------------------------------------------------------------------------
        \41\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-19-064.html.
    ---------------------------------------------------------------------------
        2. Social and Behavioral Intervention Research to Address
    Modifiable Risk Factors for Cancer in Rural Populations: \42\ This
    funding opportunity focused on research to develop, adapt, and test
    individual-, community- or multilevel interventions to address
    modifiable risk factors for cancer in rural populations. Three research
    projects have been funded after the first round, focusing on tobacco
    control in rural American Indian households, increasing physical
    activity, and utilizing telehealth options for treatment of obesity.
    ---------------------------------------------------------------------------
        \42\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-20-051.html.
    ---------------------------------------------------------------------------
        3. IDeA Clinical Research Resource Center:\43\ Increasing the
    number of clinical trials and complex observational studies in IDeA
    states is a pressing need that requires continued efforts to strengthen
    clinical research capacity and maximize the use of existing resources
    through innovative approaches. The IDeA Clinical Research Resource
    Center (I-CRRC) funding opportunity aims to 1) strengthen communication
    and develop collaborations between health research institutions in IDeA
    states and clinical trial sponsors; and 2) develop clinical research
    coordinators with the knowledge and skills to manage clinical trials
    and complex observational studies.
    ---------------------------------------------------------------------------
        \43\ grants.nih.gov/grants/guide/pa-files/PAR-22-150.html.
    ---------------------------------------------------------------------------
        NCI is committed to serving patients across the country, including
    those in rural areas who face disparities in incidence and mortality
    rates that can be attributed in part to barriers in accessing health
    services. NCI will continue to fund research and support efforts to
    improve access and better address the unique needs of these
    communities.
                                     ______

                    Questions Submitted to Dr. Anthony Fauci
                    Questions Submitted by Senator Roy Blunt
        Question. Dr. Fauci, there has been limited evidence that antiviral
    therapies to treat COVID-19, like Paxlovid, may relieve symptoms from
    long COVID. The theory is that long COVID may be caused by the virus
    persisting in parts of the body for months. What are your thoughts on
    this and what work is NIH doing in this space to determine if
    therapeutic treatments may relieve or even cure long COVID?
        Answer. While most people recover quickly and fully from infection
    with SARS-CoV-2, some experience ongoing or new symptoms or other
    health effects after the acute infection has resolved, referred to as
    post-acute sequelae of SARS-CoV-2 infection (PASC). An understanding of
    the underlying mechanisms of PASC will be crucial as we work to
    identify and test therapeutics. The National Institutes of Health (NIH)
    supports research to inform estimates of PASC prevalence as well as to
    understand the pathogenic mechanisms underlying the wide range of
    observed symptoms and the risk factors for developing PASC. This
    includes the examination of whether particular symptoms associated with
    PASC may be caused by the persistence of virus or viral particles in
    parts of the body. NIH has launched the Researching COVID to Enhance
    Recovery (RECOVER) Initiative,\44\ a trans-NIH effort that aims to
    understand, prevent, and treat the post-acute sequelae of SARS-CoV-2
    infection. The NIH RECOVER Initiative complements ongoing studies
    supported by the National Institute of Allergy and Infectious Diseases
    (NIAID) to better understand the various post-acute manifestations of
    COVID-19 and will engage more than 100 researchers at more than 30
    institutions to build a diverse national study population and support
    large-scale studies in this critical area, as well as clinical trials
    of potential treatments for PASC. The knowledge gained through these
    collective efforts will help inform the identification of effective
    treatments for PASC, including those evaluated through RECOVER.
    ---------------------------------------------------------------------------
        \44\ https://recovercovid.org/.
    ---------------------------------------------------------------------------
        Question. How many clinical trials are funded by NIH that are
    testing treatments for long COVID?
        Answer. The highly diverse symptomology of PASC observed in
    patients across the lifespan strongly suggests that PASC, rather than
    being a singular condition, is likely multiple clinical conditions that
    vary across the lifespan and demographic groups. This has important
    implications for the research approach to PASC--namely, multiple
    diverse diagnostic, treatment, and prevention strategies will be needed
    for the range of PASC conditions and patient populations. This will
    require an appropriately diverse portfolio of sufficiently scaled and
    powered clinical studies to generate high-quality data that can inform
    clinical and public health practices.
        Toward this end, the NIH RECOVER Initiative, described above, is
    preparing to launch clinical trials to identify safe and effective
    treatments to enhance recovery of patients with persistent symptoms and
    identify interventions which, if initiated early, could prevent end-
    organ and systems damage and other sequelae. RECOVER has established a
    dedicated Clinical Trials Data Coordinating Center to implement and
    manage multiple interventions addressing symptoms/symptom clusters and
    underlying mechanisms of pathobiology of PASC. RECOVER also issued a
    solicitation for clinical trial proposals testing a range of
    interventions to address symptoms/symptom clusters and underlying
    mechanisms of pathobiology. RECOVER will test a variety of therapeutic
    strategies. The first trials are anticipated to be launched by the Fall
    of 2022. As understanding of underlying mechanisms leading to post-
    acute sequelae of SARS-CoV-2 infection improves through the RECOVER and
    other research activities, additional candidate interventions will be
    evaluated and selected for testing.
        Question. How many of these trials are beyond a phase I trial?
        Answer. The RECOVER Initiative plans to launch Phase IIb-III PASC
    clinical trials that leverage fit-for-purpose design strategies to
    maximize rigor, efficiency, and flexibility. Initial trials will likely
    focus on interventions that have shown promise in other recovery
    contexts and on current hypotheses regarding pathogenesis. As our
    understanding of underlying mechanisms leading to PASC improves through
    RECOVER and other research activities, additional candidate
    interventions will be evaluated and selected for testing.
        Question. There have been recent reports of individuals taking
    Paxlovid, and then their symptoms return after their treatment is
    complete. Do you know why that may happen?
        Answer. NIH scientists, in collaboration with the Centers for
    Disease Control and Prevention (CDC) and the U.S. Food and Drug
    Administration (FDA), are looking into possible ways to better
    understand the phenomenon of COVID-19 rebound after Paxlovid treatment.
    NIH currently does not have studies underway, but the agency is
    actively discussing potential studies to learn more about who this is
    affecting, how often it is occurring, and if a longer regimen would be
    more effective in certain cases. For additional information on what is
    currently known about the case reports of patients developing symptoms
    again after completing a course of Paxlovid, please refer to ``FDA
    Updates on Paxlovid for Health Care Providers'' \45\ and the ``CDC
    Health Alert Network Health Advisory on COVID-19 Rebound After Paxlovid
    Treatment''.\46\
    ---------------------------------------------------------------------------
        \45\ http://www.fda.gov/drugs/news-events-human-drugs/fda-updates-
    paxlovid-health-care-providers.
        \46\ http://www.emergency.cdc.gov/han/2022/han00467.asp.
    ---------------------------------------------------------------------------
        Question. How much of the $1.15 billion appropriated has been
    obligated?
        How much of this funding has been obligated or committed for
    clinical trials?
        Answer. In December 2020, Congress provided $1.15 billion in NIH
    funding, available for obligation over 4 years, to support research
    into the long-term effects of SARS-CoV-2. With this funding, NIH
    launched Researching COVID to Enhance Recovery (RECOVER) in February
    2021. As of May 17, 2022, $674.5 million has been obligated. Of that
    amount, $137 million has been obligated to the launch of clinical
    trials, including the establishment of the Clinical Trials Data
    Coordinating Center.
        The remaining funding will be distributed during the final 2 years
    of the RECOVER Initiative to support outyear activities of these
    ongoing clinical research studies, including (but not limited to):
    longitudinal clinical follow up of adult and pediatric patients
    enrolled in the cohort studies, autopsy studies, central research
    services, pathobiology research, mobile health platform, data
    repositories, clinical biospecimen collection and repositories,
    Electronic Health Record/Other Real World Data studies, as well as
    support for NIH management of the RECOVER initiative through
    specialized administrative and technical expertise.
        Question. What work is NIH doing related to long COVID to address
    the most burdensome of symptoms or the most severe cases?
        Answer. The National Institutes of Health (NIH) has designed and
    launched Researching COVID to Enhance Recovery (RECOVER),\47\ a major
    research effort of national scale to improve understanding of Post-
    Acute Sequelae of SARS-CoV-2 infection (PASC), including Long COVID,
    and to inform the development of safe and effective diagnostic,
    treatment, and preventive strategies. RECOVER includes a longitudinal
    study designed to have inclusive and diverse participant enrollment
    that is representative not only of the U.S. population generally, but
    of the population of sub-groups most severely affected by coronavirus
    disease 2019 (COVID-19). RECOVER also includes electronic health
    records (EHR) studies of over 60 million patient records; a systematic
    and standardized autopsy study at scale; a mobile health platform to
    enable broader and deeper engagement of participants; pathobiology and
    mechanistic studies and development of animal models; and clinical
    trials. Importantly, RECOVER is patient-centered and engages patients
    at every level of the Initiative, from local studies to protocol
    development, to overall governance of the Initiative.
    ---------------------------------------------------------------------------
        \47\ recovercovid.org.
    ---------------------------------------------------------------------------
        NIH RECOVER is preparing to launch clinical trials to test
    treatment and preventive strategies for Long COVID. This includes
    creating a portfolio of prioritized interventions that:
      --Address symptoms/symptom clusters of high priority to patients
      --Will test a broad range of interventions
      --Address current nascent hypotheses regarding the pathogenesis of
            Long COVID
      --Have sufficient scientific rationale, appropriate safety profiles,
            technical merit, and feasibility
      --Would be available/accessible to most patients
      --Are ready to launch in the short term
        To identify which Long COVID symptoms have the highest impact on
    patients' quality of life, RECOVER is taking a broad consultative
    approach with engagement of patient, practitioner, and research
    communities. For example, both patient participants in the RECOVER
    longitudinal cohort studies and a national sample (non-RECOVER) of
    patients are periodically surveyed regarding their symptoms and the
    burden posed by them; and interviews and focus groups with highly
    affected communities and the RECOVER National Community Engagement
    Group and patient representatives are periodically conducted for in-
    depth insights into patient perceptions of the burden of Long COVID
    symptoms. The input from these engagement activities is informing
    RECOVER clinical trial design, including the selection of
    interventions, to ensure that RECOVER clinical trials address the most
    burdensome symptoms of Long COVID.
                                     ______

                    Questions Submitted to Dr. Gary Gibbons
                      Questions Submitted to Patty Murray
        Question. Our country has lost over a million people to COVID-19
    and countless more have been infected by this virus. And people of
    color have faced the worst of this crisis. Studies show that people of
    color are more likely to be hospitalized for COVID, and while some
    recover quickly and completely, others have persistent symptoms that
    linger for months. That's why, in December 2020, we appropriated more
    than $1 billion in supplemental funding for NIH to study long-COVID.
        What updates can you share about NIH's RECOVER Initiative and what
    we have learned about long COVID and how it impacts different
    communities?
        What are the challenges you're facing in terms of recruitment for
    RECOVER's clinical trials, and how is NIH ensuring that they have
    diverse representation?
        Answer. The National Institutes of Health (NIH) launched the
    Researching COVID to Enhance Recovery (RECOVER) initiative to better
    understand and ultimately to prevent and treat the broad array of post-
    acute symptoms of SARS-CoV-2 (PASC), commonly called Long COVID. At the
    center of RECOVER is a longitudinal observational study that is
    currently recruiting adults and children from other ongoing studies of
    COVID, Long COVID clinics, and other cohorts--many of which have a
    history of including people from communities disproportionately
    burdened by disease.
        The RECOVER research initiative is meant to significantly expand
    both our knowledge about the full clinical spectrum of symptoms, long
    term outcomes, and underlying biology of Long COVID, as well as our
    ability to develop safe and effective therapeutic interventions. It
    funds multi-disciplinary biomedical, clinical, and epidemiological
    studies, many focused on untangling the complex social and biological
    factors that cause higher rates of hospitalization and Long COVID in
    communities of color.
        RECOVER studies highlight diverse participation and community
    engagement, and include clinical trials, clinical studies that leverage
    cohort data and specimens, a patient registry, pathobiology studies, a
    mobile health platform, and electronic health record (EHR) studies.
    Clinical cohort institutions were selected for RECOVER studies that
    have a proven track record in reaching communities hardest hit by the
    pandemic. For example, RECOVER includes the Institutional Development
    Award (IDeA) clinical research network, which supports research in
    states that historically have had low levels of NIH funding. Their
    clinical coordinating center is one of the main hubs for the adult
    cohort study. In addition, a Research Centers in Minority Institutions
    (RCMI) program awardee is also serving as a hub for the study.
        As of May 2022, NIH has enrolled more than 5,000 people and is
    close to RECOVER's target recruitment of 6,000. Participants are
    undergoing testing at 46 sites in 23 states, along with the District of
    Columbia and Puerto Rico. Twenty-seven percent of enrollees live in
    federally designated medically underserved areas. Thirty-six additional
    sites will come online before the end of 2022. The completion dates for
    reaching target enrollment are January 2023 for adults and May 2023 for
    children.
        Other research efforts are helping to increase understanding of
    Long COVID. For example, a recent study published in The Lancet Digital
    Health,\48\ describes how researchers used Artificial Intelligence (AI)
    technology to comb through an EHR database of more than 13 million
    people to identify characteristics of people with Long COVID and those
    likely to develop it.
    ---------------------------------------------------------------------------
        \48\ www.thelancet.com/journals/landig/article/PIIS2589-
    7500(22)00048-6/fulltext.
    ---------------------------------------------------------------------------
        While recruitment into the RECOVER longitudinal observational study
    is progressing steadily, researchers are facing challenges. Strong
    competition for people with biomedical research skills has hindered
    core and site hiring and led to delays in opening local sites and study
    implementation. The enrollment of study participants--including those
    who are currently infected with COVID-19, those with Long COVID
    symptoms, and those who were previously infected but show no Long COVID
    symptoms (to act as control cases)--is still challenging. Participating
    in studies, which may require taking time off from work, is an economic
    barrier. The recent decline in the number of cases of acute SARS-CoV-2
    infection, milder symptoms associated with Omicron variants that make
    people less likely to seek medical attention, and the rapid expansion
    of home testing makes it difficult to identify and recruit acute cases.
    In addition, the extremely high transmissibility rates of recent
    variants means that many people have been re-infected, which reduces
    the ability to find people who have never been infected.
        Increasing enrollment rates in communities disproportionately
    affected by SARS-CoV-2 infection is a critical goal for RECOVER; NIH is
    therefore monitoring the diversity of enrollment closely. One of the
    challenges is limited awareness in some communities about Long COVID.
    Another is establishing trust among people with a history of mistrust
    in the biomedical research establishment and the Federal Government.
    This impedes RECOVER's ability to establish sufficient enrollment in
    clinical studies that produce enough high-quality data to provide the
    evidence base necessary to guide clinical practice and public health
    policy.
        The NIH Community Engagement Alliance (CEAL) Against COVID-19
    Disparities initiative was launched to establish a research approach to
    ensure the participation of black and brown communities in vaccine
    research trials that were then underway.\49\ CEAL now bolsters RECOVER
    recruitment by working with research teams in 21 locations across the
    country to address misinformation, foster trust in science and
    research, and ensure inclusive participation in NIH research.
    Strategies include local media and social media outreach, search engine
    optimization (SEO) tactics, local community outreach and education, and
    using SARS-CoV-2 testing programs and point-of-care settings as
    recruitment platforms. Through trusted messengers in communities hit
    hardest by the pandemic, CEAL and its community partners are helping
    increase diversity in Long COVID research.
    ---------------------------------------------------------------------------
        \49\ covid19community.nih.gov/.
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        Question. Many patients with long-COVID have been diagnosed with a
    blood circulation disorder known as postural orthostatic tachycardia
    syndrome, or POTS. Symptoms associated with POTS include
    lightheadedness, fainting and an uncomfortable, rapid increase in
    heartbeat.
        Has NIH determined the rough proportion of long-COVID patients
    whose symptoms include POTS?
        Answer. Dysautonomia refers to a disorder of autonomic nervous
    system function. The autonomic nervous system controls many of the
    unconscious and involuntary bodily processes such as heart rate, blood
    pressure, and breathing. Postural orthostatic tachycardia syndrome
    (POTS) is a relatively common dysautonomia in which moving to an
    upright position can trigger an excessive increase in heart rate
    (tachycardia) and other symptoms such as light-headedness, shortness of
    breath, chest pain, and palpitations. Other common symptoms not
    necessarily linked to posture include headache, fatigue, exercise
    intolerance, and impaired sleep, digestion, and concentration. While
    the cause of POTS is unknown, low blood volume, dysregulation of the
    autonomic nervous system, autoimmunity, and viral infection may all
    play a role, each perhaps leading to distinct subtypes of POTS. It is
    likely that POTS has multiple underlying mechanisms resulting in
    subtypes of POTS that need to be identified and characterized.
        Symptoms of the post-acute sequelae of SARS-CoV-2 infection (PASC)
    may overlap with those experienced by persons suffering with POTS/
    dysautonomia. Research on the biological causes of PASC and potential
    treatments pose a unique opportunity to possibly discover the key
    pathophysiology underlying several disorders suspected to be the
    sequelae of a viral illness in a significant subset of those affected,
    such as POTS/dysautonomia and myalgic encephalomyelitis/chronic fatigue
    syndrome (ME/CFS).
        The Researching COVID to Enhance Recovery (RECOVER) \50\ Initiative
    seeks to better understand, treat, and prevent PASC, including Long
    COVID, and to understand how SARS-CoV-2 can lead to long-lasting and
    widespread effects such as fatigue, decline in some cognitive
    abilities, pain, sleep disorders, and dysautonomia, among others.
    RECOVER is a patient-centered study of national scale with diverse
    participation and community engagement. RECOVER has multiple scientific
    aims, including to understand the clinical spectrum and the biology
    underlying recovery over time, and to define distinct sub-phenotypes of
    Long COVID. It includes multiple sub-studies: longitudinal
    observational clinical cohort studies with thousands of diverse
    participants across the lifespan, ancillary clinical studies leveraging
    the cohort data and specimens, pathobiology studies, analyses of
    electronic health records, and clinical trials. We expect RECOVER
    studies will advance understanding of other conditions believed to be
    triggered by infection, which will include COVID-19 related cases of
    POTS/dysautonomia and ME/CFS. We also expect that RECOVER studies will
    reveal the proportion of Long COVID patients that meet the criteria for
    POTS/dysautonomia and ME/CFS. RECOVER study teams and oversight bodies
    include experts in those conditions.
    ---------------------------------------------------------------------------
        \50\ recovercovid.org/.
    ---------------------------------------------------------------------------
        What work is NIH supporting to understand the underlying causes of
    POTS?
        Answer. The National Institutes of Health (NIH) has supported a
    wide range of POTS-related grants and currently funds research
    examining the autoimmune basis of POTS and the autonomic
    pathophysiology of POTS. In addition, NIH intramural researchers are
    investigating possible associations between PASC and POTS/dysautonomia
    \51\ through comprehensive testing of the extended autonomic system in
    patients experiencing PASC.
    ---------------------------------------------------------------------------
        \51\ https://reporter.nih.gov/project-details/10491027.
    ---------------------------------------------------------------------------
        At the direction of the Senate Appropriations Committee, the
    National Institute of Neurological Disorders and Stroke (NINDS) and the
    National Heart, Lung and Blood Institute (NHLB), with participation by
    Eunice Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD), jointly convened a workshop in July 2019 to
    discuss the state of the science and gaps in the current understanding
    of POTS. NINDS and NHLBI prepared and submitted a Report to Congress
    \52\ based on workshop discussions between leading experts in POTS
    research and care, officials from the three sponsoring Institutes, and
    patient advocates.\53\
    ---------------------------------------------------------------------------
        \52\ https://www.nhlbi.nih.gov/sites/default/files/media/docs/
    NIH%20RTC%20on%20POTS_Final.signed.pdf.
        \53\ chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://
    www.nhlbi.nih.gov/sites/default/files/media/docs/
    NIH%20RTC%20on%20POTS_Final.signed.pdf.
    ---------------------------------------------------------------------------
        In addition, in April 2021, NHLBI posted an article \54\ about
    research in this field, and NINDS and NHLBI issued a Notice of Special
    Interest,\55\ ``Stimulate Research on the Diagnosis, Treatment, and
    Mechanistic Understanding of Postural Orthostatic Tachycardia Syndrome
    (POTS),'' to encourage researchers to submit proposals designed to
    answer fundamental questions about POTS.\56,57\ The grant applications
    submitted in response to the Notice are currently under review. , which
    evaluates the scientific and technical merit of research applications.
    NIH peer review process, which evaluates the scientific and technical
    merit of research applications.
    ---------------------------------------------------------------------------
        \54\ https://www.nhlbi.nih.gov/news/2021/decoding-mysteries-
    postural-orthostatic-tachycardia-syndrome.
        \55\ https://grants.nih.gov/grants/guide/notice-files/NOT-HL-21-
    008.html.
        \56\ https://www.nhlbi.nih.gov/news/2021/decoding-mysteries-
    postural-orthostatic-tachycardia-syndrome.
        \57\ https://grants.nih.gov/grants/guide/notice-files/NOT-HL-21-
    008.html.
    ---------------------------------------------------------------------------
        In addition, NHLBI is leading an NIH-wide workshop on sex/gender-
    specific COVID-19 outcomes on June 16-17, 2022. The workshop will
    include a presentation and discussion of autonomic hemodynamic
    disorders, including POTS, in PASC and the need for better
    understanding of the underlying pathophysiology and development of
    specific treatment approaches. NIH continues to encourage investigator-
    initiated research grant applications on POTS.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. Dr. Gibbons, I have a question about pulmonary fibrosis,
    or PF, a complex and deadly lung disease that affects over 250,000
    people in the U.S. I am especially concerned about this disease because
    we have a lot of coal miners in West Virginia, and workers who are
    exposed to coal dust and silica are at higher risk of developing PF.
    Diagnosing this disease is complex, and by many estimates often takes
    over 2 years. In far too many cases, patients already have advanced PF
    by the time they receive a diagnosis.
        What research is the NHLBI currently funding to address the serious
    problem of late diagnosis in PF?
        Answer. Currently, Pulmonary Fibrosis (PF) has no cure, and for
    some forms of PF, such as Idiopathic Pulmonary Fibrosis (IPF), median
    survival is 3-5 years from diagnosis. Some studies show an association
    between coal and silica dust and the development of PF.
        Current efforts by the National Heart, Lung, and Blood Institute
    (NHLBI) to address PF include the Institute's Prospective Treatment
    Efficacy in IPF using genotype for N-acetylcysteine (NAC) Selection
    (PRECISIONS) study, a five-year study aiming to enroll 200 IPF
    patients. PRECISIONS will use genetic testing to identify patients
    likely to respond to the antioxidant NAC. The first PRECISIONS clinical
    trial will explore the effectiveness of precision medicine for IPF.
    NHLBI recently funded a cohort of currently unaffected but at-risk
    individuals who have more than two close family members with PF, which
    could demonstrate how genetics and family exposure could affect risk
    disease risk.
        The Lung Health Cohort, in partnership with the American Lung
    Association, follows 4,000 healthy millennials (aged 25-35) to identify
    early risk factors (e.g., lifetime air pollution, potentially noxious
    inhalation exposures) and signs of lung disease, including IPF, to
    allow earlier and effective intervention. In 2021, NHLBI-funded
    researchers identified gene expression signatures in the blood of PF
    patients. This research may reveal new therapeutic targets and help
    monitor and predict disease course.
        NHLBI is supporting collaborative projects to establish a set of
    model systems that reproduce essential IPF disease-defining features to
    advance understanding of the IPF pathogen from onset through disease
    progression. These projects will also provide a platform for
    identifying and testing novel treatment therapies. By developing
    several model systems in parallel, scientists could identify common
    fibrosis pathways.
                                     ______

                    Questions Submitted to Dr. Joshua Gordon
                  Questions Submitted by Senator Patty Murray
        Question. We understand NIMH is working to eliminate disparities in
    youth mental health by the year 2030.
        What specific areas of research are needed in order for NIMH to
    meet this ambitious goal?
        Answer. As detailed in the September 2021 National Institute of
    Mental Health (NIMH) Report to Congress ``Addressing Youth Mental
    Health Disparities,'' NIMH is prioritizing research to address and
    reduce mental health disparities among underserved and underrepresented
    youth by 2031. To meet this goal, NIMH will encourage a full and
    diverse range of research--including basic science, translational
    science, and services and implementation research--focused on
    addressing the needs of youth across race, ethnicity, culture,
    language, gender identity, sexual orientation, geography, and social
    determinants of health (e.g., education, economic stability, quality of
    housing, access to healthcare). These research efforts will aim to
    identify ways to decrease risk, increase resilience and protective
    factors, improve access to and utilization of high-quality evidence-
    based care, and improve outcomes of treatment and services among
    populations negatively impacted by mental health disparities.
        NIMH previously published information about the research needs that
    guide the activities of NIMH Divisions, Offices, and Teams that support
    mental health disparities research across the lifespan.\58\
    Additionally, in December 2021, NIMH, the National Institute on
    Minority Health and Health Disparities, and the Eunice Kennedy Shriver
    National Institute of Child Health and Human Development (NICHD) hosted
    an expert conference to further inform research efforts specifically on
    youth mental health disparities. This conference included a diverse
    group of expert panelists to assess the state of the science and the
    short- and longer-term research priorities related to improving mental
    health treatment, services, and outcomes for youth and adolescents from
    communities that experience health and related disparities.\59\
    ---------------------------------------------------------------------------
        \58\ www.nimh.nih.gov/about/organization/od/odwd/nimhs-approach-to-
    mental-health-disparities-research.
        \59\ www.nimh.nih.gov/news/events/2021/2021-youth-mental-health-
    disparities-conference-identifying-opportunities-and-priorities-in-
    youth-mental-health-disparities-research-summary.
    ---------------------------------------------------------------------------
        Specific areas of research that NIMH aims to support include:
        1. Understanding structural social determinants of mental health
    (e.g., housing instability, family income, community resources,
    neighborhood characteristics, work or school environments, and
    structural racism), how they can be modified, and how they drive risk
    of, resilience to, and protection from the development of mental
    illnesses.
        2. Identifying and understanding contextualizing factors, including
    environmental and historical factors, their impact on biology, emotion,
    cognition, and behavior, and how they mediate mental health
    disparities.
        3. Assessing how local, state, and Federal policies, laws, and
    regulations impact social determinants of mental health, mental health
    service delivery, and outcomes among youth from populations impacted by
    mental health disparities.
        4. Characterizing variation in biological and genomic processes
    within and among diverse populations historically underrepresented in
    genetics research.
        5. Conducting longitudinal studies and other research focused on
    understanding and measuring how childhood experiences confer resilience
    to or risk for mental illnesses and suicidal thoughts and behaviors in
    youth from populations impacted by mental health disparities.
        6. Improving the specificity of biomarkers and the accuracy of
    culturally appropriate diagnostic assessments (including risk
    calculators) for youth from populations impacted by mental health
    disparities.
        7. Developing and validating culturally appropriate preventive
    interventions, including systems-level approaches (e.g., in classrooms,
    schools, communities) for youth and parents from populations impacted
    by mental health disparities.
        8. Optimizing existing evidence-based approaches to minimize bias
    in diagnosis and treatment, and to improve continuity of care and
    mental health outcomes for youth from populations impacted by mental
    health disparities.
        9. Addressing co-occurring mental illnesses in youth with
    intellectual and developmental disabilities, including youth with
    intersectionality with other high-risk groups.
        10. Improving the implementation and availability of mental health
    prevention and treatment interventions and services, as well as
    programs to support youth and family functioning, within youth-serving
    institutions (e.g., educational settings, community-based after-school
    programs, faith-based programs, child welfare programs, juvenile
    justice settings).
        11. Using innovative assessment and analytic methods to examine
    sub-populations and low base-rate behaviors (e.g., death by suicide)
    and to address complex, multi-modal datasets.
        12. Developing, testing, and implementing prevention and treatment
    interventions that are relevant to communities impacted by health
    disparities across a broad range of ages (e.g., infancy through young
    adulthood).
        13. Engaging collaborative teams that include community partners to
    ensure that the outcomes and interpretation of research reflect the
    priorities of the population participating in the research.
        14. Developing targeted interventions by examining risk and
    resilience within populations impacted by youth mental health
    disparities.
                                     ______

                    Questions Submitted to Dr. Richard Hodes
                    Questions Submitted by Senator Roy Blunt
    Aduhelm Decision
        Question. Dr. Hodes, I've been watching with interest, as I suspect
    you have as well, the decisions FDA and CMS have made regarding the new
    Alzheimer's treatment, Aduhelm. What are your thoughts about CMS'
    decision to require only patients in a clinical trial to receive the
    first approved Alzheimer's drug in more than a decade? And how does
    that decision affect other NIH Alzheimer's clinical trials?
        Answer. The National Institutes of Health (NIH) notes that the
    decisions issued by the U.S. Food and Drug Administration (FDA) and
    Centers for Medicare and Medicaid Services (CMS) are regulatory
    decisions, and NIH defers to these agencies on such matters. To date,
    the impact of the aducanumab (the generic name for Aduhelm) coverage
    determination on NIH clinical trials has been minimal. NIH will
    continue to press forward with its robust and diverse research
    portfolio in the area of therapy development, building on the
    advancements we have achieved thus far. We will continue to evolve our
    understanding about Alzheimer's and to develop more ways to detect,
    treat, and prevent this disease.
        Question. Perhaps what is most concerning about the decision CMS
    made on Aduhelm is that it impacts not only this specific treatment,
    but all other monoclonal antibody treatments coming down the pike. Can
    you address what this CMS decision means for the future of NIH's
    clinical trials process for new Alzheimer's treatments?
        Answer. NIH notes that the decisions issued by FDA and CMS are
    regulatory decisions, and NIH defers to these agencies on such matters.
    These decisions underscore the need to further advance our knowledge
    and support a broad range of therapies for Alzheimer's and related
    dementias. In fact, nearly three-quarters of National Institute on
    Aging (NIA)-funded Alzheimer's and related dementias drug trials in
    early phases (phase I or phase II) are for targets other than amyloid
    proteins. NIH will continue to advance its robust and diverse research
    portfolio in therapy development, building further on the significant
    achievements thus far to effectively prevent, detect, and treat these
    devastating diseases.
        Question. Dr. Hodes, I know you had initial concerns about how CMS'
    decision may pull patients away from other NIH clinical trials and
    toward an Aduhelm trial instead, simply so they could have access to
    the new drug. Has that fear been realized and how have you worked to
    combat it?
        Answer. These concerns have not been realized. To date, the impact
    of the aducanumab coverage determination on NIH clinical trials has
    been minimal.
    Overactive Bladder
        Question. Dr. Hodes, overactive bladder affects more than 38
    million Americans, and is more common with aging and in women. Recent
    studies on anticholinergic medications, which are commonly prescribed
    drugs to treat overactive bladder, have shown that these medications
    have a negative impact on cognition and may lead to the development of
    Alzheimer's disease and related dementia. Given the potential adverse
    impact on the nation's elderly that will only increase as our
    population ages, is NIA studying these medications or working
    collaboratively with other Institutes to determine the safety and
    efficacy of anticholinergic medications, and any association they may
    have with cognitive decline and Alzheimer's disease and related
    dementia?
        Answer. Overactive bladder occurs when the bladder is triggered to
    empty at the wrong time, leading to a sudden urge to urinate that a
    person may have difficulty suppressing. The symptoms of overactive
    bladder include urinary frequency, urinary urgency, and urge
    incontinence.
        The National Institute on Aging (NIA) supports studies on a range
    of issues related to the causes, prevention, and treatment of
    overactive bladder. This includes research on the safety of long-term
    use of anticholinergic medications commonly prescribed to treat
    overactive bladder and the associated risk of cognitive impairment and
    dementia. For example, NIA is supporting a clinical trial testing
    whether discontinuing use of anticholinergics improves cognition and
    lowers the risk of Alzheimer's disease and related dementias.\60\ NIA
    is also funding a clinical trial to test a mobile app that integrates a
    personalized anticholinergic risk calculator, targeted multimedia such
    as videos and blogs to educate users regarding anticholinergics, and a
    conversation starter to help a patient self-initiate ending
    anticholinergic prescriptions with a healthcare provider.\61\ This
    trial will explore the impact of the app on prescription
    anticholinergic exposure among older adults and on cognitive function
    and quality of life. Other research studies currently funded by NIA
    seek to assess severe adverse events associated with the interaction of
    cholinesterase inhibitors used to treat Alzheimer's with
    anticholinergic medications; \62\ test mechanisms of neurotoxicity from
    anticholinergics; \63\ evaluate extended cognitive, urinary, and
    functional trajectories in older incontinent women without pre-existing
    dementia who use anticholinergic medication; \64\ utilize a novel model
    to investigate anticholinergic drug induced dementia; \65\ improve how
    older adults living with dementia, their caregivers, and clinicians
    make decisions about using anticholinergic medicines; \66\ and test
    electronic health record-based tools that engage caregivers to help
    primary care providers reduce medication overload and deprescribe
    medications that can worsen cognitive burden in patients with mild
    cognitive impairment, Alzheimer's disease, and related dementias.\67\
    In addition, a recent NIA-supported study found that exposure to strong
    anticholinergics increased the risk of transitioning from normal
    cognition to mild cognitive impairment.\68\ Another recent NIA-funded
    study that evaluated adverse outcomes of anticholinergic medicines in
    patients with dementia and overactive bladder \69\ found an increased
    risk of mortality associated with non-selective antimuscarinic (a
    subtype of anticholinergic drugs) medications in older adults with
    dementia.\70\
    ---------------------------------------------------------------------------
        \60\ reporter.nih.gov/search/Shaj-qYerkm0U6DRn1S6tg/project-
    details/10129872.
        \61\ clinicaltrials.gov/ct2/show/NCT04121858.
        \62\ reporter.nih.gov/search/pZSsBABfW0K-DPFCtVqRcQ/project-
    details/10212709.
        \63\ reporter.nih.gov/search/Ggd69UkxpkGGqF5IAEfYrg/project-
    details/10168318.
        \64\ reporter.nih.gov/search/0lm26jQsukuQXix5r_QvGw/project-
    details/10343015.
        \65\ reporter.nih.gov/search/0lm26jQsukuQXix5r_QvGw/project-
    details/10258975.
        \66\ reporter.nih.gov/search/Ggd69UkxpkGGqF5IAEfYrg/project-
    details/9926791.
        \67\ reporter.nih.gov/project-details/10370471.
        \68\ www.ncbi.nlm.nih.gov/pmc/articles/PMC6036636/.
        \69\ reporter.nih.gov/search/-xMveMuhZUWqFIMIntQeIw/project-
    details/9377896.
        \70\ pubmed.ncbi.nlm.nih.gov/32026255/.
    ---------------------------------------------------------------------------
        The National Institutes of Health (NIH) is committed to continuing
    to fund research to improve the lives of people living with overactive
    bladder and will continue to fund research towards prevention of
    cognitive impairment in this, and other, areas.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. Alzheimer's disease has certainly been in the news
    recently. While, there is plenty to discuss on Adulhelm and decisions
    regarding its coverage, I am interested in the role it can play in
    moving the science forward.
        What is on the horizon to better understand Alzheimer's disease and
    how we can prevent/slow its progression?
        Answer. Thanks to the increased investment in Federal funding for
    Alzheimer's and related dementias, the National Institutes of Health
    (NIH) has been able to embark on an ambitious research agenda and
    continues to make significant progress in discovering approaches that
    may prevent, diagnose, and treat these complex diseases.
        Understanding Alzheimer's and related dementias: Roughly 10 years
    ago, we knew of just 10 genetic areas associated with Alzheimer's
    disease, and 20 years ago, we knew of only 4. That number has grown to
    more than 70 associated genetic areas today. These advances are already
    informing new pathways for potential prevention and treatments. For
    example, NIH-supported research involving a Colombian family with more
    than 6,000 living members led to the identification of a gene variant
    that may protect against the development of Alzheimer's.\71\ Studies to
    understand how this gene and others may protect against Alzheimer's
    suggest new possibilities for treatment options, which NIH is exploring
    further.
    ---------------------------------------------------------------------------
        \71\ https://www.nia.nih.gov/news/unique-case-disease-resistance-
    reveals-possible-alzheimers-treatment.
    ---------------------------------------------------------------------------
        In addition, NIH funds research beyond genetics to understand the
    biological mechanisms associated with dementia. For example, National
    Institute on Aging (NIA) intramural researchers have identified several
    biological pathways linked to abnormal brain metabolism in people with
    Alzheimer's disease and related dementias.\72\ These researchers also
    identified 15 promising candidate drugs that have already been shown
    safe and effective for other conditions and are screening these for
    potential use in treating dementia. By studying drugs approved by the
    Food and Drug Administration (FDA) for other conditions, researchers
    may be able to accelerate the drug discovery process for Alzheimer's
    and related dementias.
    ---------------------------------------------------------------------------
        \72\ https://www.nia.nih.gov/news/nia-study-identifies-fda-
    approved-drugs-may-also-be-helpful-dementia.
    ---------------------------------------------------------------------------
        Diagnostics: In the early 2000s, researchers could only confirm an
    Alzheimer's disease diagnosis via autopsy. NIH support has been
    instrumental in developing ways to image and visualize aggregations of
    specific proteins like amyloid and tau--the hallmarks of Alzheimer's--
    in the brain, making a diagnosis possible in living persons. NIH
    continues to advance new, less invasive ways of detecting these
    proteins. For example, NIH small business innovation research funding
    helped researchers at C2N Diagnostics validate the
    PrecivityADTM test, a more affordable and less invasive
    alternative to traditional Alzheimer's tests like brain scans.\73\ This
    blood biomarker test is now available to some doctors who are sending
    blood samples to C2N's lab to analyze blood for amyloid. In
    May 2022, the FDA granted marketing authorization for the first test
    for the early detection of amyloid plaques using cerebrospinal
    fluid.\74\ The clinical study of this test utilized cerebrospinal fluid
    samples made available by the Alzheimer's Disease Neuroimaging
    Initiative, a key component of NIH-supported Alzheimer's research
    infrastructure.
    ---------------------------------------------------------------------------
        \73\ https://www.nih.gov/news-events/news-releases/nih-small-
    business-funding-boosts-alzheimers-science-advances.
        \74\ https://www.fda.gov/news-events/press-announcements/fda-
    permits-marketing-new-test-improve-diagnosis-alzheimers-disease.
    ---------------------------------------------------------------------------
        These tests are poised to transform Alzheimer's diagnostics and
    clinical trial recruitment. For example, because they can be done
    without the need for expensive PET scanners and radioactive diagnostic
    agents, they can be used in a much broader range of clinical settings,
    such as community health centers, thereby removing a potential barrier
    to participation in clinical trials.
        Clinical Trials: In 2015, NIH funded 38 clinical trials to treat
    and prevent Alzheimer's and related dementias. In 2022, NIH is
    supporting more than 400 trials, approximately half covering dementia
    treatment and prevention, and the other half covering care
    interventions for persons living with these diseases.\75\ The growth of
    NIH's clinical trial portfolio, which includes a diverse range of
    promising therapeutic approaches, is directly attributable to increased
    appropriations. In fact, the number of therapeutic targets for drug
    candidates in NIH-supported trials has more than doubled from 2015 to
    2022. This is particularly evident in early phase (phase I or phase II)
    trials, where more than three-quarters of the drug trials currently
    supported by NIH are for targets other than amyloid proteins in the
    brain.
    ---------------------------------------------------------------------------
        \75\ https://www.nia.nih.gov/research/ongoing-AD-trials.
    ---------------------------------------------------------------------------
        Some of these clinical trials will share results soon. The Exercise
    in Adults With Mild Memory Problems (EXERT) trial,\76\ which tests the
    effects of aerobic exercise on cognition in adults with Alzheimer's,
    will report topline results in August 2022. In December 2022, the
    PEACE-AD trial,\77\ which evaluates the drug Prazosin to treat severe
    agitation in adults living with Alzheimer's who require full-time
    caregiving, will share topline results. In addition, the DISCOVER
    Study\78\ testing the drug Posiphen in adults diagnosed with
    Alzheimer's is expected to report results late this year or in early
    2023.
    ---------------------------------------------------------------------------
        \76\ https://clinicaltrials.gov/ct2/show/record/NCT02814526.
        \77\ https://clinicaltrials.gov/ct2/show/NCT03710642.
        \78\ https://www.clinicaltrials.gov/ct2/show/NCT02925650.
    ---------------------------------------------------------------------------
        Prevention: We now know there are several risk and resilience
    factors that may play a role in the development of dementia. One
    example is blood pressure control. Recent NIH-supported studies showed
    that intensive high blood pressure control significantly reduces the
    occurrence of mild cognitive impairment, a precursor to dementia in
    some individuals. NIH has taken steps to share these findings with the
    public through efforts like the Mind Your Risks campaign.\79\
    ---------------------------------------------------------------------------
        \79\ www.mindyourrisks.nih.gov/.
    ---------------------------------------------------------------------------
        In addition, a recent analysis of data from two NIA-funded
    longitudinal study populations, the Chicago Health and Aging Project
    (CHAP) \80\ and the Memory and Aging Project (MAP),\81\ found that
    adhering to a combination of healthy behaviors was associated with a
    lower risk of Alzheimer's, including in individuals with genetic risk
    factors for the disease.\82\
    ---------------------------------------------------------------------------
        \80\ www.alzrisk.org/cohort.aspx?cohortid=15.
        \81\ www.alzrisk.org/cohort.aspx?cohortid=60.
        \82\ pubmed.ncbi.nlm.nih.gov/32554763/.
    ---------------------------------------------------------------------------
        The behaviors included engaging in regular physical activity,
    avoiding smoking, practicing light-to-moderate alcohol consumption,
    eating a high-quality diet, and engaging in cognitive activities.
    Practicing four or all five of these behaviors was associated with up
    to a 60 percent reduction in Alzheimer's risk.
        The finding that behavioral choices appear to have an impact on the
    development of Alzheimer's even in individuals with a higher genetic
    risk is encouraging in terms of the promise of nondrug therapies in the
    search for effective treatments. To this end, NIH continues to support
    research to identify the best ways to help prevent dementia, including
    more than 130 clinical trials on nondrug interventions like exercise,
    diet, and sleep.\83\ NIH also supports research on how to help people
    adopt and sustain these healthy behaviors over a lifetime.\84\
    ---------------------------------------------------------------------------
        \83\ www.nia.nih.gov/research/ongoing-AD-trials.
        \84\ www.nia.nih.gov/research/blog/2021/12/tis-season-healthy-
    habit-research.
    ---------------------------------------------------------------------------
                                     ______

                     Questions Submitted to Dr. Nora Volkow
                    Questions Submitted by Senator Roy Blunt
    Opioids Research
        Question. Dr. Volkow, since fiscal year 2018, NIH has been provided
    $500 million in dedicated funding annually for opioids and stimulant
    research. However, according to data released last week by the CDC,
    opioid overdoses continue to rise, with deaths up nearly 50 percent in
    the past 2 years. What research has NIH produced to move the needle on
    overdoses?
        Answer. The National Institute on Drug Abuse (NIDA) shares your
    concerns about rising rates of drug overdoses and mortality. In the
    past few years, this crisis has been driven largely by increasing
    availability of potent synthetic opioids such as fentanyl and increases
    in combined opioid and stimulant use. NIDA supports robust multi-
    pronged efforts to stem the overdose crisis, including research on drug
    use and overdose prevention interventions, emerging patterns of
    substance use, harm reduction approaches, development of medications
    for opioid and stimulant use disorders, and the impact of coronavirus
    disease 2019 (COVID-19) on substance misuse and comorbidities.
        Adolescence and young adulthood are periods of particularly high
    risk for drug initiation and the development of addiction. Through its
    prevention research portfolio and through the HEAL Prevention
    Initiative,\85\ NIDA is developing and testing strategies to prevent
    drug use risk in youth overall and specifically to prevent opioid
    initiation, misuse, and use disorder, in populations including American
    Indian/Alaska Natives, youth with justice system involvement, and youth
    experiencing homelessness. This research will also address the
    sustainability and cost of these interventions. Through one project,
    researchers have developed a patient education program to prevent
    diversion of stimulants prescribed for attention-deficit/hyperactivity
    disorder.\86\ Initial evidence showed reductions in patients'
    disclosure of their prescription to friends, their intent to share, and
    being approached to share.\87\
    ---------------------------------------------------------------------------
        \85\ heal.nih.gov/research/new-strategies/preventing-opioid-use-
    disorder.
        \86\ https://reporter.nih.gov/project-details/9980049.
        \87\ Molina BSG., Kipp, HL., Joseph, HM., et al. Stimulant
    diversion risk among college students treated for ADHD: Primary care
    provider prevention training. Acad Pediatr. 2020; 20(1): 119--127.
    ---------------------------------------------------------------------------
        In 2020, NIDA expanded its National Drug Early Warning System
    (NDEWS), which monitors patterns of drug use, morbidity, and mortality.
    By analyzing counterfeit pills seized by law enforcement, NDEWS
    established that such pills are a growing source of fentanyl.\88\ This
    suggests that many fentanyl exposures are unplanned, and that overdose
    risk could be reduced with simple tools like fentanyl test strips
    (FTS). NIDA supports studies on FTS use and research to improve FTS
    technology. NIDA's Small Business Innovation Research (SBIR) and Small
    Business Technology Transfer (STTR) programs also support innovative
    technologies to surveil drugs in community wastewater to monitor
    changes in drug use as well as the emergence of new drugs. These tools
    are valuable for assessing the impact of prevention and treatment
    interventions and helping to tailor resource allocation.
    ---------------------------------------------------------------------------
        \88\ Palamar, JJ., Ciccarone, D., Rutherford, C., et al. Trends in
    seizures of powders and pills containing illicit fentanyl in the United
    States, 2018 through 2021. Drug Alcohol Depend. 2022;1:234.
    ---------------------------------------------------------------------------
        In alignment with the National Drug Control Strategy, one of NIDA's
    priorities is to expand research on harm reduction, which focuses on
    reducing the risk of overdose and other harms associated with drug use.
    Through the NIH Helping to End Addicition Long-term (NIH HEAL
    Initiative), NIDA is establishing a new network to develop, test, and
    implement harm reduction strategies and assess the impact of state and
    local harm reduction policies.\89\ NIDA research is also evaluating the
    implementation of peer-based opioid overdose education, naloxone
    distribution, and social support interventions and their impact in
    African Americans \90\ and veterans.\91\
    ---------------------------------------------------------------------------
        \89\ RFA-DA-22-046: HEAL Initiative: Harm Reduction Policies,
    Practices, and Modes of Delivery for Persons with Substance Use
    Disorders (R01 Clinical Trial Optional).
        \90\ https://reporter.nih.gov/search/pXhkeRP_10CxXi3NjmRQig/
    project-details/10354090.
        \91\ https://reporter.nih.gov/search/pXhkeRP_10CxXi3NjmRQig/
    project-details/10298478.
    ---------------------------------------------------------------------------
        Through its Clinical Trials Network (CTN), NIDA has helped create
    an arsenal of medications for opioid use disorder (MOUD) that are
    effective in reducing overdose. NIDA supported development of naloxone,
    and more recently, Kloxxado, a nasal spray containing high-dose
    naloxone that was approved by the U.S. Food and Drug Administration
    (FDA) in 2021.\92\ NIDA continues to fund research aimed at treating
    opioid and stimulant use disorders and overdose with nearly 90
    compounds at various stages along the drug development pipeline,
    including longer-acting overdose reversal agents; and since 2019,
    NIDA's Pharmacotherapies Development Program has ushered twenty-four
    investigational new drug (IND) applications and eight IND exemptions
    through the FDA's IND process. One of the most promising preclinical
    projects underway is optimizing, characterizing, and testing the
    efficacy of a novel compound for reversing opioid-induced respiratory
    depression involving fentanyl and fentanyl analogs, alone and in
    combination with methamphetamine.\93\ Researchers are also studying the
    unique physiological and pharmacological effects of co-intoxication
    with fentanyl and methamphetamine in animal models and testing the
    ability of CS-1103 to normalize these effects.\94\ Unfortunately, NIDA-
    funded research also shows that MOUD are underutilized.\95\
    ---------------------------------------------------------------------------
        \92\ https://reporter.nih.gov/search/pXhkeRP_10CxXi3NjmRQig/
    project-details/10298478.
        \93\ https://reporter.nih.gov/search/Zmse6nG00kKHYseah5M4qw/
    project-details/10227069.
        \94\ https://reporter.nih.gov/search/51gwUKe_70eDNuM13Y1IOQ/
    project-details/10433799.
        \95\ Xu, KY., Mintz, CM., Presnall, N., et al. Comparative
    Effectiveness Associated With Buprenorphine and Naltrexone in Opioid
    Use Disorder and Cooccurring Polysubstance Use. JAMA Netw Open. 2022
    May 2;5(5).
    ---------------------------------------------------------------------------
        NIDA funds research to overcome barriers to MOUD use in diverse
    settings, including prisons and jails. For example, one recent study
    found that 6 months after Rhode Island implemented a comprehensive OUD
    screening and treatment program at its corrections facilities, the
    state saw a 12.3 percent reduction in fatal overdoses overall and a
    60.5 percent reduction among the recently incarcerated.\96\ With
    support from the NIH HEAL Initiative, the HEALing Communities Study
    \97\ and the Justice Community Opioid Innovation Network (JCOIN) \98\
    are expanding research efforts to increase MOUD use; test the
    effectiveness and adoption of new prevention interventions and
    medications; and together, use real-world evidence to address the needs
    of vulnerable populations.
    ---------------------------------------------------------------------------
        \96\ Green TC., Clarke, J., Brinkley-Rubinstein, L., et al.
    Postincarceration Fatal Overdoses After Implementing Medications for
    Addiction Treatment in a Statewide Correctional System. JAMA
    Psychiatry. 2018 Apr 1;75(4):405-407.
        \97\ https://heal.nih.gov/research/research-to-practice/healing-
    communities.
        \98\ https://heal.nih.gov/research/research-to-practice/jcoin.
    ---------------------------------------------------------------------------
        Stimulant misuse and overdose, primarily involving methamphetamine,
    have also continued to rise and often co-occur with opioid misuse.
    Unlike the case for OUD, there are no clinically proven medications for
    methamphetamine use disorder (MUD), but NIDA has supported progress on
    this front. Recent findings from a clinical trial demonstrated that
    treating MUD with naltrexone, a type of MOUD, in combination with
    bupropion, an antidepressant with stimulant effects, for six weeks
    helped patients reduce their meth use and improved other symptoms, such
    as depression \99\ (Trivedi, et al. 2021).
    ---------------------------------------------------------------------------
        \99\ https://pubmed.ncbi.nlm.nih.gov/33497547/.
    ---------------------------------------------------------------------------
        NIDA-funded research also helped establish that contingency
    management (CM) is effective for reducing misuse of opioids,
    stimulants, and other substances; in CM, patients are given incentives
    for reducing their drug use or engaging in treatment. NIDA funding led
    to the first FDA-authorized mobile apps for intended to help increase
    retention in outpatient treatment programs for SUD.\100\ These
    cognitive behavioral therapy apps are intended to be used in
    conjunction with CM and other tools and strategies to reduce drug
    craving. Ongoing studies seek to improve these apps and apply them in
    new ways, such as at-home initiation of MOUD (3R44DA042652).\101\
    ---------------------------------------------------------------------------
        \100\ https://peartherapeutics.com/products/reset-reset-o/.
        \101\ https://reporter.nih.gov/project-details/10153370.
    ---------------------------------------------------------------------------
        While these advances are moving the needle, the COVID-19 pandemic
    has exacerbated the overdose crisis. Nearly 15 percent of U.S. adults
    initiated or increased substance use to cope with pandemic-related
    stress,\102\ and drug overdose rates among adolescents doubled during
    the pandemic, after a decade of stability.\103\ While Federal drug
    regulatory and healthcare agencies implemented policy changes to expand
    treatment access for people with SUD, pandemic restrictions still
    caused disruptions in treatment.\104\ NIDA has supplemented many of its
    studies and programs during the pandemic, including the Adolescent
    Brain Cognitive Development SM Study (ABCD study), to better
    understand the risks of pandemic-related substance misuse and identify
    possible ways to intervene, and to evaluate the impact of pandemic-
    related policy changes.
    ---------------------------------------------------------------------------
        \102\ Czeisler, ME., Lane, RI., Petrosky, E., et al. Mental Health,
    Substance Use, and Suicidal Ideation During the COVID-19 Pandemic--
    United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep.
    2020;69(32):1049-1057.
        \103\ Friedman, J., Godvin, M., Shover, CL., et al. Trends in Drug
    Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA.
    2022;327(14):1398-1400.
        \104\ Meadowcroft, D. and Davis W. Understanding the Effect of the
    COVID-19 Pandemic on Substance Use Disorder Treatment Facility
    Operations and Patient Success: Evidence From Mississippi. Subst Abuse.
    2022;16:11782218221095872.
    ---------------------------------------------------------------------------
        Question. During the COVID-19 pandemic, NIH stepped up and embraced
    the sense of urgency by creating programs like RADx, which was a Shark
    Tank-style program to develop more COVID tests. How can we incorporate
    that model into the urgent needs related to the opioid epidemic?
        Answer. Addressing the addiction and overdose crisis requires
    innovation, and often, those in a position to develop solutions are not
    even aware of their potential to help. Therefore, NIDA uses the Federal
    government's small business innovation research (SBIR) and small
    business technology transfer (STTR) programs and novel, fit-for-
    purpose, funding authorities to help biotech startups develop
    innovative solutions that translate addiction science into healthcare
    and consumer products.\105\
    ---------------------------------------------------------------------------
        \105\ https://nida.nih.gov/research/nida-research-programs-
    activities/nida-challenges-program.
    ---------------------------------------------------------------------------
        Under the statutory authority of the America Creating Opportunities
    to Meaningfully Promote Excellence in Technology, Education, and
    Sciences (COMPETES) Reauthorization Act of 2010, NIDA's annual
    ``$100,000 for Start a Substance Use Disorders (SUD) Startup'' is a
    Shark Tank-style challenge that supports research ideas that are
    intended to be the foundation for the development of successful new
    startups.\106\ Each year, this challenge provides ten winners with
    $10,000 each and technical mentoring from NIDA biomedical
    entrepreneurship experts. This enables the winners to test the premise
    that their research idea can be fostered into a biotech startup that
    will eventually contribute to the pool of innovative small businesses
    that can successfully compete for NIDA's SBIR and STTR funding. Sound
    Life Sciences and Prapela were discovered and selected through this
    challenge. Sound Life Sciences used this award to build a startup
    around a novel app that turns a user's smartphone into a portable
    respiratory monitor capable of detecting changes in breathing
    associated with an overdose. If an overdose is detected, it will sound
    an alarm, provide instructions, and summon emergency services to the
    user's location.\107\ Prapela developed a hospital bassinet pad that
    delivers gentle, random vibrations to treat newborns who were exposed
    to opioids before birth. The bassinet pad may help improve newborns'
    breathing and heart rate and may also be useful in infants with
    breathing issues due to premature birth.\108\
    ---------------------------------------------------------------------------
        \106\ https://nida.nih.gov/research/nida-research-programs-
    activities/nida-challenges-program/2021-start-sud-startup.
        \107\ https://www.soundlifesci.com/.
        \108\ https://www.prapela.com/.
    ---------------------------------------------------------------------------
        Other innovative products grew out of the NIDA Market Fair, a Shark
    Tank-style funding solicitation strategy. NIDA staff pitched ideas for
    potential funding concepts to ``Sharks'' who were experts in product
    development and policy from other NIH Institutes and other Federal
    agencies. The best ideas were rapidly selected and developed into
    funding opportunities for small business applications. The Shark Tank-
    style selection of concepts for development assured that there was a
    need and a market, which, in turn, attracted the companies best suited
    to develop specific products. Biobot Analytics developed a wastewater
    testing and analysis method to detect community exposure to opioids
    that can inform local opioid response efforts; this company was also
    able to pivot and provide critical data on the presence of SARS-CoV-2
    in communities.\109\ AppliedVR developed RelieVRxTM, an FDA-
    authorized virtual reality-based tool to treat people with chronic low
    back pain by helping them learn how to better cope with pain.\110\
    ---------------------------------------------------------------------------
        \109\ https://biobot.io/.
        \110\ https://www.relievrx.com/.
    ---------------------------------------------------------------------------
        The goal is to reduce the need for opioids for many different pain
    indications and reduce the associated risk of developing an opioid use
    disorder (OUD). Workit Health is an app that uses video chat and
    messaging technology to bring trained experts directly to those with
    SUDs via a phone or computer.\111\ The company is working to develop a
    chat bot to improve patient engagement and is continually working to
    expand its services to treat additional disorders and co-occurring
    conditions. Woebot, developed by Woebot HealthTM, is a
    smartphone-based mental health chatbot intended to use artificial
    intelligence and language processing technology to deliver personalized
    cognitive behavioral therapy for people with SUDs.\112\ Woebot is being
    expanded for use in additional mental health indications. In addition,
    We the Village provides online support for families or friends of
    someone who is struggling with substance use or has a SUD.\113\ The
    online support includes a course that aims to teach people
    communication and support skills and an online Q&A to help people share
    what they've learned, with the overall aim of helping loved ones reduce
    substance use and get treatment. These and other innovative products
    developed through NIDA support demonstrate that pairing sound science
    with biotechnology entrepreneurship has great potential benefit for
    those with addiction or at risk for overdose.
    ---------------------------------------------------------------------------
        \111\ https://www.workithealth.com/.
        \112\ https://woebothealth.com/new-rct-shows-woebot-reduced-
    problematic-substance-use-
    occasions-by-one-third/
    #::text=In%20short%3A%20Woebot%20significantly%20reduced%20
    substance%20use%20occasions,a%20total%20score%20of%20%3E%2F%3D2%20on%20t
    he%20
    CAGE-AID%29.
        \113\ https://wethevillage.co/.
    ---------------------------------------------------------------------------
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. The release last week of the preliminary 2021 overdose
    statistics was a grim reminder of how much work we still have to do.
    Last Friday, I spoke with a mother who had recently lost her daughter
    to fentanyl laced methamphetamine. She shared that while the first
    responders had tried to use Narcan, since meth was the primary drug in
    her system it was ineffective.
        How is research progressing for an overdose reversal drug similar
    to Narcan for meth/stimulant overdoses?
        Answer. Unprecedented increases in drug overdose deaths in the last
    8 years have been driven mainly by fentanyl, alone and in combination
    with other drugs. Co-involvement of stimulants in fentanyl-involved
    overdose deaths as well as increases in overdose deaths involving
    stimulants without any opioids are particularly concerning the National
    Institute on Drug Abuse (NIDA).\114\ The rate of methamphetamine-
    involved overdose deaths increased by 810 percent from 2013 to 2021,
    and the rate of cocaine-involved overdose deaths increased by 398
    percent.\115\ There are currently no U.S. Food and Drug Administration
    (FDA)-approved medications to treat stimulant use disorder or stimulant
    overdose, but NIDA research is underway to better characterize
    stimulant overdoses and to develop treatments for overdoses involving
    stimulants, alone or in combination with opioids.
    ---------------------------------------------------------------------------
        \114\ https://nida.nih.gov/research-topics/trends-statistics/
    overdose-death-rates.
        \115\ cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
    ---------------------------------------------------------------------------
        Researchers have developed an antibody against methamphetamine
    (IXT-m200) that binds the drug in blood and keeps it from entering the
    brain in animal models and is safe for use in healthy humans. As a next
    step, NIDA is funding a study in emergency department patients with
    methamphetamine intoxication to test the efficacy of the antibody in
    alleviating methamphetamine overdose symptoms.\116\ NIDA-funded
    researchers have developed a small molecule (CS-1103) intended to act
    like a sponge and clear drugs from the body; they are testing its
    ability to clear either fentanyl \117\ or methamphetamine. \118\
    Researchers are also studying the unique physiological and
    pharmacological effects of co-intoxication with fentanyl and
    methamphetamine in animal models and testing the ability of CS-1103 to
    normalize these effects. \119\ Other research underway is a preclinical
    project to optimize, characterize, and test the efficacy of a novel
    compound for reversing opioid-induced respiratory depression involving
    fentanyl and fentanyl analogs, alone and in combination with
    methamphetamine. \120\
    ---------------------------------------------------------------------------
        \116\ https://reporter.nih.gov/search/Zmse6nG00kKHYseah5M4qw/
    project-details/10269933 (5U01DA053043).
        \117\  https://reporter.nih.gov/search/Lv70TeON70-p34mvyTTKXg/
    project-details/10390959 (2R44
    DA052957).
        \118\ https://reporter.nih.gov/search/uwfTgufCYka3Auu_FIsAng/
    project-details/10425422 (5U01DA053054).
        \119\ https://reporter.nih.gov/search/51gwUKe_70eDNuM13Y1IOQ/
    project-details/10433799 (3U01DA053054).
        \120\  https://reporter.nih.gov/search/Zmse6nG00kKHYseah5M4qw/
    project-details/10227069 (5U0
    1DA051373).
    ---------------------------------------------------------------------------
        In addition to the studies described above, NIDA is currently
    supporting research on nearly 90 compounds aimed at treating opioid and
    stimulant use disorders and overdose at various stages along the drug
    development pipeline. NIDA also issued funding opportunity
    announcements to solicit additional research to develop new medications
    to prevent and treat stimulant use disorders and overdose co-involving
    opioids and stimulants, \121\ to develop pharmacotherapeutics and other
    medical therapeutic and diagnostic devices for opioid use disorder and
    stimulant use disorders, \122\ and to understand the mechanisms
    underlying the toxic effects of using opioids and stimulants together.
    \123\
    ---------------------------------------------------------------------------
        \121\ NOT-DA-22-049: Notice of Special interest (NOSI): Medications
    Development for Stimulant Use Disorders.
        \122\ RFA-DA-23-021: Developing Regulated Therapeutic and
    Diagnostic Solutions for Patients Affected by Opioid and/or Stimulants
    use Disorders (OUD/StUD) (R43/R44--Clinical Trial Optional).
        \123\ NOT-DA-20-007: Notice of Special Interest (NOSI): Preclinical
    and Clinical Studies of the Interactions of Opioids and Stimulants.
    ---------------------------------------------------------------------------

                              SUBCOMMITTEE RECESS

        Senator Murray. And this committee will next meet in
    Dirksen 138, Tuesday, May 24, at 10 a.m., for a hearing on the
    Biden Administration's Budget Request for the Department of
    Education.
        The committee is adjourned.
        [Whereupon, at 11:29 a.m., Tuesday, May 17, the
    subcommittee was recessed, to reconvene at 10 a.m., Tuesday,
    May 24.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2023

                                  ----------

                             TUESDAY, JUNE 7, 2022

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:32 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairman) presiding.
        Present: Senators Murray, Reed, Shaheen, Schatz, Baldwin,
    Manchin, Blunt, and Braun.

                            DEPARTMENT OF EDUCATION

    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 2023
    request for the Department of Education. Senator Blunt and I
    will each have an opening statement, and then I will introduce
    our witness. After his testimony, Senators will each have 5
    minutes for a round of questions.
        We are unable again 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 are in need of
    accommodations, including closed captioning, please reach out
    to the committee or the Office of Congressional Accessibility
    Services.

                                 SCHOOL SAFETY

        Mr. Secretary, I know everyone on this committee is focused
    on what we can do to protect our kids and educators in light of
    the tragedy at Robb Elementary School in Texas. Those families
    are in my heart and the need for action is heavy on my mind.
    And of course, 10 days before the mass shooting at a school in
    Texas, there was a mass shooting in a grocery store in Buffalo.
        Last week there were several more, including one at a
    health center. And we have also seen mass shootings at movie
    theaters, concerts, houses of worship. When a mass shooting
    happens everywhere, this isn't just a school problem, it is a
    gun problem.
        So, while there is much to say about how we can protect our
    kids from gun violence, we can't fix this by asking educators
    to be soldiers and bringing more guns into schools. We cannot
    fix it by turning classrooms into prisons or simply buying more
    metal detectors. We have to pass common sense gun safety
    reforms. There is no getting around it. Universal background
    checks. Assault weapons ban. Red flag laws.
        I am ready to work with any Republican to make any kind of
    meaningful change here, and I hope that after years of blocking
    progress, they reverse course because as a mother and a
    grandmother and a former preschool teacher, it is not hard for
    me to choose between guns and kids. And I don't think that
    should be a hard choice for anybody.
        I believe prioritizing our kids and making sure everyone of
    them receives a great public education and can pursue higher
    education is one of the best decisions we can make every time.
    I am constantly hearing from parents across Washington State
    who feel the same. That is a belief that got me into politics,
    and it drives my work every day.

                            RECENT MAJOR INVESTMENTS

        It is why I pushed so hard in our recent bipartisan funding
    bill to make the largest increase in more than a decade to
    Title I funding for public schools, and to Pell Grants, and it
    is why I am glad this budget calls for even more resources to
    support students from preschool through college and career
    readiness, and to address inequities in education that harm so
    many students.
        And it is why Democrats worked so hard to pass the American
    Rescue Plan to help schools get our kids back in the classroom
    safely, and address students' academic and mental health needs,
    which were worsened by the COVID-19 pandemic. The fact almost
    all schools are operating in person today is a clear testament
    to how useful those resources were.

                            CHALLENGES TO EDUCATION

        But there is more work ahead to address the challenges this
    pandemic has exposed and exacerbated for families and kids,
    especially. The childcare crisis is a huge weight on families,
    on businesses, on our entire economy. I am continuing to push
    with everything I have got for an investment through
    reconciliation of the size and scope we need to fix this. If we
    do that, we can get parents, especially moms, back to work, put
    more money back in their pockets, and set our kids up for a
    brighter future.
        I have heard from so many parents and educators and
    students back home also about the mental health challenges our
    kids are facing. And I have been making sure the Biden
    Administration hears from them, too, from the students who
    joined me and Surgeon General Murthy to discuss these
    challenges earlier this year, to the mental health
    professionals that sat down with me and Secretary Becerra in
    Washington State a few weeks ago.
        We need to make sure that our kids and everyone in our
    communities get the help they need. That is why I am working to
    take action on youth mental health as part of a larger
    bipartisan package. Another enormous challenge for schools and
    students is the learning loss that this pandemic caused.
    Educators are working tirelessly to reengage students to
    address their academic needs and tackle the years of disrupted
    learning.
        But it is not easy to get things on track in the wake of a
    pandemic, especially amid the staffing shortages. And this work
    is all the more urgent for kids who were already facing the
    greatest barriers in education, only to face the greatest
    burdens of this pandemic as well. That includes students of
    color, students with disabilities, English learners, students
    from families with low incomes, and students experiencing
    homelessness.

                         THE PRESIDENT'S BUDGET REQUEST

        So, Mr. Secretary, I am pleased to see that this budget
    provides a critical boost to our public education system,
    especially increasing in the Title I program that serves over
    60 percent of public schools in the U.S. It prioritizes support
    for students with disabilities, an issue where States and
    districts have fought for too long, struggling to fill the gaps
    in Federal funding.
        And it increases support for the more than 5 million
    English learners and youth, including immigrants. Mr.
    Secretary, these are worthwhile investments, but there is room
    for improvement, particularly when it comes to helping students
    experiencing homelessness. The pandemic has been especially
    challenging for these kids, and we have to invest in their
    success. We also need to address the crushing burden of student
    debt. There is one word that keeps coming up when I talk to
    people about our student loan system, broken.
        So, I applaud the Biden Administration's recent move to
    provide full debt relief to the over half a million students
    who were ripped off by Corinthian Colleges. And I know the
    Department is also moving on long needed fixes to income driven
    repayment plans and the public service loan forgiveness program
    like I have been pushing.
        For too long, these programs were mismanaged, and the
    previous Administration simply ignored struggling borrowers who
    were asking for help. I am glad to see that change under
    President Biden, but I am not content, and I won't be until we
    finally have a system that actually works for students and
    borrowers.
        And that means finally seeing this Administration extend
    the current repayment pause until at least 2023 and provide
    immediate relief by forgiving some debt for all borrowers while
    working on creating a student loan system that provides real
    help, especially to those who need it the most. And of course,
    we have got to address the root of the problem, higher
    education is just too expensive. We have got to do everything
    we can to lower the cost of college.
        So, I am really glad this budget supports efforts I pushed
    for to simplify the Federal Student Aid application process and
    expand eligibility for those with the greatest need. It
    increases funding for TRIO and retention and completion grants
    and increases Pell Grant awards to put the program on a path to
    doubling the maximum award, a fitting tribute for the 50th
    anniversary of Pell this year.
        But cost is not the only barrier that prevents students
    from pursuing higher education goals, which is why working to
    make college more accessible means investing in historically
    black colleges, tribal colleges and universities, and other
    minority-serving institutions as well.
        Mr. Secretary, I always say a budget is a statement of
    values, and this budget shows President Biden truly understands
    the value of ensuring every student in our country gets a high-
    quality public education.

                        ACCESS TO FREE PUBLIC EDUCATION

        That is no surprise when we have an educator as the first
    lady. But unfortunately, that stands in sharp contrast to the
    statements we have seen from some Republicans, like the
    Governor of Texas, who is planning to challenge the decades old
    Supreme Court precedent establishing the right to a public
    education for all children, including undocumented students.
    That should be shocking and concerning to everyone.
        Public education is a foundation of this democracy, and no
    one should be playing politics with our kids' futures. The last
    thing any kid needs is a politician making life harder for them
    because of where they are from or who they are or who they
    love.
        I am focused on what matters most when it comes to
    education, and that is not banning books, not punishing
    teachers for teaching history, or targeting gay and Trans
    teachers and kids who just want to talk about what they did
    with their family over the weekend, or just be a part of a team
    with their friends. It is making sure that every child in our
    country can get an excellent public education that prepares
    them to succeed in life.
        We are talking about the basics here. It is also making
    sure our students are safe from gun violence, from
    discrimination, from harassment, and assault. And it is making
    sure parents have more time to spend on the things they care
    about most, making it easier for them to be involved at their
    kids' schools.

                 PARENTAL INVOLVEMENT AND SUPPORT FOR FAMILIES

        Look, I got my start in politics as a parent advocate. I
    organized thousands of moms and dads to save a preschool
    program. I served on my local school board. I know how valuable
    it is to have parents involved, and I know making sure parents
    can get involved in their kids' education starts with
    supporting families and delivering good paying jobs, so parents
    actually have the time to ask their kids about school,
    affordable childcare and healthcare and guaranteed paid family
    and medical leave.
        Those investments will take stress off the shoulders of
    parents. And when mom and dad aren't trying to figure out how
    to afford their kid's insulin, they can spend more time helping
    them on their homework or just asking them how their day went.
    These are the issues parents and students back in Washington
    State are focused on.
        They are the issues I am focused on, and it is great to see
    President Biden is focused on them, too. With that, I will turn
    it over to Senator Blunt for his opening remarks.

                         STATEMENT OF SENATOR ROY BLUNT

        Senator Blunt. Good morning, chair, and thank you for
    having this hearing today. Secretary Cardona, thank you for
    appearing before the subcommittee today to discuss the
    Department of Education's fiscal year 2023 budget request.
        I appreciate so much of what you are doing at the
    Department, and in the last year we have gotten a chance to
    know each other. I don't think we have ever had a conversation
    that didn't include catching up on your family, and I
    appreciate your commitment to them and to education.
        Before we turn to the budget request, I want to acknowledge
    the terrible tragedy that occurred at Robb Elementary in
    Uvalde, Texas, 2 weeks ago. Like many Americans, I am
    heartbroken for the lives of the 19 students that will go
    unlived, of the two teachers that were lost.
        No family should ever suffer the loss of a child in this
    kind of horrific act of violence. The community and many of the
    families in it will be changed forever because of what happened
    there. I want to look at what we can do in a bipartisan way, as
    the chair has mentioned, her commitment in that same vein, to
    prevent another tragedy like this from occurring.
        During my time on this committee, I have worked with my
    colleagues to provide significant increases to enhance school
    safety, expand access to mental health support, and restart gun
    violence research at both NIH (National Institutes of Health)
    and CDC (Centers for Disease Control and Prevention).
        We need to continue working together to ensure everyone who
    has a mental or behavioral health issue can get the treatment
    they need and when they need it. I also want to say that people
    with mental health challenges are more likely to be the victims
    of a crime than they are to be the perpetrators of a crime.
        But clearly, there is a thread through these kinds of
    horrific events where a better mental health support system
    would have made a difference and needs to make a difference and
    needs to be there for all kinds of reasons, and this is one of
    them. This is my last year in the Senate, and my final
    Department of Education budget hearing.
        As the first person in my family to graduate from college,
    as a former teacher, as a former university President, I know
    firsthand the importance of education, both in an individual's
    life and in improving our country as a whole. As I reflect on
    my time here working on behalf of Missourians and for our
    country, I am proud to say I have worked to strengthen our
    education programs that provide the most opportunities to every
    American.
        In the K-12 space, I have supported programs that provide
    maximum flexibility for schools to decide how to best use
    limited resources to address the educational needs of all
    children and their families. This includes support for key
    formula programs such as Title I, IDEA (Individuals with
    Disabilities Education Act), and career technical education
    State grants.
        During my time as the chairman of the committee or now as
    the top Republican on the committee, we have increased funding
    for education formula grants by more than $5.3 billion. That
    includes an increase of $3.1 billion for Title I, and $2
    billion for IDEA. I have been a longtime champion of the
    charter school program, which supports the expansion of
    innovative, high quality public schools.
        Coming out of the COVID-19 pandemic, now more than ever,
    parents need to be involved. Parents want to have the
    flexibility to choose the school that best meets their child's
    needs. This is evident, frankly, by the increased enrollment at
    public charter schools as traditional public school enrollment
    has declined.Given these trends, as you and I have talked about
    before, I am frustrated that your department is moving forward
    with what I think are overreaching charter school program
    regulations that would create a chilling effect on the
    expansion of high-quality public charter schools that families
    so clearly want to have as an alternative. I encourage you to
    reconsider those regulations.
        Those funds were set aside specifically by the Congress to
    encourage the creation of more charter school opportunities.
    And your regulations, frankly, make that highly unlikely.
        I have also spent the last 7 years focused on prioritizing
    investment in bipartisan efforts to promote college access,
    affordability, and competition. With the 50th anniversary of
    the Pell Grant this year, something the Chair just mentioned, I
    am proud that we have accomplished a number of things there.
        Over the past seven Labor-HHS (Department of Health and
    Human Services) bills, we have increased the maximum Pell Grant
    award from $1,120 to $6,895. That includes increasing the
    discretionary portion of the--like I said, from $1,120--I meant
    by $1,120 to $6,895. This includes increasing the discretionary
    portion of the maximum Pell Grant award for five consecutive
    years through Labor-HHS bills, which prior to 2018 had not been
    increased through the appropriation process for a decade.
        With Senator Murray's active help, as at that time the top
    Democrat on the authorizing committee, as well as the top
    Democrat on this committee, and Chairman Alexander's assistance
    as well, who was the chairman of the committee at the time, we
    also reinstated year-round Pell, a critical tool to help
    students stay continuously enrolled in school, complete their
    degree program faster, graduate with less debt, and enter or
    reenter the workforce more quickly.
        I believe that one of the best ways to reduce the student
    debt burden is to help students identify post-secondary
    pathways to careers sooner and assist students as they complete
    their post-secondary education.
        Investments through this committee and Pell Grants,
    programs like TRIO and GEAR UP are and have been crucial to
    helping students succeed. We built one of the greatest higher
    education systems in the world, in part because the Federal
    Government supports it without trying to control it.
        I hope we continue to do that by building on the efforts of
    the past and not completely rewriting a playbook that has
    produced great results in terms of the quality of higher
    education in our country. Therefore, I am glad to see that this
    year's budget did not include the misguided proposal to make
    community college free.
        As you have heard me say before, if you really want to make
    college expensive, make it free, and have the Federal
    Government pay the bill. While this budget request doesn't
    include any specific student loan proposals, I am alarmed by
    the potential of what I believe, and what the Speaker of the
    House and the President have believed and said in the past,
    would be illegal student loan forgiveness currently under
    discussion by the Administration.
        I don't think I am in the minority when I say that it is
    really unconscionable that the 85 percent of Americans who do
    not have Federal student loans would be stuck with the bill for
    this political giveaway. And if it happens, it is likely to
    happen between now and Election Day. And even worse, loan
    forgiveness would disproportionally benefit those who can and
    should be able to pay back their debt.
        This is evidenced by the fact that the top 40 percent of
    households by income hold almost 60 percent of the student loan
    debt, while the bottom 40 percent hold less than 20 percent of
    the outstanding debt. Let me reiterate for you and for my
    colleagues, student loan forgiveness, as it is currently being
    considered and discussed, would greatly benefit those who truly
    are not in need of it.
        If limited even to $10,000 per borrower and individuals
    making less than $150,000 per year, the Committee for
    Responsible Federal Budget estimates that student loan
    forgiveness would cost at least $230 billion, and those in the
    top half of the income scale would receive 71 percent of the
    benefits.
        This is on top of the $100 billion that it has already cost
    the American taxpayers to pause student loans for the past 20
    months during the COVID-19 pandemic. To put that in
    perspective, we could fund the Pell Grant program, which is
    actually, targeted towards low income students for more than a
    decade at the cost of these misguided, regressive policies.
        Finally, student loan forgiveness does nothing to drive
    down college costs, and in fact it is likely to lead to
    increased costs and quicker student loan debt accumulation than
    before, with the expectation that there would be another round
    of forgiveness in the future. What Americans really need right
    now is relief from crushing inflation, not more bad policies
    that will only further drive up inflation.
        Even the New York Times editorial board agrees that loan
    forgiveness is, ``legally dubious, economically unsound,
    politically fraught, and educationally problematic.'' I hope
    the Administration will put a pause on this unfair, expensive
    idea and truly consider who it might be hurting rather than who
    might be helped.
        Mr. Secretary, as we work through the appropriations
    process and your 2023 budget request, I hope we can set
    partisan politics aside and pass a bill with meaningful
    investments to support fair access to quality education for all
    students.
        I look forward to working with the Chair and others on the
    committee to come up with a product that we can all support
    before the full committee and before the House. Thank you
    again, Mr. Secretary, for being here today.
        [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 fiscal year 2023 budget request.
        Before we turn to the budget request, I want to acknowledge the
    terrible tragedy that occurred at Robb Elementary in Uvalde, Texas two
    weeks ago. I am heartbroken for the lives of the 19 students and two
    teachers that were lost. No family should ever have to suffer the loss
    of a child to a horrific act of violence.
        I want to look at what we can do, in a bipartisan way, to prevent
    another tragedy like this from occurring. During my time on this
    Committee, I have worked with my colleagues to provide significant
    increases to enhance school safety, expand access to mental health
    support, and restart research into gun violence. We need to continue
    working together to ensure anyone who has a mental or behavioral health
    issue can get the treatment they need, when they need it.
        This is my last year in the U.S. Senate and my final Department of
    Education budget hearing. As a first generation college graduate,
    former teacher and college president, I know firsthand the importance
    of education, both in an individual's life and in improving our country
    as a whole. As I reflect on my time in Washington, working on behalf of
    Missourians and our nation, I am proud to say I've strived to
    strengthen our education programs that provide the most opportunities
    to every American.
        In the K-12 space, I've supported programs that provide maximum
    flexibility for schools to decide how to best use limited resources to
    address the educational needs of all children and their families. This
    includes support for key formula programs such as Title I, IDEA, and
    career and technical education state grants.
        During my time as the Chairman of this Subcommittee, and now as the
    top Republican, we have increased funding for education formula grants
    by more than $5.3 billion. That includes an increase of $3.1 billion
    for Title I and a $2 billion increase for IDEA.
        I've also been a longtime champion of the charter school program,
    which supports the expansion of innovative, high-quality public
    schools. Coming out of the COVID-19 pandemic, now more than ever,
    parents want the flexibility to choose the school that best meets their
    child's needs.
        This is evident by the increase in student enrollment at public
    charter schools as traditional public school enrollment declines. Given
    these trends, I'm frustrated that your Department is moving forward
    with overreaching charter school program regulations that would create
    a chilling effect on the expansion of high-quality public charter
    schools that families so clearly want, and I urge you to reconsider
    those regulations.
        I have also spent the last 7 years focused on prioritizing
    investment in bipartisan efforts to promote college access,
    affordability, and completion.
        With the 50th anniversary of the Pell Grant this year, I am proud
    of all we've accomplished in strengthening this critical program. Over
    the past seven Labor/HHS bills, we have increased the maximum Pell
    Grant award by $1,120 to $6,895. This includes increasing the
    discretionary portion of the maximum Pell grant award for five
    consecutive years through the Labor/HHS bill, which prior to 2018 had
    not been increased through the appropriations process for a decade.
        We also reinstated Year-Round Pell, a critical tool to help
    students stay continuously enrolled in school, complete their program
    or degree faster, graduate with less debt, and enter or re-enter the
    workforce more quickly.
        I believe that one of the best ways to reduce the student debt
    burden is to help students identify postsecondary pathways to careers
    sooner and assist students as they complete their postsecondary
    education. Investments through the Labor/HHS bill in Pell Grants, and
    other programs like TRIO and GEAR UP, are crucial to helping students
    succeed.
        We have built one of the greatest higher education systems in the
    world in part because the Federal Government supports it, without
    trying to control it. I hope we continue to do that by building on the
    efforts of the past and not completely rewriting the playbook.
    Therefore, I was glad to see that this year's budget did not include
    the misguided proposal to make community college ``free.'' As many have
    said before me, ``let's see how expensive college will be when it's
    free.''
        While this budget request doesn't include any specific student loan
    proposals, I am alarmed by the potential for illegal student loan
    forgiveness currently under discussion by the administration. I do not
    think I'm in the minority when I say that it is unconscionable that the
    87 percent of Americans who do not have Federal student loans would get
    stuck with the bill for this political giveaway.
        And even worse, loan forgiveness would disproportionately benefit
    those who can and should be able to pay back their debt, evidenced by
    the fact that the top 40 percent of households by income hold almost 60
    percent of the student loan debt, while the bottom 40 percent have less
    than 20 percent of outstanding debt. Let me reiterate that for you and
    for my colleagues: student loan forgiveness, as it's currently being
    considered and discussed, would largely benefit those who do not truly
    need it.
        Even if limited to $10,000 per borrower and individuals making less
    than $150,000 per year, the Committee for a Responsible Federal Budget
    estimates that student loan forgiveness would cost at least $230
    billion and those in the top half of the income scale would receive 71
    percent of the benefits. This is on top of the $100 billion that it has
    already cost the American taxpayer to pause student loan repayments via
    executive order for the past 20 months during the COVID-19 pandemic. To
    put that in perspective, we could fund the Pell grant program, which is
    actually targeted towards low-income students, for more than a decade
    at the cost of these misguided regressive policies.
        Finally, student loan forgiveness does nothing to drive down
    college costs and, in fact, is likely to lead to increased costs and
    quicker student loan debt accumulation than before with the expectation
    of another round of forgiveness to come. What Americans really need
    right now is relief from crushing inflation, not more bad policies that
    will only further drive up inflation. Even the New York Times Editorial
    Board agrees that loan forgiveness is ``legally dubious, economically
    unsound, politically fraught, and educationally problematic.'' I hope
    the Administration will put a pause on this unfair, expensive idea, and
    truly consider who it might be hurting rather than helping.
        Mr. Secretary, as we work through the appropriations process and
    your fiscal year 2023 budget request, I hope we can set partisan
    politics aside and pass a bill with meaningful investments that support
    fair access to quality education for all students.
        Thank you again for being here today.

        Senator Murray. Thank you, Senator Blunt. Our witness today
    is Miguel Cardona, the Secretary of the Department of
    Education. Thank you so much for joining us today. We look
    forward to your testimony, and you may begin.

                    SUMMARY STATEMENT OF HON. MIGUEL CARDONA

        Secretary Cardona. Thank you, Chair Murray, Ranking Member
    Blunt, and members of this distinguished subcommittee. Good
    morning, and again, thank you for having this hearing today.
    While I will focus on the budget and the priorities of the
    Department of Education, I must start by sharing that together
    we must meet this moment.

                                 SCHOOL SAFETY

        After attending the wakes of former murdered children and
    attending the funeral of a teacher, Irma Garcia, who died
    protecting her students and her husband, Joe, who died of a
    broken heart, I spoke with teachers from Robb Elementary School
    in Uvalde, Texas. In between tears, they asked for help.
        They asked that we see what they are experiencing so that
    we could do everything in our power to help them and the
    millions of students and educators we serve across the country.
    So today, respectfully, I ask us to do something. Our teachers
    and educators did everything we asked of them these last 2
    years.
        Now we must listen to them and act. For the last 2 years,
    with greater risks to their own lives, our students and
    teachers rose to the moment and safely returned to school,
    despite fears and the risks that were associated with it. Now
    we must do the same. We must rise to the moment, despite
    whatever fears may exist, to support our students and our
    teachers.
        On May 24, the following schoolchildren and teachers were
    murdered in one of our schools, Irma Garcia, Eva Mireles,
    Makenna Lee Elrod, Layla Salazar, Maranda Mathis, Nevaeh Bravo,
    Jose Manuel Flores, Jr., Xavier Lopez, Tess Marie Mata, Rojelio
    Torres, Eliahna Ellie Amyah Garcia, Eliahna Torres, Annabell
    Guadalupe Rodriguez, Jackie Cazares, Uziyah Garcia, Jayce
    Carmelo Luevanos, Maite Yuleana Rodriguez, Jailah Nicole
    Silguero, Amerie Joe Garza, Alexandria Lexi Aniyah Rubio,
    Alithia Ramirez. We must say their names as we remember the
    responsibility that we have. Americans are looking to us to
    solve difficult problems. We should be humbled by this
    opportunity to make a more perfect union. We need to do better.
    Our kids deserve better. Let's find a path forward.
        Before I start, I want to thank you for confirming key
    Education Department positions. We are eagerly awaiting
    confirmation of additional nominees so that the Department can
    continue its critical work on behalf of students, families, and
    educators. Today's hearing is about more than the President's
    proposed investments for education in the fiscal year 2023. It
    is about the needs of our students and how we can meet them if
    we work together.

                         THE PRESIDENT'S BUDGET REQUEST

        The priorities in this budget reflect what I have learned
    during visits to 33 States across America, in my conversations
    with students, with parents, educators, and leaders in small
    towns and affluent suburbs and urban and rural communities,
    including our tribal communities. Addressing opportunity and
    achievement gaps that were made worse in the pandemic is more
    important than ever.
        This budget focuses on this by investing in our Title I
    schools and investing in full-service community schools, which
    provide high poverty communities with easier access to services
    for health and nutrition, enrichment, education, adult
    education, and much more. This budget also invests $1 billion
    in hiring staff to support the growing mental health needs.
    Students are six times more likely to access mental health
    supports in schools versus community settings.
        To address the teacher shortage crisis, let's invest an
    additional $350 million for recruiting and retaining teachers.
    I have traveled the country listening to parents. They share
    their concerns with the recovery--they are concerned with their
    kids' reading grade--reading at grade level, and they are
    concerned with getting back to school, not letting politics and
    division get into the classroom.
        Let's work together. The American Rescue Plan got us this
    far. We went from 46 percent of our schools fully open at the
    beginning of the Biden-Harris Administration to over 99 percent
    today. With your investments, let's build more inclusive,
    affordable pathways to higher education and rewarding careers
    for all of our students. Let's increase Pell by $1,775 for
    fiscal year 2023 so more kids can get to college.
        Our budget also calls for investments in community
    colleges, historically black colleges and universities,
    Hispanic-serving institutions, tribal colleges, and other
    inclusive institutions. We are proposing $200 million for
    career connected learning, so more underserved students'
    graduate high school with industry credentials and college
    credits. Our high school graduates need more options.
        Look, education gave me the tools to achieve the American
    dream. I grew up in a blue collar community. I only had what my
    public schools offered. I attended a Title I school and
    graduated from a technical high school. I became a first
    generation college student. I am a bilingual certified educator
    who benefited from quality teacher preparation programing and
    good professional development.
        I am a product of the investments in this budget. Education
    brought me the promise of this country. It made it a life for
    me. We must renew that promise for today's students and those
    to come. For the last 2 years, we were tested in ways we could
    never imagine. Through intentional collaboration and strong
    leadership, we persevered.
        As this moment requires even more of us, we must lead with
    an even greater sense of urgency. Our students are watching.
    Let's not let them down. Thank you.
        [The statement follows:]
                      Prepared Statement of 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 2023 Budget Request for the Department
    of Education. This request reflects President Biden's deep belief in
    the importance of education and the success and well-being of our
    nation's students. It's my hope that Congress answers the President's
    call for increased investments at the Federal level that will help our
    schools continue to recover from the COVID- 19 pandemic, address long-
    standing inequities that have existed in our school systems, and
    elevate our country's education system to lead the world. Our task is
    to reimagine and strengthen our entire system of education, from pre-
    kindergarten through adult education. As we recover from the crisis,
    let's focus on the opportunities to do just that.
        Last summer traveling in Michigan, I met a woman named Ruth who is
    a middle-aged woman working just to make ends meet. She had a health
    issue that forced her to go to the hospital during the pandemic, which
    opened her eyes to a future in the healthcare field. As she told me,
    ``After seeing what our country is going through, I want to live the
    rest of my life helping others who are going through health issues.''
    Using a Pell Grant, she is returning to school to be a nurse
    practitioner. My point is that it is never too late to go back to
    school, and it's never too late the seize the opportunities ahead and
    we can make it easier for learners of all ages like Ruth to reignite
    their passions and discover new ones.
                     fiscal year 2022 congressional action
        I want to begin by thanking the Members of the Subcommittee--and
    your staff--who worked so hard to provide a fiscal year 2022
    appropriations bill. That bipartisan funding package delivers for our
    students and families by making essential investments in our schools
    and building on a cornerstone of the Biden-Harris Administration--
    keeping equity at the center of all we do. This bill includes an
    important commitment, shared by President Biden, to significantly
    increase funding for the Title I program by providing $17.5 billion in
    funding, a $1 billion increase. This is the largest increase for Title
    I in over a decade and an important first step that we look forward to
    working with you to build upon. The bipartisan package makes important
    strides to meet the needs of the whole child, to support effective
    teaching and learning, and to strengthen and diversify the educator
    pipeline. The 2022 appropriations bill also makes college more
    affordable by increasing the maximum Pell Grant by $400, which is a
    down payment on the President's call to double Pell and will help more
    students pursue an education or training beyond high school. The
    President's 2023 Budget Request builds upon this legislation by
    increasing investments in our schools with high-poverty rates; helping
    meet the needs of students with disabilities and multilingual learners;
    and expanding access to postsecondary education and increasing college
    completion.
        There is one technical detail that I would like the members of this
    Subcommittee to keep in mind when reviewing our fiscal year 2023 Budget
    Request. Due to the timing of the passage of the fiscal year 2022
    appropriations legislation, the baseline for our fiscal year 2023
    request levels was the fiscal year 2021 enacted level and does not
    reflect final fiscal year 2022 appropriations action. A comparison of
    our request with actual fiscal year 2022 levels could suggest that we
    are proposing a number of decreases for fiscal year 2023, when that is
    not the case. On the contrary, our goal is to maintain and build on
    these critical investments. The Administration is excited about the
    support of Congress and the many increases provided to Department of
    Education funding in fiscal year 2022. We look forward to working with
    Congress to provide technical assistance during upcoming fiscal year
    2023 appropriations action. The numbers I will be citing in my
    testimony today will mostly reflect differences between the fiscal year
    2022 appropriation and our request.
                     department of education funding levels
        The President's fiscal year 2023 request calls for a significant
    increase in Federal support for education from birth through college
    and career. The proposed discretionary request is $88.3 billion for
    Department of Education programs, an increase of almost $12 billion
    over the fiscal year 2022 enacted level. The 2023 Budget would make
    historic investments in the Nation's future prosperity by prioritizing
    funding for five core themes that are at the heart of this
    Administration's vision for education in America: 1) Supporting
    Students Through Pandemic Response and Recovery Over the Long Term; 2)
    Boldly Addressing Opportunity and Achievement Gaps; 3) Supporting a
    Talented and Diverse Educator Workforce; 4) Making Higher Education
    Inclusive and Affordable; and 5) Building Pathways Through
    Postsecondary Education that Lead to Successful Careers.
           supporting students through pandemic response and recovery
        Even with 99 percent of schools open for full-time, in-person
    learning, many students continue to be affected by the pandemic. We
    know that in our communities most impacted by COVID, their recovery
    could take many years. Disruptions caused by the COVID-19 pandemic
    continue to take a toll on the academic success, and physical, social,
    emotional, and mental health of students. It has also taken a toll on
    the well-being of our educators and school staff.
        Responding to these needs can often be a challenge for many
    schools. For example, there continues to be a critical gap, that
    existed prior to and was only made worse by the pandemic, between the
    number of school-based health service providers needed and the number
    of such providers currently serving in our schools, particularly in
    school districts and schools with high rates of poverty. This is why
    the Budget includes a $1 billion investment to bridge that gap through
    the School-Based Health Professionals program, both by building the
    pipeline of such professionals and by providing the dedicated funding
    needed to hire them. We appreciate the additional $90 million Congress
    provided to support similar activities in the fiscal year 2022
    legislation, and we are committed to building on this investment as
    more is still needed. The Administration estimates that our requested
    funding, together with State and local matching funds, would allow LEAs
    to hire an additional 21,000 school counselors, nurses, social workers,
    and school psychologists.
        Our request further supports students through pandemic response and
    recovery by including $468 million to dramatically expand the Full-
    Service Community Schools (FSCS) program. A 2020 study from the Rand
    Corporation, Illustrating the Promise of Community Schools: An
    Assessment of the Impact of the New York City Community Schools
    Initiative, found that community schools in New York City had a
    positive impact on student attendance, on-time grade progression, high
    school graduation rates, disciplinary incidents for elementary and
    middle school students, math achievement, credit accumulation for high
    school students, shared responsibility for student success at
    elementary and middle schools, and students' sense of connectedness to
    adults and peers for elementary and middle school students. Additional
    studies have found similar outcomes for evidence-based approaches to
    Full-Service Community Schools. Our request would allow the Full-
    Service Community Schools program to create an estimated 800 new
    community schools serving up to 2.4 million additional students, family
    members, and community members in districts that want to advance this
    approach.
        For districts that may not have the capacity to implement the
    broader community schools approach supported by FSCS, this request also
    includes $25 million for the provision of integrated student supports
    (ISS), one of the pillars of evidence-based approaches to community
    schools. ISS grants would help provide access to services that meet the
    social, emotional, mental and physical health, and academic needs of
    students and families through cross-agency efforts and partnerships
    between districts and with community-based organizations.
               boldly addressing opportunity and achievement gaps
        Even before the pandemic, too many elementary and secondary school
    students faced daunting barriers to receiving a high-quality education.
    This budget seeks to remove those barriers by providing the resources
    needed so that every student can be successful. Core to that effort is
    Title I, which helps schools provide students from low-income
    communities the learning opportunities and supports they need to
    succeed. This budget boosts funding for Title I by $19 billion over
    fiscal year 2022 through a mix of discretionary and mandatory funding.
    This substantial new support for the program, which serves 25 million
    students in nearly 90 percent of school districts across the Nation,
    would be a major step toward fulfilling the President's commitment to
    addressing long-standing funding disparities between under-resourced
    schools--which disproportionately serve students of color--and their
    wealthier counterparts. The Budget also includes a first-time $30
    million investment to improve education and outcomes for children and
    youth in foster care, one of our most vulnerable populations.
        The President and I are committed to ensuring that children and
    youth with disabilities receive the services and support they need to
    thrive in school and graduate ready for college and career. I am very
    excited that our request provides an additional $3.3 billion over 2021
    enacted levels--which would be the largest two-year increase ever
    outside of the American Rescue Plan--for Individuals with Disabilities
    Education Act (IDEA) Grants to States, with a total of $16.3 billion to
    support special education and related services for students in grades
    Pre-K through 12. The Budget also nearly doubles funding to $932
    million for IDEA Part C grants, which support early intervention
    services for infants and families with disabilities that have a proven
    record of improving academic and developmental outcomes. The increased
    funding would support States in implementing critical reforms to expand
    their enrollment of underserved children, including children of color,
    children from low-income backgrounds and children living in rural
    areas. The increase for Part C includes $200 million to expand and
    streamline enrollment of children at risk of developing disabilities,
    which would help mitigate the need for more extensive services later in
    childhood and further expand access to the program for underserved
    children. In addition, our request includes a sizeable increase for the
    Preschool Grants program. More than 80 percent of children
    participating in the Preschool Grants program have demonstrated
    significant improvement in academic, behavioral and social and
    emotional outcomes, which is consistent with numerous studies that have
    found that the provision of special education and related services for
    preschool-aged children significantly improved outcomes in these areas.
        Recent results from the National Assessment of Educational Progress
    continue to show significant achievement gaps remain between English
    Learners and their peers. This is directly tied to the educational
    opportunities and resources that are available to support their
    success.
        These barriers to a high-quality education are especially pressing,
    as many states and school districts have experienced an increase in
    arrivals of immigrant children, including refugees from countries
    impacted by war. Accordingly, this Budget includes a significant
    increase of $244 million to the English Language Acquisition grants
    program, for a total fiscal year 2023 funding level of $1.1 billion.
    Further, the increased investment proposed for fiscal year 2023 would
    greatly strengthen the Department's capacity to work with its State and
    local partners to elevate meeting the needs of English learners in the
    context of encouraging multilingualism as a necessary skill for success
    in our globally competitive economy.
              supporting a talented and diverse educator workforce
        The Administration is committed to not only honoring educators but
    making sure they are treated with the respect and the dignity they
    deserve. In addition to promoting supportive working conditions and
    welcoming educators' voices as critical partners to improve education,
    we must make sure education jobs are ones that people from all
    backgrounds want to pursue.
        For decades, the education sector has faced shortages in critical
    staffing areas, such as special education and bilingual education,
    disproportionately impacting students of color and students from low-
    income backgrounds. The COVID-19 pandemic and tight labor market have
    made shortages worse. These shortages negatively impact the education
    students receive and continue to fall hardest on students in
    underserved communities. For example, teacher shortages in areas such
    as STEM, Career and Technical Education, and advanced placement and
    dual enrollment/early college programs can result in these high-quality
    pathways and opportunities being out of reach for students. In addition
    to comprehensive investments across several programs to support a
    diverse and well-prepared pipeline of educators, the Budget includes
    $514 million for the Education Innovation and Research program,
    including $350 million focused on identifying and scaling models that
    improve recruitment and retention of staff in education.
        These funds would support innovative efforts to improve resources
    and support for educators, provide teacher access to leadership
    opportunities that improve teacher recruitment and retention, and
    expand the impact of great teachers within and beyond their classrooms.
        Other key investments include $132 million for Teacher Quality
    Partnership grants to effectively prepare aspiring teachers by
    supporting pathways into the profession such as high- quality teacher
    residencies and Grow Your Own programs, that improve educator
    diversity, effectiveness, and retention; $250 million for IDEA, Part D,
    to support the pipeline of special education teachers and personnel;
    and $20 million for Augustus Hawkins Centers of Excellence to support
    teacher preparation programs at Historically Black Colleges and
    Universities (HBCUs), Tribally-Controlled College and Universities
    (TCCUs), and minority-serving institutions (MSIs). We are incredibly
    appreciative that fiscal year 2022 appropriations provided first time
    funding for the Augustus Hawkins program to support teacher preparation
    programs at these institutions. Recognizing that school leaders are
    second only to classroom teachers among school factors that affect
    student learning, our request includes $40 million in funding for the
    reauthorized School Leader Recruitment and Support program to improve
    the recruitment, preparation, placement, support, and retention of
    effective principals and other school leaders in underserved schools.
                making higher education inclusive and affordable
        Too many students today are deciding that a postsecondary education
    is out of reach. That is unacceptable. To make higher education more
    inclusive and affordable, the Budget increases the maximum Pell Grant
    by $1,775 over the 2022-2023 award year through a mix of discretionary
    and mandatory funding, helping an estimated 6.7 million students from
    low- and middle-income backgrounds overcome financial barriers. This
    historic increase is one piece of the Budget's comprehensive proposal
    to double the maximum Pell Grant by 2029. The Administration continues
    to support expanding Federal student aid, including Pell Grant
    eligibility, to students who are Deferred Action for Childhood
    recipients--commonly known as DREAMers--and we are committed to working
    with Congress to advance this goal.
        Any approach we take to postsecondary education must put students
    and families first. Too many people currently see our student aid
    delivery system as broken, with a few, but notable, bad actors taking
    advantage of students looking to get ahead and student aid systems that
    have not kept pace with today's demands. Our request will improve the
    services we provide students and families to help them pay for college
    through a historic investment in Student Aid Administration. We are
    requesting $2.65 billion to administer the Federal student aid programs
    in fiscal year 2023, an increase of $620 million over fiscal year 2022
    enacted. Specifically, the increase will allow us to implement customer
    service and accountability improvements to student loan servicing and
    ensure the successful transition from the current short-term loan
    servicing contracts to a more stable long-term servicing environment.
    The increase is also critical to ensure full implementation of the
    FAFSA Simplification Act for the 2024--25 award year.
        Of course, access to higher education is just one piece of the
    puzzle. It is also critical to help students obtain the support they
    need to be successful, and to provide institutions with resources to
    ensure their students' success. Just as so many students do not seek
    education beyond high school, too many start but don't complete their
    postsecondary degree or certification. The President and I are
    committed to not only ensuring an education beyond high school is
    accessible and affordable, but that students are provided equitable
    access to resources and supports to persist and complete. The Budget
    supports strategies to improve the retention, transfer, and completion
    rates of students by creating a Retention and Completion Grant program
    in the Fund for the Improvement of Postsecondary Education. The Budget
    also promotes academic success by providing critical resources to
    support students' basic needs, including a $30 million increase to
    institutions providing affordable child care for student parents with
    low- incomes. The request includes significant increases for Federal
    TRIO programs and GEAR UP to expand services that promote access and
    completion in postsecondary education for underserved individuals. The
    Budget would also enhance institutional capacity at HBCUs, TCCUs, MSIs,
    and low-resourced institutions, including community colleges, by
    providing an increase of $703 million over the 2022 enacted level. This
    funding includes a $450 million initiative to expand research and
    development infrastructure at four-year HBCUs, TCCUs, and MSIs.
         building pathways through postsecondary education that lead to
                               successful careers
        While increased funding for student aid and higher education is
    vitally important, the key to access and affordability really begins
    before any student applies to college. It begins in high school and
    even earlier. This is why the President's Request would help create
    stronger college and career pathways between our Pre-k through grade 12
    systems, our two- and four-year colleges and universities, and our
    workforce partners. We are requesting $200 million for a new Career-
    Connected High Schools Initiative within Career and Technical Education
    National Programs, to provide competitive grants that support
    partnerships between local educational agencies, institutions of higher
    education (including community colleges), and employers to support
    early enrollment in postsecondary and career-connected coursework;
    work-based learning opportunities; and academic and career-connected
    instruction across the last 2 years of high school and the first 2
    years of postsecondary education. Our request also supports adult
    learners through a College Bridge Initiative, funded through Adult
    Education National Leadership Activities, and new grants to support
    disconnected youth without a high school diploma.
                        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 19 percent increase
    for the Office for Civil Rights to protect students, providing a total
    of $161 million to advance equity in educational opportunity and
    delivery at Pre-K through 12 schools and at institutions of higher
    education.
                                closing remarks
        This is our moment to truly reimagine education so that all
    students can succeed. Thank you again for this opportunity to share
    more about the President's plan to invest in students of all ages--like
    Ruth from Michigan--and the schools and institutions that serve them.
    As I and the President have said before, our budget is a reflection of
    our values and I look forward to working with you to advance this
    historic budget request. I am committed to learning more about your
    individual interests and priorities related to Department of Education
    programs and activities and 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.

        Senator Murray. Thank you, Mr. Secretary, for a very
    compelling opening statement. And I think it is incumbent upon
    all of us to remember the names of those students that you said
    out loud and our job here to make sure that students like them
    across the Nation get the kind of help and support they need
    from the Federal Government.

                                 STUDENT LOANS

        So, thank you very much for that. Let me begin by asking
    you about the Department's attempts to improve student loan
    programs, like addressing the longstanding problems in the
    income driven repayment program and the public service loan
    forgiveness program, forgiving loans for borrowers ripped off
    by for profit colleges, including many in my home State.
        But there is significantly more work to really fix this,
    our broken loan system, and make sure that it works for all of
    our students. I have been very clear that this Administration
    should extend the current repayment pause until 2023 so you can
    get all this work done.
        I wanted to ask you this morning, what is the Department
    doing to comprehensively address issues in our student aid
    system, from students filling out the FAFSA (Free Application
    for Federal Student Aid), initially applying for the aid, to
    the borrowers making their last payment or having their balance
    forgiven?
        Secretary Cardona. Thank you for that question and for an
    opportunity to share with you. We are really, as was described
    by your opening comments, addressing a broken system. The
    system is broken. So as much as there is conversation about
    student loan forgiveness, we take the work of fixing a broken
    system very seriously at the Department of Education. What we
    don't want to do is end up in a situation where 5 years from
    now, we have the same problems that we have today.
        Our FSA (Federal Student Aid) office is really improving
    services, providing an onramp with better communication, a
    better support for our borrowers, better communication. We are
    upgrading systems that haven't been upgraded in 45 years to
    make the process much more user friendly. The simplification
    process for FAFSA is underway, as you know, and you have been
    advocating for. It has to be simpler.
        I have met too many students who by 6th, 7th grade decided
    that college is not for them because their parents are afraid
    of that process. Imagine the talent we have in this country
    that is untapped because students are afraid of this process.
    We have a responsibility at the Department of Education to
    address, in my opinion, a system that isn't working for
    students and for borrowers.
        And we have done a lot of work to address loan forgiveness
    for those who deserve it. Like for the public service loan
    forgiveness, for the thousands of borrowers, 408,000 borrowers
    that have total and permanent disabilities, who are eligible
    for loan forgiveness but never got it. We are fixing that. But
    we are also improving the college scorecard.
        We are improving FSA Office of Enforcement. We are doing a
    lot of things to improve systems that are broken, and part of
    that is what you brought up, making sure the system works for
    the borrowers and it is--they can get information quickly and
    easily.
        Senator Murray. You recently announced plans for this new
    student loan servicing solution, unified servicing and data
    solution. How will that make sure we have better accountability
    and high quality service for student borrowers?
        Secretary Cardona. Well, what we are going to do is be more
    engaged in the outcomes of those services. We have very high
    expectations, and we are going to make sure that we have
    rigorous standards for those companies that partner with us to
    engage in. Obviously, we are going to communicate with our
    borrowers directly and we are going to hear from them on the
    progress of that.
        So, oversight increase, accountability, higher standards,
    better communication with our partners, and more communication
    with our students is how we are going to determine if it is
    working.

                        OFFICE FOR CIVIL RIGHTS STAFFING

        Senator Murray. Okay. In my minute left, I just wanted to
    ask you about the backlog at the Office for Civil Rights. We
    have rising caseloads, large backlog. So, I was glad to see
    actually that the President Biden budget requested an increase.
    But just tell us quickly what is at stake for our students and
    parents, if the Office of Civil Rights doesn't get a boost in
    funding?
        Secretary Cardona. Well, we have seen an increase during
    the pandemic, especially of cases regarding students with
    disabilities. And it is our responsibility to make sure that we
    are serving our students and our families who are concerned
    that their rights were violated. We need to have additional
    staff to address this backlog and address the increase in
    cases.
        Senator Murray. And that is what that additional boost----
        Secretary Cardona. And that is what the funding request is
    for.
        Senator Murray. Okay. Thank you very much. Senator Blunt.
        Secretary Cardona. Thank you.
        Senator Blunt. Thank you, Chair. Mr. Secretary, as you
    know, one of the things that I have worked on hard, and this
    committee has too is to get in a situation where we treat
    mental health like all other 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 psychologist, social workers.

                                 MENTAL HEALTH

        In the budget year we are in now, we provided $111 million
    for that purpose, which was an increase of $95 million over the
    previous year. Can you give me an update on what you hope to do
    with that $111 million and how quickly you think we are going
    to begin to see some results in terms of people available to
    fill the need you see in schools for these professional
    services?
        Secretary Cardona. Thank you, Senator. And first of all,
    thank you for your service over the years as you--this is your
    last hearing. Thank you for the advocacy on behalf of our
    students.
        Senator Blunt. Thank you.
        Secretary Cardona. Mental health is significantly--has to
    be significantly greater in how we educate our students moving
    forward. There were issues with mental health access before the
    pandemic, much worse. I am pleased that with ESSER (Elementary
    and Secondary School Emergency Relief) funds, there has been a
    65 percent increase in social workers, 17 percent increase in
    counselors. But in my conversations across the country, it is
    not enough, and we need more.
        And there needs to be long term funding to make sure that
    these resources are available for the long term. And you are
    absolutely right, there is a shortage of school social workers
    and community social workers. In our budget, we have funds
    aimed at promoting a partnership between higher education
    institutions and K-12 institutions to make sure that we are
    producing social workers.
        And we hope to fund programs like that with these funds so
    that students have access to the supports that they need.
    Additionally, mental health support also includes access to
    afterschool programing or engaging with a mentor or having
    other activities that give students an opportunity to engage in
    a positive social climate with their peers.
        So addressing mental health supports does include
    increasing social workers and access to community providers,
    but it also means increasing access to positive peers for our
    students.
        Senator Blunt. So, Mr. Secretary, the money that was
    available to schools through the COVID pandemic relief, I think
    that money could have been used for mental health, maybe in the
    way you just defined it. Do you see schools doing that? And if
    they are not doing it, why do you think they are not using it
    for those mental health purposes?
        Secretary Cardona. Yes, I do see them using it that way. A
    Future Ed report confirmed that, you know, a high percentage of
    staffing is aimed at providing more mental health support. I do
    believe that they are using it very well. I have seen examples.
    I remember visiting New Mexico recently and having a circle
    with about 15 to 20 students, high school students who are
    really affected by the pandemic.
        At least two of the students in that circle lost a parent
    during the pandemic. And one of the students said the only
    reason why he is back in school is because of that counselor
    that brought them back over the summer to connect with them.
    And the student is doing better now. But he said if it weren't
    for those supports there, he would not be in school.
        I have seen it firsthand, and I know the money is being put
    to good use, not only with additional social workers, but with
    programs that reconnect students that have been disengaged or
    family members that have been disconnected from our schools.
        Senator Blunt. Well, I hope we are encouraging them to use
    this money that way and to use it in the near term rather than
    some program way out there. Because just like you said, I think
    people, the disruption of in-person school and other things has
    created some significant challenges we didn't have before.

             FREE APPLICATION FOR FEDERAL STUDENT AID DATA RELEASE

        I am very concerned about the recent news reports that data
    from individuals completing their free application for student
    aid was shared with Facebook through the Meta Pixel code. Could
    you talk to me a little about that?
        I think initially the Department did not think that
    happened, but Richard Cordray, the Student Aid Chief Operating
    Officer, said it did happen. Could you talk about that?
        Secretary Cardona. Sure. Yes. What we found was in May
    2020, during the last Administration, the Department
    inadvertently activated a more sophisticated advertising tool
    that did share some information, but not Social Security
    numbers, dates of birth, or personal financial information.
        Once we found that out, we immediately stopped that
    feature. And we are moving quickly now to investigate this and
    find out what was shared. And we had two Congressional update
    meetings already, but we plan on being very open and
    transparent about this information.
        Senator Blunt. Well, I heard you mention May 2020. Let me
    just finish my thought out here. Cordray says it was
    inadvertently shared after FSA engaged in a March 2022
    advertising campaign. And it came out later that that
    information was shared with Facebook as early as January 2022.
    It could be there is also a January 2020 or May 2020 situation,
    but I think there are clearly situations in the current year
    where this material was faced. Thank you, Chair.
        Senator Murray. Senator Reed.

                               SCHOOL FACILITIES

        Senator Reed. Thank you very much, Madam Chairman. And
    thank you, Mr. Secretary, for your service. In the 2021 State
    of Our Schools report, it was found that there was an $85
    billion per year gap between what school facilities need to be
    brought up to standard today, to sophistication and relevancy,
    versus what money has been committed by the States.
        And last month, my colleague and friend Bobby Scott passed
    in the committee the Reopen and Rebuild American School Act,
    which I am the co-sponsor over here. And it called for a $130
    billion investment by 10 years by the Federal Government to get
    these buildings up to speed. And you know yourself, they are
    closing schools early because of heat in Philadelphia.
        Those schools weren't built when air conditioning was a
    standard feature. In my community of Cranston, Rhode Island,
    they had to keep the windows open all winter and the kids in
    coats because the ventilation system and COVID was too much.
    So, isn't it time we made a significant investment?
        I know the President has called for $2 million to have a
    coordinating office in your department to help move money
    around. I know there are funds in the American Rescue Plan,
    etcetera, but do you think it is time we have a Federal
    commitment to fixing up these facilities, helping the States?
        Secretary Cardona. Yes, sir. And I think these issues are
    even more highlighted when we talk about school security. I can
    tell you, when I served as a principal of an elementary school,
    a fairly modern elementary school, the cafeteria and the media
    center were the only air conditioned spaces.
        So, in May and June, I had a schedule of teachers rotating
    through those spaces so that they and their students could get
    fresh air and could breathe easier. That is how our schools are
    operating in many places across the country. I can also tell
    you, Senator, that when I visited schools at the beginning part
    of my time as Secretary of Education, some schools reopening
    efforts were impacted by the impacts of deferred maintenance.
        Schools that had poor circulation, poor air flow, and their
    reopening was delayed because of that. We do have to take a
    very serious look at our schoolhouses and look at it as
    infrastructure is equity.
        Unfortunately, there are different standards in different
    places, and we have to make sure that our schools are places
    where children can learn, where our staff want to work, and it
    is safe for students. And I do believe our efforts are there to
    look at this, but I do believe a commitment is needed for this
    to take place.
        Senator Reed. No, you are actually right. And I think it
    obviously is an equity issue because you go to places in Rhode
    Island, Central Falls High School, which is the smallest
    community in the State, a mile by a mile, mostly Latinos and
    Latinas.
        They have a high school that was built in the 1920s, I am
    guessing. They are going to build a new high school, but you
    can see that everywhere. We have, in the United States, an
    estimated 43 million adults who are low skilled in literacy and
    63 million adults who are low skilled in numeracy.

                                ADULT EDUCATION

        And in this modern, sophisticated economy, if you can't
    read or write, getting a job beyond the local fast food is
    challenging. Do we have to do more to help adult education in
    the United States, increase funding?
        Secretary Cardona. Absolutely. I believe not only is it
    important that we focus on our adult education population
    because the system didn't work for them the first time around,
    but we also know that not only for their family, but for their
    community, it pays economic dividends. You know, their quality
    of life improves, and their ability to contribute improves. And
    there are programs out there, especially now with the economy
    the way it is and the job opportunities that exist.
        We need to do a better job connecting them with high paying
    jobs. That is just quality of life for their family. And as was
    mentioned in one of the earlier statements, you know, this has
    a multi-generational approach, right. If the parent has a
    better paying job, they might have more opportunity to be with
    their children at home and help them with their homework.
        So, I do believe we have a responsibility to improve adult
    education, and there is an opportunity here for success for
    these students and for their communities.

                    PELL GRANTS AND EDUCATIONAL OPPORTUNITY

        Senator Reed. Well, in the final seconds, I have to mention
    the 50th anniversary of the Pell Grant. I had the distinction
    of succeeding Senator Pell. No one could replace him. And if
    you really wanted to feel good about yourself, you marched in
    the parade with him and you pretended they were cheering for
    you.
        [Laughter].
        Senator Reed. It is a very good technique. But we have to
    do more, I think, than just simply bump up the Pell Grant every
    year. And Senator Collins and I have the Pass Act, which is a
    much more comprehensive way to set goals at the State level for
    attainment to have a systematic sort of from preschool, grammar
    school, all the way into college so that they are ready--
    people, young people are ready to go to school. So, I would ask
    you to look very closely at that, Mr. Secretary. And thank you
    very much.
        Senator Murray. Thank you. Senator Manchin.
        Senator Manchin. Thank you, Madam Chairman. Secretary, it
    is good to have you here. Thank you for being here and thank
    you for your service. And next, let me say, on behalf of the
    great people of West Virginia and my entire State, our deepest
    sympathy to the families of the children and the teachers who
    were lost in Uvalde in a horrible tragedy.

                                 SCHOOL SAFETY

        Along those lines, school safety has been a major topic of
    late of what we could have done, what we can do, and what we
    should do, especially following that tragic shooting in Uvalde.
    In March 2018, President Trump appointed then Secretary DeVos
    to lead the Federal Commission on School Safety.
        That commission found that while there is no universal
    school safety plan that will work for every school across the
    country, the Federal Government does and can play a role in
    enhancing school safety. So, in your budget, the Department
    asked for $129 million to address school safety, national
    activities, $23 million increase.
        That includes $24.7 million for new grants under Project
    Prevent, and just $2 million for a proposed national
    clearinghouse on school infrastructure sustainability to help
    with technical assistance. On school facility construction and
    improvement, which you might--maybe recommend, you might want
    to evaluate that and look at that and if that is enough to do
    the job.
        Issues such as self-locking doors, armed security guards,
    active shooter training for teachers and students, bulletproof
    windows, and other training have all been discussed as ways to
    help students improve student safety.
        So, my question would be, on the finding of the 2018 school
    safety report, that was an active shooter preparedness and
    mitigation, I know the Department has undertaken a review of
    the report and I am wondering what the status of that review is
    or has been or where you are in evaluating that and if it has
    been implemented.
        Secretary Cardona. Yes. You know, we--thank you for that,
    Senator. We take the responsibility to support the safety of
    our schools, our students, and our staff. It is the highest
    priority, you know.
        As a father, I can tell you there nothing more important to
    me than the safety of my children and their peers and their
    teachers when they are in school. Our Administration is
    reviewing the report, the Federal Commission on School Safety
    Report issued by former Secretary DeVos.
        And as I said before, in the budget we do ask for funds
    that can assist. You mentioned Project Prevent, $25 million
    there for projects to support community school strategies that
    help prevent community violence. There is also funding for
    mental health grants of $55 million for school based mental
    health grants. You know, this is going to be something that is
    going to be ongoing.
        And while the money is important, I think it is really
    important that the Department take a lead on providing
    technical assistance to the States----
        Senator Manchin. Sorry to interrupt. Do you have any--are
    you all monitoring that to find out how many schools or school
    districts are participating in this actively?
        Secretary Cardona. Yes.
        Senator Manchin. And because this started back in 2013 with
    the Sandy Hook shootings. We did a bill at that time, which is
    a background check, but we had school safety in that
    background, the Manchin-Toomey bill, and that school safety
    basically found out that we should harden all first floor
    schools, you know, with a windows and doors and bulletproof and
    lock down and single entry. I don't know how much of that was
    followed through and schools that took advantage of it or not.
        Secretary Cardona. I can definitely have more information
    provided to your office. Happy to follow up with you. Sure.
        Senator Manchin. If you could. If we can monitor this a
    little bit. And also, you have the tool of holding some of your
    Federal funds if they are not, and it is so important. They
    have got to do everything humanly possible.
        It is awful to look back and say, we should have done this
    or should have done that, and I would hope you all would look
    at that seriously about using the one tool you have, which is
    the money that goes to them if they are going to use it to
    protect our children.

                  TEACHERS WITH A HISTORY OF ASSAULT OR ABSUSE

        Back in 1997, a young student from Fayette County, West
    Virginia, was killed by his teacher. That same teacher had
    previously taught at a school in Pennsylvania but was dismissed
    following the string of allegations involving sexual misconduct
    with student.
        That teacher somehow received a positive recommendation
    just to get rid of that teacher from that school district and
    shoved him down to our school district, which has some horrific
    naming for this. And we don't want to go into that talking
    about teachers and all the things they have said.
        But to allow this to happen, we have 130 teachers and
    teachers' aids that have reportedly been arrested for sexual
    related crimes. So, Secretary, Senator Toomey and I again
    introduced a bill that has been put into law. So why are States
    that are not complying with the law still receiving any
    funding?
        Secretary Cardona. You know, we take the safety, as I said
    earlier, the safety of students very seriously. We published a
    report that was developed in the last Administration, and we
    are setting up communication with districts--or with States.
        We are going to award States and we are going to have a
    higher level of accountability and reporting on what is being
    done, and holding them accountable for complying with the
    report.
        Senator Manchin. How does that teacher's record get
    transferred--so if Indiana, Senator Braun's school district is
    basically going to hire a person that was in West Virginia and
    didn't know that that person had been let go in West Virginia
    for violation to their student, sexual--you know, whatever it
    may have been. And they think they are hiring them with a good
    recommendation. How does that get into the system?
        Secretary Cardona. We are going to strengthen the system to
    make sure the States are complying with the recommendations of
    the report and the expectations of the report. And again, it
    just goes back to making sure we are holding States accountable
    for following the law.

                                  UPWARD BOUND

        Senator Manchin. And my final question, I know my time has
    run out. The Upward Bound program. The only thing I would say
    on that is that it has been such a wonderful program, helped so
    many kids in my State of West Virginia. But it didn't come out
    until the week before deadline and just didn't give us enough
    time to do the job. So, if you could, sir, anything you can do
    on the Upward Bound program. It is a tremendous program.
        Secretary Cardona. Thank you.
        Senator Manchin. Thank you, Madam Chair.
        Senator Murray. Senator Braun.

                           PARENTS' ROLE IN EDUCATION

        Senator Braun. Thank you, Madam Chair. Last September, we
    had a conversation. And I was educated in a great public school
    system in my hometown in Jasper, Indiana. We have got issues in
    education, and I am a big believer that, and I think I told
    you, that parents should be the main stakeholder in their own
    kid's education, and I believe there should be choice along the
    way.
        We had an election that transpired in Virginia where that
    was a key issue. And I asked you then if that was something you
    would be comfortable saying. Are the parents the most important
    part in a kid's education, their own kid's education, K through
    12? Have you reconsidered kind of your stance on that?
        Secretary Cardona. Senator, for the last over two decades
    of serving as an educator, I have always felt teachers,
    teachers and parents have to work together. And parents are the
    most influential and most important teachers that our children
    have. So, yes, parents are the most important partner with
    educators, and they know their children most. So schools are
    more effective when parent voice is incorporated in every
    aspect of learning.
        Senator Braun. Well, I am glad to see that maybe that has
    changed a bit.
        Secretary Cardona. Never changed, sir.

                SCHOOL CHOICE AND DOLLARS FOLLOWING THE STUDENT

        Senator Braun. I think it is a cornerstone of how things
    work. Coming to the idea of choice. We had a public school
    system to where that was almost a moot point that was so good.
    Not all places have that. Part of what works in Indiana is the
    money follows the child, not the building, not the district, so
    to speak.
        Do you believe in that concept so that we are putting
    resources to the places that have the kids there? Or do you
    think it should be maybe the old paradigm that other places
    work off of, to where you are funding the school itself and not
    following the child?
        Secretary Cardona. I believe the latter. I believe we need
    to make sure all of our schools are well resourced, so we don't
    have a system of winners and losers. All schools, and this
    budget reflects an attempt to make sure that we are addressing
    inequities so that we don't have schools where students attend
    and maybe they are not taking advantage of different options
    that they have. We have to make sure our schools provide all
    students with high quality education.
        Senator Braun. So, you do believe in the money following
    the child?
        Secretary Cardona. No. No, I believe that we need to fund
    public schools so that every student that attends a public
    school can have a high quality education.
        Senator Braun. Regardless, though, of what the performance
    is at that given school that parents may not be happy about if
    they don't have other options?
        Secretary Cardona. Sir, I believe there has to be an equal
    part, support and accountability, right. So, you provide
    adequate resources, adequate professional learning
    opportunities, but then there has to be an equivalent amount of
    oversight and accountability to make sure that those schools
    are producing.
        And I understand that in some cases that is not happening.
    And that is why I am a big believer in making sure we are
    disaggregating data to make sure that some subgroups of
    students are not receiving a poorer education. But that is also
    why in this budget, sir, I request for Title I and IDEA to make
    sure that those students with additional needs get the support
    that they need.

                         CAREER AND TECHNICAL EDUCATION

        Senator Braun. So, in traveling Indiana, pre-COVID, and
    especially exacerbated by COVID, workforce, workforce,
    workforce. Do you think there is enough emphasis being put on
    career and technical education for the high demand, high wage
    jobs that are mostly out there in Indiana? We have got great
    post-secondary institutions there, but we are starving for a
    better high school education that is going to give you at least
    life skills regardless of what you want to do.
        Secretary Cardona. Sir, I couldn't agree with you more. I
    don't think we are doing enough. We need to do better. We need
    to evolve our high schools to make sure that there are better
    career pathways. In the budget, we propose $200 million for
    career connected pathways for that same reason, for students in
    Indiana to have options when they graduate.
        They can go to a good, high paying, high skilled job
    because there are good connections with our workforce partners.
    They can go to 2-year school to level up on their skills, or
    they could go to a 4-year school. But then those skills that
    they get should be transferable into high paying jobs in the
    community that they live. I'm strongly in support of that.
        Senator Braun. I am glad to see that that is your point of
    view because sadly, and when I looked into it, some guidance
    counselors were stigmatizing that pathway as not being one
    worthwhile pursuing. Brings me to my final question, the high
    cost of post-secondary education. $1.7 trillion in debt is the
    manifestation of what that is about.

                        COST OF POSTSECONDARY EDUCATION

        We have only got one university President across the
    country that I think is paying any attention to it, Mitch
    Daniels at Purdue, has held tuition flat, I think, for around 9
    years. What are we going to do to address how expensive post-
    secondary education has gotten, and what do we do to disrupt
    the system to make it more within reach for those who choose to
    go that direction?
        Secretary Cardona. Thank you, Senator. I couldn't agree
    with you more. We have to fix that system. We increased the
    college scorecard requirements. We are meeting with
    institutions of higher education and saying this has to change.
    We have an office of enforcement at FSA. We recognize that
    college needs to be a good return on investment, and we are
    working really hard to fix a system that has led to like a
    runaway train of costs.
        Senator Braun. Well, that is good, because to solve the
    problem, you got to lower the cost. And that begs the question
    of how we accumulate so much debt in the process, so thank you.
        Secretary Cardona. Thank you.
        Senator Murray. Senator Schatz.

                                ARMING TEACHERS

        Senator Schatz. Thank you, Chair. Thank you, Secretary, for
    being here. Let me just start with an easy one. I think it is
    an easy one. Would arming teachers makes schools safer?
        Secretary Cardona. No.
        Senator Schatz. Can you elaborate a bit?
        Secretary Cardona. Look, our educators over the last few
    years have bent over backwards for our students to think that
    arming our teachers and now having them be responsible for
    discharging a firearm in our schools, is just ludicrous to
    think about. I think it is a further reflection of the lack of
    respect that this profession has, and I would stand against
    that. That is not the way to move forward.

                          ONLINE AND BLENDED LEARNING

        Senator Schatz. Thank you for that. What is your view of
    online learning? We are in a new phase of this pandemic. I will
    just give you my prejudices here. I just think it didn't work.
    I think it was understandable. I think we knew less about the
    virus. And this--a lot of those choices were made before the
    availability of the vaccine and our deeper understanding of how
    the virus impacts children. I think online learning was a total
    disaster. And I would just be interested to hear your views on
    this.
        Secretary Cardona. Sure. You know, having to develop a
    reopening plan in Connecticut when we know very little about
    the pandemic, there were no vaccines, testing took 5 days to
    get a response, and we didn't know transmissibility. We were
    working with OSHA (Occupational Safety and Health
    Administration), with epidemiologists.
        I think the decision to close schools and provide safe
    alternatives was the best and the right decision. Moving
    quickly to reopening schools was a priority across the country.
    With that said, blended learning or hybrid learning is no
    substitute for in-person learning. I can agree with that.
        I do think blended learning has a role as we move forward
    in education, but I don't think that the transition to fully
    online learning worked for most students, although for others--
    for some students, a small number of students in my visits have
    reported that they felt more comfortable that way. The majority
    of students wanted to return back to in-person learning.

                               SECOND CHANCE PELL

        Senator Schatz. Amen. Let me ask you about Pell restoration
    and second chance Pell Grants. As the Department transitions
    from the second chance Pell pilot to the full Pell restoration,
    does the Department plan to integrate existing pilot sites into
    the new prison education program to prevent a gap in education
    programing?
        Secretary Cardona. Yes, we are proud of the increase in the
    Second Chance Pell experiment. We added, as you know, 73
    additional sites and now we are at 200. And we do look at this
    as an opportunity to help provide skills that could then
    translate into productive lives and jobs for those who are
    getting a second chance. And we do want to see that continue
    and continue to expand to close those gaps that were
    established.

                                 MENTAL HEALTH

        Senator Schatz. I want to talk to you about mental health
    support for students. In a recent School Pulse panel, 70
    percent of public schools reported an increase in the
    percentage of students seeking mental health services.
        And by the way, I think it is 100 percent of the schools
    having an increase in mental health challenges, 70 percent
    reporting. And only 56 percent of public schools reported that
    their schools are able to effectively provide mental health
    services. We are not going to have enough money for the Federal
    Department of Education to address this.
        I am wondering how we can lift up what is working and scale
    it and provide it to Departments of education and schools,
    because I don't think we can necessarily pile on. There should
    be mental health resources spent, but some of this is going to
    be about lifting up what is already working. And I am wondering
    if you can comment on that.
        Secretary Cardona. Sure. And I can tell you, as an
    educator, we have never had enough mental health support
    available to our students. We haven't. You pile on pandemic,
    you pile on fears now of safety. You know, the ratio in some--I
    was in Michigan recently. The ratio between the school
    counselor and a student was like 700, over 700 in a particular
    community. That is unacceptable.
        So, I recently was on a call with Governors from
    different--a bipartisan group of Governors talking about the
    importance at the State level, also that mental health supports
    get elevated. It can't just be the American Rescue Plan
    dollars. That is insufficient. Our budget does provide funding
    requests for long term help, but it is all hands on deck States
    and local communities also.

                       NATIVE HAWAIIAN EDUCATION PROGRAM

        Senator Schatz. Final question, do I have your commitment
    to continue supporting the funding for the Native Hawaiian
    Education program?
        Secretary Cardona. Absolutely.
        Senator Schatz. Thank you.
        Senator Murray. Senator Shaheen.

                                  UPWARD BOUND

        Senator Shaheen. Thank you, Madam Chair. Secretary Cardona,
    thank you for being here this morning and for your testimony.
    Senator Manchin talked about the Upward Bound program. I have
    had direct experience in New Hampshire with the Upward Bound
    program when I worked at the University of New Hampshire.
        It is one of two Upward Bound programs we have, and it has
    actually been in existence since 1966. Keene State College is
    the other in existence since 1974. These programs, like all
    others, have to recompete every 5 years to continue to operate
    Upward Bound. But I am concerned because given that this is a
    predictable funding cycle for a longstanding Federal program, I
    don't understand why the Department is not able to award these
    grants on time.
        I recognize that there are challenges--when there are
    budget challenges with certainty around your budget, that that
    creates a concern. But explain to me why you can't award these
    programs, because the delays put programs through crises. Their
    instructors and applicants are notified that they may not be
    able to get their funding. It has an impact on their ability to
    continue in higher education. And I just don't understand why
    this continues to be such a problem.
        Secretary Cardona. Thank you, Senator, for highlighting the
    importance of TRIO programs. I couldn't agree with you more. My
    wife is a graduate of a TRIO program, went on to get her degree
    in communications and she went back to teach at the TRIO
    program. So certainly I could see the benefits of that.
        And, you know, as Senator Manchin mentioned and yourself,
    you know, there was no risk for delay with Upward Bound grants.
    There were--grantees were notified 2 weeks prior to the
    expiration. But what I am hearing from you is, could that
    process be improved so that it is not so late?
        So what I will do, Senator, is convene with my team to
    discuss this, and then I will have someone from my team reach
    out to you about the process to see if there is anything we can
    do.
        Senator Shaheen. That would be very helpful. I know that
    all of those who participate in those programs would appreciate
    it as well.
        Secretary Cardona. Thank you.

                       STUDENT LOAN REPAYMENT MORATORIUM

        Senator Shaheen. I want to go back now to the issue of
    student loan payments. And you probably don't remember, but
    last year I asked you about the moratorium end date. And what
    you told me is that the Department would try and provide some
    certainty on when those student loan payments would be expected
    to resume.
        Unfortunately, over that last year, the Administration has
    made three last minute extensions of the current payment
    moratorium. I am sure that all of those recipients appreciate
    that, but it doesn't provide the kind of certainty that they
    really need as they are planning their lives and trying to
    figure out what they need to do in order to ensure that they
    can start making those loan payments again.
        So can you tell me what process is in place to try and
    determine when this moratorium will end and when those who need
    to repay their student loans are going to have to start those
    payments again?
        Secretary Cardona. Thank you. Yes. You know, the
    information from the Federal Reserve helps drive decisions on
    whether to extend or not. And we recognize that while the
    economy has improved, many Americans are still struggling to
    make ends meet and pay their bills and get their childcare
    bills back up, their mortgage. So, we felt that another
    extension was warranted.
        We do, as I said last year, want to provide our borrowers a
    long onramp so that they understand when it is going to start,
    to better prepare them for this process. And we have resources
    at the Department of Education that are available now that
    weren't available before to help them.
        Senator Shaheen. So, do you have any sense of when this
    current moratorium will end?
        Secretary Cardona. I don't have any information now to
    share with you about when it would end, or whether or not, you
    know, what the conversations are about, when it is going to be
    lifted.
        I know we have a date, and it could be that it is extended,
    or it could be that it starts there. But what I will say is
    that our borrowers will have ample notice and we will
    communicate that with you as well.

                          MENTAL HEALTH PROFESSIONALS

        Senator Shaheen. Thank you. You talked in your opening
    statement about the challenges that students are facing, the
    mental health challenges that we are seeing with students.
        And one of the real issues we have, I know, across the
    country is not having enough professionals to address mental
    health challenges. Can you talk about what kind of plans the
    Department could put in place, what kind of legislation we
    might need to pass in order to help address that?
        Secretary Cardona. Yes. Thank you for that question. You
    know, we have an opportunity to really reimagine how we are
    looking at providing support for students. And there is a
    continuum, right. The social worker, the school social worker,
    the community social worker is obviously a major support, but
    additional funding and support for students having access to
    afterschool programs, to good summer programing, to a mentor.
        Those are all good ways of doing it. Supporting programs
    that allow high school students that are thinking about a
    career in social work because it is just a shortage area to
    receive incentives to go into that field, and to create
    throughways between our K-12 systems and our 4 year
    institutions, to have these students get into the schools
    earlier, to do field work out there while they are getting
    college credits.
        These are all creative ways that we are hearing about as
    they visit different States. But to incentivize that across the
    Nation, I think we are at that point now because there is a
    shortage there and in many other areas. Another area is
    incentivizing connections between schools and community based
    providers.
        You know, in Connecticut, we benefited from the community
    health center tremendously. I have seen models where we have
    hospitals that are connected to school systems, and the level
    of care is great because there is a connection with the
    hospital and a 4 year university that helps train and educate
    these social workers.
        So, I think there is room for growth there. I really want
    across the country for us to be a little bit more innovative
    and bold, saying that this has to be a foundational part of the
    educational experience.
        Senator Shaheen. Well, thank you. I certainly agree with
    that. And anything that we can do on this committee, I am sure
    we stand ready. Thank you, Madam Chair.
        Senator Murray. Senator Baldwin.

                         CAREER AND TECHNICAL EDUCATION

        Senator Baldwin. Thank you, Madam Chairman. Thank you for
    being here, Secretary Cardona. I wanted to start by discussing
    career and technical education. Despite the growing demand for
    CTE (career and technical education), Federal programs
    supporting career education and skills training have been
    persistently underfunded.
        The President's budget proposes new innovative programs
    like the Career Connected High Schools Grant Program. However,
    the budget request does not have enough funding to launch these
    programs in every State, and the Administration did not request
    an increase for important existing programs that are helping to
    build a strong workforce in my home State of Wisconsin.
        So, I want to ask you if you can ensure--well, if you will
    ensure that the Administration's new initiatives support,
    rather than supplant, the existing funding streams that are
    helping to connect students to skill and career focused
    services.
        Secretary Cardona. Thank you for the advocacy on behalf of
    that important and often pushed aside component of education. I
    believe it was Senator Braun who mentioned that in some cases
    it is not looked at as a viable option. And I can tell you, as
    a technical high school graduate myself, you know, leaving high
    school with options helps the students, the community.
        So I am a big proponent of really just like with mental
    health, reimagining what career connected high schools and
    programing that are connected to our workforce partners, to the
    regional needs in the community, to our 2 year schools, 4 year
    schools, that has to be systematized across the country.
        And while this $200 million proposals for competitive
    awards, I recognize that the support--that those communities
    that are trying to do this has to increase as well, so I will
    continue to advocate and find ways to support those programs
    and find ways to make whatever new money is available eligible
    to those who are already doing some of this work.

                   STUDENT LOAN PREDATORY BEHAVIOR AND SCAMS

        Senator Baldwin. Thank you. You have had a number of
    discussions already on student debt. It is a burden for many
    students in Wisconsin. But part of it is made worse by
    predatory behavior of those who target students struggling to
    make ends meet.
        That is why I was proud to introduce and witness the
    passage of the Stop Student Debt Relief Scams or Stop Act. That
    created criminal penalties for unauthorized access of student
    loan information.
        And an important part of that bill was the creation of a
    third party data access system to ensure that there is a safe
    and secure way for legitimate actors like legal aid groups to
    easily and efficiently access the information that borrowers
    want them to have.
        Secretary Cardona, what actions has the Department of
    Education taken to implement the Stop Act, and when can we
    expect to see the designated third party access system up and
    running?
        Secretary Cardona. Thank you for your hard work to protect
    students from scams out there on debt relief. We are faithfully
    implementing the Stop Act, and some of the ways we are doing
    that is we are implementing that third party access form as
    required by the Stop Act.
        We are working with an investigator general to notify
    victims of fraud. We are updating the FSA website to allow
    borrowers to access their information more quickly. And these
    are just some ways that we are trying to improve services for
    those who have loans out there and make the information more
    open and transparent.
        Senator Baldwin. But do you know when that third party
    access system will be up and running?
        Secretary Cardona. We are currently implementing that.

                  SCHOOL DESEGREGATION AND EDUCATIONAL EQUITY

        Senator Baldwin. Okay. Multiple reports and investigations
    have found that nearly 70 years since Brown versus Board of
    Education decision, schools in Milwaukee and Waukesha remain
    some of the most segregated in the Nation. Despite prior
    intervention by the Department of Education, suspension and
    expulsion rates at Milwaukee Public Schools remain deeply
    unequal.
        Every child in Wisconsin, regardless of their zip code,
    income, or background, deserves the opportunity to learn and
    thrive in a school that is safe and supportive. But sadly,
    these reports suggest that we have a lot of work left to do to
    realize that goal.
        While the causes of educational inequality are complex, we
    cannot expect our State and local partners to carry this burden
    on their own. What is the Department of Education doing to
    address persistent inequities in education, and how are you
    working with State and local partners to secure better learning
    environments for all children in Wisconsin?
        Secretary Cardona. Thank you. You know, as an educator, I
    can tell you and the research proves that students learn better
    when they are in a diverse environment.
        In our budget, we requested $100 million to have new
    competitive grants to provide better programs that provide more
    racially and socially and economically diverse schools and
    classrooms, something that we pay very close attention to, and
    we want to make sure that all students in all schools achieve
    at high levels, which is why in our funding proposals, we also
    ask for additional funds to some of those schools where there
    may not be performing as well.
        Title I schools that are disproportionately
    underperforming. So, you know, we are supporting it. We do have
    it in our proposal, and we continue to monitor if we feel that
    students are not being given opportunities or schools are used
    to segregate students. We also accept investigation requests in
    our Office for Civil Rights.
        Senator Baldwin. Thank you.
        Senator Murray. Thank you, Mr. Secretary, our Nation's
    students have been through a lot in the past few years, as you
    well know, and it has done a lot of harm to their learning,
    their mental health, their development.

                                 LEARNING LOSS

        And as you are aware, the American Rescue Plan provided
    $122 billion under the Elementary and Secondary School
    Emergency Relief Fund to give our schools more resources to
    safely offer in-person instruction, address the academic,
    social, and emotional needs of students, and support evidence
    based strategies to tackle learning loss and help students get
    back on track, particularly those disproportionately impacted
    by the pandemic.
        I know that over the past month your staff has worked
    really hard to review the State implementation plans and help
    local school districts meet those requirements. Can you tell us
    what evidence based practices you are seeing making the biggest
    difference in helping our students catch up?
        Secretary Cardona. I definitely can. And I can tell you
    from experience myself, Deputy Secretary Martin has been
    traveling the country too, seeing firsthand how the American
    Rescue Plan dollars are being used. The higher Ed level as
    well. Undersecretary Kvaal has seen many great examples. And I
    have to tell you, I am proud of our educators. I am proud of
    our students.
        I am proud of our parents who have gone through such a
    disruption. And looking at our schools now, that sense of
    community that that they have lost, and students are thriving.
    Yes, they need help. It is not going to be a quick fix. But
    when I visit White Plains and I see that they focus on improved
    ventilations, which increased the confidence of the community
    to go back into the schools, I know that the money is being
    used well.
        I remember going to Oregon and seeing a summer program that
    was three times the size it was the previous time they held it
    because of the American Rescue Plan dollars. I have seen high
    quality, high dosage tutoring implemented in communities where
    students missed out on school for a long time, and they are
    catching these students up.
        You know, we talk a lot about mental health support, but
    without question, we must focus on the academic recovery of our
    students, the literacy, the numeracy, and school systems are
    providing extended school days, smaller class sizes, additional
    support teachers, and better parent liaison strategies.
        I remember visiting a school, I think it was in Nevada,
    where they hired an additional group of parent liaisons that
    went out into the community, those communities where the
    students were chronically absent or not engaged as much because
    of the impacts of the pandemic.
        And they got those families back into the school wraparound
    services. I am seeing such good use of the American Rescue Plan
    dollars. We wouldn't be at 99 percent of our schools open full
    time if it weren't for the American Rescue Plan. I would be
    talking to you now about colleges closing, about students that
    we can't find if it weren't for the American Rescue Plan
    dollars.
        And I can tell you, you know, Future Ed reported $30
    billion going toward academic recovery and $26 billion going
    toward additional staff, which help academic and mental health.
    $3 billion a month is being used to support our students, and I
    am thankful that we have those funds. Thank you for the support
    of them.
        Senator Murray. Yes, I think that we are seeing a really
    diverse use of those needs across the country, and I think over
    the long term it would be very interesting to go back and see
    which ones really did help kids academically or mentally and
    what made a real difference in their lives and getting back on
    track.
        Secretary Cardona. Yes. Thank you.

                MEETING THE BASIC NEEDS OF POSTSECONDARY STUENTS

        Senator Murray. Let me go to higher education again. And I
    am talking more than tuition fees and books, because if we want
    to really help our students, none of them should be worried
    about where they are going to get their next meal or how they
    are going to put a roof over their head, or how they are in or
    for childcare or get mental healthcare because those are
    barriers to them to be able to get a degree.
        We know that three in five higher education students face
    housing or food insecurity, and two in five students drop out
    of college, do so because of financial pressures. And those
    are, of course, connected to mental health challenges as well.
        So significantly, expanding Federal student aid, including
    doubling the Pell Grant, is a big part of a solution to that,
    but so are programs that are specifically targeted at
    addressing those students basic needs.
        I wanted to ask you how the Department is using funds we
    provided that included both annually appropriated funding and
    COVID supplemental funding to meet student basic needs,
    connecting students to other Federal benefits like child tax
    credit or SNAP (Supplemental Nutrition Assistance Program).
        Secretary Cardona. Yes. Some of the best stories from my
    visits are those students who have benefited from those funds.
    I remember talking to a gentleman who was in a 2 year program
    at a community college, and he was sharing all his progress,
    and he went back to school a little bit later in life.
        Later in the story he shared he was homeless, and that the
    college provided him with meals, with help so that he could
    have a place to stay so he is not sleeping in his car, and he
    can continue to get that degree. I was just floored by that.
    The $198 million for basic needs as part of the American Rescue
    Plan, I have seen examples of that working.

                CHILDCARE ACCESS MEANS PARENTS IN SCHOOL PROGRAM

        I remember visiting Bergen Community College and announcing
    that and talking to a student who was able to continue her
    studies because there were childcare costs that were covered on
    campus, so her twins could be cared for while she continues to
    get her degree. So those funds are being used to help folks
    change the trajectory not only of their life, but of their
    children's lives.
        And I have seen great examples of that. And any dollar that
    goes to that is used to help them stay in school, help them get
    better earning potential, help them take care of some of those
    basic needs that are critical.
        Senator Murray. Great. Very good. Okay. Thank you. Senator
    Blunt.
        Senator Blunt. Thank you, Chair. On student loans again,
    though this would be collecting the student loans, not
    forgiving the student loans.

                       STUDENT LOAN COLLECTION AGREEMENTS

        In the fiscal year 2021 appropriations bill, the first one
    you had as Secretary, we gave authority to extend the current
    loan collection agreements, which I believe you did. You
    extended them through December of next year.
        What is your plan to go ahead and move forward on defining
    what those agreements will look like and issuing the
    agreements? And does your plan include the likelihood of a bid
    protest?
        We can run through a timeline pretty quickly that gets
    beyond December 2023 if we are not thinking about this. So what
    is your plan for collecting the student loans that will be
    collected?
        Secretary Cardona. Thank you. So, what we are not going to
    do is go to a single servicer or system. We are pursuing long
    term servicing contracts to maintain that long term stability
    of the loan servicing environment, increase the accountability,
    make sure that we improve cybersecurity, and improve borrower
    experiences.
        So that is a critical part of it, the borrower experience
    and outcomes. Obviously, we have partners in the process that
    we want to engage in this work, and we will be communicating
    with them so that they have information on what we are
    expecting in order for them to be a part of that process.
        Senator Blunt. So you would still anticipate having a
    significant number of different servicers?
        Secretary Cardona. We do plan on having different
    servicers, yes.
        Senator Blunt. And when do you think you will issue
    whatever sort of proposal you need to as to what those
    contracts would look like?
        Secretary Cardona. You know, what I will do is I will have
    my team, who has more specific information, reach back out to
    you about the timeline for that.
        Senator Blunt. All right. All right. I would like to see
    that. And Chair, I will probably have some other questions for
    the record, but I think that is all I have for today.
        Senator Murray. Thank you very much. And that will end our
    hearing today. And I want to thank you, Secretary Cardona, for
    a very thoughtful discussion about how we can support our
    students and our educators and our schools. This is so
    important to me and families across my State and the country.
        So, I am going to continue to keep pushing to make sure
    that every child in this country receives a safe, high quality
    public education and that our students and families can access
    affordable, high quality postsecondary education.

                         ADDITIONAL COMMITTEE QUESTIONS

        With that, for any Senators who wish to ask additional
    questions, questions for the record will be due June 17, 5 p.m.
    The hearing record will also remain open until then for members
    who do 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 Secretary Miguel Cardona
                  Questions Submitted by Senator Patty Murray
        Question. What are the Department's plans for evaluating and
    strengthening its monitoring and support for the use of funds provided
    by the Elementary and Secondary School Emergency Relief Fund (ESSER) in
    the American Rescue Plan Act (ARP) for evidence-based strategies to
    tackle learning loss and help students get back on track, particularly
    students disproportionately impacted by the pandemic? How will the
    Department monitor and support improvements to the targeting and
    effectiveness of the evidence-based interventions being implemented by
    State educational agencies and local educational agencies, particularly
    for students disproportionately impacted by the pandemic?
        Answer. In fiscal year 2022, the Department implemented a process
    for regularly reviewing a high-priority issue (e.g., monitoring local
    educational agency (LEA) uses of funds, stakeholder engagement, State
    educational agency (SEA) reservations for evidence-based interventions)
    in all States. States are required to provide documentation in advance
    of the review and the goals of these reviews are to:
      --Identify strong practices that can be shared across SEAs;
      --Identify technical assistance needs; and
      --Inform areas where more focused monitoring is needed.
        These monitoring reviews will continue through the duration of the
    grant period and liquidation of funds.
        The first review, conducted in May 2022, addressed (1) how States
    are supporting LEAs in use of the at least 20 percent set-aside to
    address the impact of lost instructional time (``learning loss'')
    through evidence-based interventions, and (2) whether States have fully
    awarded at least 90 percent of their total ARP ESSER allocations to
    LEAs as required. The Department plans to share an executive summary
    with States that highlight successes and challenges that States have
    shared in supporting LEA required spending to address learning loss.
    The Department will uplift resources that States highlighted regarding
    their success. Additional resources will be shared from the Department
    and the Department's federally funded TA centers to address challenges
    identified. An internal report will be created that highlights State
    specific challenges and support each State is requesting. This
    information will be shared with program offices that can support with
    each request and technical assistance will be identified and provided.
        In fiscal year 2023, the Department will continue to monitor the
    implementation of evidence-based strategies by SEAs and LEAs as a part
    of its monitoring strategy for all K-12 COVID relief programs,
    including ARP ESSER. States will be identified in September 2022 for
    monitoring using a risk assessment and notified of the intent of the
    Department to comprehensively monitor the implementation of COVID-19
    programs. This review will include the implementation of evidence-based
    strategies intended to ensure that students disproportionately impacted
    by the pandemic get back on track academically. These monitoring
    activities are in addition to monthly check-ins with SEAs and the bi-
    annual reviews to occur in the fall of 2022 and spring of 2023 for
    fiscal year 2023.
        Question. Please identify the specific steps and timeline for
    providing more information to state and local educational agencies
    about the late liquidation process outlined in the Department's May 13,
    2022 letter to the AASA, The School Superintendents Association. That
    letter rightly noted the urgency of spending ARP ESSER funds to meet
    the immediate needs of students and address the long-term impact of the
    pandemic. How will you work with SEAs on quickly implementing an
    efficient and effective process for submission of late liquidation
    requests for LEAs under the process outlined in your May letter to
    AASA?
        Answer. During the month of June, the Department engaged with
    various stakeholder groups about their priorities, needs, and general
    feedback regarding a liquidation extension request process. We continue
    to shape a process that prioritizes:
      --Developing of a mechanism to provide sufficient oversight for the
            late liquidation of K-12 COVID relief funds
      --Minimizing burden for SEAs to request approval on behalf of LEAs
            and ensuring support to SEAs in implementing approved requests
      --Providing sufficient time to adjust state-level systems and control
            processes to support liquidation of CARES-funded obligations
        Stakeholders included representative State educational agencies
    (SEAs), local educational agencies (LEAs), members of the Association
    for Latino Administrators and Superintendents (ALAS) and members of the
    National Association of State Auditors, Comptrollers, and Treasurers
    (NASACT), and the Council of Chief State School Officers.
        These groups reported challenges with expending funds, including
    supply chain challenges, diminished access to labor (instructional and
    operational personnel), a shortage of available or willing contractors,
    and a consistent need for additional time, particularly in reference to
    the expenditure of American Rescue Plan (ARP) funding. High-level
    priorities for the request process include state-level responsibility
    for LEA requests, clear procedures and examples, and communication
    tools that can assist in supporting the requirements and the narrative
    of a liquidation extension.
        Question. How will you ensure LEAs and SEAs have early knowledge
    that eligible liquidation requests are approvable as early as possible
    for the contracts they are signing today for authorized activities that
    cannot be completed without an extension of the liquidation requirement
    under 2 CFR Sec. 200.344(b)?
        Answer. The Department will provide technical assistance to all
    grantees on the requirements to submit requests for late liquidation of
    CARES ESSER and GEER funds as soon as the request package is finalized.
    In addition, the Department will review each State grantee's request in
    a timely manner provided all required documentation is submitted. The
    Department cannot, however, approve late liquidation requests in
    advance of receiving required documentation.
        Question. The American Rescue Plan Act included a new fiscal equity
    requirement, maintenance of equity, that applied conditions to States
    and LEAs who receive ESSER money to prevent disproportionate education
    budget cuts to high-need LEAS or high-need schools, and no budget cuts
    for the highest-need schools.
        Which States has the Department identified that are not in
    compliance (or on track to be in compliance) with the 2022 State-level
    maintenance of equity requirements?
        Answer. In late July, the Department initiated technical assistance
    activities with States where preliminary State data indicated one or
    more high poverty LEAs may require additional State funding for the
    State to satisfy Maintenance of Equity requirements. As data are still
    preliminary, the Department has not yet identified instances of non-
    compliance.
        Question. What is the Department's plan for bringing any such
    States into compliance, and what are anticipated consequences if a
    States does not comply with such requirements?
        Answer. All States have been notified if their initial fiscal year
    2022 data indicates the State is not maintaining equity in one or more
    high-need or highest-poverty LEAs. Following this notification, the
    Department is conducting calls with all non-compliant States and
    prioritizing those with the highest concentration of issues. The
    Department may take a range of enforcement actions to remedy such
    violations, since this requirement cannot be waived, which include
    applying a grant condition, designating a non-compliant SEA as a high-
    risk grantee, using SEA non-compliance as a factor in selecting
    grantees under discretionary grant competitions, and recovering funds.
        Question. A recent report from the Association of School Business
    Officials International (https://asbointl.org/Web/About/PR/2022/
    20220510.aspx) found almost one in five LEA respondents indicated that
    ``Conflicting Federal and State guidance and confusing rules about how
    funds can be used are slowing down spending for some districts''.
        What additional steps and outreach will the Department take to
    bring more clarity and consistency about ESSER's uses of funds for
    SEAs, LEAs, and oversight bodies that is needed to allow timely and
    effective uses of these funds?
        Answer. The Department of Education has produced many publicly
    available resources in the form of Frequently Asked Questions (FAQs)
    documents, webinar recordings and transcripts, letters to grantees, and
    monitoring reports (see links below). We are currently in the process
    of updating the ESSER and GEER Use of Funds FAQs that will include both
    new FAQs addressing issues about which we have received inquiries from
    multiple States as well as incorporating several of the separate,
    related FAQs, such as the vaccination FAQs, the public safety FAQs, and
    the transportation FAQs, and the preventing, preparing for and
    responding to COVID-19 document so that grantees have use of funds
    information all in one document. When the revised ESSER and GEER FAQs
    are final, the Department will conduct another webinar for grantees. In
    addition to the ESSER and GEER Use of Funds FAQs (issued May 2021),
    previous use of funds FAQs include the spring 2020 ESSER Use of Funds
    and the GEER Use of Funds.
        The Department receives daily inquiries from States regarding
    allowable uses of ESSER or GEER funds, and works to provide timely
    responses. Weekly program meetings (ESSER, EANS, GEER/MOE/MOEq) are
    convened to discuss inquiries received from grantees and other policy-
    related matters, and additional meetings are convened as needed. Every
    day, the Department of Education staff meets with staff from State
    educational agencies to answer questions, provide guidance, or address
    issues that have arisen. We also develop and widely disseminate
    communications to share with grantees that address emerging issues
    associated with program implementation. When local school districts
    come to us with questions about uses of funds, we ask them to connect
    with their SEAs as the SEA is ultimately accountable for approving or
    not district-level uses of funds.
        Finally, the Department's ESSER website includes valuable
    information for grantees, including an awards resources page, a
    deadlines and announcement page, as well as links to related important
    documents, such as the Equitable Services FAQs. The website also
    contains links to webinars that the Department has conducted on such
    issues as using ESSER or GEER funds for HVAC improvements and the 2022
    Compliance Supplement, as well as the Office Hours that were held to
    assist grantees in developing their ARP ESSER State Plans.
        Question. In a 2020 Government Accountability Office (GAO) report,
    GAO estimated that 41 percent of LEAs needed to update or replace their
    heating, ventilation, and air conditioning (HVAC) systems in at least
    half of their schools. Such investments not only would help reduce the
    spread of COVID-19 and other infectious diseases, but also improve
    overall air quality for students and school staff, including millions
    of students with respiratory allergies that can cause a student to be
    absent from school.
        What additional steps will the Administration take to support the
    use of Federal resources authorized to be used for investments that
    would improve air quality in our schools?
        Answer. The Department has provided frequent guidance to SEAs,
    LEAs, and public stakeholders on the use of CARES Act, CRRSA Act, and
    ARP Act funds to improve air quality in schools. This guidance has
    taken place through live office hours presentations, webinars,
    published FAQs, and web pages, described below. In addition to this,
    the Department has responded to over twenty unique inquiries from SEAs
    regarding the allowable use of ESSER, GEER, or EANS funds on improving
    school air quality. We continue to respond to SEA and LEA-related
    questions on a daily basis and encourage grantees to reach out whenever
    they have a question.
        The Department made several resources available to the public which
    describe allowable uses of Federal resources for improving air quality
    in schools. In particular, the Department hosts a web page on Improving
    Ventilation in Schools, Colleges, and Universities to Prevent COVID-19
    which describes the allowable use of ESSER, GEER, and HEER funds
    towards improved ventilation. The Department published a set of ESSER
    and GEER FAQs that specifically allow funding to be spent on upgrading
    spaces to improve the indoor air quality in school facilities (ESSER/
    GEER FAQs, B-7). These FAQs direct interested parties to the CDC
    guidance on how to improve ventilation in schools and buildings. The
    Department also published a set of EANS FAQs that provide guidance on
    the allowability of a non-public school to apply to receive services
    for improving ventilation systems (EANS FAQs, D-1, D-16).
        On June 17, 2021, the Department held an office hours presentation
    on the use of ESSER funds to support school construction, providing
    guidance on the use of funds to improve HVAC. The slides from the
    presentation are published on the Department website here.
        On September 2, 2021, the Department hosted a webinar on ``Using
    COVID Relief Funds for Facility Upgrades, Renovations, and
    Construction.'' In additional to Departmental guidance on the use of
    funds towards construction, this webinar included speakers and
    resources related to indoor air quality from the U.S. Environmental
    Protection Agency, the U.S. Department of Energy, the Maine Department
    of Education, and the Salt Lake City School District. The Department
    has made the slides from the presentation available on its website
    here.
        On July 8, 2022, the Department held a webinar on ``Improving Air
    Quality in Schools,'' where Secretary Cardona, White House COVID
    Response Coordinator Dr. Ashish Jha, and experts from the CDC and the
    EPA discussed the importance of improving air quality in schools and
    the use of ARP Act funds to upgrade ventilation in schools.
        Question. What are the Department's plans for strengthening parent
    and family engagement in our schools and sharing and supporting
    implementation of evidence-based practices that create strong and
    effective relationships that serve the best interests of students?
        Answer. Parents are our kids' first, and often most influential,
    teachers. From Day One, this Department has worked to not just listen
    to parent voices but uplift them and make sure they're heard in our
    school communities. The Department has held numerous engagements with
    parents and heard from more than 8,650 parents about their experiences,
    challenges, concerns, and ideas as we work to rebuild our schools
    better than they were before the pandemic.
        This Administration believes it's essential for school districts to
    work closely with parents, and we provide resources to help ensure this
    can happen across the country. During my travels, I've held
    roundtables, listening sessions, and conversations with parents. In
    Texas, I learned about a school that was using American Rescue Plan
    funds to pay for a parent specialist who worked to keep parents
    connected and engaged in the school community. And I've worked to
    elevate that story for other states and schools because the feedback
    and perspective parents provide is invaluable.
        In June, the Department launched the National Parents and Families
    Engagement Council (the Council) to facilitate strong and effective
    relationships between schools and parents, families and caregivers.
    Families' voices play a critical role in how the nation's children are
    recovering from the pandemic.
        To ensure students are set up for success, the Department is
    working to answer the President's call to action and is calling on
    states and school districts to continue using American Rescue Plan
    funds to fully staff schools and provide high-quality tutoring, summer
    learning and enrichment, and afterschool programs to support, on
    average, an additional 4 months of learning gains in reading and math.
    The Department recently launched the National Partnership for Student
    Success and the Engage Every Student program to do just that.
        Additionally, the Department of Education launched a campaign
    through the Best Practices Clearinghouse to highlight states and
    schools using ARP funds to support learning recovery and student mental
    health in evidence-based ways. The Department is calling on education
    leaders to nominate work for national recognition through the
    Clearinghouse.
        I hope you will share the news about our Council and encourage your
    constituents to continue to be engaged with their local school
    communities.
        Question. How will the National Parents and Families Engagement
    Council support the Department's engagement with parents and families
    at the local level, including families of students of color, students
    with disabilities, students from low-income backgrounds, English
    learners, migrant students, military connected students, students
    experiencing homelessness, and students in the foster care system?
        Answer. The Council currently consists of parent, family, or
    caregiver representatives from national organizations that will work
    with the Department to help families engage at the local level.
        The Council will be a channel for parents and families to
    constructively participate in their children's education.
        I believe there's no one better equipped to work with schools and
    educators on what students need to recover than parents and families.
    The Council will serve as an important link between families and
    caregivers, education advocates and their school communities. The
    Council will help foster a collaborative environment where we can work
    together to serve the best interest of students.
        The Department's commitment to all parents, and their crucial role
    in their children's education, is unwavering. I will continue to not
    just listen to parents but seek out their counsel and feedback because
    a school community works best when parents and educators are working
    together.
        Question. How is the Department working with the Department of
    Health and Human Services to maximize the impact of Federal funding
    available for mental healthcare for children and youth, including by
    supporting increased use of the Medicaid in Schools program? When will
    the Department take the actions outlined in the March 24, 2022 letter
    issued jointly with the Secretary of Health and Human Services?
        Answer. The Departments of Health and Human Services and Education
    continue to collaborate on strategies to increase access to mental
    health services elementary and secondary education students. The
    Bipartisan Safer Communities Act places HHS in the primary role with
    mandatory collaboration with Education, to develop guidance on how
    local educational agencies can partner with their state's Medicaid
    program to increase the availability of health services, including
    mental health services in schools. In addition, the law establishes a
    national technical assistance center to assist with this process and
    provides $50 million to states to address this work. We anticipate the
    ED and HHS collaboration's efforts, including the updates to the May
    2003 Medicaid School-Based Administrative Claiming Guide, and the 1997
    Medicaid and Schools Technical Assistance Guide, will be completed in
    accordance with the law's timeline.
        Question. Please describe your monitoring and technical assistance
    plans in fiscal year 2023 and future years related to resource equity
    requirements of the Elementary and Secondary Education Act.
        Answer. In spring and summer 2022, the Department has been
    conducting a targeted monitoring review of two resource equity
    provisions: (1) ESEA section 1111(d)(3)(A)(ii), which requires an SEA
    to periodically review resource allocation to support school
    improvement in each LEA in the State serving a significant number of
    schools identified for support and improvement; and (2) ESEA section
    1111(d)(1)(B), which requires each comprehensive support and
    improvement and additional targeted support and improvement plan to
    identify the resource inequities to be addressed in the plan. After the
    conclusion of those reviews, the Department intends to share best
    practices, findings, and recommendations more broadly with all States
    and determine how to further conduct oversight of these important
    requirements in fiscal year 2023.
        In addition to targeted monitoring, all resource equity provisions
    in Title I, Part A are included as part of the Department's
    consolidated monitoring, which is the Office of Elementary and
    Secondary Education's in-depth monitoring protocol that covers several
    formula grant programs and over-arching, cross-program fiscal
    requirements. The Department is currently finalizing its plans
    regarding the number of States that will participate in consolidated
    monitoring in fiscal year 2023.
        Finally, for the past 3 years, the Department has conducted a
    review of each State's website to determine if States and districts
    were in compliance with report card requirements, looking at a subset
    of the requirements each year. This work begins in January to review
    the report cards for the prior school year. This year, the Department
    reviewed State websites to look for disaggregated performance and
    participation rate data on State assessments, per-pupil expenditures,
    and chronic absenteeism.
        Question. The Comprehensive Literacy State Development Grants
    program provides resources to improve literacy instruction in high-need
    schools and early childhood education programs. Funds may be used by
    state educational agencies for coordination with institutions of higher
    education on strengthening and enhancing pre-service teacher training
    on explicit, systematic, and intensive instruction in evidence-based
    literacy methods for children from birth through 12th grade.
        How many grantees have used funds for this purpose? How has the
    Department supported this work?
        Answer. Currently, a few CLSD grantees use a small portion of the 5
    percent set-aside in CLSD funds to coordinate with Institutions of
    Higher Education (IHEs). However, all grantees have expressed an
    interest in doing more in this area to complement the work that is
    already going on within their states through other initiatives.
    According to information we received, WY, MO and AZ are using a portion
    of CLSD monies for pre-service and in-service teachers as well as
    building capacity and knowledge about the Science of Reading. The
    Office of Well-Rounded Education (OWRE) is working to provide support
    through its the CLSD contractor for technical assistance to CLSD
    grantees.
        Question. How would this budget further support this and other
    efforts to expand implementation of high-quality literacy instruction
    using the science of reading?
        Answer. Funds can be used to conduct Communities of Practice (CoP)
    topical meetings, and other convenings to support and expand the
    implementation of high quality literacy instruction and the science of
    reading.
        Question. Special education teachers and service provider shortages
    continue to be a significant challenge for more than 40 states and
    Puerto Rico. The budget includes $250 million for the Personnel
    Preparation program that can help alleviate these challenges including
    for low-incidence disabilities like deaf-blindness.
        Please describe the Department's plans to use requested resources
    to support additional grants for the training of interveners for
    services to deaf-blind students.
        Answer. The Department's Interdisciplinary Preparation in Special
    Education, Early Intervention, and Related Services for Personnel
    Serving Children with Disabilities who have High-Intensity Needs (325K)
    program funds projects that prepare special education, early
    intervention, and related services personnel at the master's degree,
    educational specialist degree, or clinical doctoral degree levels for
    professional practice in a variety of education settings. While
    intervening services are not a part of IDEA's definition of related
    services, universities who apply to the 325K programs may include
    coursework focusing on the training of interveners as a component of
    their training program. The Office of Special Education Programs (OSEP)
    has made significant investments in the preparation of interveners
    through our National and State Deaf-Blind projects. The OSEP-funded
    National Center on Deaf-Blindness has developed The Open Hands, Open
    Access: Deaf-Blind Intervener Learning Modules (OHOA modules) that were
    designed specifically for state deaf-blind projects and colleges/
    universities to use as part of intervener training programs. While, on
    their own, these intervener training modules do not constitute a
    complete training program, they are offered as part of a comprehensive
    training and coaching program provided by qualified individuals who
    work with our State Deaf-Blind projects. The Department acknowledges
    that despite widespread recognition by many of the OSEP-funded state
    deaf-blind project directors regarding the need to provide intervener
    services for students with deaf-blindness, most states have not
    mandated intervener services, and therefore, most school districts do
    not hire for intervener positions. If additional funds become
    available, OSEP will explore incentivizing states, through
    discretionary grants, to increase the supply of interveners and support
    their acceptance as providers of support for a free appropriate public
    education for deaf-blind children.
        Question. In a 2021 qualitative study of the Department's national
    technical assistance center on deaf-blindness, (https://
    www.nationaldb.org/media/doc/2021InterviewsStateDeaf-
    BlindProjects_a.pdf) several of the state deaf-blind project directors
    reported ``that their state has no mandate to provide intervener
    services, and therefore, the school districts cannot hire for
    intervener positions. Nearly all the interviewees considered
    interveners to be a valuable service provider that needs to be offered
    to students with deaf-blindness, and many expressed frustration with
    their state's department of education for not supporting the
    position''. This is despite an August 2, 2018 letter from the
    Department indicating that ``the members of the child's IEP
    [individualized education program] team . . . . must make individual
    determinations of in light of each child's unique abilities and needs
    about whether the service, such as an intervener, is required to assist
    the child to benefit from special education.''
        What additional steps will the Department take to ensure that
    parents, school officials, and IEP teams are aware of a deaf-blind
    child's right to receive intervener services as determined appropriate
    by the IEP team?
        Answer. All IDEA eligible children, including children with deaf-
    blindness, are entitled to receive effective instruction that will lead
    to positive educational and career outcomes. Each state's Parent
    Training and Information Center(s) (PTI) help guide parents through the
    process of ensuring that school districts develop individualized
    education programs (IEPs) that contain evidence of what a child needs
    to access the General Education Curriculum and free appropriate public
    education (FAPE). In addition, OSEP will continue to support the
    National Deaf-Blind Center and State Deaf-Blind projects, the Early
    Childhood TA Center, and the Progress Center (which stands for
    Promoting Rigorous Outcomes and Growth by Redesigning Educational
    Services for Students With Disabilities Center), all of which provide
    information, resources, tools, and technical assistance services to
    support local educators, leaders and parents in understanding rights of
    their children with disabilities and how to improve outcomes for
    students with disabilities, including students with deaf-blindness.
    Based on an increased appropriation in 2022, OSEP will be providing
    additional funds to each of the PTIs to better support parents.
    Finally, the Department is exploring options to provide further
    guidance that would emphasize, among other matters, the need for the
    IEP Team to ensure that the services of an intervener are provided
    without undue delay if the team determines that a student could benefit
    from such support.
        Question. The 2020-21 program year saw a 17 percent decline in Part
    C enrollment from the previous academic year. However, a recent Infant
    & Toddler Coordinators Association survey response from Part C
    coordinators in 43 states shows in this program year, 60.5 percent are
    exceeding their 2020 child counts and 30.2 percent are exceeding their
    2019 child counts. The Department requested $932 million for Grants for
    Infants and Families. This is a substantial increase of $436 million to
    help States implement statewide systems of early intervention services
    for children from birth through age 2. The request also proposes
    several changes through appropriations language to strengthen program
    implementation and improve equity by (1) allocating formula funds, in
    part, on the basis of poverty; (2) requiring States to develop and
    implement equity plans under Part C of the IDEA; (3) providing States
    with the flexibility to use program funds to support new parents of
    infants and toddlers with disabilities; (4) prohibiting out-of-pocket
    expenses for families participating in the program; (5) requiring
    States to provide adequate notice before instituting limits on
    eligibility under the program; (6) providing financial incentives to
    States to serve at risk infants and toddlers; and (7) increasing
    flexibility for States to offer summer bridge services to children
    transitioning from the Part C program into their State's Part B
    program.
        How does the President's fiscal year 2023 budget proposal support
    states to address increases in Part C enrollment and how would the
    proposed flexibilities and requirements better serve infants and
    toddlers with disabilities especially from underrepresented
    populations?
        Answer. The Biden-Harris Administration is committed to ensuring
    that every child receives the services and supports they need to grow
    and thrive. To that end, the President's fiscal year 2023 Budget
    Request proposes historic increases and important reforms for the
    Grants for Infants and Families program that would support a
    significant expansion of early intervention services for infants and
    toddlers with disabilities and infants and toddlers at-risk of
    experiencing a substantial developmental delay, particularly for
    historically underserved children such as children of color, children
    from rural areas and children from low-income families. The COVID-19
    pandemic resulted in a substantial decline in the number of children
    receiving services under the Part C program, likely due in significant
    part to difficulties in effectively identifying and evaluating children
    who were less likely to be regularly accessing services and supports
    that typically serve as vehicles for State child find systems (e.g.,
    daycare centers, pediatricians).
        As a result, the Administration believes States are likely to see a
    significant increase in the number of new children into the program
    over the coming years as pandemic-related barriers to identification
    and participation decrease and that these newly enrolled children are
    likely to have more intensive needs associated with the delay in
    identification, evaluation, and service provision. The requested
    funding increase for this program would provide critical support to
    increase States' capacity to serve more children such as by ensuring
    that they have enough high-quality and well-trained service providers
    to meet the increased demand.
        Key activities supported by our request include more comprehensive
    State planning to engage and meet the needs of underserved groups,
    including proposed budgets for executing those plans; improving initial
    entry into the Part C system by expanding outreach to and engagement
    with individuals who are expected to become parents of an infant or
    toddler with a disability, which can result in earlier service
    provision which research has shown improves outcomes for children;
    eliminating fees and out-of-pocket expenses that can be a barrier to
    program participation; ensuring advance notice of eligibility changes
    that can disrupt or discourage program participation; and expanding
    services to children at-risk of developing delays and disabilities so
    that a child highly likely to develop a delay does not have to wait for
    the delay to clinically manifest before receiving services, which can
    both improve outcomes and increase access to the program for children
    of color, children from rural areas and children from low-income
    families who are disproportionately likely to qualify for services
    through risk factors for delays and disabilities.
        In addition, the request also proposes to continue appropriations
    language initially provided in prior years which would allow States to
    subgrant funds they receive under this program and that would allow the
    Department to maximize the amount of funds distributed for State
    Incentive Grants and would allow States to offer summer bridge services
    through Part C to children prior to the beginning of the preschool year
    after their third birthday.
        Question. In the 2020-2021 program year, 3.2 percent of infants and
    toddlers--or 365,715 infants and toddlers--were served under Part C.
    Coordination and seamless transition between services under IDEA Part C
    and Part B is critical for these thousands of children with
    disabilities to successfully begin K-12 learning. The Presidents fiscal
    year 2023 budget includes the authority for the Secretary to reserve up
    to $5 million under section 611 of the Individuals with Disabilities
    Education Act to conduct a study to examine the ``implications of
    establishing a comprehensive system of services and supports for
    children with disabilities from birth through age five.''
        Please describe the expected timeframe, scope and desired outcome
    of the study.
        Answer. The proposed study would involve listening sessions and
    convenings of stakeholders to identify and discuss major issues and
    barriers to providing seamless services, such as issues of legal
    authorities, differing eligibility criteria, multiple service
    providers, and uncoordinated services. The products of these listening
    sessions and convenings would be analyzed by an expert panel to develop
    a report. This publication would include recommendations and best
    practices for addressing barriers and creating a more seamless early
    childhood system that could improve program administration and
    integration for States, school districts, and early intervention
    providers while improving outcomes and access for children with
    disabilities. This publication would likely be available within 2-3
    years of appropriations becoming available for this purpose. The
    requested funding, up to $5 million, would be a one-time request--the
    Department does not anticipate additional funding would be needed in
    future years. A robust body of evidence shows that birth through 5 are
    critical years for a child's development and providing States and
    school districts with evidence-based recommendations and best practices
    for serving these children and their families could produce benefits
    that far outweigh the modest investment requested.
        Question. The budget requests $3 million within the Program
    Administration account for the development of a P-12 equity data
    dashboard at the Department.
        How would the requested funds be spent? Are they sufficient to
    develop and operate the system? If so, for how long? If not, how much
    additional funding would be required?
        Answer. The budget request of $3 million assumes 1 year of
    development, user testing, and iteration before posting a public
    website, covering costs for a prototype computing environment,
    operational computing environment, and contracted labor. It does not
    include additional Federal staff. The Department is in the process of
    determining the cost for the continued operations and maintenance of
    the system.
        Question. How will the Department determine which existing
    information to include in the dashboard, including consideration of its
    significance as a factor in educational outcomes and opportunities?
    What steps would be considered to access or develop other information
    that research demonstrates or may demonstrate is an important factor in
    educational opportunities and outcomes?
        Answer. The Department plans to incorporate data from existing
    sources into a dashboard that is accessible and easy to navigate, while
    also looking at a range of outcomes and factors that contribute to the
    educational experience and success. The data dashboard will be designed
    to highlight where opportunities gaps do and don't exist, and where
    progress is being made, so that school communities can work on
    improving educational opportunities and outcomes. It is critically
    important that data used in the dashboard is reliable and comes from
    high-quality sources.
        Question. What are the plans to engage stakeholders on the
    development of the system?
        Answer. The Department plans to engage a wide range of stakeholders
    to ensure that the dashboard fulfills a need and will be useful for
    years to come. Once the Department has narrowed down a list of
    indicators, we will engage stakeholders on that list, and how best to
    present that data so that is accessible to all.
        Question. The last two appropriations bills provided the Office for
    Civil Rights with a total increase of $5.5 million, significantly less
    than the budget requests for OCR.
        Please describe the impact of those unfortunate decisions on timely
    and thorough resolution of complaints filed with OCR and its ability to
    vigorously enforce civil rights laws under its jurisdiction.
        Answer. The underfunding of the last few years has strained OCR's
    ability efficiently to carry out its mission of safeguarding the civil
    rights of America's students. OCR has seen a sharp increase in
    complaints over the last year: to a projected 10,843 in fiscal year
    2022, a 22 percent increase over the total in fiscal year 2021 thus far
    in fiscal year 2022, OCR has received nearly 17,500 complaints,
    compared with 8,951 complaints received in all of fiscal year 2021. OCR
    anticipates further increases based on the return to in-person
    schooling, the lingering trauma of the pandemic, and the Biden-Harris
    administration's efforts to ensure that students, families, and
    advocates are aware of the rights and responsibilities contemplated by
    the Federal civil rights laws that OCR enforces.
        While the number of complaints has risen, staffing levels have not,
    with the small increases contained in the last two appropriations bills
    allowing for little more than covering rising personnel expenses. As of
    January, OCR had 330 investigative staff, roughly 100 fewer than were
    on board at the end of the Obama-Biden administration. Also as of that
    date, OCR's investigators carried an average of 24 cases per staff--
    ranging from 16 cases per staff to over 50 cases per staff, depending
    on the regional office in question--an unreasonable and largely
    unmanageable caseload. OCR hopes to reach 15 cases per investigative
    staff, a caseload closer to manageable and one that would allow for the
    careful attention to each investigation that is necessary to resolve
    complaints effectively and efficiently.
        Question. In The Future of Education Research at IES: Advancing an
    Equity-Oriented Science released earlier this year, the National
    Academies of Sciences, Engineering and Medicine made recommendations
    related to meeting the future educational needs of the nation through
    the work of the Institute of Education Science's National Center for
    Education Research and National Center for Special Education Research,
    two of IES's four centers.
        Please describe plans and resource requirements for implementing
    each of the recommendations made in this report.
        Please also describe how resources requested for all four IES
    centers would be used to advance IES's collective efforts to implement
    the recommendations in the National Academies' reports.
        Answer. In response to these questions, IES notes that NASEM's
    recommendations were not available when the President's fiscal year
    2023 Congressional Justification for IES was developed. Timing of
    NASEM's report publication coincided with the transmittal of the fiscal
    year 2023 President's Budget from the Department to Congress (on March
    28th). Therefore, IES is now coordinating with the Department to
    respond without contradicting the President's fiscal year 2023 Budget
    and to determine what additional resources may be necessary to address
    the NASEM recommendations. We are unable to provide detailed resource
    requirements at this time and expect such details to be included in the
    President's fiscal year 2024 budget request.
        Within the larger IES appropriations account, the Research,
    Development, and Dissemination (RD&D) line supports NCER research and
    research training grants programs along with other activities, such as
    support for the Small Business Innovation Research (SBIR) program, work
    by the National Center for Education Evaluation and Regional Assistance
    (NCEE), and the IES-wide dissemination and communication
    infrastructure. The Research in Special Education (RiSE) line supports
    NCSER research and research training grant programs. Funds from both
    RDD and RiSE program appropriations are used to support application
    receipt, processing, and scientific peer review activities managed by
    the Office of Science.
        Responding to NASEM's recommendations would require increases in
    both program and staffing appropriations, however (as described above)
    since the timing of these reports coincided with the transmission of
    the fiscal year 2023 PBR, we will include additional details on funding
    needed in the fiscal year 2024 request.
        (1) The NASEM panel recommended that IES provide greater
    transparency about who is applying for and receiving funding, who is
    applying to and participating as trainees in our training programs, and
    who is serving as peer reviewers. The panel also recommended that IES
    collect and report more information about study participants in funded
    projects. In addition to this set of recommendations for descriptive
    information, the panel recommended that IES create a systematic,
    periodic, and transparent process for analyzing the state of the field.
        IES has been working to improve the data we collect and report in
    these areas for many years, but has been constrained by limited staff,
    financial resources, and infrastructure. In order to implement NASEM's
    suite of recommendations pertaining to data transparency, IES will
    require significant additional resources to support a new central
    capacity to collect, analyze, and share data about our research
    investments (including data about applicants, grantees, trainees, and
    peer reviewers). Note that both NSF and NIH have multiple offices
    solely dedicated to collecting and reporting data about applicants,
    grantees, trainees, and peer reviewers.
        IES also intends to support enhanced transparency on how our
    understanding of the state of the field relates to NCER and NCSER focal
    topics through collaboration with the National Center for Education
    Evaluation (NCEE). To do so, IES proposes to expand the work of NCEE's
    What Works Clearinghouse (WWC) to gather systematic information about
    the state of rigorous research in broad areas of education practice and
    policy. Historically, the WWC has sought to review and synthesize
    research evidence in support of addressing specific educator and
    student needs, resulting in publications such as Providing Reading
    Interventions for Students in Grades 4-9 and Designing and Delivering
    Career Pathways at Community Colleges. Going forward, the WWC intends
    to pilot a new approach whereby IES, in collaboration with leading
    experts, emerging scholars, and practitioners from a wide array of
    districts, would conduct broad field scans that yield more
    comprehensive understandings of the landscape of research in one or
    more topical areas.
        The resulting product would help to inform decisions about where to
    invest our research funds, either in new topics within our primary
    field-initiated competitions, or in standing up new research networks
    designed to rapidly improve our evidence base in targeted areas.
    However, the breadth of topics able to be addressed is limited by
    funding available to expand the WWC's current work and staff to
    effectively oversee the new approach.
        (2) The NASEM panel recommended that IES broaden our research
    investments and diversify participation in our training programs and on
    our peer review panels.
        The NASEM panel recommended new competitions or topics within
    existing competitions in areas of national need, such as teacher
    education and education workforce development, education technology,
    data science and learning analytics, teaching practices, and school
    contexts associated with improved outcomes for students with
    disabilities. These recommendations align with areas of critical
    national need that IES has already made limited investments in, but
    where we could likely play a transformative role with additional
    resources to devote to these topics.
        New competitions would require individuals to serve as program
    officers, science office staff to manage peer review, and additional
    grants administration staff. Such competitions would also require new
    and different expertise, from non-academic and research settings.
        In recent years, both NCER and NSCER have had to limit the number
    of competitions they run annually due to limitations on available
    funds. More specifically, due to funding constraints, neither center
    was able to fund all highly ranked applications in our primary research
    competitions in fiscal year 2021. In fiscal year 2022 NCSER was unable
    to run any of its primary research competitions in special education
    due to funding limitations, and NCER faced a $16.5M shortfall. Given
    budget limitations and the number of highly ranked applications
    unfunded in the previous competition, NCER made the painful decision to
    not hold its primary competition--the Education Research Grants
    program--in fiscal year 2023.
        This decision (and NCSER's decision for fiscal year 2022) are the
    equivalent of NIH telling the biomedical research community that they
    are unable to accept any applications for R01s. This not only puts many
    critical education research investments on hold for a year or more, it
    impedes our ability to help States and schools understand and respond
    quickly to improve outcomes for learners disproportionately impacted by
    the global pandemic. To meet the requirements of ESRA, NCER must also
    set aside at least $8-10 million in fiscal year 2024 to compete 4 new
    R&D Centers or Networks with comparable continuation costs. Before
    initiating new competitions, or expanding existing ones, NCER and NCSER
    need sufficient funds to support our primary competitions aligned with
    our legislative mission and requirements.
    Investing in Areas of High National Need
        To stand up new competitions in areas of high national need,
    including areas recommended in the NASEM report, IES would require a
    substantial increase in program funds and staffing for NCER, NCSER, and
    the Office of Science. As noted above, IES is already engaging in work
    in many of the areas recommended by NASEM, including using extant
    digital data to ask and answer key questions more quickly and
    efficiently. NCER recently received responses to an RFI on large
    datasets that will inform our next investments in research
    opportunities using digital data, and we are investing in methods
    training in data science in fiscal year 23, so that we will have a
    cadre of scholars with appropriate expertise to tackle key questions in
    this area.
        To carry out research that will improve outcomes for learners and
    schools, IES needs to expand our investments in methodological
    innovation and measurement. For example, we need to build
    methodological tools that will help us expand our use of learning
    analytics and machine learning techniques to transform instructional
    decisionmaking and personalized learning. We also need to create
    reliable and valid measures that use technological innovation to
    rapidly assess student needs and abilities, including academic
    knowledge, student mental health, and school climate. While the field
    has developed many high-quality measures in literacy and mathematics,
    we need to make sure that they are appropriate for the wide variation
    in learners, including those with disabilities and English Learners. In
    addition, there are disciplinary areas where high quality measures are
    rare. Science, computer science, engineering, civics, and history all
    lack measures that can be used to assess what learners across age and
    grade spans know. If classroom teachers are unable to assess what
    learners do and do not know, they cannot adjust their instruction to
    ensure that every learner in the classroom has an equal opportunity to
    learn.
    Efforts to Diversify and Broaden Participation
        IES has also started the process of acquiring contract support to
    expand our efforts to diversify and broaden participation in our
    research and research training investments. A similar effort has been
    undertaken to diversify participation in our peer review process. One
    critical task in our initial contract to support this work involves
    preparing a landscape analysis of what other Federal research funders
    are doing to diversify and broaden participation. For example, we are
    interested in identifying which programs focused on researchers from
    underrepresented groups have been successful at engaging early career
    researchers, and whether funding provided for mid-career researchers to
    join existing grants has led to increases in project team diversity.
    For IES to adopt strategies that emerge from this analysis, we will
    need additional programmatic funding and staffing resources to support
    the outreach and capacity building efforts. Such activities might
    include, for example, preparing branded outreach materials for
    distribution with communities of researchers who have not historically
    applied for funding from IES, and developing a set of ``how to apply''
    materials and video materials that may be used to reach and address
    these communities more effectively.
        IES would welcome the opportunity to expand programs intended to
    broaden participation in the education sciences, particularly in
    research training. However, neither NCER nor NCSER have program staff
    whose sole responsibility is research training. To fully implement a
    suite of activities focused on broadening participation in research
    training, NCER would need additional staff who can dedicate time and
    expertise to this work. With the benefit of such resources, NCER would
    expand the Pathways to the Education Sciences Research Training program
    by offering more grants. We would also offer it more frequently
    (currently it is competed every 4-5 years), and we would run a special
    Predoctoral Research Training competition limited to institutions that
    have not received an IES predoctoral training grant. As an example of
    the likely projected additional costs this might involve, to award 5
    new Pathways programs and 10 new predoctoral training programs NCER
    would require $12 million annually over a 5-year-period.
        In addition, IES would like to offer supplements to existing
    projects to broaden participation in currently funded research
    projects. The supplemental award mechanism has been used by NIH for
    several years to broaden participation in health research. To do
    something similar within IES, both the RDD and RiSE budget lines would
    need additional program funding. Such increases would support wider
    participation in current projects through supplemental funding of a
    diverse group of fellows in NCER and NCSER.
        (3) The NASEM panel recommended that IES more directly support
    research on knowledge mobilization. IES has invested and continues to
    invest in developing a better understanding of strategies to increase
    the likelihood of educators and policymakers using research evidence to
    inform their work. Recent examples include investments by NCER in the
    National Center for Research in Policy and Practice ($5 million; 2014-
    2019) and the Center for Research Use in Education ($5 million; 2015-
    2020). Both projects highlighted the importance of IES' largest
    knowledge mobilization effort--NCEE's Regional Educational Laboratory
    (REL) Program--in promoting the use of rigorous evidence to address
    pressing problems of educational practice and policy.
        Currently, REL research activities are focused on generating
    evidence that serves the needs of the state education agencies, local
    education officials, and institutions of higher education in 10 regions
    nationwide. With additional resources, NCEE could undertake a program
    of research that spans all 10 RELs, using the program as a ``testbed''
    for new research on knowledge mobilization. For IES to (1) develop a
    knowledge mobilization learning agenda in collaboration with existing
    RELs, state and district partners, and experts in the use of research
    evidence; (2) design and deploy one or more studies across the program
    in service of answering priority learning questions; and (3) share
    actionable findings with key stakeholders inside and outside of the
    program, we estimates it would require additional staff and program
    resources each year for next 5 fiscal years, over the duration of the
    next cycle of REL contracts.
        Question. In A Pragmatic Future for NAEP: Containing Costs and
    Updating Technologies released earlier this year, the National
    Academies of Sciences, Engineering and Medicine made recommendations
    related to innovations for meeting the cost-effectiveness of the
    National Assessment of Educational Progress while maintaining or
    improving its technical quality and the information it provides.
        Please describe National Center for Education Statistics and
    National Assessment Governing Board plans and resource requirements for
    implementing each of the recommendations made in this report.
        Answer. In response to these questions, IES notes that NASEM's
    recommendations were not available when the President's FY23
    Congressional Justification for IES was developed. NASEM's report
    publication coincided with the transmittal of the fiscal year 2023
    President's Budget from the Department to Congress (on March 28th).
    Therefore, IES is now coordinating with the Department to respond
    without contradicting the President's fiscal year 2023 Budget and to
    determine what additional resources may be necessary to address the
    NASEM recommendations. We are unable to provide detailed resource
    requirements at this time and expect such details to be included in the
    President's fiscal year 2024 budget request.
        NCES and NAGB welcomed the National Academies' recommendations,
    most of which endorse efforts the NAEP program is already undertaking
    to modernize the program, while others point to promising directions
    for the program. Below are NCES responses to key NASEM recommendations,
    including resource needs. NAGB's responses are submitted under separate
    cover, reflecting NAGB's independent status. However, you will see from
    the NCES and NAGB responses that we are working together to build on
    the National Academies' recommendations to modernize and advance the
    program.
        At the time the Department transmitted the fiscal year 2023 budget
    request for NAEP and NAGB to Congress (in March), the total requested
    amount for fiscal year 2023 was $193 million, including $185 million
    for NAEP and $7.8M for NAGB. NCES is working with the Department to
    develop estimates of total program and staffing resources necessary to
    implement NASEM'S recommendations. In these responses we are providing
    rough amounts that may change as we work with the Department and OMB to
    develop the President's fiscal year 2024 budget for NAEP.
        We anticipate the need for approximately $3 million in one-time
    programmatic costs to fund a review of the NAEP cost structures and to
    establish an independent panel for stress-testing and providing
    guidance on development of NAEP's digital assessment platform (eNAEP).
    We also anticipate an annual increase of $9 million in program funds
    over the current enacted amount of $180 million in fiscal year 2022 to
    implement an R&D program in response to the National Academies'
    recommendations and NCES's and NAGB's broader innovation goals. NAGB,
    in its response anticipates that it will require an increase of
    approximately $1.7M in fiscal year 2023. Taking this into
    consideration, the total request for fiscal year 2023 for NAEP would be
    in the range of $201.4M, which is $16.4 over the fiscal year 2023
    President's Budget submitted to Congress.
        As stated above, IES and NCES are working with the Department to
    further refine these estimates, and we expect that the fiscal year 2024
    President's Budget will reflect such changes. Everything in this
    response should be considered an estimate.
        NCES has a detailed response to each of NASEM's recommendations,
    which we can share with Congressional staff as desired. Here we present
    just a few of our responses.
        The NASEM report focused on cost controls and innovations to keep
    NAEP on the cutting edge of large-scale assessments.
        First, we believe that NAEP requires a dedicated R&D funding stream
    that is separate from NAEP's Assessment program appropriation. Taking
    steps to ensure that there are protected funds to support routine
    modernization and enhancements over time is critical, and we see a
    dedicated R&D funding line as the best way to ensure that NAEP
    continues to invest sufficiently in keeping the assessment (along with
    the assessment administration infrastructure) modern and responsive to
    changing societal needs. We believe that this R&D fund should be 5
    percent of the total NAEP/Assessment account budget, which would amount
    to approximately $9 million in program funds annually at current levels
    of NAEP funding. This R&D funding set-aside would be dedicated solely
    to advancing NAEP's cost-efficiency, quality, and use.
        Second, NASEM devoted considerable time analyzing the next
    generation of the NAEP on-line test administration platform (eNAEP).
    NCES agrees with the panel's recommendation that eNAEP components
    should be custom-built only if rigorous analysis shows that there are
    clearly large net benefits to this approach. However, NCES does not
    agree with the panel's position that current eNAEP does not have
    ``contemporary data architecture.'' NCES is already deploying
    approaches that address these points with the new Next-Gen eNAEP
    development.
        Wherever possible, mature, open-source and commercial components
    are already used and integrated as components into the eNAEP platform.
    In some cases, when no available technologies meet NAEP's technical or
    security requirements, custom-built software solutions are developed
    following open standards and best practices for reusability and cost-
    saving. The Next-Gen eNAEP platform was developed based on informed
    decisions on what to build versus buy considering development cost and
    efficiency as well as the total cost of ownership. NCES will commission
    a system review of the Next-Gen eNAEP and will establish an ongoing
    independent panel to support continued improvement of eNAEP. Similarly,
    we will empanel an independent set of experts to ``stress test'' eNAEP,
    as recommended by NASEM.
        Finally, NASEM also recommends a clearer and more accessible
    description of NAEP's operating structure, costs, and cost drivers. We
    are committed to providing more transparency on these issues. NCES is
    developing a set of brief white papers and workshops for stakeholders
    designed to describe key aspects of NAEP's contracting and cost
    structure. These will be available to Congressional staff (and the
    public) as they are completed.
        In response to NASEM's recommendation to improve visibility and
    coherence of research activities, NCES will produce a white paper
    describing our plans to modernize the program. NCES will post the white
    paper on its website in a new research and development hub
    disseminating information on NAEP research and development efforts.
    Please note that these research and development efforts include those
    recommended by the National Academies focusing on cost savings, as well
    as the broader program of innovations for advancement of the program
    being developed with NAGB. See also the NAGB response to this
    recommendation.
        The National Academies' NAEP report provided the National
    Assessment Governing Board (Governing Board) and the National Center
    for Education Statistics (NCES) with contributions that will lead to
    improvements--and potentially cost savings--in NAEP administration and
    operations. Because the responsibility for implementing the
    recommendations (and for NAEP more broadly) is shared between NCES and
    the Governing Board, both entities are submitting responses under
    separate cover. This document includes the Governing Board's response
    to the Senate's question for the record.
        The Governing Board is encouraged by NCES' recent efforts to
    initiate structural changes in the program, including device-agnostic
    administration (meaning NAEP can be administered on different types of
    devices); automated scoring using artificial intelligence; and adaptive
    test design that adjusts in real-time based on students' responses. The
    fiscal year 2022 funding increase provided to NAEP contributed to
    making these modernization efforts possible.
        Importantly, the Governing Board and NCES have identified
    additional opportunities for improvements in the program that NASEM did
    not address. As the joint stewards of NAEP, the Board and NCES are
    embarking upon an innovation agenda driven by relevance, utility,
    equity, efficiency, and adaptability. We have jointly determined the
    following innovation activities to be priorities in fiscal year 2023
    and fiscal year 2024:
      --Develop additional assessment items and testing methodologies to
            better describe the performance and needs of our nation's
            lowest performing students;
      --Use geospatial data, linked with Census and IRS data, to provide
            more precise information about students socioeconomic status
            than can currently be reported by free and reduced priced lunch
            status;
      --Develop remote testing capabilities, which means being able to test
            students wherever they are, e.g., virtual academies;
      --Examine innovative ways to maintain trend, which currently relies
            on extensive and expensive bridge studies when changes are made
            to NAEP frameworks or elements of the test design;
      --Capitalize on assessment process data as a critical source of
            information that is currently underdeveloped and underutilized
            in reporting; and
      --Report more actionable information so that states and districts use
            NAEP as an essential source of information in their education
            systems (e.g., policy-relevant reporting, data visualization
            that helps communicate NAEP results to lay audiences, etc.).
        Of these priorities for innovation, NCES will be responsible for
    implementing many of them. The Governing Board is responsible for
    innovation initiatives to strategically and proactively address
    stakeholder needs and to maintain assessment frameworks in ways that
    keep the NAEP assessments modern and relevant without threatening the
    valuable trend lines. To fulfill these objectives, the Governing Board
    requires its first budget increase in more than a decade. Our current
    funding level is $7.745 million annually; we have requested a total of
    $9.4 million in fiscal year 2023 and $10 million in fiscal year 2024 as
    described in more detail below. We look forward to working
    collaboratively with NCES and in consultation with Congress to maintain
    NAEP as the gold standard while increasing relevance and utility.
        In the table below, please find the Governing Board's responses to
    NASEM recommendations where the Board holds responsibility.

        Question. In A Vision and Roadmap for Education Statistics released
    earlier this year, the National Academies of Sciences, Engineering and
    Medicine recommended changes to NCES's programs, operations, staffing,
    and use of contractors for the non-assessments work of the National
    Center for Education Statistics considering developments in collecting
    and using data and recent trends and future priorities.
        Please describe plans and resource requirements for the National
    Center for Education Statistics to implement each of the
    recommendations made in this report.
        Answer. In response to these questions, IES notes that NASEM's
    recommendations were not available when the President's FY23
    Congressional Justification for IES was developed. Timing of NASEM's
    report publication coincided with the transmittal of the fiscal year
    2023 President's Budget from the Department to Congress (on March
    28th). Therefore, IES is now coordinating with the Department to
    respond without contradicting the President's fiscal year 2023 Budget,
    and to determine what additional resources may be necessary to address
    the NASEM recommendations. We are unable to provide detailed resource
    requirements at this time and expect such details to be included in the
    President's fiscal year 2024 budget request.
        To support NCES efforts to implement NASEM's recommendations, the
    NASEM Panel provided a roadmap suggesting how the Panel's
    recommendations should be implemented over time. Consistent with that
    roadmap, NCES is now developing a formal Strategic Plan (Recommendation
    2-1), which will serve as the foundation of our work to implement the
    remaining recommendations. We fully agree with NASEM's observation that
    our stakeholders need more modern, timely, actionable, and reliable
    information. To this end, the plan is focused on several areas:
      --Prioritizing NCES's most important work
      --Embedding diversity, equity, inclusion, and accessibility in all
            aspects of NCES' work
      --Strengthening existing partnerships and developing new ones
      --Improving internal processes, while adhering to all legal
            requirements
        In coming months, NCES expects to have a plan that we will use to
    engage stakeholders, gather their input and ideas, and help us
    prioritize our work so that the statistics we produce are aligned with
    the nation's needs. Meanwhile, NCES is actively engaging with
    constituents here in the Department (including the Office of the
    Secretary, the IES director and other center leads, the Chief Data
    Officer, and the Evaluation Officer) on a number of critical issues
    raised in the report. These issues include how the Department and IES,
    as NCES's parent organization, can support NCES efforts to increase the
    relevance of the information we produce, improve efficiency and
    timeliness in publishing official statistics, and support the NCES
    Commissioner's role as the Statistical Official (Recommendations 2-2
    and 2-3).
        We are focusing our current plans and resources on near-term
    actions that will lay the foundation for future improvements. Many
    recommendations will require additional program and staffing resources
    beginning in fiscal year 2023. Successful implementation of first steps
    will determine how and when we implement other recommended changes.
        The need for action is immediate. There are several recommendations
    in the report that direct NCES to begin action this year. NCES' ability
    to fully address most of these recommendations depends on additional
    program and staffing resources being made available in the coming year,
    sooner than the fiscal year 2024 President's Budget cycle. As noted,
    resources needed to address fiscal year 2023 work were not included in
    the President's budget request for IES/NCES in fiscal year 2023,
    because the report was released late in the budget cycle, just several
    days before the Budget was transmitted to Congress.
        Developing an NCES Strategic Plan is an immediate priority. Items
    we expect to identify in this plan include continuing the School Pulse
    Survey (Recommendation 3-1), increasing coordination with and building
    the data capacity of our state partners (Recommendation 4-4), enhancing
    the Office of the Commissioner to meet the needs of the Evidence Act
    (Recommendation 3-2), incorporating equity in our data collections and
    products (Recommendation 2-4), and strengthening collaborations with
    other Federal statistical agencies (Recommendation 4-2). We believe
    that moving forward with these activities now will enhance NCES'
    capacity to produce and disseminate statistical products that meet the
    information needs of our stakeholders.
        In fiscal year 2023, we intend to have both a Strategic Plan and an
    expanded Office of the Commissioner in place. This latter step is
    necessary to implement Titles II & III of the Foundations for Evidence-
    Based Policymaking Act (Evidence Act). After fiscal year 2023, NCES
    intends to continue following the roadmap within the NASEM report and
    focus on implementing the remaining recommendations, which include:
      --exploring alternative data sources, more modern modes of accessing
            data, and in increased use of data science methods (all in
            conjunction with IES' new data science unit),
      --modernizing standard language on consent and planned uses to enable
            greater access to data,
      --deepening and broadening engagement with data users, including
            potential users, developing new feedback loops to ensure NCES
            data collections are serving constituents,
      --establishing and beginning work with an external consulting body to
            gather input for prioritizing our initiatives,
      --establishing a joint statistical research program matching internal
            staff with external experts, and
      --transforming our current programs, operations, and activities to
            build greater internal capacity.
      --NCES and IES both look forward to continuing dialog with Congress
            as we work to realize the full potential of NCES as a
            statistical agency and its mission to provide meaningful,
            reliable, and timely Federal education data.
        Question. The Department planned this year to expand its monitoring
    of States for homeless education programs, including the Title I, Part
    A LEA set-aside.
        Please describe the Department's completed actions and plans for
    fiscal years 2023 and 2024.
        Answer. This year, the Department's homeless education program team
    developed a new integrated monitoring plan for the Education for
    Homeless Children and Youth (EHCY) and American Rescue Plan--Homeless
    Children and Youth (ARP-HCY) programs. Four States were monitored--
    Kansas, South Dakota, New Hampshire, and New Jersey between April and
    June 2022. Reports will be posted on the Department's website as they
    are finalized. The EHCY and ARP-HCY monitoring plan is also located
    there at https://oese.ed.gov/files/2022/01/SSA-EHCY-ARP-HCY-Monitoring-
    Plan-FY-22.docx. https://oese.ed.gov/files/2022/01/SSA-EHCY-ARP-HCY-
    Monitoring-Plan-FY-22.docx.
        The Department plans to monitor six States in fiscal year 2023 and
    between six and nine States in fiscal year 2024. This is an increase
    over the prior several years. It allows the Department to balance
    competing priorities to monitor and provide oversight while also
    providing technical assistance to States and districts and the
    Department's other requirements for administering a Federal program
    (e.g., reviewing State and local data, coordinating with other agencies
    on programs addressing homelessness) with the current small number of
    staff for this program and in partnership with the National Center for
    Homeless Education.
        Question. Please describe how what you are learning through these
    and other efforts will inform future monitoring and support of the
    effective use of Federal funds for students experiencing homelessness.
        Answer. The Department is still finalizing the monitoring reports
    from the four States reviewed in fiscal year 2022. Our initial analysis
    indicates that more attention is needed on analyzing LEA-level homeless
    student enrollment and performance data to identify LEAs for
    subrecipient monitoring or to provide technical assistance to improve
    performance, for EHCY and ARP-HCY subgrantee LEAs and for all LEAs. In
    some cases, an LEA that has students experiencing homelessness has not
    set aside funds under the Title I, Part A program to provide services
    to those students, as required. In addition, the Department observed
    that the per-pupil amounts varied widely in most States.
        The Department is planning to strengthen and update its technical
    assistance. Regarding the Title I set-aside, we will host, and post
    online, a webinar with knowledge checks and a certificate of completion
    through the National Center of Homeless Education. We will continue to
    provide support and assistance to State homeless coordinators to ensure
    they are providing guidance to all LEAs on the requirements to provide
    services to homeless students. Finally, we are adding questions related
    to the Title I set-aside to the Title I monitoring protocol.
        In our monitoring, we also observed innovative and effective uses
    of funds at the local level.. For example, a school in Kansas City,
    Kansas was being converted into a family transitional housing program
    with several supportive service providers co-located at the site and
    the targeted provision of supplies and other supports to high school
    students experiencing homelessness through graduation in Olathe,
    Kansas.
        Question. What actions will the Department take in working across
    the Administration to address the impact housing instability and other
    challenges have on the education of children experiencing homelessness,
    from early childhood through higher education?
        Answer. The Department works across the agency and with our
    colleagues across the Federal Government to provide supports for
    children and youth experiencing homelessness and those involved in the
    child welfare or juvenile justice systems. The Department will continue
    our role as a core agency of the U.S. Interagency Council on
    Homelessness especially in preventing and ending or reducing family,
    child and unaccompanied youth homelessness. The Department's homeless
    education program team also coordinates with HUD on the Youth
    Homelessness Demonstration Program coordinated technical assistance and
    evaluation; the Family Youth Services Bureau of HHS on using the
    National Runaway Safeline; and the Office of Juvenile Justice and
    Delinquency Prevention at DOJ on preventing homelessness among
    reentering youth. The Department is also collaborating with the
    Department of Labor and National Youth Employment Coalition as well as
    the Department's Office of Career and Technical Education regarding the
    Perkins program requirements for serving youth experiencing
    homelessness, the Workforce Investment Opportunities Act funding for
    disconnected youth, and the Performance Partnership Pilot programs for
    disconnected youth.
        On early childhood education, the later this year, the Department
    will release the 2022 Early Childhood Homelessness State Profiles. For
    postsecondary education, the Department's homeless education program
    team, along with our National Center for Homeless Education (NCHE), are
    coordinating with our Offices of Federal Student Aid and Postsecondary
    Education to provide technical assistance and guidance on FAFSA
    simplification.
        Question. The calculation of current expenditures used under the
    ESEA excludes ESEA Title I-A funding. The amount of funding provided
    for COVID education relief, particularly through the Elementary and
    Secondary School Emergency Relief Fund (ESSER), is significantly more
    funding than is provided annually through Title I-A.
        If the COVID relief funds are not dropped from the current
    expenditures calculation, how could this potentially affect grant
    amounts under Federal elementary and secondary education programs that
    incorporate current expenditures into the formula grant calculation?
        Answer. See response below under (b.)
        Question. Would state shares of formula grants shift from previous
    years as a result of the inclusion of these funds?
        Answer. (b.) By the end of September 2022, the Department expects
    to have received from States preliminary current expenditure data for
    fiscal year 2021 (July 1, 2020, to June 30, 2022) that will include
    COVID education relief expenditures as part of the current expenditures
    reported and the COVID education relief expenditures also reported
    separately. Once the Department has received these data, we will be in
    a position to analyze of the potential effects of these funds on
    allocations.
        Question. If the funds remain in the calculation, would this
    distort measures of state and local effort to support public elementary
    and secondary education given the unprecedented Federal investment in
    these areas during the COVID19 pandemic?
        Answer. With respect to the ESEA's local educational agency
    maintenance of effort (MOE) requirement, the Department's MOE
    regulations require that expenditures of Federal funds be excluded from
    the MOE calculation. Therefore, expenditures by a local educational
    agency of COVID relief funds will not have an effect on whether the LEA
    meets the ESEA's MOE requirements. With respect to the Title I
    Education Finance Incentive Grant formula's State MOE requirement that
    is based on current expenditure data, the Department will be in a
    position to analyze the potential effects once current expenditure data
    from fiscal year 2021 are available.
        Question. In addition, does ED have a sense of the extent to which
    the Governor's Emergency Education Relief Fund and ESSER might be used
    for capital expenditures in some places and not others, which could
    create a situation in which some entities would have their COVID funds
    counted in their current expenditures calculation and others would not,
    depending on how the funds were used (as capital outlays are not
    included in current expenditures)?
        Answer. ``Current expenditures comprise expenditures for the day-
    to-day operation of schools and school districts for public elementary
    and secondary education, including expenditures for staff salaries and
    benefits, supplies, and purchased services. General administration
    expenditures and school administration expenditures are also included
    in current expenditures. Expenditures associated with repaying debts
    and capital outlays (e.g., purchases of land, school construction, and
    equipment) are excluded from current expenditures. Programs outside the
    scope of public prekindergarten through grade 12 education, such as
    community services and adult education are not included in current
    expenditures. Payments to private schools and payments to charter
    schools outside of the school district are also excluded from current
    expenditures.'' (Cornman, S.Q., Ampadu, O., Wheeler, S., Hanak, K. and
    Zhou, L. (2019), p. B-2).
        According to this definition capital outlays (e.g., purchases of
    land, school construction, and equipment) are excluded from current
    expenditures. The vast majority of State Education Agencies (SEAs) and
    school districts across the country follow this definition of current
    expenditures and exclude capital outlays.
        Furthermore, the U.S. Department of Education guidance on Every
    Student Succeed Act (ESSA) report cards provides in pertinent part that
    ``If an SEA wants to ensure that data are uniform, understandable, and
    comparable across each LEA and school in a State, the SEA may establish
    uniform statewide procedures for calculation of per-pupil
    expenditures.'' (See https://oese.ed.gov/files/2020/07/report-card-
    guidance-final.pdf.).
        Commencing in October 2020, NCES has held quarterly meetings with
    State Fiscal Coordinators to facilitate the consistent collection and
    submission of accurate data. The technical workshops facilitate
    reporting accurate, consistent and timely information because the
    finance data item definitions and survey instructions are discussed in
    exhaustive detail. The primary purpose of the technical workshop is to
    make the reporting procedures on NPEFS, the F-33, and the School Level
    Finance Survey (SLFS) surveys as efficient and cost effective as
    possible. The foregoing definition of current expenditures is discussed
    in detail at each and every quarterly meeting held with State Fiscal
    Coordinators. The workshops include an interactive discussion on the
    reporting and editing processes associated with the surveys; detailed
    information about the items that comprise the surveys; and discussion
    of how to coordinate submission of Common Core of Data (CCD) data with
    the respective state's data systems.
        Current expenditures and capital expenditures paid from COVID--19
    Federal Assistance Funds were collected as separate and distinct data
    items on the state level National Public Education Financial Survey
    (NPEFS) and the district level School District Financial Survey (F-33)
    for the fiscal year (FY) 2020 (school year 2019-20).
        Current expenditures and capital expenditures paid from COVID--19
    Federal Assistance Funds are currently being collected on the fiscal
    year 2021 (school year 2020-2021) NPEFS and F-33 surveys. Specifically,
    in fiscal year 2021, the NPEFS and F-33 surveys contained 10 data items
    which requested revenue amounts broken out by program and 8 data items
    which requested expenditure amounts from all COVID-19 Federal
    assistance funds for specific functions or objects.
        Going forward for the fiscal year 2022 NPEFS and F-33 data
    collections, certain divisions within the U.S. Department of Education
    such as the Institute of Education Sciences (IES), the Office of
    Elementary and Secondary Education (OESE), the Office of Planning,
    Evaluation, and Policy Development (OPEPD), and the Budget Office
    recommended that the surveys be expanded to collect expenditures by
    specific sources of COVID--19 revenue.
        State Fiscal Coordinators Workshops were held on October 21, 2021
    and February 17, 2022. During these workshops, poll questions were
    conducted and the State Fiscal Coordinators provided feedback on their
    ability to report expenditures by source of revenue from COVID-19
    Federal assistance funds. In December 2021, an expert panel comprised
    of State Fiscal Coordinators and district level school business
    officials also discussed the possibility of adding expenditures by
    source of revenue to the NPEFS and F-33. During these meetings, Federal
    staff collaborated with the state fiscal coordinators and district
    level personnel to make every effort to ensure that there is ``match''
    between the data that the NCES is requesting and data that the SEAs can
    actually produce.
        From October 2021 through April 2022, NCES carefully reviewed the
    recommendations on adding expenditures by source of COVID-19 Federal
    assistance fund on NPEFS and F-33 submitted by the respective divisions
    within the Department; select State Fiscal Coordinators and LEA-level
    personnel; and all State fiscal coordinators. On the basis of the
    comprehensive meetings set forth above and the ability of states to
    report the additional data, NCES recommended to the Office of
    Management and Budget (OMB) that NPEFS and F-33 be revised to expand
    the collection of expenditures to include current expenditures,
    instructional expenditures, and capital outlay by seven specific
    sources of funds.
        These recommendations were presented to state fiscal coordinators
    at the quarterly meeting on April 28, 2022. The majority of states will
    be able to report on the new variables. However, some states are only
    able to collect data from LEAs on grants that are allocated and awarded
    through the state department of education. These states may not be able
    to report on grants that flow through to LEAs from other agencies, such
    as the State and Local Fiscal Recovery Funds. In these cases, states
    may report on only that data which is available and should provide
    appropriate explanations in their state notes. Some states also
    expressed concerns about the additional burden of the new survey codes.
    In some cases, states lack the resources required to make programming
    changes to their collection and reporting systems.
        The 21 additional items to be added to the fiscal year 2022 (school
    year 2021-2022) NPEFS and F-33 surveys are set forth in blue font
    below.
      --Current expenditures paid from ESSER I funds (objects 100-600, 810,
            820, 835, and 890 for functions 1000, 2000, 3100, and 3200;
            excluding objects 511, 561, 564, 567, and 591)--AE1A
      --Current expenditures paid from ESSER II funds (objects 100-600,
            810, 820, 835, and 890 for functions 1000, 2000, 3100, and
            3200; excluding objects 511, 561, 564, 567, and 591)--AE1B
      --Current expenditures paid from ARP ESSER funds (objects 100-600,
            810, 820, 835, and 890 for functions 1000, 2000, 3100, and
            3200; excluding objects 511, 561, 564, 567, and 591)--AE1C
      --Current expenditures paid from GEER I funds (objects 100-600, 810,
            820, 835, and 890 for functions 1000, 2000, 3100, and 3200;
            excluding objects 511, 561, 564, 567, and 591)--AE1D
      --Current expenditures paid from GEER II funds (objects 100-600, 810,
            820, 835, and 890 for functions 1000, 2000, 3100, and 3200;
            excluding objects 511, 561, 564, 567, and 591)--AE1E
      --Current expenditures paid from the CRF (objects 100-600, 810, 820,
            835, and 890 for functions 1000, 2000, 3100, and 3200;
            excluding objects 511, 561, 564, 567, and 591)--AE1F
      --Current expenditures paid from the SLFRF (objects 100-600, 810,
            820, 835, and 890 for functions 1000, 2000, 3100, and 3200;
            excluding objects 511, 561, 564, 567, and 591)--AE1G
      --Instructional expenditures paid from ESSER I funds (objects 100-
            600, 810, and 890 for function 1000; excluding objects 561,
            564, 567, and 591)--AE2A
      --Instructional expenditures paid from ESSER II funds (objects 100-
            600, 810, and 890 for function 1000; excluding objects 561,
            564, 567, and 591)--AE2B
      --Instructional expenditures paid from ARP ESSER funds (objects 100-
            600, 810, and 890 for function 1000; excluding objects 561,
            564, 567, and 591)--AE2C
      --Instructional expenditures paid from GEER I funds (objects 100-600,
            810, and 890 for function 1000; excluding objects 561, 564,
            567, and 591)--AE2D
      --Instructional expenditures paid from GEER II funds (objects 100-
            600, 810, and 890 for function 1000; excluding objects 561,
            564, 567, and 591)--AE2E
      --Instructional expenditures paid from the CRF (objects 100-600, 810,
            and 890 for function 1000; excluding objects 561, 564, 567, and
            591)--AE2F
      --Instructional expenditures paid from the SLFRF (objects 100-600,
            810, and 890 for function 1000; excluding objects 561, 564,
            567, and 591)--AE2G
      --Capital outlay expenditures paid from ESSER I funds (objects 100-
            700, and 890 for function 4000; object 700 for ALL functions)--
            AE4A
      --Capital outlay expenditures paid from ESSER II funds (objects 100-
            700, and 890 for function 4000; object 700 for ALL functions)--
            AE4B
      --Capital outlay expenditures paid from ARP ESSER funds (objects 100-
            700, and 890 for function 4000; object 700 for ALL functions)--
            AE4C
      --Capital outlay expenditures paid from GEER I funds (objects 100-
            700, and 890 for function 4000; object 700 for ALL functions)--
            AE4D
      --Capital outlay expenditures paid from GEER II funds (objects 100-
            700, and 890 for function 4000; object 700 for ALL functions)--
            AE4E
      --Capital outlay expenditures paid from the CRF (objects 100-700, and
            890 for function 4000; object 700 for ALL functions)--AE4F
      --Capital outlay expenditures paid from the SLFRF (objects 100-700,
            and 890 for function 4000; object 700 for ALL functions)--AE4G
        The results of poll questions posed to State Fiscal Coordinators
    were very high with respect to reporting current expenditures,
    instruction expenditures, and capital outlays by specific source of
    COVID--19 revenues.
        In summary, NCES recommended that the NPEFS and F-33 be revised to
    expand the collection of expenditures to include current expenditures,
    instructional expenditures, and capital outlay by 7 specific sources of
    COVID--19 Federal assistance funds.
        The 60 day Federal register notice for fiscal year 2022 through
    fiscal year 2024 NPEFS survey came out on June 7, 2022. The comment
    period ends on August 8, 2022.
        As a direct result of the quarterly meetings with State Fiscal
    Coordinators and the expert panel, it is submitted that the SEAs can
    report total current expenditures, instructional expenditures, and
    capital outlay expenditures broken out by source of revenue (21 new
    data items) on the NPEFS and F-33 surveys. The COVID--19 revenue
    streams include:
      --ESSER I
      --ESSER II
      --ESSER III ARP Funds
      --Coronavirus State and Local Fiscal Recovery Funds under ARP
      --GEER I Funds
      --GEER II Funds
      --Coronavirus Relief Funds (CRF) under CARES Act
        Question. Average daily attendance (ADA) is a factor that is
    included in several Federal elementary and secondary education program
    formulas.
        Given what appears to be substantial shifts in ADA in some areas
    and potential problems counting students accurately and consistently,
    how is the Department considering using ADA data from the 2019-2020,
    2020-2021, and 2021-2022 school years in grant calculations, and how
    would this affect grant allocations?
        Answer. The Department published a letter to the Chief State School
    Officers on January 27th, 2022 addressing the collection of average
    daily attendance in school years 2019-2020 and 2020-2021 in light of
    the impacts of the COVID-19 pandemic. In the letter, the Department
    outlines flexibilities SEAs could utilize when collecting and reporting
    ADA in school year 2019-2020. In accordance with Section 8101(1) of the
    Elementary and Secondary Education Act of 1985, each SEA is still
    expected to report ADA based on either the Federal definition or its
    respective State definition. However, the letter addressed what SEAs
    should do during the periods of remote instruction. For example, in
    cases where the SEA was using the Federal definition but was unable to
    report during the periods of remote instruction, SEAs were advised to
    report the aggregate number of days of attendance of all students up
    until school facilities closed. The letter further notes that the
    expectation is that SEAs resume normal tracking of student attendance
    regardless of school building operational status.
        The Department is in the process of collecting ADA data on school
    year 2020-2021 and will conduct an analysis of the impact of COVID-19
    on the reporting of ADA as well as how shifts in the data impact grant
    allocations.
        Response Specific to the REAP Program: To administer the Rural
    Education Achievement Program (REAP) in fiscal year 2022 the Department
    communicated with State Rural Coordinators during summer 2021 to assess
    if SEAs anticipated reporting issues due to average daily attendance
    (ADA) data quality concerns. Three SEAs reported data concerns in
    August 2021. These SEAs received technical assistance, helping to
    ensure compliance with the REAP eligibility requirement under section
    5231(a) of the Elementary and Secondary Education Act of 1965 (ESEA),
    that requires a local educational agency (LEA) to conduct an annual
    census not earlier than the start of the school year and not later than
    December 1 of each year to determine the number of students in ADA in
    kindergarten through grade 12 at each school served by an LEA for the
    purposes of eligibility and allocations.
        To incorporate additional SEA and LEA input on ADA data collection,
    the Department requested public comment on a proposed revision of a
    currently approved collection necessary to implement REAP in fiscal
    year 2023 (see here). In addition, because the ESEA does not clearly
    define how a census should be conducted and section 8101(1) of the ESEA
    includes a definition of ADA that differs from the process outlined in
    section 5231 of the ESEA, the Department included in the Unified Agenda
    report for Spring 2022 a plan to initiate rulemaking in May 2023 (RIN:
    1810-AB65). The Department plans to clarify the process for calculating
    ADA for REAP, including the census determination process, under Section
    5231(a) of the ESEA.
        Question. The National Center for Education Statistics provided
    flexibility for collecting ADA data during the 2019-2020 school year.
    Did this flexibility result in reliable ADA counts or could an entity
    be advantaged or disadvantaged in the determination of formula grants
    based on the counting method that it used?
        Answer. School finance experts from NCES and the Census Bureau
    performed an analysis of reporting on the 2019-2020 school year, which
    concluded that the flexibility provided by NCES: (a) resulted in
    reliable ADA data, and (b) the counting method an entity selected did
    not advantage or disadvantage them in the determination of formula
    grants. Results of this study were shared at the American Education
    Finance and Policy Associate conference this year.
        This analysis also reviewed changes in ADA and state per pupil
    expenditures (SPPE) to determine if there were differences in reported
    ADA by the policy option, or counting method, that was selected by the
    state. We found there were no differences in the change in average ADA
    for those that included attendance for remote learning days compared to
    those that did not.
        We note that since fiscal year 2020 contains several months of
    pandemic data, NCES will need to continue to monitor ADA and SPPE for
    impacts of COVID-19.

        Question. Students of color and students with disabilities are
    disciplined at significantly higher rates than their white and
    nondisabled peers. These forms of discipline, ranging from suspensions
    and expulsions to restraint and corporal punishment, can have a
    disastrous impact not only on the academic stability of these students,
    but also on their physical, mental, and emotional health.
        How would President Biden's fiscal year 2023 budget proposal for
    Education help to support and encourage the use of more positive
    alternatives to punitive and exclusionary discipline practices which
    disproportionately impact students of color and students with
    disabilities?
        Answer. President Biden's fiscal year 2023 budget proposal
    describes several activities that the Department of Education would
    carry out under the Individuals with Disabilities Education Act (IDEA)
    Part B Grants to States. First, it references the existing requirements
    for States, on an annual basis, to determine whether there is
    significant disproportionality in race and ethnicity in the State or
    the LEAs of the State with respect to the identification (including
    identification of children with a particular disability), placement in
    particular education settings, and discipline of students with
    disabilities. While data from 2019-2020 revealed that 298 LEAs were
    identified with significant disproportionality on the basis of
    discipline, the Department has focused much of its attention on the
    effective collection and analysis of this data and has not yet been
    able to effectively respond to the identified disproportionality. Once
    an LEA is identified as having significant disproportionality, the LEA
    must conduct a root cause analysis and reserve 15 percent of its IDEA
    Part B allocation to provide comprehensive coordinated early
    intervening services (comprehensive CEIS) to students. Moving forward,
    the Department is committed to making this second phase of the
    significant disproportionality requirements a major focus in monitoring
    and technical assistance efforts. Additionally, the fiscal year 2023
    Budget requests $5 million to establish an Equity in IDEA Technical
    Assistance Center, which will support LEAs in conducting root cause
    analyses and identifying evidence-based strategies for effectively
    deploying funds reserved for comprehensive CEIS. With effective
    supports to identify the root causes of the disproportionality, as well
    as a better understanding of the most effective ways to provide
    comprehensive CEIS to students, LEAs can meaningfully address their
    disproportionality and set a path towards more equitable services of
    all students. Furthermore, the Center will disseminate research, data
    analyses and best practices related to equitably serving children with
    disabilities to provide all schools strategies to proactively prevent
    disproportionality.
        Additionally, the fiscal year 2023 budget proposal indicates that
    the Department will issue updated guidance on the topics of restraint
    and seclusion--practices that disproportionately impact and harm
    students of color and students with disabilities--and will continue to
    leverage our investments under the IDEA Technical Assistance and
    Dissemination program to support efforts to limit the use of seclusion
    and physical restraint, reduce exclusionary discipline practices, and
    promote positive behavioral interventions and supports in schools. For
    example, the National Technical Assistance Center on Positive Social,
    Emotional, and Behavioral Outcomes for Students with Disabilities can
    reduce seclusion and restraint by improving State and local capacity to
    address the social, emotional, and behavioral development of young
    children with disabilities, while the National Technical Assistance
    Center on Positive Behavior Interventions and Supports provides schools
    with guidance on deploying school-wide strategies to improve school
    climates that can proactively reduce seclusion and restraint.
        These efforts can help reduce the disproportionate use of punitive
    and exclusionary discipline of students with disabilities as well as
    students of color. In addition, the fiscal year 2023 Budget request for
    ED will enable OCR to add approximately 92 FTE over the 2021 enacted
    level. This funding will allow OCR to continue its enforcement and
    technical assistance efforts to ensure nondiscrimination in student
    discipline based on race, color, national origin, or disability. The
    President's fiscal year 2023 budget proposal will also enable OCR to
    continue to collect critical data regarding the discipline of students
    with disabilities and students of color, including corporal punishment,
    referral to law enforcement, school-based arrest, expulsion, transfer
    to alternative school, out-of-school suspensions, and in-school
    suspensions, as well as disaggregated data on school days lost due to
    out-of-school suspensions.
        Question. Relatedly, what is the Department's timetable for
    releasing forthcoming school discipline guidance?
        Answer. The now-rescinded guidance under Title VI of the Civil
    Rights Act of 1964, first issued in 2016, remains under review by the
    Departments of Justice and Education. On July 19, 2022, however, ED
    released two sets of guidance and resources on the topic of students
    with disabilities and discipline. OCR released Supporting Students with
    Disabilities and Avoiding the Discriminatory Use of Student Discipline
    under Section 504 of the Rehabilitation Act of 1973, a guidance
    document explaining that Section 504 requires schools to provide
    behavioral supports and services to students with disabilities who need
    them in order to receive a FAPE.
        OCR's guidance makes clear that providing the individualized
    services and supports required by Section 504 can help prevent or
    reduce disability-based behaviors that might otherwise lead to student
    discipline; outlines how Section 504's requirements to provide a free
    appropriate public education, or FAPE, apply to long-term disciplinary
    sanctions, such as out-of-school suspensions and expulsions; explains
    Section 504's general nondiscrimination requirements, in the context of
    discipline, which applies to school staff and to the conduct of
    everyone with whom the school has a contractual or other arrangement,
    such as security staff and school police; and makes clear that Section
    504 requires schools to provide reasonable modifications to policies,
    practices, and procedures when necessary to avoid discrimination.
        OSERS released three documents related to addressing the needs of
    children with disabilities and IDEA's discipline provisions. The
    guidance package included: (1) Dear Colleague Letter: Addressing the
    Needs of Children with Disabilities and IDEA's Discipline Provisions;
    (2) Questions and Answers: Addressing the Needs of Children with
    Disabilities and IDEA's Discipline Provisions; and (3) Stakeholders'
    Guide: Positive, Proactive Approaches to Supporting Children with
    Disabilities. This guidance describes the Department's concerns about
    the disparities in the use of aversive practices such as restraint and
    seclusion, and in student disciplinary practices such as suspensions
    and expulsions, in K-12 schools and early childhood settings for
    children with disabilities, particularly Black children with
    disabilities. It reminds SEAs and LEAs of their obligations under IDEA
    and urges them to examine existing policies, practices, and procedures
    to unpack the causes of discipline disparities. It also provides SEAs,
    LEAs, and educators resources to fulfill their obligations, to
    implement evidence-based, proactive practices to meet the needs of
    children with disabilities and prevent the need for exclusionary
    discipline.
        Question. Additionally, has the Department considered collecting
    data on threat assessment practices to provide a better understanding
    of a practice that some research and advocates have indicated has a
    disproportionate impact on students of color and students with
    disabilities?
        Answer. As discussed in Supporting Students with Disabilities and
    Avoiding the Discriminatory Use of Student Discipline under Section 504
    of the Rehabilitation Act of 1973, under Section 504, ``schools must
    avoid any disability discrimination in their use of threat or risk
    assessments, such as unnecessarily treating students with disabilities
    differently from other students, and must safeguard a student with a
    disability's [rights to a free appropriate public education] throughout
    any threat or risk assessment process.'' Similarly, the recently
    released guidance from OSERS describes how LEAs must continue to comply
    with IDEA and states that ``the procedural safeguards and right to FAPE
    for a child with a disability must be protected throughout any threat
    or risk assessment process, including the provision of services during
    any removals beyond 10 cumulative school days in a school year.''
    Further, it clarifies that ``States and LEAs should ensure that school
    personnel involved in screening for, and conducting, threat or risk
    assessments of children with disabilities are aware that the child has
    a disability and are sufficiently knowledgeable about the LEA's
    obligation to ensure FAPE to the child, including IDEA's discipline
    provisions. Where appropriate, the LEA can ensure that the school
    personnel conducting the threat or risk assessment have access to, and
    are coordinating with, the child's IEP Team.''
        With respect to the collection of data, OCR in December 2021
    submitted to the Federal Register a proposed survey for the 2021-22
    CRDC, and is reviewing comments submitted during the 60-day public
    comment period that ended February 11, 2022. In the coming months, OCR
    plans to announce the second, and final, 30-day public comment period
    and welcomes input on the collection of information related to threat-
    assessment practices.
        Question. Research shows that funding matters. Increased school
    spending leads to increases in graduation rates, higher wages, and
    reduction in adult poverty, especially for students from low-income
    families. However, data shows that school districts serving the largest
    populations of Black, Latino, or Native students receive 13 percent
    less per student in state and local funding than those serving the
    fewest students of color. For a school district with 5,000 students,
    this gap equals a shortage of $9 million per year.
        How does the President's fiscal year 2023 budget proposal encourage
    states to begin to address the inequitable state and local funding
    systems that perpetuate these gaps, and what else is the Department
    doing to remedy these inequities?
        Answer. President Biden is keenly aware of the longstanding and
    unacceptable inequities in State and local education funding that led
    to significant gaps in academic, career, and life outcomes for students
    of color. This is why his fiscal year 2023 request for Title I Grants
    to Local Educational Agencies included a $20 billion increase
    specifically intended to close gaps in funding that undermine the
    ability of our public education system to prepare all students to
    succeed, regardless of their zip code, family's income, race,
    ethnicity, or disability. In addition, our request would make available
    up to $100 million to support comprehensive reviews of school finance
    systems by paying the costs of (1) voluntary State school funding
    equity commissions and (2) voluntary local educational agency equity
    reviews.
        Voluntary State equity commissions could carry out activities such
    as identification of funding and educational opportunity gaps based on
    measures of equity and adequacy; development of action plans to address
    existing gaps, including new formulas and a plan to transition to a new
    formula; and public reporting on the State's progress in addressing
    school funding inequities. Local educational agency equity reviews
    would involve similar analyses of educational opportunity and funding
    gaps, as well as efforts to more equitably, adequately, and effectively
    target existing Federal, State, and local resources to meet student
    needs.
        The 2023 request also would help address inequitable State and
    local funding through development of a P-12 equity data dashboard at
    the Department (see description of request in the Program
    Administration account). The dashboard would aggregate existing
    information about factors affecting P-12 educational opportunity and
    equity--including school-level data on resources (including per-pupil
    expenditures), school environmental factors, opportunities to engage in
    high-quality learning, access to well-rounded coursework, entry into
    college and career pathways, and access to most prepared and effective
    school staff--and make such data readily available to the public. The
    Administration believes that such transparency would increase
    meaningful engagement in education by diverse stakeholders, including
    parents, and promote informed State and local decisionmaking that can
    help eliminate inequities in our P-12 education systems.
        Question. Research has demonstrated that Black and Latino students
    across the country experience inequitable access to advanced coursework
    opportunities, despite the fact that they are successful in these
    courses when given the opportunity. Not only are these students locked
    out of these opportunities at an early age by being denied access to
    gifted and talented programs, but they also face numerous systemic
    barriers, including funding inequities and educator bias, which prevent
    them from participating in advanced courses in secondary school,
    including Advanced Placement, International Baccalaureate, and dual
    enrollment courses. For example, a recent study found that despite
    roughly 2 in 5 Black and Latino students stating that they really enjoy
    STEM courses and aspire to go to college, less than 3 percent are
    enrolling in AP STEM courses. As a result, these students are missing
    out on critical opportunities that can set them up for success in
    college and future careers.
        Please identify budget proposals that would support advanced
    coursework opportunities for students, particularly students of color
    and students from low-income backgrounds, and the actions the
    Department can take to help overcome the systemic barriers preventing
    these students from participating and succeeding in these courses.
        Answer. The Administration strongly supports efforts to close
    persistent gaps in student preparation for, access to, and success in
    advanced coursework. To this end, the President's Budget dramatically
    increases funding under Title I Grants to LEAs that high-poverty
    schools can use to increase student participation in advanced courses
    and provide the supports needed to succeed, including foundational
    content and qualified educators. In addition, school districts can use
    funds for this purpose under Title IV-A Student Support and Academic
    Enrichment Grants. Finally, the Department stands ready to provide
    technical assistance to States and school districts that seek to
    examine the causes of inequitable access to rigorous coursework and
    develop plans to eliminate systemic barriers to student success.
        Question. As students have returned to the classroom, however, it
    has become increasingly clear that more must be done by our schools to
    help address the significant mental and emotional toll the pandemic has
    had on our nation's students. Programs designed to address a student's
    social, emotional, and academic development can have a transformational
    impact in helping to address these challenges facing students.
    Furthermore, these programs can help to equip educators with the skills
    and resources necessary to better address the complex and evolving
    needs of their students. That is why Congress continued to robustly
    support social emotional learning initiatives and other whole child
    approaches in recent appropriations bills, including the Education
    Innovation and Research program, Supporting Effective Educator
    Development program, Full-Service Community Schools, and more.
        Please describe how increased investments in social emotional
    learning initiatives and other related efforts can help to better equip
    educators with the skills and resources necessary to address student
    needs, and how might the Department help support these programs and
    other efforts to create a positive and healthy school climate and
    culture?
        Answer. The Bipartisan Safer Communities Act provides the
    Department with an additional $1.5 billion in funding to help schools
    put in place comprehensive strategies to create safe and healthy
    learning environments for all students and expand the number of
    qualified mental health service providers in schools.
        Given the critical role that SEL and school safety play in
    students' overall well-being and academic experiences, the Department
    also administers the following programs designed to help support the
    mental health, social, emotional, and behavioral well-being of children
    and students:
      --Project Prevent Grant Program (https://oese.ed.gov/offices/office-
            of-formula-grants/safe-supportive-schools/project-prevent-
            grant-program), which provides grants to school districts to
            increase their capacity to help schools in communities with
            pervasive violence better address the needs of affected
            students and break the cycle of violence.
      --Trauma Recovery Demonstration Grant Program (https://oese.ed.gov/
            offices/office-of-formula-grants/safe-supportive-schools/
            trauma-recovery-demonstration-grant-program), which supports
            model programs that enable students from a low-income families
            who have experienced trauma that negatively affects the
            educational experience to access the trauma-specific mental-
            health services from the provider.
      --The Mental Health Service Professional Demonstration Grant Program
            (https://oese.ed.gov/offices/office-of-formula-grants/safe-
            supportive-schools/mental-health-service-professional-
            demonstration-grant-program), which provides competitive grants
            to support and demonstrate innovative partnerships to train
            school-based mental health service providers for employment in
            schools.
      --The School-Based Mental Health Services Grants Program (https://
            oese.ed.gov/offices/office-of-formula-grants/safe-supportive-
            schools/school-based-mental-health-services-grant-program),
            grant which provides competitive grants to SEAs to increase the
            number of qualified mental health service providers that
            provide school-based mental health services to students in
            local educational agencies; and
      --School Emergency Response to Violence (Project SERV) (https://
            oese.ed.gov/offices/office-of-formula-grants/safe-supportive-
            schools/project-serv-school-emergency-response-to-violence),
            which funds short-term education-related services for school
            districts and institutions of higher education to help them
            recover from violent or traumatic events.
        In additional to these programs, the Department supports technical
    assistance centers that provide information, training, and other
    valuable resources to schools and communities address mental health and
    trauma, including:
      --Center to Improve Social and Emotional Learning and School Safety
            (https://selcenter.wested.org), which provides technical
            assistance in the implementation of social and emotional
            learning evidence-based programs and practices;
      --National Center on Safe and Supportive Learning Environments
            (https://safesupportivelearning.ed.gov), which supports efforts
            aimed at creating and nurturing safe and supportive learning
            environments;
      --Center on Positive Behavioral Interventions and Supports (https://
            www.pbis.org), which helps States, districts, and schools to
            increase their capacity for implementing a multi-tiered
            approach to social, emotional and behavioral supports; and
      --Readiness and Emergency Management for Schools (REMS) Technical
            Assistance (TA) Center (https://rems.ed.gov, which helps State
            and local educational agencies, with their community partners,
            manage safety, security, and emergency management programs;
        In the Education Innovation and Research (EIR) discretionary grant
    program, social emotional learning (SEL) has been an explicit
    competition priority since fiscal year 2020. The fiscal year 2022 EIR
    competitions invited SEL projects in a wide variety of topics such as
    educator capacity to support SEL; multi-tiered systems of supports,
    including trauma-informed practices; and equitable access to social
    workers, psychologists, counselors, nurses, or mental health
    professionals; project-based learning to strengthen metacognitive,
    self-direction, self-efficacy, etc. fiscal year 2022 applications have
    closed and awards will be made by December 2022. In fiscal year 2021,
    EIR funded 14 SEL projects; in fiscal year 2020, EIR funded 10 SEL
    projects. The program office has various ongoing technical assistance
    efforts devoted to support grantee implementation of SEL projects and
    disseminate key learnings to the field (including a white paper and
    webinar).
        Question. Students in foster care face enormous obstacles to
    accessing and succeeding in school, including frequent home and school
    changes, missing credits, unreliable access to appropriate support
    services, confusion over education decisionmaking authority, and
    inconsistent access to special education services. These students have
    higher rates of absenteeism than their peers; lower test scores on
    standardized tests; and are three times more likely drop out of school.
    New requirements included in The Every Student Succeeds Act require
    state education agencies to ensure students in foster care remain in
    their school of origin unless it is not in their best interest and to
    collaborate with child welfare agencies on plans for providing cost-
    effective transportation for students to remain so enrolled, among
    other requirements.
        How can existing Federal funds in the Department and Department of
    Health and Human Services be used to strengthen partnerships between
    State and local education and child welfare agencies necessary to
    support educational stability and improve education outcomes of
    children in foster care?
        Answer. Title I, Part A of the Elementary and Secondary Education
    Act of 1965 (ESEA), as amended by The Every Student Succeeds Act,
    includes requirements designed to enhance the educational stability of
    students in foster care. Collaboration between educational agencies and
    child welfare agencies is essential to the effective implementation of
    these requirements, and the ESEA requires such collaboration at the
    State level. Two staff members in the Office of Elementary and
    Secondary Education (OESE) support the implementation of these
    educational stability requirements. OESE staff members work closely
    with State educational agencies (SEAs), Federal staff from the U.S.
    Department of Health and Human Services' Administration on Children and
    Families, and non-Federal partners to encourage interagency
    collaboration through various technical assistance initiatives.
    Further, the Department has not received dedicated funds, such as
    national activity funds under Title I, specifically dedicated to the
    implementation of the educational stability provisions, staff have
    formed partnerships with a number of other Department offices to
    provide technical assistance.
        For example, the Department's National Comprehensive Center has
    dedicated a small portion of its available resources to fund an online,
    collaborative space for SEA foster care points of contact, known as the
    Foster Care Exchange. Through the Foster Care Exchange, SEA foster care
    points of contact can collaborate asynchronously with one another by
    sharing resources, engaging in peer-to-peer learning, and creating a
    network of practitioners. The Foster Care Exchange is a password-
    protected space that is currently only available to SEA foster care
    points of contact; the Department intends to make a future iteration of
    the platform available to State child welfare agency points of contact.
        Additionally, staff in OESE have partnered with the Department's
    Office of the Chief Data Officer (OCDO) to fund a study on interagency
    data-sharing agreements between SEAs and State child welfare agencies.
    This study, which will be completed in fall 2022, examines the
    prevalence and impact of State-level exchanges of data related to
    students in foster care. The Department will produce a series of State
    profiles demonstrating how States of different sizes and resources can
    establish their own data exchanges to improve educational outcomes for
    students in foster care. The Department will use these profiles as a
    key technical assistance tool to encourage States to establish (or
    improve) data exchanges between SEAs and State child welfare agencies.
        Finally, OESE staff frequently present on webinars and at
    conferences about the importance of interagency collaboration to
    effectively support students in foster care. For example, the
    Department hosted a webinar in March 2022 that shared preliminary
    findings from its study on interagency data-sharing agreements (see
    above). The Department will also present three sessions, specifically
    focused on the needs of students in foster care, at the National
    Association for the Education of Homeless Children and Youth's
    (NAEHCY's) annual national conference in fall 2022. (These conference
    sessions will focus on an overview of the Title I, Part A educational
    stability provisions, interagency data-sharing agreements, and best
    interest determinations.) To model interagency collaboration, the
    Department has requested that its partners from the U.S. Department of
    Health and Human Services co-present the sessions at the NAEHCY
    conference. The Department will also present a session at the National
    Association of ESEA State Program Administrators' (NAESPA's) annual
    national conference in February 2023; this presentation will focus on
    the importance of interagency partnerships to improve outcomes students
    in foster care.
        Question. How would additional funds further such partnerships?
        Answer. While the Department has been able to provide technical
    assistance to grantees to support implementation of the Title I, Part A
    educational stability provisions, OESE's capacity to provide such
    technical assistance is limited. As mentioned, two staff members
    support the implementation of these requirements; however, both staff
    members split their time across other Federal programs and, thus, have
    limited bandwidth to focus on OESE's activities related to the foster
    care provisions. Further, while program staff have established
    important partnerships with internal and external stakeholders to
    provide technical assistance to grantees, the absence of a technical
    assistance center--dedicated solely to supporting the implementation of
    the Title I, Part A educational stability provisions and enhancing
    outcomes for students in foster care--limits the breadth and frequency
    of OESE's technical assistance offerings.
        Additional funding that would establish a technical assistance
    center to support the implementation of the Title I, Part A educational
    stability provisions would allow OESE to more consistently and
    strategically provide technical assistance to grantees. The
    establishment of a technical assistance center would further stretch
    our internal capacity unless the Department also had additional funding
    to increase staff capacity for the foster care program. With these
    additional technical assistance resources and the extra staff capacity,
    OESE would be better positioned to continue and expand its
    collaborative efforts with its partners at the U.S. Department of
    Health and Human Services and other non-Federal partners.
        Question. How will you and the Secretary of Health and Human
    Services collaborate on supporting implementation of requirements
    related to remaining in school of origin; making best interest
    determinations; and planning for transportation needed to remain in
    school of origin, among other requirements intended to improve
    education for children in foster care?
        Answer. OESE staff regularly collaborate with partners at the U.S.
    Department of Health and Human Services to share information, to design
    and provide technical assistance to their respective grantees, and to
    coordinate messaging to practitioners and other stakeholders. For
    example, in July 2022 senior leaders from OESE and the Children's
    Bureau jointly authored a blog on the importance of interagency
    collaboration to support students in foster care, and the blog was
    posted simultaneously on the Department's Homeroom Blog and the
    Department of Health and Human Services' Family Room Blog. As mentioned
    previously, staff from both agencies will continue to co-facilitate
    presentations at national conferences to discuss the effective
    implementation of the ESEA provisions related to the educational
    stability of students in foster care. (OESE staff have also presented
    on webinars sponsored by the Children's Bureau about the implementation
    of the Fostering Connections to Success and Increasing Adoptions Act of
    2008, and the Department will continue to support its partners at the
    Department of Health and Human Services in this way.)
        Staff from both agencies meet regularly to share information and
    discuss opportunities for additional collaboration. For the next fiscal
    year, staff hope to undertake several joint projects, including an
    update to the jointly published non-regulatory guidance (published in
    June 2016) and the development of a technical assistance toolkit to
    support the creation and maintenance of interagency data-sharing
    agreements between State and local educational agencies and child
    welfare agencies.
        Question. Please share the Department's plans in fiscal year 2023
    and fiscal year 2024 for supporting, enhancing and monitoring resource
    allocation reviews by state and local education agencies and schools.
        Answer. In spring and summer 2022, the Department is conducting a
    targeted monitoring review of two resource equity provisions: 1) ESEA
    section 1111(d)(3)(A)(ii), which requires an SEA to periodically review
    resource allocation to support school improvement in each LEA in the
    State serving a significant number of schools identified for support
    and improvement; and 2) ESEA section 1111(d)(1)(B), which requires each
    comprehensive support and improvement and additional targeted support
    and improvement plan to identify the resource inequities to be
    addressed in the plan. After the conclusion of those reviews, the
    Department intends to share best practices, findings, and
    recommendations more broadly with all States and determine how to
    further conduct oversight of these important requirements in fiscal
    year 2023.
        In addition to targeted monitoring, all resource equity provisions
    in Title I, Part A are included as part of the Department's
    consolidated monitoring, which is the Office of Elementary and
    Secondary Education's in-depth monitoring protocol that covers several
    formula grant programs and over-arching, cross-program fiscal
    requirements. The Department is currently finalizing its plans
    regarding the number of States that will participate in consolidated
    monitoring in fiscal year 2023.
        Question. Please describe the Department's plan for ensuring states
    and school districts comply with ESSA's policy requiring the reporting
    of actual personnel and non-personnel 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 is taking several steps to ensure that SEAs
    and LEAS meet the report card requirements in ESEA section 1111(h). 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).
        To help ensure SEAs and LEAs comply with applicable requirements, 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, for the past 3 years, the Department has conducted a
    review of each State's website to determine if SEAs and LEAs were in
    compliance with report card requirements, looking at a subset of the
    requirements each year. This work begins in January to review the
    report cards for the prior school year. This year, the Department
    reviewed State websites to look for disaggregated performance and
    participation rate data on State assessments, per-pupil expenditures,
    chronic absenteeism, and (to the extent available) information on
    access to technology consistent with the assurance as part of the
    waiver of accountability and school identification for the 2020-2021
    school year that most States received.
        Based on our review this year, 50 States had posted per pupil
    expenditure data from at least one of the two prior fiscal years. As
    part of its annual review, the Department looked for actual personnel
    and non-personnel expenditures, as well as disaggregation by Federal
    and State and local funds. The Department followed up with any State
    that did not meet these requirements and intends to send letters to
    States that have not posted the required information this summer.
        The Department is also providing on-going technical assistance to
    States to help them improve the collection, reporting, and use of these
    data. We have established communities of practice with States,
    districts, and other stakeholders to discuss these requirements. We ran
    a competition for interested individuals to partner with States to
    design interactive report card websites and to report per-pupil
    expenditure data. Through the Department's National Comprehensive
    Center, we have funded external experts to provide tools and resources
    for States and districts to support the reporting and use of
    expenditure data.
        Question. How many competitive grant programs will include an
    evidence priority in fiscal years 2022 and 2023? Please describe the
    ways in which the Department is supporting or plans to support evidence
    building and use in ESEA formula grant programs.
        Answer. Evidence Use in Fiscal Year 2022 Competitions.--The
    Department uses evidence in many of its grant competitions, either as
    ``entry evidence,'' which involves elements in the application to align
    projects with a particular threshold, or ``exit evidence,'' which is
    defined as elements to develop lessons learned from the review of the
    program interventions.
        For fiscal year 2022, the Department is running 72 discretionary
    grant competitions. 47 competitions include entry evidence requirements
    or priorities, and 11 competitions involve exit evidence. For a more
    detailed breakdown of these requirements, please see the table, below:

    ------------------------------------------------------------------------
                                                             Entry     Exit
    ------------------------------------------------------------------------
    Total.................................................       47       11
    Demonstrates a Rationale..............................       36        -
    Promising Evidence....................................        6        5
    Moderate Evidence.....................................        3        3
    Strong Evidence.......................................        1        3
    Logic Model...........................................        1        -
    ------------------------------------------------------------------------

        The Department continues to support grantees in building and using
    evidence through ESEA formula grant programs. For example, the
    Department prioritized the use of evidence-based interventions in
    Frequently Asked Questions released in February 2022 about implementing
    school accountability systems, given the impact of COVID-19. The
    Department also supports evidence building and use through the
    Comprehensive Center program, which operates 20 Comprehensive Centers,
    including 1 National Center and 19 Regional Centers. The Comprehensive
    Centers provide high-quality universal and targeted capacity-building
    services, including in the area of implementing and scaling evidence-
    based practices, to State educational agencies (SEAs), regional
    educational agencies (REAs), local educational agencies (LEAs), and
    schools to improve educational outcomes for all students, close
    achievement gaps, and improve the quality of instruction. In addition,
    the Comprehensive Centers Network and other technical assistance
    providers identify evidence-based interventions that support states and
    school districts in using evidence in the work supported by their ESEA
    formula grants. In addition, the Institute of Education Sciences (IES)
    administers the Regional Educational Laboratories program, which
    supports ten Regional Educational Laboratories (RELs) that collaborate
    with school districts, state departments of education, and other
    education stakeholders to help these stakeholders translate and apply
    evidence, with the goal of improving learner outcomes.
        Question. In the fiscal year 2023 congressional justification, the
    Department indicated ``The Department also continues to advance its
    data strategy to realize the full potential of data to improve
    education outcomes and lead the nation in a new era of evidence-based
    policy insights and data-driven operations.''
        Please describe the key activities the Department has taken and
    planned to advance this strategy. How will the Department work with
    other Federal agencies to advance the strategy?
        Answer. The Department of Education's Data Strategy--published
    December 2020 and found online here--documents the agency's vision
    along with specific goals and objectives planned for calendar years
    2021 and 2022. As of July 2022, the agency has already achieved 12 of
    its 19 objectives. These accomplishments include improving data
    maturity scores in 93 percent of principal offices; establishing a Data
    Coordinators Council and Data Professionals Community of Practice;
    creating Federal Government's first data literacy program to improve
    basic data skills of all staff; launching the agency's Data Science
    Training Program to upskill 41 existing data staff; conducting an
    internal three-day training conference attended by 400 agency staff to
    improve data visualization skills; and a data workforce plan to guide
    the agency's human capital efforts as it relates to data-related
    positions.
        In that time, the program management office overseeing the Data
    Strategy (the Office of the Chief Data Officer) also oversaw the
    development, launch, and maintenance of emergency and other major data
    solutions. This includes overseeing the Department's emergency data
    collections associated with the Education Stabilization Fund (HEER,
    GEER, ESSER, and OA equivalents), the ESF Public Transparency Portal
    (Education Stabilization Fund), and the College Scorecard (College
    Scorecard | College Scorecard (ed.gov), among others.
        By calendar year-end, the Department also plans to release a Data
    Quality Playbook to help grant managers reduce grantee burden and
    improve data quality; provide recommendations to agency leadership for
    a Data Investment Management process to improve the agency's return on
    data investments; launch the agency's first truly enterprise-wide data
    repository and analytics platform to bridge siloed data assets; publish
    an Open Data Plan informed by public input on how and what the agency
    will prioritize to make its data more accessible; and launch a process
    for external stakeholders to access non-public microdata for research
    purposes.
        By December of 2022, the Department plans to publish a refreshed
    Data Strategy to guide its efforts in forthcoming years. Many of the
    planned initiatives--already in development with other agencies with
    similar customers--focus on enhancing collaboration, reducing cost, and
    improving products across Federal agencies. This will include
    streamlining the administrative processes for data sharing; developing
    solutions to share content and services related to internal workforce
    development programs already developed by ED such as its Data Science
    Training Program; and developing shared public-facing data products key
    life experiences that cut across Federal agencies, its programs, and
    its data.
        Question. Please describe the state-identified challenges the
    Department seeks to address through the proposed 2 percent technical
    assistance and capacity building set-aside for English Acquisition
    State grants.
        Answer. The Title III, Part A formula grant program continues to
    receive feedback from our state grantees that more technical assistance
    is needed to support the use of evidence-based practices and to build
    State and local capacity to implement their formula grant funds. In
    reviewing the Grantee Satisfaction Results for the Title III, Part A
    program, questions about satisfaction with ED's technical assistance,
    products, and services have received marks that are below those of
    programs with established Technical Assistance centers.
        There are many factors that make the Title III, Part A formula
    program particularly challenging for States to implement, including the
    crossover with Civil Rights requirements that must be implemented
    irrespective of the availability of these funds and the prohibition on
    using Title III, Part A formula grant funds to supplant not only State
    and local funds, but also other Federal funds. Furthermore, the data
    reporting requirements for this program are among the most complex
    across the Office of Elementary and Secondary Education's (OESE's)
    formula grant data collections. Due to these challenges, States and
    districts may hesitate to explore more innovative and evidence-based
    uses of these funds to meet the needs of English learners, defaulting
    to a limited suite of activities that have not raised concerns in past
    monitoring reviews and outreach from ED.
        Staff capacity in the Title III, Part A formula program has
    increased slightly in the past year but still falls well below what is
    necessary to provide proactive technical assistance to our grantees in
    order to clarify the requirements of the grant and highlight evidence-
    based practices that could potentially be allowable uses of funds. The
    National Clearinghouse for English Language Acquisition and Language
    Instruction Educational Program (NCELA) disseminates important
    information on practices for English learners to the field, but the
    statute limits its funding to $2 million and its work to targeted
    areas, primarily dissemination of information. For these reasons and
    more, ED is looking to use this set-aside to provide more timely and
    tailored technical assistance for the Title III, Part A formula grant
    program as well as create opportunities for State grantees to
    collaborate with each other to learn about and share evidence-based
    practices.
        Question. How would the proposal to focus $320 million within the
    Education Innovation and Research program on improving educator
    recruitment and retention be designed to ensure projects address the
    disproportionate numbers of low-income students and students of color
    being taught by less experienced and effective teachers?
        Answer. The Department recognizes that shortages of certified and
    experienced educators disproportionately affect low-income students and
    students of color. To address these disparities, which the pandemic has
    exacerbated, the Department could give priority for funds under the
    requested $320 million to applicants that propose to develop and
    implement innovative educator recruitment and retention strategies in
    areas with concentrations of these students.
        Question. A recent review of states' report cards showed that
    states largely failed to provide context for how schools are supporting
    students during recovery and, if data is not available, explain why.
    Public-facing report cards have been a requirement for states for 20
    years since the passage of No Child Left Behind. When ESEA was
    reauthorized in 2015, the Every Student Succeeds Act required states to
    include additional student groups in their report cards. This year, 28
    states disaggregated achievement data by all federally required student
    groups--an increase of three from 2019. However, while nine states
    added this information to their report cards, six states removed it. Of
    the 43 states that had already published 2021 report cards: 16 states
    did not include 2021 assessment data; 25 states did not include 2021
    high school graduation rates; 26 states did not include 2020-21 chronic
    absenteeism data. Of the 25 states that included some form of
    translation, only 7 states had translations that were considered high
    quality.
        Please describe the Department's work to monitor states'
    implementation of the annual public report card requirement under ESEA
    as well as the additional technical assistance and support the
    Department will provide to ensure every state is meeting all of the
    report card requirements specified in ESEA, including disaggregation
    requirements and also providing this information to the public in an
    accessible, understandable, and up-to-date format?
        Answer. The Department is taking several steps to ensure that SEAs
    and LEAS meet the report card requirements in ESEA section 1111(h). 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).
        To help ensure SEAs and LEAs comply with applicable requirements, 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, for the past 3 years, the Department has conducted a
    review of each State's website to determine if States and districts
    were in compliance with report card requirements, looking at a subset
    of the requirements each year. This work begins in January to review
    the report cards for the prior school year. This year, the Department
    reviewed State websites to look for disaggregated performance and
    participation rate data on State assessments, per-pupil expenditures,
    chronic absenteeism, and (to the extent available) information on
    access to technology consistent with the assurance as part of the
    waiver of accountability and school identification for the 2020-2021
    school year that most States received.
        We believe the information provided in this question is based on a
    report from the Data Quality Campaign that is based on a review of data
    in February 2022. While accurate at the time, it is no longer accurate.
    All States have posted disaggregated achievement data, though in some
    cases, the data was posted significantly later than in prior years,
    likely due to fall administration of assessments from the 2020-2021
    school year and challenges related to COVID-19. Of those, 41 States (of
    50 required to post assessment data for that year) posted assessment
    data for all subgroups, including the new subgroups that are required
    under the ESEA, as amended by ESSA.
        Regarding chronic absenteeism, this information is typically not
    required to be on State and local report cards, though it was a
    condition of the accountability waivers that were provided to most
    States for the 2020-2021 school year. Based on our review of State
    websites, 46 States posted disaggregated chronic absenteeism or
    attendance data and one State posted attendance data for all students
    but not disaggregated.
        Following the Department's initial review of selected requirements
    in January 2021, the Department has followed up with each State
    regarding the status of its report card and any missing requirements.
    The Department intends to send letters to each State that is still
    missing any required element from our 2020-2021 report card review this
    summer.
        Question. The Biden Administration required states to resume the
    ESEA requirement to annually assess students in mathematics and
    English/language arts for the 2020-2021 school year and to maintain all
    state and local report card requirements, including the requirements to
    publish disaggregated data by student subgroup. However, according to
    recent analysis, only seventeen states published both disaggregated
    data and complete participation information for the 2020-21 school year
    assessments, meaning thirty-four states (including D.C.) did not
    provide the federally required data on student performance in each
    grade and participation information across student groups. Seven states
    only published overall proficiency data, and three states did not
    publicly release any performance data.
        Please describe the steps the Department is taking to ensure states
    that remain in non-compliance do expeditiously comply with these
    requirements from the 2020-21 school year. In addition, please describe
    the steps you are taking to support states in meeting these
    requirements in a timely manner for the 2021-22 school year.
        Answer. We believe the information provided in this question is
    based on a report from the Data Quality Campaign that is based on a
    review of data in February 2022. While accurate at the time, it is no
    longer accurate. Each year since the implementation of ESSA, the
    Department has conducted a review of State and local report cards.
    Beginning in January each year and continuing throughout the spring,
    the Department conducts reviews of select report card requirements.
    This year, the review focused on whether the State had reported
    disaggregated participation and performance data on State assessments,
    chronic absenteeism data, and per-pupil expenditure data. Following the
    Department's initial review of selected requirements in January 202,
    the Department contacted each State regarding the status of its report
    card and any missing requirements and has conducted follow up with each
    State. Every State has published disaggregated assessment data, though
    a small number have not published data for all required student
    subgroups. The Department has continued to follow up with each State.
    Most recently, we sent a letter in August to the 11 States that are
    still missing any required element from our 2020-2021 report card
    review. The State is required to respond demonstrating within 30 days
    that the issue has been resolved and, once the 2021-2022 report cards
    are published this fall or winter, to provide documentation that the
    State report card includes information currently missing on the 2020-
    2021 report cards. The Department will once again review State and
    local report cards in January 2022 for the 2021-2022 school year.
        Question. When Congress reauthorized the Elementary and Secondary
    Education Act in 2015, Congress included multiple provisions to help
    alleviate the burden of standardized testing on states and school
    districts. For example, ESEA includes provisions that allow states to
    administer the statewide assessment in multiple statewide interim
    assessments during the course of a school year, so long as these
    interim assessments aggregate into a summative score. The law also
    permits states to use assessments that include portfolios and extended
    performance tasks. ESEA also allows for states to utilize computer
    adaptive assessments that meet certain Federal guardrails. ESEA also
    provided authority for states to conduct audits of state and local
    assessment systems to reduce duplicative and unnecessary assessments.
    Congress also authorized the Innovative Assessment Demonstration
    Authority (IADA), with key civil rights and equity guardrails to
    provide states with the authority to innovative in the assessment
    space. Finally, Congress reauthorized funding for assessment design
    including competitive grants for states and districts to improve their
    assessment systems. To date, it does not appear many states have
    utilized many of these flexibilities and authorities, despite calls for
    even more flexibility in assessments. Please answer the following:
        How many states are utilizing through course assessments in their
    statewide assessment systems?
        Answer. The Department does not annually collect information from
    every State regarding this fine-grained a detail on assessment designs.
    We know that some States have either begun to implement assessments
    that could be described as ``through course'' or ``through year''
    assessments (e.g., Nebraska, Maine--though both currently administer
    the assessments at multiple points during the year but use only the
    final administration as the summative score for the student). We know
    Florida, and perhaps others, are planning to implement a through course
    design. Two States (Georgia, Louisiana) are piloting similar designs
    through the Innovative Assessment Demonstration Authority (IADA).
        Question. How many states are using computer adaptive assessments
    in their statewide assessment systems?
        Answer. As noted above, the Department currently does not annually
    collect information from every State regarding this fine-grained a
    detail on assessment designs, so our information is incomplete. We know
    that at least 14 States are using a common assessment (Smarter
    Balanced) that is a computer adaptive test. There are several other
    States that have their own tests in reading/language arts and
    mathematics (e.g., Michigan, Kansas) that are based on an adaptive
    design.
        We also know that at least 21 States are using a computer adaptive
    test for alternate assessments of alternate academic achievement
    standards (AA-AAAS) for students with the most significant cognitive
    disabilities (Dynamic Learning Maps). More than 40 States use the WIDA
    Access English language proficiency assessment for English Learners,
    which has adaptive components to it.
        Question. How many states are utilizing portfolios and extended
    performance tasks in their statewide assessments as allowed under the
    law?
        Answer. Again, the Department currently does not annually collect
    information from every State regarding this fine-grained a detail on
    assessment designs, so our information is incomplete. The Department
    knows of two States (Massachusetts, Florida) using portfolios as part
    of their AA-AAAS. Massachusetts is piloting the development of extended
    performance tasks in science as part of its IADA plan, which was
    approved in 2020. New Hampshire was piloting a system of locally based
    extended performance tasks from 2015-19 under a series of waivers and
    then IADA, for which it was approved in 2018. New Hampshire withdrew
    from IADA in the 2021-22 school year (see https://oese.ed.gov/files/
    2022/04/NHIADAWithdrawal3.9.2022.pdf) citing, in part, the significant
    administrative burden on educators and school leaders that detracted
    from instructional time, the cost to implement, and because the pilot
    assessments fell short of expectations for assessment quality.
        Question. How many states have conducted audits of the assessment
    systems and as a result of those audits, made changes to their state
    and local assessment systems?
        Answer. States are not required to provide information to the
    Department regarding assessment system audits. The Department is
    unaware of any State that has recently conducted an assessment audit.
    Conducting assessment audits is a permitted activity under Section 1203
    of the ESEA.
        Question. Please provide an update on implementation of the IADA
    and any plans to make recommendations for changes to that program.
        Answer. In 2018, two States (New Hampshire and Louisiana) were
    approved for IADA. In 2019, Georgia and North Carolina were approved.
    In 2020, Massachusetts received IADA. In 2021, no States applied to a
    Notice Inviting Applications (NIA) for IADA. During the Covid pandemic,
    the States were unable to administer their IADA proposals for the 2019-
    2020 and 2020-2021 school years. As noted above, this past year New
    Hampshire notified the Department that it would no longer be
    implementing its IADA proposal.
        In addition to the States that have IADA, Hawaii was awarded a
    Competitive Grant for State Assessments (CGSA) in 2020 to support
    planning for a future IADA application. The Institute for Education
    Sciences is working to complete a report for Congress on the initial
    implementation of the IADA, which will inform future decisions
    regarding IADA.
        Question. Please provide an update on how the Department is using
    the funding Congress provided for assessment development in last year's
    bill to encourage states to improve their statewide assessments to
    provide more timely and relevant data to educators and stakeholders.
        Answer. On February 16, 2022, the Department released a Notice
    Inviting Applications (see https://www.Federalregister.gov/documents/
    2022/02/16/2022-03290/applications-for-new-awards-competitive-grants-
    for-state-assessments-program) to award grants to States for the
    purpose of improving Statewide assessments. The NIA included the two
    priorities established by Congress for the use of these funds: (1) the
    use of multiple measures, and (2) the development of comprehensive
    academic instruments based upon a competency based educational model.
    The NIA also included a competitive priority that incentivized projects
    to improve the reporting of timely and relevant data to educators and
    stakeholders. The Department combined the $20.9 million appropriated by
    Congress for fiscal year 2022 with $8.8 million set aside from fiscal
    year 2021 to fund worthy projects. In May 2022, 16 States submitted
    applications. The Department conducted a peer review of the
    applications and we anticipate announcing awards for these funds by
    September 2022.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        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. Last month, the Department provided widespread relief to
    Corinthian Colleges students through group borrower defense discharge.
    This relief totaled $5.8 billion for 560,000 borrowers--regardless of
    whether they submitted a borrower defense application--and represents
    the largest single loan discharge in the history of the Department. I
    applaud the Department for taking steps to offer group borrower defense
    discharge to students, including former Corinthian Colleges and
    Marinello Schools of Beauty students. These students were misled by
    unscrupulous for-profit colleges, and they are not the only students
    who are crippled with student loan debt and a worthless degree. Since
    the closure of Corinthian, I have urged the Department to ensure that
    students are not left holding the bag, and I have supported group
    borrower defense discharge early on for students who have been
    defrauded by for-profit colleges. For example, I recently sent a follow
    up letter to the Department urging it to provide group discharge for
    former Illinois Westwood College students who were enrolled in the
    criminal justice program. Please provide, disaggregated for ITT
    Educational Services, Inc., Charlotte School of Law, Education
    Corporation of America, Vatterott Colleges, and Dream Center Education
    Holdings, respectively:
        The number of borrower defense applications that have been
    received, approved, denied, ineligible, and closed;
        Answer. The requested data is provided in the below chart.

    ----------------------------------------------------------------------------------------------------------------
                                                          Denied
         School/Ownership Group          Approved      (Ineligible)       Closed          Pending     Total Received
    ----------------------------------------------------------------------------------------------------------------
    Charlotte School of Law.........               0               0             <50           1,300           1,300
    ECA.............................               0           2,100             100           6,800           9,000
    Dream Center....................               0           2,000             100           7,200           9,300
    ITT Technical Institute.........          22,700           6,600           1,000          16,300          46,600
    Vatterott College...............               0             500             <50           1,000           1,600
    ----------------------------------------------------------------------------------------------------------------
    Cases pulled using the fields School Owner or Primary School from the Customer Engagement Management System in
      July 2022 (except ECA, which was based on a list of OPE IDs).
    Data has been rounded to the nearest 100 cases, and small cell sizes have been redacted. Due to rounding, totals
      may not sum as expected.
    Data was retrieved from Customer Engagement Management System in July 2022.

        Question. The total loan amount of such borrowers for whom the
    Department estimates are eligible for group borrower defense discharge;
        Answer. None of these school ownership groups have been identified
    for group borrower defense discharge.
        Question. The number of borrowers and the total loan amount that
    has been discharged through a borrower submitting a borrower defense
    application;
        Answer. 15,500 ITT borrowers with an approved borrower defense
    application have received approximately $371 million in loan discharges
    directly associated with an ITT loan. An additional 4,500 ITT borrowers
    have received approximately $120 million in loan discharges associated
    with a consolidation loan.
        Question. And the number of borrowers and the total loan amount
    that has been discharged through group borrower defense discharge.
        Answer. None of these school ownership groups have been identified
    for group borrower defense discharge.
        Question. Since June 2018, the Department has released borrower
    defense data on a quarterly basis:
        Please provide the reason that no data has been released for 2022.
        Answer. Borrower defense data through June 30, 2022 is currently
    available on FSA's Data Center at studentaid.gov/data-center/student/
    loan-forgiveness/borrower-defense-data.
        Question. Please provide a breakdown of ``total denied'' borrower
    defense claims to date by institution.
        Answer. An Excel file providing the requested data as of mid-May
    2022 is enclosed.

    Denied Borrower Defense Applications by Institution as of May 2022 Note:
                       Totals may not sum due to rounding.
    ------------------------------------------------------------------------
                                                                  Rounded
         OPEID                     School Name                  Ineligible
                                                                Case Count
    ------------------------------------------------------------------------
            020988   UNIVERSITY OF PHOENIX..................           20080
            010727   DEVRY UNIVERSITY.......................            7400
            001499   ALTIERUS CAREER COLLEGE................            4720
            004586   PURDUE UNIVERSITY GLOBAL...............            4070
            030106   VIRGINIA COLLEGE.......................            2120
            007234   HEALD COLLEGE..........................            2070
            007329   ITT TECHNICAL INSTITUTE................            1910
            001881   ASHFORD UNIVERSITY.....................            1450
            009157   WYOTECH................................            1430
            021136   AMERICAN INTERCONTINENTAL UNIVERSITY...            1420
            001534   Everest University.....................            1410
            011858   EVEREST COLLEGE........................            1390
            023001   ALTIERUS CAREER COLLEGE................            1350
            010148   COLORADO TECHNICAL UNIVERSITY..........            1330
            009079   EVEREST COLLEGE........................            1310
            009828   ALTIERUS CAREER EDUCATION..............            1260
            021799   ARGOSY UNIVERSITY......................            1110
            030314   SANFORD-BROWN COLLEGE..................            1000
            008090   EVEREST COLLEGE........................             960
            021160   SANFORD-BROWN COLLEGE..................             910
            020754   Keller Graduate School of Management...             900
            007470   ART INSTITUTE OF PITTSBURGH (THE)......             870
            008532   Heald College..........................             830
            021004   EVEREST INSTITUTE......................             830
            004646   MINNESOTA SCHOOL OF BUSINESS...........             760
            004503   ALTIERUS CAREER COLLEGE................             760
            022613   ALTIERUS CAREER COLLEGE................             740
            026175   ALTIERUS CAREER COLLEGE................             680
            001123   BROOKS INSTITUTE.......................             660
            011109   EVEREST COLLEGE........................             650
            008146   Everest University--Pompano Beach......             620
            025042   WALDEN UNIVERSITY......................             610
            008093   Heald College..........................             610
            025693   LE CORDON BLEU COLLEGE OF CULINARY ARTS             600
            007190   WYOTECH................................             590
            022052   SANFORD-BROWN COLLEGE..................             580
            001459   STRAYER UNIVERSITY.....................             580
            021875   Heald College..........................             580
            025933   Heald College..........................             580
            025932   Heald College..........................             570
            023621   FULL SAIL UNIVERSITY...................             560
            022631   ANTHEM COLLEGE.........................             560
            032103   LE CORDON BLEU COLLEGE OF CULINARY ARTS             560
            004811   EVEREST INSTITUTE......................             560
            021519   KEISER UNIVERSITY......................             550
            012873   WYOTECH................................             540
            025998   Everest University.....................             540
            026167   LE CORDON BLEU COLLEGE OF CULINARY ARTS             530
            009267   ALTIERUS CAREER COLLEGE................             520
            030226   LE CORDON BLEU COLLEGE OF CULINARY ARTS             510
            026062   EVEREST COLLEGE........................             510
            030723   EVEREST COLLEGE........................             510
            021603   SANFORD-BROWN COLLEGE..................             500
            010356   EVEREST INSTITUTE......................             500
            004507   ALTIERUS CAREER COLLEGE................             480
            011123   EVEREST COLLEGE........................             480
            004642   GLOBE UNIVERSITY.......................             470
            033953   ICDC COLLEGE...........................             470
            032673   CAPELLA UNIVERSITY.....................             470
            025931   Heald College..........................             460
            022932   ATI CAREER TRAINING CENTER.............             450
            030032   Everest Institute......................             450
            030764   BRYMAN SCHOOL OF ARIZONA (THE).........             450
            022375   LAS VEGAS COLLEGE......................             440
            022950   EVEREST COLLEGE PHOENIX................             440
            021218   Everest Institute......................             430
            007236   Art Institute of California--Los                    420
                      Angeles (The).........................
            007477   Heald College..........................             410
            007531   ACADEMY OF ART UNIVERSITY..............             400
            010195   ART INSTITUTE OF FORT LAUDERDALE (THE).             400
            026164   SANFORD-BROWN COLLEGE..................             400
            008350   ART INSTITUTE OF PHILADELPHIA (THE) -..             390
            025997   VATTEROTT COLLEGE......................             390
            022506   EVEREST COLLEGE........................             390
            030340   Heald College..........................             380
            023058   FLORIDA CAREER COLLEGE.................             360
            008221   UNIVERSAL TECHNICAL INSTITUTE..........             350
            005127   Brown Mackie College-Cincinnati........             340
            010490   REGENCY BEAUTY INSTITUTE...............             340
            007327   ITT Technical Institute................             340
            009270   ART INSTITUTE OF ATLANTA (THE).........             340
            025911   CAREER POINT COLLEGE...................             340
            020789   ART INSTITUTE OF COLORADO (THE)........             330
            011024   BRYMAN COLLEGE.........................             330
            012584   ILLINOIS INSTITUTE OF ART (THE)........             320
            021584   HARRISON COLLEGE.......................             310
            008329   ITT Technical Institute................             310
            030727   WESTWOOD COLLEGE--LOS ANGELES..........             310
            011626   WESTWOOD COLLEGE--SOUTH BAY............             300
            011510   EVEREST INSTITUTE......................             300
            026110   HERITAGE COLLEGE.......................             290
            030068   LE CORDON BLEU INSTITUTE OF CULINARY                290
                      ARTS..................................
            022865   ITT Technical Institute................             290
            007362   MEDTECH COLLEGE........................             270
            013039   SOUTH UNIVERSITY.......................             270
            030734   ITT Technical Institute................             270
            011107   EVEREST COLLEGE........................             270
            009748   CARRINGTON COLLEGE.....................             260
            021749   Collins College........................             260
            035493   ULTIMATE MEDICAL ACADEMY...............             260
            038323   DADE MEDICAL COLLEGE...................             260
            007548   WESTWOOD COLLEGE--DENVER NORTH.........             260
            022985   EVEREST COLLEGE........................             260
            010627   ITT Technical Institute................             250
            023598   ITT Technical Institute................             250
            040513   ART INSTITUTE OF LAS VEGAS (THE).......             250
            023522   LE CORDON BLEU COLLEGE OF CULINARY ARTS             240
                      IN CHICAGO............................
            033803   STAR CAREER ACADEMY....................             230
            003807   MOUNTAIN STATE UNIVERSITY..............             220
            007351   SANFORD-BROWN COLLEGE..................             220
            007091   EVEREST INSTITUTE......................             220
            002678   BRYANT & STRATTON COLLEGE..............             200
            021005   UNIVERSAL TECHNICAL INSTITUTE..........             200
            023276   Art Institute of California--San Diego.             200
            025593   UNITED EDUCATION INSTITUTE.............             200
            026142   MILLER--MOTTE TECHNICAL COLLEGE........             200
            007557   ITT Technical Institute................             200
            007804   STAR CAREER ACADEMY....................             190
            022913   ART INSTITUTE OF SEATTLE (THE).........             190
            026150   SANFORD-BROWN COLLEGE..................             190
            004494   EVEREST COLLEGE........................             190
            010248   ART INSTITUTES INTERNATIONAL MINNESOTA              180
                      (THE).................................
            020757   BRIARCLIFFE COLLEGE....................             180
            022023   PITTSBURGH CAREER INSTITUTE............             180
            004898   MCCANN SCHOOL OF BUSINESS & TECHNOLOGY.             170
            012461   LINCOLN TECHNICAL INSTITUTE............             170
            021171   ART INSTITUTE OF HOUSTON (THE).........             170
            022915   ITT Technical Institute................             170
            023218   ITT Technical Institute................             170
            030876   ITT Technical Institute................             170
            004583   Brown Mackie College-South Bend........             160
            031151   HERITAGE COLLEGE.......................             160
            023217   ITT Technical Institute................             160
            002667   DOWLING COLLEGE........................             150
            004729   MOUNT WASHINGTON COLLEGE...............             150
            007819   ART INSTITUTE OF PORTLAND (THE)........             150
            020652   ITT Technical Institute................             150
            022202   LE CORDON BLEU COLLEGE OF CULINARY ARTS             150
            022392   ANTHEM COLLEGE.........................             150
            023462   WYOTECH................................             150
            025971   HERITAGE INSTITUTE.....................             150
            023610   ITT Technical Institute................             150
            030875   ITT Technical Institute................             150
            008694   RASMUSSEN UNIVERSITY...................             140
            009088   ITT Technical Institute................             140
            023286   ITT Technical Institute................             140
            025256   ART INSTITUTE OF NEW YORK CITY (THE)...             140
            030265   REMINGTON COLLEGE......................             140
            030623   WESTECH COLLEGE........................             140
            030704   ITT Technical Institute................             140
            030846   Art Institute of Las Vegas (The).......             140
            007486   NEW ENGLAND INSTITUTE OF ART (THE).....             140
            009837   ITT Technical Institute................             140
            004992   MILLER-MOTTE TECHNICAL COLLEGE.........             130
            021207   SAN JOAQUIN VALLEY COLLEGE.............             130
            023611   ITT Technical Institute................             130
            025396   Art Institute of Dallas (The)..........             130
            035343   JONES INTERNATIONAL UNIVERSITY.........             130
            022916   ITT Technical Institute................             130
            004673   BAKER COLLEGE..........................             120
            020655   BROOKS COLLEGE.........................             120
            021105   Art Institute of Charlotte (The).......             120
            022171   PIMA MEDICAL INSTITUTE.................             120
            025321   BUSINESS CAREER TRAINING INSTITUTE.....             120
            025889   MEDTECH COLLEGE........................             120
            031623   FOUR-D COLLEGE.........................             120
            004553   ITT Technical Institute................             120
            031954   EVEREST COLLEGE........................             120
            008878   MIAMI INTERNATIONAL UNIVERSITY OF ART &             110
                      DESIGN................................
            009420   SANFORD-BROWN COLLEGE..................             110
            011574   BAUDER COLLEGE.........................             110
            011852   ITT Technical Institute................             110
            020530   LIBERTY UNIVERSITY.....................             110
            022159   ATI CAREER TRAINING CENTER.............             110
            023620   UNIVERSAL TECHNICAL INSTITUTE..........             110
            030718   ITT TECHNICAL INSTITUTE................             110
            001583   MORRIS BROWN COLLEGE...................             100
            002704   COLLEGE OF NEW ROCHELLE (THE)..........             100
            007586   Remington College--Tampa Campus........             100
            009777   KAPLAN COLLEGE.........................             100
            011647   SBI CAMPUS--AN AFFILIATE OF SANFORD-                100
                      BROWN.................................
            023219   ITT Technical Institute................             100
            023329   DeVry Institute of Technology..........             100
            023344   CENTURA COLLEGE........................             100
            001509   NOVA SOUTHEASTERN UNIVERSITY-DAVIE.....              90
            007303   LINCOLN TECHNICAL INSTITUTE............              90
            008441   ANTHEM INSTITUTE.......................              90
            009224   Devry Institute of Technology..........              90
            021006   CARRINGTON COLLEGE.....................              90
            021209   ITT Technical Institute................              90
            022187   Florida Technical College..............              90
            022188   BROOKLINE COLLEGE......................              90
            025594   INTERCOAST COLLEGES....................              90
            026055   Remington College--Mobile Campus.......              90
            026162   Brown Mackie College-Findlay...........              90
            030714   ITT Technical Institute................              90
            002937   KING'S COLLEGE.........................              80
            003076   Miami--Jacobs Career College...........              80
            006755   BROWN MACKIE COLLEGE (THE -)...........              80
            008443   ITT Technical Institute................              80
            008889   LEHIGH VALLEY COLLEGE..................              80
            010217   International Academy of Design and                  80
                      Technology............................
            034264   ANTHEM INSTITUTE.......................              80
            002249   DAVENPORT UNIVERSITY...................              70
            002580   SOUTHERN NEW HAMPSHIRE UNIVERSITY......              70
            008322   DeVry Institute of Technology..........              70
            009228   DeVry College of Technology............              70
            010913   MADISON MEDIA INSTITUTE................              70
            012877   SANFORD-BROWN COLLEGE..................              70
            020552   HARRINGTON COLLEGE OF DESIGN...........              70
            021123   RIDLEY--LOWELL BUSINESS & TECHNICAL                  70
                      INSTITUTE.............................
            021279   SOJOURNER-DOUGLASS COLLEGE.............              70
            022788   SOUTHERN TECHNICAL COLLEGE.............              70
            025769   CHARTER COLLEGE........................              70
            026092   VATTEROTT COLLEGE......................              70
            026149   SANFORD-BROWN INSTITUTE................              70
            030897   CAREER INSTITUTE OF HEALTH AND                       70
                      TECHNOLOGY............................
            030955   ASA COLLEGE............................              70
            032323   Lincoln Technical Institute............              70
            037563   ANAMARC COLLEGE........................              70
            030874   ITT Technical Institute................              70
            001448   HOWARD UNIVERSITY......................              60
            002455   Devry Institute of Technology..........              60
            003642   TEXAS SOUTHERN UNIVERSITY..............              60
            007481   SANFORD-BROWN COLLEGE..................              60
            007506   Lincoln Technical Institute............              60
            009621   HERZING UNIVERSITY.....................              60
            009982   VICTORY UNIVERSITY.....................              60
            010057   AMERICAN COMMERCIAL COLLEGE............              60
            010779   PORTER AND CHESTER INSTITUTE...........              60
            011112   FASHION INSTITUTE OF DESIGN &                        60
                      MERCHANDISING -.......................
            011121   BRYMAN COLLEGE.........................              60
            021032   BROWN MACKIE COLLEGE-MERRILLVILLE......              60
            021715   WESTERN INTERNATIONAL UNIVERSITY.......              60
            022418   AMERICAN CAREER COLLEGE................              60
            022662   HELMS CAREER INSTITUTE.................              60
            022838   BEAUTY SCHOOLS OF AMERICA..............              60
            025720   VISTA COLLEGE..........................              60
            030777   DECKER COLLEGE.........................              60
            038094   MICROPOWER CAREER INSTITUTE............              60
            038193   AMERICAN PUBLIC UNIVERSITY SYSTEM......              60
            012061   BRYMAN COLLEGE.........................              60
            023186   EVEREST INSTITUTE......................              60
            001081   ARIZONA STATE UNIVERSITY...............              50
            001401   POST UNIVERSITY........................              50
            001746   Robert Morris University Illinois......              50
            003099   Devry Institute of Technology..........              50
            003191   CONCORDIA UNIVERSITY...................              50
            007297   SPARTAN COLLEGE OF AERONAUTICS AND                   50
                      TECHNOLOGY............................
            007405   WOOD TOBE--COBURN SCHOOL...............              50
            007501   VATTEROTT COLLEGE......................              50
            007678   SPARTAN COLLEGE OF AERONAUTICS AND                   50
                      TECHNOLOGY............................
            010059   AMERICAN COMMERCIAL COLLEGE............              50
            010351   PSI INSTITUTE..........................              50
            021483   MANHATTAN BEAUTY SCHOOL................              50
            025829   KAPLAN CAREER INSTITUTE................              50
            030353   SOUTHERN CAREERS INSTITUTE.............              50
            030911   ACT COLLEGE............................              50
            031131   MARIC COLLEGE..........................              50
            031254   Art Institute of California-Hollywood                50
                      (The).................................
            032783   CHARTER COLLEGE........................              50
            032943   BLUE CLIFF COLLEGE.....................              50
            033394   WESTERN GOVERNORS UNIVERSITY...........              50
            033484   MATTIA COLLEGE.........................              50
            001328   UNIVERSITY OF SOUTHERN CALIFORNIA......              40
            001467   BETHUNE COOKMAN UNIVERSITY.............              40
            001497   JONES COLLEGE..........................              40
            002193   MOUNT IDA COLLEGE......................              40
            002410   JACKSON STATE UNIVERSITY...............              40
            002521   WEBSTER UNIVERSITY.....................              40
            002629   RUTGERS, THE STATE UNIVERSITY OF NEW                 40
                      JERSEY................................
            002751   LONG ISLAND UNIVERSITY.................              40
            003329   PENNSYLVANIA STATE UNIVERSITY (THE)....              40
            003404   JOHNSON & WALES UNIVERSITY.............              40
            004730   MCINTOSH COLLEGE.......................              40
            004731   DANIEL WEBSTER COLLEGE.................              40
            004799   MONROE COLLEGE.........................              40
            005203   Remington College--Lafayette Campus....              40
            007777   Remington College--Cleveland Campus....              40
            007814   BROOKSTONE COLLEGE OF BUSINESS.........              40
            008537   CONCORDE CAREER COLLEGE................              40
            009635   FLORIDA INTERNATIONAL UNIVERSITY.......              40
            010139   DeVry Institute of Technology..........              40
            010198   ECPI UNIVERSITY........................              40
            011005   KAPLAN COLLEGE.........................              40
            011460   NATIONAL UNIVERSITY--LA JOLLA..........              40
            011644   UNIVERSITY OF MARYLAND GLOBAL CAMPUS...              40
            012891   ANTONELLI COLLEGE......................              40
            021151   BUTLER BUSINESS SCHOOL.................              40
            021368   AMERICAN COMMERCIAL COLLEGE............              40
            022008   AMERICAN COMMERCIAL COLLEGE............              40
            022949   INSTITUTE OF AUDIO RESEARCH............              40
            023287   ITT TECHNICAL INSTITUTE................              40
            025154   CITY COLLEGE...........................              40
            025412   STRATFORD UNIVERSITY...................              40
            025654   KAPLAN COLLEGE.........................              40
            030306   CORTIVA INSTITUTE......................              40
            030358   HERITAGE INSTITUTE.....................              40
            030425   CARRINGTON COLLEGE.....................              40
            030427   LAURUS TECHNICAL INSTITUTE.............              40
            030445   KAPLAN COLLEGE.........................              40
            030675   INSTITUTE OF TECHNOLOGY................              40
            031133   UEI COLLEGE............................              40
            031239   SOUTHEASTERN COLLEGE...................              40
            031281   COLLEGE OF HEALTH CARE PROFESSIONS                   40
                      (THE).................................
            033903   LINCOLN TECHNICAL INSTITUTE............              40
            033993   BRYAN COLLEGE..........................              40
            038133   NORTHCENTRAL UNIVERSITY................              40
            039035   SOUTHERN TECHNICAL COLLEGE.............              40
            041215   COLUMBIA SOUTHERN UNIVERSITY...........              40
            041900   RADIANS COLLEGE........................              40
            007606   BRYMAN COLLEGE.........................              40
            030792   WESTWOOD COLLEGE--DUPAGE...............              40
            001083   UNIVERSITY OF ARIZONA (THE)............              30
            001480   FLORIDA AGRICULTURAL & MECHANICAL                    30
                      UNIVERSITY............................
            001665   COLUMBIA COLLEGE CHICAGO...............              30
            002284   MARYGROVE COLLEGE......................              30
            002329   WAYNE STATE UNIVERSITY.................              30
            002456   COLUMBIA COLLEGE.......................              30
            002772   MERCY COLLEGE..........................              30
            002785   NEW YORK UNIVERSITY....................              30
            003043   CHANCELLOR UNIVERSITY..................              30
            003051   KENT STATE UNIVERSITY..................              30
            003123   UNIVERSITY OF AKRON (THE)..............              30
            004617   NATIONAL COLLEGE.......................              30
            004625   DELGADO COMMUNITY COLLEGE..............              30
            004893   DUBOIS BUSINESS COLLEGE................              30
            007394   BERKELEY COLLEGE.......................              30
            007484   NEWBURY COLLEGE........................              30
            007931   PACIFIC TRAVEL TRADE SCHOOL--MAIN                    30
                      CAMPUS................................
            008417   STENOTYPE INSTITUTE OF JACKSONVILLE....              30
            008871   CONCORDE CAREER COLLEGE................              30
            009268   KELSEY -JENNEY COLLEGE.................              30
            010405   PINNACLE CAREER INSTITUTE..............              30
            012482   ATI TECHNICAL TRAINING CENTER..........              30
            020712   KAPLAN COLLEGE.........................              30
            021066   AMERICAN INSTITUTE.....................              30
            021192   COURT REPORTING INSTITUTE OF ST LOUIS..              30
            021283   INSTITUTE FOR BUSINESS & TECHNOLOGY....              30
            021316   PENNCO TECH............................              30
            021571   CONCORDE CAREER COLLEGE................              30
            021676   KAPLAN COLLEGE.........................              30
            021785   EAGLE GATE COLLEGE.....................              30
            022539   Berks Technical Institute..............              30
            023013   PRISM CAREER INSTITUTE.................              30
            024915   SOUTHWEST UNIVERSITY OF VISUAL ARTS....              30
            025389   INTERNATIONAL BUSINESS COLLEGE-........              30
            025476   FLORIDA NATIONAL UNIVERSITY............              30
            025762   MID-CONTINENT UNIVERSITY...............              30
            025982   UNIVERSITY OF SOUTHERNMOST FLORIDA.....              30
            026068   Career Technical College...............              30
            030121   REMINGTON COLLEGE......................              30
            031085   EVERGLADES UNIVERSITY..................              30
            031100   ACADEMY OF HEALING ARTS................              30
            031264   Centura College........................              30
            033683   MIDWEST TECHNICAL INSTITUTE............              30
            034254   CENTRAL FLORIDA INSTITUTE..............              30
            034483   BUSINESS INDUSTRIAL RESOURCES..........              30
            039696   UEI COLLEGE............................              30
            041160   VIDEO SYMPHONY ENTERTRAINING...........              30
            041223   GRANTHAM UNIVERSITY....................              30
            041480   NEW LIFE BUSINESS INSTITUTE............              30
            001526   SAINT LEO UNIVERSITY...................              30
            001528   ST. PETERSBURG COLLEGE.................              30
            001671   DEPAUL UNIVERSITY......................              30
            002782   NEW YORK INSTITUTE OF TECHNOLOGY.......              30
            003420   BENEDICT COLLEGE.......................              30
            004866   STAUTZENBERGER COLLEGE.................              30
            006750   VALENCIA COLLEGE.......................              30
            007844   Sanford-Brown Institute................              30
            009407   LINCOLN COLLEGE OF NEW ENGLAND.........              30
            009451   Brown Mackie College...................              30
            010142   TOURO UNIVERSITY.......................              30
            010633   HOUSTON COMMUNITY COLLEGE..............              30
            012362   NORTHWESTERN COLLEGE...................              30
            020555   DELTA SCHOOL OF BUSINESS AND TECHNOLOGY              30
            020693   VATTEROTT COLLEGE......................              30
            022151   HALLMARK INSTITUTE OF PHOTOGRAPHY......              30
            022195   MILDRED ELLEY..........................              30
            023378   COLLEGE OF OFFICE TECHNOLOGY...........              30
            025578   ART INSTITUTE OF YORK (THE)--                        30
                      PENNSYLVANIA..........................
            025801   IVERSON INSTITUTE......................              30
            025965   ATI- CAREER TRAINING CENTER............              30
            031081   SUMMIT COLLEGE.........................              30
            031287   MT. SIERRA COLLEGE.....................              30
            031724   CALIBER TRAINING INSTITUTE.............              30
            033043   CENTURA COLLEGE........................              30
            035954   ANGLEY COLLEGE.........................              30
            037893   UNITECH TRAINING ACADEMY...............              30
            038663   GALIANO CAREER ACADEMY.................              30
            041379   BRENSTEN EDUCATION.....................              30
            023139   WESTWOOD COLLEGE--O'HARE AIRPORT.......              30
            001002   ALABAMA AGRICULTURAL & MECHANICAL                    20
                      UNIVERSITY............................
            001005   ALABAMA STATE UNIVERSITY...............              20
            001117   AZUSA PACIFIC UNIVERSITY...............              20
            001139   CALIFORNIA STATE UNIVERSITY, LONG BEACH              20
            001150   CALIFORNIA STATE UNIVERSITY--SACRAMENTO              20
            001153   CALIFORNIA STATE UNIVERSITY, NORTHRIDGE              20
            001154   SAN FRANCISCO STATE UNIVERSITY.........              20
            001155   SAN JOSE STATE UNIVERSITY..............              20
            001315   UNIVERSITY OF CALIFORNIA, LOS ANGELES..              20
            001342   WHITTIER COLLEGE.......................              20
            001360   METROPOLITAN STATE UNIVERSITY OF DENVER              20
            001363   REGIS UNIVERSITY.......................              20
            001444   GEORGE WASHINGTON UNIVERSITY...........              20
            001456   SOUTHEASTERN UNIVERSITY................              20
            001469   FLORIDA INSTITUTE OF TECHNOLOGY........              20
            001481   FLORIDA ATLANTIC UNIVERSITY............              20
            001489   FLORIDA STATE UNIVERSITY...............              20
            001500   BROWARD COLLEGE........................              20
            001504   STATE COLLEGE OF FLORIDA, MANATEE-                   20
                      SARASOTA..............................
            001506   MIAMI DADE COLLEGE.....................              20
            001520   SEMINOLE STATE COLLEGE OF FLORIDA......              20
            001536   UNIVERSITY OF MIAMI....................              20
            001544   ALBANY STATE UNIVERSITY................              20
            001559   CLARK ATLANTA UNIVERSITY...............              20
            001574   GEORGIA STATE UNIVERSITY...............              20
            001577   KENNESAW STATE UNIVERSITY..............              20
            001694   CHICAGO STATE UNIVERSITY...............              20
            001737   NORTHERN ILLINOIS UNIVERSITY...........              20
            001758   SOUTHERN ILLINOIS UNIVERSITY AT                      20
                      CARBONDALE............................
            001805   INDIANA INSTITUTE OF TECHNOLOGY........              20
            001813   INDIANA UNIVERSITY--PURDUE UNIVERSITY                20
                      INDIANAPOLIS..........................
            001842   VALPARAISO UNIVERSITY..................              20
            001983   ST. CATHARINE COLLEGE..................              20
            002006   GRAMBLING STATE UNIVERSITY.............              20
            002025   SOUTHERN UNIVERSITY AND AGRICULTURAL &               20
                      MECHANICAL COLG AT BATON ROUGE........
            002083   MORGAN STATE UNIVERSITY................              20
            002130   BOSTON UNIVERSITY......................              20
            002205   QUINCY COLLEGE.........................              20
            002211   SPRINGFIELD COLLEGE....................              20
            002259   EASTERN MICHIGAN UNIVERSITY............              20
            002290   MICHIGAN STATE UNIVERSITY..............              20
            002330   WESTERN MICHIGAN UNIVERSITY............              20
            002362   MINNEAPOLIS COMMUNITY AND TECHNICAL                  20
                      COLLEGE...............................
            002407   HINDS COMMUNITY COLLEGE................              20
            002441   UNIVERSITY OF SOUTHERN MISSISSIPPI.....              20
            002569   UNIVERSITY OF NEVADA--LAS VEGAS........              20
            002617   MONTCLAIR STATE UNIVERSITY.............              20
            002732   HOFSTRA UNIVERSITY.....................              20
            002791   PACE UNIVERSITY........................              20
            002905   NORTH CAROLINA AGRICULTURAL AND                      20
                      TECHNICAL STATE UNIVERSITY............
            002909   BARBER-SCOTIA COLLEGE..................              20
            002950   NORTH CAROLINA CENTRAL UNIVERSITY......              20
            002968   SAINT AUGUSTINE'S UNIVERSITY...........              20
            003018   BOWLING GREEN STATE UNIVERSITY.........              20
            003026   CENTRAL STATE UNIVERSITY...............              20
            003090   OHIO STATE UNIVERSITY (THE)............              20
            003125   UNIVERSITY OF CINCINNATI...............              20
            003131   UNIVERSITY OF TOLEDO...................              20
            003196   LANE COMMUNITY COLLEGE.................              20
            003199   MARYLHURST UNIVERSITY..................              20
            003213   PORTLAND COMMUNITY COLLEGE.............              20
            003249   COMMUNITY COLLEGE OF PHILADELPHIA......              20
            003256   DREXEL UNIVERSITY......................              20
            003448   UNIVERSITY OF SOUTH CAROLINA--COLUMBIA.              20
            003509   UNIVERSITY OF MEMPHIS (THE)............              20
            003510   MIDDLE TENNESSEE STATE UNIVERSITY......              20
            003522   TENNESSEE STATE UNIVERSITY.............              20
            003524   Tennessee Temple University............              20
            003594   UNIVERSITY OF NORTH TEXAS..............              20
            003630   PRAIRIE VIEW AGRICULTURAL & MECHANICAL               20
                      UNIVERSITY............................
            003712   TIDEWATER COMMUNITY COLLEGE............              20
            003728   OLD DOMINION UNIVERSITY................              20
            003739   SAINT PAUL'S COLLEGE...................              20
            003749   GEORGE MASON UNIVERSITY................              20
            003764   VIRGINIA STATE UNIVERSITY..............              20
            003765   NORFOLK STATE UNIVERSITY...............              20
            003827   WEST VIRGINIA UNIVERSITY...............              20
            003866   MILWAUKEE AREA TECHNICAL COLLEGE.......              20
            003896   UNIVERSITY OF WISCONSIN--MILWAUKEE.....              20
            003954   UNIVERSITY OF CENTRAL FLORIDA-MAIN                   20
                      CAMPUS................................
            003969   UNIVERSITY OF MINNESOTA--TWIN CITIES...              20
            003993   MIDLANDS TECHNICAL COLLEGE--AIRPORT                  20
                      CAMPUS................................
            004072   NORTHWOOD UNIVERSITY...................              20
            004220   Hamilton College.......................              20
            004453   DALLAS COLLEGE.........................              20
            004692   DORSEY COLLEGE.........................              20
            004920   TRIDENT TECHNICAL COLLEGE..............              20
            004938   SOUTH COLLEGE..........................              20
            005208   COLLEGE OF WESTCHESTER (THE)...........              20
            006731   CASA LOMA COLLEGE......................              20
            006867   COLUMBUS STATE COMMUNITY COLLEGE- MAIN               20
                      CAMPUS................................
            007120   DES MOINES AREA COMMUNITY COLLEGE......              20
            007164   BRYAN UNIVERSITY.......................              20
            007229   WESTERN BEAUTY INSTITUTE...............              20
            007401   MANDL SCHOOL...........................              20
            007439   FOUNTAINHEAD COLLEGE OF TECHNOLOGY.....              20
            007440   Nashville Auto-Diesel College..........              20
            007518   APEX TECHNICAL SCHOOL..................              20
            007572   AMERICAN MUSICAL & DRAMATIC ACADEMY....              20
            007759   Lincoln Technical Institute............              20
            007845   NEW ENGLAND INSTITUTE OF TECHNOLOGY....              20
            007870   HILLSBOROUGH COMMUNITY COLLEGE.........              20
            007946   Kaplan College.........................              20
            008071   CONCORDE CAREER COLLEGE................              20
            008217   PAUL MITCHELL THE SCHOOL GREEN BAY.....              20
            008501   Rasmussen College......................              20
            008887   CONCORDE CAREER COLLEGE................              20
            009022   ASSOCIATED TECHNICAL COLLEGE...........              20
            009043   ELMIRA BUSINESS INSTITUTE..............              20
            009432   ESS COLLEGE OF BUSINESS................              20
            009520   NATIONAL ACADEMY OF BEAUTY ARTS........              20
            009618   TULSA WELDING SCHOOL...................              20
            009721   BRADFORD SCHOOL........................              20
            010279   HICKEY COLLEGE.........................              20
            010362   COLLEGE OF SOUTHERN NEVADA.............              20
            010503   WICHITA TECHNICAL INSTITUTE............              20
            010542   EMPIRE BEAUTY SCHOOL...................              20
            010577   UNITED COLLEGE OF BUSINESS.............              20
            010831   NEW COLLEGE OF CALIFORNIA..............              20
            010881   STARK STATE COLLEGE....................              20
            010930   SUBURBAN TECHNICAL SCHOOL..............              20
            011031   TECHNICAL CAREER INSTITUTES............              20
            011145   LONE STAR COLLEGE SYSTEM...............              20
            011166   BROADVIEW COLLEGE......................              20
            011707   NORTH-WEST COLLEGE.....................              20
            011979   BLAKE BUSINESS SCHOOL..................              20
            012027   GALEN COLLEGE OF CALIFORNIA............              20
            012262   USA TRAINING ACADEMY HOME STUDY........              20
            012346   Dover Business College.................              20
            012872   NORTH-WEST COLLEGE.....................              20
            013005   OLYMPIAN ACADEMY OF COSMETOLOGY........              20
            020692   PACIFIC COAST COLLEGE..................              20
            020741   CAPITOL CITY TRADE & TECHNICAL SCHOOL..              20
            020977   AMERICAN BUSINESS INSTITUTE............              20
            021107   CLEVELAND INSTITUTE OF DENTAL--MEDICAL               20
                      ASSISTANTS............................
            021280   SUPERIOR TRAINING SERVICES.............              20
            021415   SAVANNAH COLLEGE OF ART AND DESIGN.....              20
            021511   ATI COLLEGE OF HEALTH..................              20
            021553   CHICAGO SCHOOL OF PROFESSIONAL                       20
                      PSYCHOLOGY............................
            021618   MUSICIANS INSTITUTE....................              20
            021642   FOREST INSTITUTE OF PROFESSIONAL                     20
                      PSYCHOLOGY............................
            021732   EMPIRE BEAUTY SCHOOL...................              20
            021775   RIO SALADO COMMUNITY COLLEGE...........              20
            022025   NEW ENGLAND TRACTOR TRAILER TRAINING                 20
                      SCHOOL OF CONN........................
            022053   SAVANNAH RIVER COLLEGE.................              20
            022180   CARRINGTON COLLEGE.....................              20
            022449   GOODWIN UNIVERSITY.....................              20
            022452   MTI COLLEGE OF BUSINESS AND TECHNOLOGY.              20
            022552   PENNSYLVANIA SCHOOL OF BUSINESS........              20
            022774   SOUTH COAST COLLEGE....................              20
            022957   NATIONAL ACADEMY OF BEAUTY ARTS........              20
            022965   MASTERS INSTITUTE......................              20
            022966   DeVry Institute of Technology..........              20
            023040   MISSOURI TECHNICAL SCHOOL..............              20
            023112   AMERICAN SCHOOL OF TECHNOLOGY..........              20
            023301   PIONEER PACIFIC COLLEGE................              20
            023385   GLENDALE CAREER COLLEGE................              20
            023397   ROSS MEDICAL EDUCATION CENTER..........              20
            023616   CONCORDE CAREER COLLEGE................              20
            024911   BECKFIELD COLLEGE......................              20
            025399   STAR TECHNICAL INSTITUTE...............              20
            025587   PRISM CAREER INSTITUTE.................              20
            025590   UNIVERSITY OF ADVANCING COMPUTER                     20
                      TECHNOLOGY............................
            025779   SANTA BARBARA BUSINESS COLLEGE.........              20
            025862   Florida Career College.................              20
            025964   SPARTAN COLLEGE OF AERONAUTICS &                     20
                      TECHNOLOGY............................
            026089   PINNACLE COLLEGE.......................              20
            026220   SOUTHWEST ACUPUNCTURE COLLEGE..........              20
            030125   NEW WAVE HAIR ACADEMY..................              20
            030198   PCI HEALTH TRAINING CENTER.............              20
            030235   CAMELOT COLLEGE........................              20
            030258   DAWN CAREER INSTITUTE..................              20
            030399   FREMONT UNIVERSITY.....................              20
            030627   PLATT COLLEGE..........................              20
            030669   INTELLITEC COLLEGE.....................              20
            030682   OHIO MEDIA SCHOOL......................              20
            030706   SANFORD-BROWN COLLEGE..................              20
            030716   CBT TECHNOLOGY INSTITUTE...............              20
            030837   GALEN HEALTH INSTITUTES................              20
            030878   ITT TECHNICAL INSTITUTE................              20
            031043   CAREER TECHNICAL INSTITUTE.............              20
            031087   ROYAL BEAUTY CAREERS...................              20
            031090   SCHOOL OF COMMUNICATION ARTS OF NORTH                20
                      CAROLINA..............................
            031103   SALON ACADEMY (THE)....................              20
            031150   ARIZONA COLLEGE........................              20
            031384   AMERICAN COLLEGE OF MEDICAL TECHNOLOGY.              20
            031963   Lincoln Technical Institute............              20
            031973   INSTITUTE FOR HEALTH EDUCATION (THE)...              20
            033163   LINCOLN TECHNICAL INSTITUTE--HARTFORD..              20
            033943   REMINGTON COLLEGE--SAN DIEGO CAMPUS....              20
            034003   QUEST COLLEGE..........................              20
            035423   CONCORDE CAREER COLLEGE................              20
            036253   PERFORMANCE TRAINING INSTITUTE.........              20
            036274   JACKSONVILLE BEAUTY INSTITUTE..........              20
            036984   CALIFORNIA COLLEGE OF VOCATIONAL                     20
                      CAREERS...............................
            037063   HOLLYWOOD INSTITUTE....................              20
            038123   OMNITECH INSTITUTE.....................              20
            038753   MCI INSTITUTE OF TECHNOLOGY............              20
            039713   AMERICAN CAREER COLLEGE................              20
            039733   SAE EXPRESSION COLLEGE.................              20
            040383   ATA COLLEGE............................              20
            041157   REGINA'S COLLEGE OF BEAUTY.............              20
            041279   TRIDENT UNIVERSITY INTERNATIONAL.......              20
            041345   SAN DIEGO COLLEGE......................              20
            041359   ORION COLLEGE..........................              20
            041414   LAURUS COLLEGE.........................              20
            041493   PARK WEST BARBER SCHOOL................              20
            041523   GEORGIA BEAUTY ACADEMY.................              20
            041618   BRANDMAN UNIVERSITY....................              20
            041625   HOLLYWOOD INSTITUTE OF BEAUTY CAREERS..              20
            041848   VANTAGE COLLEGE........................              20
            001028   MILES COLLEGE..........................              10
            001044   STILLMAN COLLEGE.......................              10
            001047   TROY UNIVERSITY........................              10
            001051   UNIVERSITY OF ALABAMA..................              10
            001052   UNIVERSITY OF ALABAMA AT BIRMINGHAM....              10
            001057   UNIVERSITY OF SOUTH ALABAMA............              10
            001077   MESA COMMUNITY COLLEGE.................              10
            001078   PHOENIX COLLEGE........................              10
            001082   NORTHERN ARIZONA UNIVERSITY............              10
            001087   ARKANSAS BAPTIST COLLEGE...............              10
            001090   ARKANSAS STATE UNIVERSITY..............              10
            001092   UNIVERSITY OF CENTRAL ARKANSAS.........              10
            001101   UNIVERSITY OF ARKANSAS AT LITTLE ROCK..              10
            001138   CALIFORNIA STATE UNIVERSITY, EAST BAY..              10
            001140   CALIFORNIA STATE UNIVERSITY, LOS                     10
                      ANGELES...............................
            001142   CALIFORNIA STATE UNIVERSITY, SAN                     10
                      BERNARDINO............................
            001147   CALIFORNIA STATE UNIVERSITY, FRESNO....              10
            001164   CHAPMAN UNIVERSITY.....................              10
            001325   UNIVERSITY OF SAN FRANCISCO............              10
            001378   CENTRAL CONNECTICUT STATE UNIVERSITY...              10
            001416   UNIVERSITY OF BRIDGEPORT...............              10
            001428   DELAWARE STATE UNIVERSITY..............              10
            001434   AMERICAN UNIVERSITY (THE)..............              10
            001441   UNIVERSITY OF THE DISTRICT OF COLUMBIA.              10
            001475   DAYTONA STATE COLLEGE..................              10
            001477   FLORIDA SOUTHWESTERN STATE COLLEGE.....              10
            001484   FLORIDA STATE COLLEGE AT JACKSONVILLE..              10
            001486   FLORIDA MEMORIAL UNIVERSITY............              10
            001535   UNIVERSITY OF FLORIDA..................              10
            001537   UNIVERSITY OF SOUTH FLORIDA............              10
            001562   Georgia Perimeter College..............              10
            001572   GEORGIA SOUTHERN UNIVERSITY............              10
            001580   MERCER UNIVERSITY......................              10
            001599   VALDOSTA STATE UNIVERSITY..............              10
            001692   ILLINOIS STATE UNIVERSITY..............              10
            001775   UNIVERSITY OF ILLINOIS URBANA-CHAMPAIGN              10
            001776   UNIVERSITY OF ILLINOIS AT CHICAGO......              10
            001807   INDIANA STATE UNIVERSITY...............              10
            001809   INDIANA UNIVERSITY--BLOOMINGTON........              10
            001822   INDIANA WESLEYAN UNIVERSITY............              10
            001825   PURDUE UNIVERSITY......................              10
            001827   PURDUE UNIVERSITY NORTHWEST............              10
            001833   SAINT JOSEPH'S COLLEGE.................              10
            001948   UNIVERSITY OF KANSAS...................              10
            001962   UNIVERSITY OF THE CUMBERLANDS..........              10
            001968   KENTUCKY STATE UNIVERSITY..............              10
            001989   UNIVERSITY OF KENTUCKY.................              10
            001999   UNIVERSITY OF LOUISVILLE...............              10
            002002   WESTERN KENTUCKY UNIVERSITY............              10
            002015   UNIVERSITY OF NEW ORLEANS (THE)........              10
            002024   SOUTHEASTERN LOUISIANA UNIVERSITY......              10
            002103   UNIVERSITY OF MARYLAND, COLLEGE PARK...              10
            002155   HARVARD UNIVERSITY.....................              10
            002199   NORTHEASTERN UNIVERSITY................              10
            002218   SUFFOLK UNIVERSITY.....................              10
            002243   CENTRAL MICHIGAN UNIVERSITY............              10
            002270   HENRY FORD COLLEGE.....................              10
            002278   LANSING COMMUNITY COLLEGE..............              10
            002323   UNIVERSITY OF DETROIT MERCY............              10
            002360   MINNESOTA STATE UNIVERSITY, MANKATO....              10
            002396   ALCORN STATE UNIVERSITY................              10
            002397   BELHAVEN UNIVERSITY....................              10
            002424   MISSISSIPPI VALLEY STATE UNIVERSITY....              10
            002440   UNIVERSITY OF MISSISSIPPI..............              10
            002480   LINDENWOOD UNIVERSITY..................              10
            002503   MISSOURI STATE UNIVERSITY..............              10
            002540   COLLEGE OF SAINT MARY..................              10
            002568   UNIVERSITY OF NEVADA , RENO............              10
            002579   NEW ENGLAND COLLEGE....................              10
            002607   FAIRLEIGH DICKINSON UNIVERSITY.........              10
            002613   NEW JERSEY CITY UNIVERSITY.............              10
            002622   KEAN UNIVERSITY........................              10
            002632   SETON HALL UNIVERSITY..................              10
            002657   NEW MEXICO STATE UNIVERSITY............              10
            002663   UNIVERSITY OF NEW MEXICO...............              10
            002777   MEDAILLE COLLEGE.......................              10
            002790   NYACK COLLEGE..........................              10
            002806   ROCHESTER INSTITUTE OF TECHNOLOGY......              10
            002823   SAINT JOHN'S UNIVERSITY................              10
            002834   EXCELSIOR COLLEGE......................              10
            002842   SUNY COLLEGE AT BUFFALO................              10
            002872   MONROE COMMUNITY COLLEGE...............              10
            002873   NASSAU COMMUNITY COLLEGE...............              10
            002923   EAST CAROLINA UNIVERSITY...............              10
            002962   SHAW UNIVERSITY........................              10
            003030   OHIO CHRISTIAN UNIVERSITY..............              10
            003032   CLEVELAND STATE UNIVERSITY.............              10
            003040   CUYAHOGA COMMUNITY COLLEGE.............              10
            003046   FRANKLIN UNIVERSITY....................              10
            003145   YOUNGSTOWN STATE UNIVERSITY............              10
            003157   LANGSTON UNIVERSITY....................              10
            003216   PORTLAND STATE UNIVERSITY..............              10
            003258   DUQUESNE UNIVERSITY OF THE HOLY SPIRIT.              10
            003273   HARRISBURG AREA COMMUNITY COLLEGE......              10
            003290   LINCOLN UNIVERSITY.....................              10
            003315   BLOOMSBURG UNIVERSITY OF PENNSYLVANIA..              10
            003317   CHEYNEY UNIVERSITY OF PENNSYLVANIA.....              10
            003394   WILKES UNIVERSITY......................              10
            003446   SOUTH CAROLINA STATE UNIVERSITY........              10
            003478   AUSTIN PEAY STATE UNIVERSITY...........              10
            003480   BETHEL UNIVERSITY......................              10
            003494   HIWASSEE COLLEGE.......................              10
            003497   KNOXVILLE COLLEGE......................              10
            003501   LEMOYNE-OWEN COLLEGE...................              10
            003530   UNIVERSITY OF TENNESSEE................              10
            003577   HUSTON--TILLOTSON UNIVERSITY...........              10
            003585   LON MORRIS COLLEGE.....................              10
            003590   MCLENNAN COMMUNITY COLLEGE.............              10
            003593   NAVARRO COLLEGE........................              10
            003599   UNIVERSITY OF TEXAS RIO GRANDE VALLEY..              10
            003606   SAM HOUSTON STATE UNIVERSITY...........              10
            003612   UNIVERSITY OF HOUSTON--DOWNTOWN........              10
            003615   TEXAS STATE UNIVERSITY.................              10
            003626   TARRANT COUNTY COLLEGE DISTRICT........              10
            003634   TEXAS STATE TECHNICAL COLLEGE..........              10
            003644   TEXAS TECH UNIVERSITY..................              10
            003652   UNIVERSITY OF HOUSTON..................              10
            003656   UNIVERSITY OF TEXAS AT ARLINGTON.......              10
            003661   UNIVERSITY OF TEXAS AT EL PASO.........              10
            003692   NORWICH UNIVERSITY.....................              10
            003727   NORTHERN VIRGINIA COMMUNITY COLLEGE....              10
            003735   VIRGINIA COMMONWEALTH UNIVERSITY.......              10
            003752   VIRGINIA INTERMONT COLLEGE.............              10
            003798   UNIVERSITY OF WASHINGTON...............              10
            003800   WASHINGTON STATE UNIVERSITY............              10
            003842   CONCORDIA UNIVERSITY...................              10
            003938   INTER AMERICAN UNIVERSITY OF PUERTO                  10
                      RICO--SAN GERMAN CAMPUS...............
            003941   UNIVERSIDAD ANA G. MENDEZ--CAROLINA                  10
                      CAMPUS................................
            003965   BAY STATE COLLEGE......................              10
            003985   ORAL ROBERTS UNIVERSITY................              10
            003991   GREENVILLE TECHNICAL COLLEGE...........              10
            004579   INTERNATIONAL BUSINESS COLLEGE.........              10
            004844   WAKE TECHNICAL COMMUNITY COLLEGE.......              10
            004852   CLARK STATE COLLEGE....................              10
            004853   BRADFORD SCHOOL........................              10
            004889   CAMBRIA-ROWE BUSINESS COLLEGE..........              10
            004925   HORRY GEORGETOWN TECHNICAL COLLEGE.....              10
            004947   WEST TENNESSEE BUSINESS COLLEGE........              10
            005541   MINNESOTA STATE COMMUNITY AND TECHNICAL              10
                      COLLEGE...............................
            005753   OWENS COMMUNITY COLLEGE................              10
            006961   JEFFERSON COMMUNITY AND TECHNICAL                    10
                      COLLEGE...............................
            007372   AUSTIN'S SCHOOL OF SPA TECHNOLOGY......              10
            007430   ANTONELLI INSTITUTE....................              10
            007437   PITTSBURGH TECHNICAL COLLEGE...........              10
            007502   BERKELEY COLLEGE.......................              10
            007549   COYNE COLLEGE..........................              10
            007573   EMPIRE BEAUTY SCHOOL...................              10
            007605   ACADEMY PACIFIC TRAVEL COLLEGE.........              10
            007607   CONCORDE CAREER COLLEGE................              10
            007648   DENVER TECHNICAL COLLEGE...............              10
            007686   SOUTHERN UNIVERSITY AT SHREVEPORT--                  10
                      BOSSIER CITY..........................
            007832   Lincoln Technical Institute............              10
            007930   CONCORDE CAREER COLLEGE................              10
            008178   EMPIRE BEAUTY SCHOOL...................              10
            008310   AUBURN UNIVERSITY MONTGOMERY...........              10
            008635   IBMC COLLEGE...........................              10
            009032   EMPIRE COLLEGE.........................              10
            009077   UTICA SCHOOL OF COMMERCE...............              10
            009230   WAYNE COUNTY COMMUNITY COLLEGE DISTRICT              10
            009447   WEBSTER CAREER COLLEGE.................              10
            009449   PENNCO TECH............................              10
            009482   MANSFIELD BUSINESS COLLEGE.............              10
            009741   UNIVERSITY OF TEXAS AT DALLAS..........              10
            009769   METROPOLITAN COLLEGE OF NEW YORK.......              10
            009784   NATIONAL EDUCATION CENTER-BAUDER                     10
                      COLLEGE CAMPUS........................
            009917   IVY TECH COMMUNITY COLLEGE OF INDIANA..              10
            010035   SOUTHERN COLLEGE.......................              10
            010061   BRYANT AND STRATTON COLLEGE -VIRGINIA                10
                      BEACH CAMPUS..........................
            010115   UNIVERSITY OF TEXAS AT SAN ANTONIO.....              10
            010286   SUNY EMPIRE STATE COLLEGE..............              10
            010345   CINCINNATI STATE TECHNICAL & COMMUNITY               10
                      COLLEGE...............................
            010372   ADELPHI BUSINESS COLLEGE...............              10
            010463   NATIONAL TECHNICAL SCHOOLS.............              10
            010509   HALLMARK UNIVERSITY....................              10
            010554   CONCORDIA COLLEGE ALABAMA..............              10
            010847   Arizona Automotive Institute...........              10
            010877   AMERICAN BUSINESS INSTITUTE............              10
            010998   PENNSYLVANIA INSTITUTE OF TECHNOLOGY...              10
            011122   SAWYER COLLEGE.........................              10
            011219   COLUMBIA SCHOOL OF BROADCASTING, HOME                10
                      STUDY.................................
            011719   UNIVERSIDAD ANA G. MENDEZ--GURABO                    10
                      CAMPUS................................
            011745   OHIO TECHNICAL COLLEGE.................              10
            011810   TAYLOR BUSINESS INSTITUTE..............              10
            011911   BRICK COMPUTER SCIENCE INSTITUTE.......              10
            012015   AUSTIN COMMUNITY COLLEGE...............              10
            012425   STONE ACADEMY..........................              10
            012606   EMPIRE BEAUTY SCHOOL...................              10
            012896   NORTH COAST COLLEGE, THE...............              10
            012912   MTI COLLEGE............................              10
            020543   TRUMBULL BUSINESS COLLEGE..............              10
            020551   HAWAII BUSINESS COLLEGE................              10
            020609   BROWN COLLEGE OF COURT REPORTING.......              10
            020662   NEW SCHOOL, THE........................              10
            020753   UNIVERSITY OF ARKANSAS--PULASKI                      10
                      TECHNICAL COLLEGE.....................
            020794   EMPIRE BEAUTY SCHOOL...................              10
            020924   RIDLEY-LOWELL SCHOOL OF BUSINESS.......              10
            020926   PTC CAREER INSTITUTE...................              10
            020997   ROSS MEDICAL EDUCATION CENTER..........              10
            021206   SAYBROOK UNIVERSITY....................              10
            021208   YORKTOWNE BUSINESS INSTITUTE...........              10
            021324   BARCLAY COLLEGE........................              10
            021474   CLEVELAND CHIROPRACTIC COLLEGE.........              10
            021527   CENTER FOR THE MEDIA ARTS..............              10
            021578   AMERICAN HI-TECH BUSINESS TECHNOLOGY...              10
            021604   WILFRED ACADEMY OF HAIR DESIGN & BEAUTY              10
                      CULTURE...............................
            021654   TRAINCO BUS SCHOOL.....................              10
            021801   ROSS MEDICAL EDUCATION CENTER..........              10
            021884   SIERRA VALLEY COLLEGE OF COURT                       10
                      REPORTING.............................
            022062   BEAUTY INSTITUTE (THE).................              10
            022168   CALIFORNIA INSTITUTE...................              10
            022196   OMEGA INSTITUTE........................              10
            022229   INTERNATIONAL AIR & HOSPITALITY ACADEMY              10
            022288   Lincoln Technical Institute--East                    10
                      Windsor...............................
            022342   KEYSTONE TECHNICAL INSTITUTE...........              10
            022702   INTERNATIONAL AVIATION AND TRAVEL                    10
                      ACADEMY...............................
            022708   JOYCE UNIVERSITY OF NURSING AND HEALTH               10
                      SCIENCES..............................
            022843   INTERACTIVE COLLEGE OF TECHNOLOGY......              10
            022847   CHICAGO INSTITUTE OF TECHNOLOGY........              10
            022952   UNITED SCHOOLS.........................              10
            022959   AMERICAN CAREER TRAINING TRAVEL SCHOOL.              10
            023045   HERITAGE INSTITUTE.....................              10
            023124   LA COLLEGE INTERNATIONAL...............              10
            023178   AMERICAN INSTITUTE OF TRUCKING.........              10
            023268   MERIDIAN COLLEGE.......................              10
            023342   SOUTHEASTERN ACADEMY...................              10
            023398   SOUTHERN INSTITUTE OF COSMETOLOGY......              10
            023405   ST. LOUIS COLLEGE OF HEALTH CAREERS....              10
            023543   GEORGIA SCHOOL OF BARTENDING...........              10
            023608   PROVO COLLEGE..........................              10
            024905   HAIR FASHIONS BY KAYE BEAUTY COLLEGE...              10
            025454   NORTH AMERICAN TRADE SCHOOLS...........              10
            025464   MTI BUSINESS COLLEGE...................              10
            025681   TEXAS BARBER COLLEGE...................              10
            025728   VISTA COLLEGE..........................              10
            025812   CC'S COSMETOLOGY COLLEGE...............              10
            025844   NEW ENGLAND TRACTOR TRAILER TRAINING                 10
                      SCHOOL OF MASSACHUSETTS...............
            026009   AVEDA ARTS & SCIENCES INSTITUTE                      10
                      COVINGTON.............................
            026095   CAREER TRAINING ACADEMY................              10
            026128   LOS ANGELES RECORDING SCHOOL...........              10
            026154   STAR TECHNICAL INSTITUTE...............              10
            026215   CAREER COLLEGE OF NORTHERN NEVADA......              10
            030097   Harrison College.......................              10
            030316   DPT BUSINESS SCHOOL....................              10
            030644   REGENCY BEAUTY INSTITUTE...............              10
            030780   MIAMI MEDIA SCHOOL.....................              10
            030913   REGENT UNIVERSITY......................              10
            031226   EASTERN INTERNATIONAL COLLEGE..........              10
            031733   ATLANTA'S JOHN MARSHALL LAW SCHOOL.....              10
            032753   COSMETOLOGY CAREER INSTITUTE...........              10
            033674   COMMUNITY CARE COLLEGE.................              10
            034225   Blue Cliff College.....................              10
            034275   UNIVERSITY OF ANTELOPE VALLEY..........              10
            034293   HARRIS SCHOOL OF BUSINESS..............              10
            034455   FAYETTE BEAUTY ACADEMY.................              10
            034685   MDT COLLEGE OF HEALTH SCIENCES.........              10
            034793   PCI COLLEGE............................              10
            035134   APEX SCHOOL OF THEOLOGY................              10
            035233   AVIATION INSTITUTE OF MAINTENANCE......              10
            035253   Blue Cliff College.....................              10
            036393   TRIAD EDUCATION........................              10
            036764   HEALTHY HAIR ACADEMY...................              10
            037503   PROSPECT COLLEGE.......................              10
            037863   ADVANCED COLLEGE.......................              10
            037974   CAREER CARE INSTITUTE..................              10
            038385   NORTHWEST CAREER COLLEGE...............              10
            038525   CIT COLLEGE OF INFOMEDICAL TECHNOLOGY..              10
            039104   NATIONAL POLYTECHNIC COLLEGE...........              10
            039153   CAREER QUEST LEARNING CENTERS..........              10
            039394   CENTURA INSTITUTE......................              10
            040573   ASHER COLLEGE..........................              10
            041245   MYCOMPUTERCAREER AT COLUMBUS...........              10
            041317   SOUTHWEST UNIVERSITY AT EL PASO........              10
            041341   JERSEY COLLEGE.........................              10
            041431   PROFESSIONAL HANDS INSTITUTE...........              10
            041477   LAKE LANIER SCHOOL OF MASSAGE..........              10
            041500   CENTRAL NURSING COLLEGE................              10
            041587   HOLLYWOOD BEAUTY COLLEGE...............              10
            041772   REAL BARBERS COLLEGE (THE).............              10
            041893   ALLIED AMERICAN UNIVERSITY.............              10
    rrrrrrrrrrrrrrrr
                     Schools with less than 10 denied                  11510
                      applications..........................
    ------------------------------------------------------------------------

        Question. Please provide a breakdown of ``total
    ineligible'' borrower defense claims to date by institution.
        Answer. Beginning in May 2021, the term ``total
    ineligible'' was no longer used in the borrower defense
    reports. This term was replaced by ``total denied.'' See
    response to 3b.
        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
    mid-May 2022 is enclosed.

    Closed Borrower Defense Applications by Institution as of May 2022PNote:
                       Totals may not sum due to rounding.
    ------------------------------------------------------------------------
                                                              Rounded Closed
         OPEID                     School Name                  Case Count
    ------------------------------------------------------------------------
            007234   HEALD COLLEGE..........................            1290
            001499   ALTIERUS CAREER COLLEGE................            1050
            007329   ITT TECHNICAL INSTITUTE................             670
            012873   WYOTECH................................             260
            020988   UNIVERSITY OF PHOENIX..................             240
            009157   WYOTECH................................             240
            011109   EVEREST COLLEGE........................             180
            010727   DEVRY UNIVERSITY.......................             170
            001534   Everest University.....................             170
            008090   EVEREST COLLEGE........................             170
            030723   EVEREST COLLEGE........................             170
            009828   ALTIERUS CAREER EDUCATION..............             150
            004494   EVEREST COLLEGE........................             140
            023001   ALTIERUS CAREER COLLEGE................             120
            011123   EVEREST COLLEGE........................             120
            007190   WYOTECH................................             110
            004811   EVEREST INSTITUTE......................             110
            010356   EVEREST INSTITUTE......................             110
            011510   EVEREST INSTITUTE......................             110
            026062   EVEREST COLLEGE........................              90
            011858   EVEREST COLLEGE........................              80
            022950   EVEREST COLLEGE PHOENIX................              80
            009079   EVEREST COLLEGE........................              70
            021004   EVEREST INSTITUTE......................              70
            022613   ALTIERUS CAREER COLLEGE................              70
            022506   EVEREST COLLEGE........................              70
            004586   PURDUE UNIVERSITY GLOBAL...............              60
            008532   Heald College..........................              60
            008146   Everest University--Pompano Beach......              60
            008093   Heald College..........................              60
            021875   Heald College..........................              60
            009267   ALTIERUS CAREER COLLEGE................              60
            011107   EVEREST COLLEGE........................              60
            021799   ARGOSY UNIVERSITY......................              50
            004503   ALTIERUS CAREER COLLEGE................              50
            026175   ALTIERUS CAREER COLLEGE................              50
            004507   ALTIERUS CAREER COLLEGE................              50
            011024   BRYMAN COLLEGE.........................              50
            030727   WESTWOOD COLLEGE--LOS ANGELES..........              50
            007548   WESTWOOD COLLEGE--DENVER NORTH.........              50
            022985   EVEREST COLLEGE........................              50
            007091   EVEREST INSTITUTE......................              50
            001881   ASHFORD UNIVERSITY.....................              40
            021136   AMERICAN INTERCONTINENTAL UNIVERSITY...              40
            025933   Heald College..........................              40
            025932   Heald College..........................              40
            021218   Everest Institute......................              40
            037713   AMERICAN CAREER INSTITUTE..............              30
            010148   COLORADO TECHNICAL UNIVERSITY..........              30
            025998   Everest University.....................              30
            025931   Heald College..........................              30
            030032   Everest Institute......................              30
            022375   LAS VEGAS COLLEGE......................              30
            007477   Heald College..........................              30
            040513   ART INSTITUTE OF LAS VEGAS (THE).......              30
            007476   MARINELLO SCHOOL OF BEAUTY.............              20
            025909   WRIGHT CAREER COLLEGE..................              20
            030106   VIRGINIA COLLEGE.......................              20
            030314   SANFORD-BROWN COLLEGE..................              20
            007470   ART INSTITUTE OF PITTSBURGH (THE)......              20
            004646   MINNESOTA SCHOOL OF BUSINESS...........              20
            001123   BROOKS INSTITUTE.......................              20
            001459   STRAYER UNIVERSITY.....................              20
            022631   ANTHEM COLLEGE.........................              20
            032673   CAPELLA UNIVERSITY.....................              20
            030340   Heald College..........................              20
            007327   ITT Technical Institute................              20
            025911   CAREER POINT COLLEGE...................              20
            008329   ITT Technical Institute................              20
            011626   WESTWOOD COLLEGE--SOUTH BAY............              20
            010627   ITT Technical Institute................              20
            030876   ITT Technical Institute................              20
            030875   ITT Technical Institute................              20
            004553   ITT Technical Institute................              20
            031954   EVEREST COLLEGE........................              20
            030718   ITT TECHNICAL INSTITUTE................              20
            012061   BRYMAN COLLEGE.........................              20
            007606   BRYMAN COLLEGE.........................              20
            001074   GRAND CANYON UNIVERSITY................              10
            022239   DRAKE COLLEGE OF BUSINESS..............              10
            021160   SANFORD-BROWN COLLEGE..................              10
            020754   Keller Graduate School of Management...              10
            032103   LE CORDON BLEU COLLEGE OF CULINARY ARTS              10
            021519   KEISER UNIVERSITY......................              10
            026167   LE CORDON BLEU COLLEGE OF CULINARY ARTS              10
            030226   LE CORDON BLEU COLLEGE OF CULINARY ARTS              10
            021603   SANFORD-BROWN COLLEGE..................              10
            030764   BRYMAN SCHOOL OF ARIZONA (THE).........              10
            026164   SANFORD-BROWN COLLEGE..................              10
            025997   VATTEROTT COLLEGE......................              10
            009270   ART INSTITUTE OF ATLANTA (THE).........              10
            012584   ILLINOIS INSTITUTE OF ART (THE)........              10
            022865   ITT Technical Institute................              10
            013039   SOUTH UNIVERSITY.......................              10
            030734   ITT Technical Institute................              10
            038323   DADE MEDICAL COLLEGE...................              10
            023598   ITT Technical Institute................              10
            007351   SANFORD-BROWN COLLEGE..................              10
            007557   ITT Technical Institute................              10
            023217   ITT Technical Institute................              10
            023610   ITT Technical Institute................              10
            007486   NEW ENGLAND INSTITUTE OF ART (THE).....              10
            009837   ITT Technical Institute................              10
            022916   ITT Technical Institute................              10
            030874   ITT Technical Institute................              10
            023139   WESTWOOD COLLEGE--O'HARE AIRPORT.......              10
            030792   WESTWOOD COLLEGE--DUPAGE...............              10
            023186   EVEREST INSTITUTE......................              10
    rrrrrrrrrrrrrrrr
                     No school information listed...........            3110
                    --------------------------------------------------------
                     Schools with less than 10 closed                   4180
                      applications..........................
    ------------------------------------------------------------------------

        Question. Please provide the top five reasons that borrower defense
    claims are placed in ``total denied,'' ``total ineligible,'' and
    ``total closed.'' Please also provide the number and corresponding
    percentage for borrower defense claims placed in each category.
        Answer. Per our response to Durbin 3, ``total ineligible'' is no
    longer used as a category in borrower defense reporting.
        As of mid-July 2022, the top five reasons applications have been
    deemed denied were as follows (numbers have been rounded to the nearest
    5):
      --Lack of Evidence (81,525 applications or 59 percent);
      --No Claim Stated (36,875 applications or 27 percent);
      --Failed Job Placement Rate-No Other Obligation (16,105 or 12
            percent)
      --Failure to State a Claim Actionable Under BD Regulations (1,465
            applications or 1 percent)
      --Reason Not Reported (1,005 applications or 1 percent).
        As of mid-July 2022, the top five reasons applications have been
    closed were as follows (numbers have been rounded to the nearest 5):
      --No Loans (e.g., no Federal loans; loans paid in full; no loans at
            the applicable school) (6785 applications or 51 percent);
      --No Response from Customer (2565 applications or 19 percent);
      --Borrower Received an Automatic Closed School Discharge (965
            applications or 7 percent);
      --Incomplete Application (775 applications or 6 percent);
        Borrower Requested Case Closure (545 applications or 4 percent).
        Question. How many and which institutions is the Department
    currently investigating for purposes of making findings related to
    borrower defense? Please provide a list of those schools.
        Answer. The Borrower Defense regulations require the Department to
    ``resolve claims through a fact-finding process'' conducted by the
    Department, 34 C.F.R. Sec. 685.222. That process is defined as follows:
        As part of the fact-finding process, the Department official
    notifies the school of the borrower defense application and considers
    any evidence or argument presented by the borrower and also any
    additional information, including--
      --Department records;
      --Any response or submissions from the school; and
      --Any additional information or argument that may be obtained by the
            Department official. 34 C.F.R. Sec. 685.222.
        Although the Department does not comment on deliberative or
    preliminary work, including disclosing a number or list of institutions
    that may be subject to such work until the outcomes of any work has
    been made public, but the Department is committed to fulfilling its
    regulatory obligations and to providing relief to borrowers when
    appropriate.
        Question. How many schools have submitted information to the
    Department based on the school's right to respond to a pending borrower
    defense application? Please provide a list of those schools.
        Answer. The 2016 and 2020 regulations require the Department to
    provide notice of borrower defense applications and an opportunity to
    respond to all open institutions prior to granting borrower defense and
    discharging Federal loans. The Department is committed to fulfilling
    its regulatory obligation and is in the process of providing notice to
    numerous schools.
        Question. How many borrowers have received a direct notice via
    email or postal mail that they may be eligible for borrower defense
    cancellation under the Department's new borrower defense findings?
        Answer. Any time the Borrower Defense Group issues a new finding,
    FSA posts an announcement to the Borrower Defense Updates website
    (https://studentaid.gov/announcements-events/borrower-defense-update).
    The Borrower Defense Updates website includes executive summaries
    explaining the school's misconduct that resulted in the finding(s) and
    when the misconduct occurred, statements of fact detailing the
    misconduct and who may be eligible for relief, and other borrower
    defense information, such as a link to the borrower defense application
    portal.
        Question. The current borrower defense form is 25 pages and is
    difficult for student loan borrowers to navigate without an attorney.
    When does the Department anticipate publishing and using a new, easier
    to understand, and shorter borrower defense form?
        Answer. The Department is committed to providing prospective
    applicants with a borrower-friendly application form. The Department is
    uncertain as to when this form will be updated due the lengthy
    regulatory review process and changes that may be required pursuant to
    the 2023 regulation.
        Question. How many Department staff currently are assigned to
    determine whether to provide group discharges to borrowers?
        Answer. The Department dedicates staff resources from Enforcement,
    the Office of General Counsel (OGC), and the Office of the Under
    Secretary (OUS) to working on group discharges issues. FSA's Borrower
    Defense Group writes recommendations regarding group discharges, OGC
    reviews recommendations, and the Under Secretary ultimately determines
    whether to grant a group discharge. As of July 12, 2022, there are 2-3
    attorneys in OGC and 2 individuals in OUS who spend time working on
    group discharges. There are 33 attorneys in the Borrower Defense Group,
    some of whom work on group discharge matters as well.
        Question. How many Department staff currently are assigned to
    adjudicate individual borrower defense applications?
        Answer. There are thirty-three attorneys in the Borrower Defense
    Group, all of whom play some role in the process for considering
    individual borrower defense applications.
        Question. Please provide an organizational chart detailing who is
    tasked with making group discharge decisions, individual application
    adjudications, and drafting and finalizing communications with
    borrowers regarding borrower defense discharges.
        Answer. The Department dedicates staffing resources from
    Enforcement, the Office of General Counsel (OGC), and the Office of the
    Under Secretary (OUS) to make group discharge decisions, adjudicate
    individual applications, and draft and finalize communication with
    borrowers. FSA's Borrower Defense Group makes recommendations regarding
    individual adjudication and group discharges. OGC reviews
    recommendations. The Under Secretary determines whether to grant a
    group discharge. Drafting and finalizing communications is a
    collaborative effort by FSA's office of Student Experience and Aid
    Delivery (SEAD), the Borrower Defense Group, OGC, and OUS.
    Communication with the borrower regarding discharges is handled by the
    post processing Borrower Defense Team in FSA.
        The Department does not have a specific organizational chart of
    everyone involved in the group discharge or individual application
    adjudication process or communication process.
        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 of
    total borrowers does this number represent?
        Answer. FSA requires our vendors to remove the credit tradeline for
    any loans that are approved for 100 percent borrower defense relief.
        Question. The Department previously notified me and other Members
    of Congress that former 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. The Department is committed to exercising the exceptional
    circumstances authority for closed school discharges when the Secretary
    determines it is warranted. We are continuing to review past closures
    to identify any instances where an exceptional circumstance did occur.
        Question. In that same notification, the Department noted that
    former Secretary DeVos had not yet reached a decision on the request
    made by me and other Members of Congress 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. As noted above, we are committed to looking at instances
    where it would be warranted to use the exceptional circumstance
    authority.
        Question. Please provide, disaggregated for 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 borrowers who
            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, or assigned to private collection agencies).
        Answer. Please find an Excel file with the requested data enclosed.

    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               Durbin 14.a-Estimated     Durbin 14.b-Borrowers     Durbin 14.c-Borrowers       Durbin 14d-Borrowers Who      Durbin 14.e-the number
                                                              Eligible Borrowers for    Who Applied for a Non-      Who Received Closed       Received Automatic Closed       of borrowers and the
                                                             Closed School  Discharge   automatic, Traditional       School Discharge              School Discharge           total loan amount of
                                                            --------------------------  Closed School Discharge -----------------------------------------------------------  such borrowers in some
                                                                                      --------------------------                                                             form of debt collection
                                                                                                                                                                             (Treasury offset, wage
                                                                                                                                                                            garnishment, assigned to
                                                                          Dollars (in                                         Dollars (in                   Dollars (in              PCAs).
                                                              Borrowers    millions)    Borrowers   Dollars (in   Borrowers    millions)    Borrowers        millions)     -------------------------
                                                                                                     millions)                                                                             Value of
                                                                                                                                                                             Borrowers*   Loans (in
                                                                                                                                                                                          millions)*
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Charlotte School of Law................................          100           $6          200          $20          100           $5          <10  Privacy Restricted            0            0
    Dream Center Education Holdings........................        7,900          178        9,600          301        4,300          103        3,300                 $60            0            0
    Education Corporation of America.......................       11,900           81       11,700          120        6,500           39        4,200                  31            0            0
    ITT Educational Service................................       25,800          349       30,700          569       18,600          250      113,300               1,391            0            0
    Vatterott Acquisition Co...............................        1,500           20        1,300           20          900           11          600                   8            0            0

    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Notes:

    Estimated eligibility for closed school discharge excludes Title IV borrowers who graduated, transferred, or whose loans were subsequently cancelled. Non-Title IV aid recipients are not
      eligible for closed school discharge.
    Borrower counts are rounded to the nearest 100. Dollar counts are rounded to the nearest million.
    Borrowers may be counted more than once in the discharge numbers if the same borrower attended more than one location of the school.
    14d includes the ITT borrowers received a discharge under the extended lookback window. https://www.ed.gov/news/press-releases/extended-closed-school-discharge-will-provide-115k-borrowers-itt-
      technical-institute-more-11b-loan-forgiveness.
    Data for Durbin 14e is 0 since pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, all collection activities on federal student loans are suspended as of March 13,
      2020.

        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 also are
    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. 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 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 $32.6 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 received recoupment funds
    from any for-profit college since 2014. This administration,
    however, is prioritizing accountability and taxpayer protection
    through recoupment of borrower defense discharges, including
    where discharges are granted with respect to schools that
    continue to operate. To that end, in August 2022 the Department
    initiated a recoupment proceeding against DeVry University.
        Question. According to the most recently published borrower
    defense report (December 2021), the Department currently has
    nearly 109,953 pending borrower defense claims. Please provide:
        The average length of time the 109,953 claims have been
    pending.
        Answer. The average length of time that all applications
    have been pending as of mid-July 2022, is 517 days. This is not
    specific to the 109,953 claims referenced, but rather the total
    number of pending applications, as of mid-July 2022.
        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.
        A breakdown of the 109,953 pending claims by institution.
        Answer. As of mid-May 2022, 83 percent of total pending
    applications were related to for-profit institutions; 8 percent
    were related to public institutions; and 9 percent were related
    to private not-for-profit institutions. A small number of
    applications (less than 1 percent) related to foreign
    institutions. Applications without a school listed were
    excluded from this calculation.
        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. An Excel file providing the requested data as of
    mid-May 2022 is enclosed.

    Denied Borrower Defense Applications by Institution as of May 2022 Note:
                       Totals may not sum due to rounding.
    ------------------------------------------------------------------------
                                                                  Pending
         OPEID                 Primary School Name             Applications
    ------------------------------------------------------------------------
            010727   DEVRY UNIVERSITY.......................          26,600
            020988   UNIVERSITY OF PHOENIX..................          15,200
            004553   ITT Technical Institute................          15,200
                     No School Listed.......................           9,800
            007477   Heald College..........................           4,600
            030846   Art Institute of Las Vegas (The).......           3,900
            021799   ARGOSY UNIVERSITY......................           3,800
            007491   BRIGHTWOOD COLLEGE.....................           3,600
            004586   PURDUE UNIVERSITY GLOBAL...............           3,300
            007351   SANFORD-BROWN COLLEGE..................           3,100
            001881   ASHFORD UNIVERSITY.....................           2,900
            001499   ALTIERUS CAREER COLLEGE................           2,900
            007470   ART INSTITUTE OF PITTSBURGH (THE)......           2,600
            020754   Keller Graduate School of Management...           2,500
            010148   COLORADO TECHNICAL UNIVERSITY..........           2,100
            012651   Marinello School of Beauty.............           2,000
            021136   AMERICAN INTERCONTINENTAL UNIVERSITY...           1,900
            025042   WALDEN UNIVERSITY......................           1,800
            030106   VIRGINIA COLLEGE.......................           1,600
            022202   LE CORDON BLEU COLLEGE OF CULINARY ARTS           1,400
            012584   ILLINOIS INSTITUTE OF ART (THE)........           1,400
            009079   EVEREST COLLEGE........................           1,300
            007548   WESTWOOD COLLEGE--DENVER NORTH.........           1,300
            001074   GRAND CANYON UNIVERSITY................           1,200
            009270   ART INSTITUTE OF ATLANTA (THE).........           1,200
            032673   CAPELLA UNIVERSITY.....................           1,200
            001534   Everest University.....................           1,200
            004646   MINNESOTA SCHOOL OF BUSINESS...........           1,100
            041435   CHARLOTTE SCHOOL OF LAW................           1,100
            003674   INDEPENDENCE UNIVERSITY................           1,000
            001459   STRAYER UNIVERSITY.....................           1,000
            007547   Lincoln College of Technology..........           1,000
            013039   SOUTH UNIVERSITY.......................             900
            030727   WESTWOOD COLLEGE--LOS ANGELES..........             900
            023036   Fortis College.........................             900
            007236   Art Institute of California--Los                    900
                      Angeles (The).........................
            021218   Everest Institute......................             900
            007501   VATTEROTT COLLEGE......................             800
            004910   BRIGHTWOOD CAREER INSTITUTE............             800
            023462   WYOTECH................................             800
            025909   WRIGHT CAREER COLLEGE..................             700
            025593   UNITED EDUCATION INSTITUTE.............             700
            021519   KEISER UNIVERSITY......................             600
            008350   ART INSTITUTE OF PHILADELPHIA (THE) -..             600
            010195   ART INSTITUTE OF FORT LAUDERDALE (THE).             600
            023621   FULL SAIL UNIVERSITY...................             600
            004642   GLOBE UNIVERSITY.......................             600
            004666   AMERICAN COLLEGE FOR MEDICAL CAREERS...             600
            007506   Lincoln Technical Institute............             600
            008878   MIAMI INTERNATIONAL UNIVERSITY OF ART &             600
                      DESIGN................................
            004934   Daymar College.........................             600
            022159   ATI CAREER TRAINING CENTER.............             500
            022392   ANTHEM COLLEGE.........................             500
            022239   DRAKE COLLEGE OF BUSINESS..............             500
            021171   ART INSTITUTE OF HOUSTON (THE).........             500
            005127   Brown Mackie College-Cincinnati........             500
            007486   NEW ENGLAND INSTITUTE OF ART (THE).....             500
            023276   Art Institute of California--San Diego.             500
            020789   ART INSTITUTE OF COLORADO (THE)........             500
            010851   BRANFORD HALL CAREER INSTITUTE.........             500
            004057   NATIONAL AMERICAN UNIVERSITY...........             400
            003726   AMERICAN NATIONAL UNIVERSITY...........             400
            023139   WESTWOOD COLLEGE--O'HARE AIRPORT.......             400
            002455   Devry Institute of Technology..........             400
            022913   ART INSTITUTE OF SEATTLE (THE).........             400
            010248   ART INSTITUTES INTERNATIONAL MINNESOTA              400
                      (THE).................................
            030792   WESTWOOD COLLEGE--DUPAGE...............             400
            023263   Fortis Institute.......................             400
            007804   STAR CAREER ACADEMY....................             400
            009748   CARRINGTON COLLEGE.....................             400
            008146   Everest University--Pompano Beach......             400
            022950   EVEREST COLLEGE PHOENIX................             400
            025256   ART INSTITUTE OF NEW YORK CITY (THE)...             300
            008221   UNIVERSAL TECHNICAL INSTITUTE..........             300
            009828   ALTIERUS CAREER EDUCATION..............             300
            031254   Art Institute of California-Hollywood               300
                      (The).................................
            005009   Bryant & Stratton College..............             300
            021105   Art Institute of Charlotte (The).......             300
            006755   BROWN MACKIE COLLEGE (THE -)...........             300
            020530   LIBERTY UNIVERSITY.....................             300
            008694   RASMUSSEN UNIVERSITY...................             300
            034274   CAREER COLLEGES OF AMERICA.............             300
            011031   TECHNICAL CAREER INSTITUTES............             300
            025965   ATI-CAREER TRAINING CENTER.............             300
            025862   Florida Career College.................             300
            007434   COMPUTER SYSTEMS INSTITUTE.............             300
            035493   ULTIMATE MEDICAL ACADEMY...............             300
            004583   Brown Mackie College-South Bend........             300
            006385   CHAMBERLAIN UNIVERSITY.................             300
            001123   BROOKS INSTITUTE.......................             300
            026162   Brown Mackie College-Findlay...........             300
            010198   ECPI UNIVERSITY........................             300
            012482   ATI TECHNICAL TRAINING CENTER..........             300
            021521   Academy of Court Reporting and                      300
                      Technology............................
            007819   ART INSTITUTE OF PORTLAND (THE)........             300
            002580   SOUTHERN NEW HAMPSHIRE UNIVERSITY......             300
            030764   BRYMAN SCHOOL OF ARIZONA (THE).........             300
            020757   BRIARCLIFFE COLLEGE....................             300
            025911   CAREER POINT COLLEGE...................             300
            007398   KATHARINE GIBBS SCHOOL.................             300
            030097   Harrison College.......................             200
            025027   UEI (United Education Institute).......             200
            007531   ACADEMY OF ART UNIVERSITY..............             200
            007607   CONCORDE CAREER COLLEGE................             200
            007362   MEDTECH COLLEGE........................             200
            007946   Kaplan College.........................             200
            021040   HARRIS SCHOOL OF BUSINESS..............             200
            004673   BAKER COLLEGE..........................             200
            033394   WESTERN GOVERNORS UNIVERSITY...........             200
            031133   UEI COLLEGE............................             200
            011626   WESTWOOD COLLEGE--SOUTH BAY............             200
            033953   ICDC COLLEGE...........................             200
            025991   REMINGTON COLLEGE......................             200
            008865   Empire Beauty School...................             200
            038193   AMERICAN PUBLIC UNIVERSITY SYSTEM......             200
            007421   Berkeley College.......................             200
            026142   MILLER--MOTTE TECHNICAL COLLEGE........             200
            023068   MILLER-MOTTE COLLEGE...................             200
            033743   FLORIDA COASTAL SCHOOL OF LAW..........             200
            007606   BRYMAN COLLEGE.........................             200
            030068   LE CORDON BLEU INSTITUTE OF CULINARY                200
                      ARTS..................................
            041314   ARIZONA SUMMIT LAW SCHOOL..............             200
            021207   SAN JOAQUIN VALLEY COLLEGE.............             200
            022418   AMERICAN CAREER COLLEGE................             200
            026110   HERITAGE COLLEGE.......................             200
            003371   TEMPLE UNIVERSITY......................             200
            025720   VISTA COLLEGE..........................             200
            010319   FORTIS INSTITUTE--TOWSON...............             200
            021715   WESTERN INTERNATIONAL UNIVERSITY.......             200
            004898   MCCANN SCHOOL OF BUSINESS & TECHNOLOGY.             200
            009917   IVY TECH COMMUNITY COLLEGE OF INDIANA..             200
            007488   KAPLAN CAREER INSTITUTE................             200
            010193   Herzing University.....................             200
            009795   MISSOURI COLLEGE.......................             200
            024973   MILAN INSTITUTE........................             200
            025943   COLLEGEAMERICA DENVER..................             200
            009602   Regency Beauty Institute...............             200
            025294   AMERICAN CAREER INSTITUTE..............             100
            011159   SAWYER SCHOOL (THE)....................             100
            022838   BEAUTY SCHOOLS OF AMERICA..............             100
            021511   ATI COLLEGE OF HEALTH..................             100
            021192   COURT REPORTING INSTITUTE OF ST LOUIS..             100
            003807   MOUNTAIN STATE UNIVERSITY..............             100
            007844   Sanford-Brown Institute................             100
            022171   PIMA MEDICAL INSTITUTE.................             100
            025321   BUSINESS CAREER TRAINING INSTITUTE.....             100
            004619   SULLIVAN UNIVERSITY....................             100
            009451   Brown Mackie College...................             100
            025578   ART INSTITUTE OF YORK (THE)--                       100
                      PENNSYLVANIA..........................
            038133   NORTHCENTRAL UNIVERSITY................             100
            030955   ASA COLLEGE............................             100
            031264   Centura College........................             100
            038323   DADE MEDICAL COLLEGE...................             100
            030998   ILLINOIS SCHOOL OF HEALTH CAREERS......             100
            025830   GWINNETT COLLEGE.......................             100
            011246   BROOKS COLLEGE.........................             100
            022023   PITTSBURGH CAREER INSTITUTE............             100
            001401   POST UNIVERSITY........................             100
            007341   INTERNATIONAL BEAUTY SCHOOL............             100
            035453   UNIVERSITY OF THE ROCKIES..............             100
            004618   Spencerian College.....................             100
            001081   ARIZONA STATE UNIVERSITY...............             100
            001509   NOVA SOUTHEASTERN UNIVERSITY-DAVIE.....             100
            030675   INSTITUTE OF TECHNOLOGY................             100
            021867   HARRISON CAREER INSTITUTE..............             100
            034933   ALL-STATE CAREER.......................             100
            001666   CONCORDIA UNIVERSITY...................             100
            025769   CHARTER COLLEGE........................             100
            011259   CONCORDE CAREER INSTITUTE..............             100
            021749   Collins College........................             100
            008424   LA' JAMES INTERNATIONAL COLLEGE........             100
            012891   ANTONELLI COLLEGE......................             100
            004992   MILLER-MOTTE TECHNICAL COLLEGE.........             100
            023522   LE CORDON BLEU COLLEGE OF CULINARY ARTS             100
                      IN CHICAGO............................
            023328   CENTER FOR EMPLOYMENT TRAINING.........             100
            021210   SOUTHERN TECHNICAL COLLEGE.............             100
            025396   Art Institute of Dallas (The)..........             100
            007507   GIBBS COLLEGE..........................             100
            011647   SBI CAMPUS--AN AFFILIATE OF SANFORD-                100
                      BROWN.................................
            007164   BRYAN UNIVERSITY.......................             100
            001746   Robert Morris University Illinois......             100
            030693   WESTERN CAREER COLLEGE.................             100
            026055   Remington College--Mobile Campus.......             100
            020997   ROSS MEDICAL EDUCATION CENTER..........             100
            002667   DOWLING COLLEGE........................             100
            011644   UNIVERSITY OF MARYLAND GLOBAL CAMPUS...             100
            023565   AMERICAN BEAUTY ACADEMY................             100
            022375   LAS VEGAS COLLEGE......................             100
            011574   BAUDER COLLEGE.........................             100
            025154   CITY COLLEGE...........................             100
            004729   MOUNT WASHINGTON COLLEGE...............             100
            011460   NATIONAL UNIVERSITY--LA JOLLA..........             100
            025842   NEWBRIDGE COLLEGE......................             100
            022188   BROOKLINE COLLEGE......................             100
            040373   LOS ANGELES FILM SCHOOL (THE)..........             100
            001583   MORRIS BROWN COLLEGE...................             100
            003076   Miami--Jacobs Career College...........             100
            031248   Platt College..........................             100
            021553   CHICAGO SCHOOL OF PROFESSIONAL                      100
                      PSYCHOLOGY............................
            034095   CHESTER CAREER COLLEGE.................             100
            035343   JONES INTERNATIONAL UNIVERSITY.........             100
            010057   AMERICAN COMMERCIAL COLLEGE............             100
            002704   COLLEGE OF NEW ROCHELLE (THE)..........             100
            040393   SULLIVAN AND COGLIANO TRAINING CENTERS.             100
            030012   MCNALLY SMITH COLLEGE OF MUSIC.........             100
            010854   THOMAS JEFFERSON SCHOOL OF LAW.........             100
            002383   CROWN COLLEGE..........................             100
            007296   COLEMAN UNIVERSITY.....................             100
            041215   COLUMBIA SOUTHERN UNIVERSITY...........             100
            007297   SPARTAN COLLEGE OF AERONAUTICS AND                  100
                      TECHNOLOGY............................
            022796   CORTIVA INSTITUTE......................             100
            008441   ANTHEM INSTITUTE.......................             100
            001328   UNIVERSITY OF SOUTHERN CALIFORNIA......             100
            011112   FASHION INSTITUTE OF DESIGN &                       100
                      MERCHANDISING -.......................
            001526   SAINT LEO UNIVERSITY...................             100
            007586   Remington College--Tampa Campus........             100
            030695   SAGE COLLEGE...........................             100
            031239   SOUTHEASTERN COLLEGE...................             100
            021315   NORTHWESTERN COLLEGE...................             100
            034225   Blue Cliff College.....................             100
            002751   LONG ISLAND UNIVERSITY.................             100
            033583   ALLEN SCHOOL...........................             100
            022231   HERITAGE INSTITUTE.....................             100
            022460   ROSS UNIVERSITY, SCHOOL OF MEDICINE....             100
            030778   Brown Mackie College-North Canton......             100
            021082   Brown Mackie College-Louisville........             100
            010633   HOUSTON COMMUNITY COLLEGE..............             100
            001466   BARRY UNIVERSITY.......................             100
            003404   JOHNSON & WALES UNIVERSITY.............             100
            009635   FLORIDA INTERNATIONAL UNIVERSITY.......             100
            003329   PENNSYLVANIA STATE UNIVERSITY (THE)....             100
            041319   FASTTRAIN OF MIAMI.....................             100
            002249   DAVENPORT UNIVERSITY...................             100
            022195   MILDRED ELLEY..........................             100
            021032   BROWN MACKIE COLLEGE-MERRILLVILLE......             100
            010779   PORTER AND CHESTER INSTITUTE...........             100
            022187   Florida Technical College..............             100
            007437   PITTSBURGH TECHNICAL COLLEGE...........             100
            001484   FLORIDA STATE COLLEGE AT JACKSONVILLE..             100
            036183   INSTITUTE OF TECHNICAL ARTS............             100
            008417   STENOTYPE INSTITUTE OF JACKSONVILLE....             100
            004731   DANIEL WEBSTER COLLEGE.................             100
            002937   KING'S COLLEGE.........................             100
            023301   PIONEER PACIFIC COLLEGE................             100
            031281   COLLEGE OF HEALTH CARE PROFESSIONS                  100
                      (THE).................................
            001480   FLORIDA AGRICULTURAL & MECHANICAL                   100
                      UNIVERSITY............................
            002629   RUTGERS, THE STATE UNIVERSITY OF NEW                100
                      JERSEY................................
            001574   GEORGIA STATE UNIVERSITY...............             100
            030522   COURT REPORTING INSTITUTE,INC..........             100
            002456   COLUMBIA COLLEGE.......................             100
            041223   GRANTHAM UNIVERSITY....................             100
            004692   DORSEY COLLEGE.........................             100
            011145   LONE STAR COLLEGE SYSTEM...............             100
            023071   COMPUTER LEARNING CENTER...............             100
            030353   SOUTHERN CAREERS INSTITUTE.............             100
            009743   BELLEVUE UNIVERSITY....................             100
            002785   NEW YORK UNIVERSITY....................             100
            001467   BETHUNE COOKMAN UNIVERSITY.............             100
            025594   INTERCOAST COLLEGES....................             100
            003121   TIFFIN UNIVERSITY......................             100
            010217   International Academy of Design and                 100
                      Technology............................
            003642   TEXAS SOUTHERN UNIVERSITY..............             100
            033683   MIDWEST TECHNICAL INSTITUTE............             100
            021540   DIVERS ACADEMY OF THE EASTERN SEABOARD.             100
            002649   SANTA FE UNIVERSITY OF ART AND DESIGN..             100
            009228   DeVry College of Technology............             100
            001671   DEPAUL UNIVERSITY......................             100
            010913   MADISON MEDIA INSTITUTE................             100
            004799   MONROE COLLEGE.........................             100
            021108   CALIFORNIA COLLEGE SAN DIEGO...........             100
            003051   KENT STATE UNIVERSITY..................             100
            035133   LACY COSMETOLOGY SCHOOL................             100
            011166   BROADVIEW COLLEGE......................             100
            020552   HARRINGTON COLLEGE OF DESIGN...........             100
            003954   UNIVERSITY OF CENTRAL FLORIDA-MAIN                  100
                      CAMPUS................................
            005203   Remington College--Lafayette Campus....             100
            009591   COMPUTER LEARNING CENTERS, INC. LOS                 100
                      ANGELES...............................
            001537   UNIVERSITY OF SOUTH FLORIDA............             <50
            001047   TROY UNIVERSITY........................             <50
            030623   WESTECH COLLEGE........................             <50
            001822   INDIANA WESLEYAN UNIVERSITY............             <50
            041320   FASTTRAIN OF FORT LAUDERDALE...........             <50
            010405   PINNACLE CAREER INSTITUTE..............             <50
            002834   EXCELSIOR COLLEGE......................             <50
            002329   WAYNE STATE UNIVERSITY.................             <50
            003522   TENNESSEE STATE UNIVERSITY.............             <50
            031203   COLLEGEAMERICA--FLAGSTAFF..............             <50
            022662   HELMS CAREER INSTITUTE.................             <50
            002521   WEBSTER UNIVERSITY.....................             <50
            002772   MERCY COLLEGE..........................             <50
            010861   WEST VIRGINIA BUSINESS COLLEGE.........             <50
            009572   COMPUTER LEARNING CENTER OF ALEXANDRIA.             <50
            003656   UNIVERSITY OF TEXAS AT ARLINGTON.......             <50
            033993   BRYAN COLLEGE..........................             <50
            031623   FOUR-D COLLEGE.........................             <50
            001448   HOWARD UNIVERSITY......................             <50
            002025   SOUTHERN UNIVERSITY AND AGRICULTURAL &              <50
                      MECHANICAL COLG AT BATON ROUGE........
            036933   CARNEGIE CAREER COLLEGE................             <50
            005452   AVIATION INSTITUTE OF MAINTENANCE......             <50
            007777   Remington College--Cleveland Campus....             <50
            001153   CALIFORNIA STATE UNIVERSITY, NORTHRIDGE             <50
            001481   FLORIDA ATLANTIC UNIVERSITY............             <50
            036983   WEST COAST UNIVERSITY..................             <50
            025494   South Texas Vocational Technical                    <50
                      Institute.............................
            026068   Career Technical College...............             <50
            001528   ST. PETERSBURG COLLEGE.................             <50
            001694   CHICAGO STATE UNIVERSITY...............             <50
            021279   SOJOURNER-DOUGLASS COLLEGE.............             <50
            022449   GOODWIN UNIVERSITY.....................             <50
            009982   VICTORY UNIVERSITY.....................             <50
            020748   LIFE UNIVERSITY........................             <50
            001805   INDIANA INSTITUTE OF TECHNOLOGY........             <50
            001665   COLUMBIA COLLEGE CHICAGO...............             <50
            002290   MICHIGAN STATE UNIVERSITY..............             <50
            024915   SOUTHWEST UNIVERSITY OF VISUAL ARTS....             <50
            004853   BRADFORD SCHOOL........................             <50
            003256   DREXEL UNIVERSITY......................             <50
            006867   COLUMBUS STATE COMMUNITY COLLEGE- MAIN              <50
                      CAMPUS................................
            003125   UNIVERSITY OF CINCINNATI...............             <50
            023378   COLLEGE OF OFFICE TECHNOLOGY...........             <50
            022482   MILAN INSTITUTE OF COSMETOLOGY.........             <50
            008889   LEHIGH VALLEY COLLEGE..................             <50
            001559   CLARK ATLANTA UNIVERSITY...............             <50
            006750   VALENCIA COLLEGE.......................            <<50
            023089   MASTERS OF COSMETOLOGY COLLEGE.........             <50
            011707   NORTH-WEST COLLEGE.....................             <50
            002193   MOUNT IDA COLLEGE......................             <50
            001469   FLORIDA INSTITUTE OF TECHNOLOGY........             <50
            001489   FLORIDA STATE UNIVERSITY...............             <50
            041322   FASTTRAIN OF JACKSONVILLE..............             <50
            034414   NEWBRIDGE COLLEGE--SAN DIEGO EAST......             <50
            004531   PHILLIPS JUNIOR COLLEGE................             <50
            004938   SOUTH COLLEGE..........................             <50
            021415   SAVANNAH COLLEGE OF ART AND DESIGN.....             <50
            004467   TUCSON COLLEGE.........................             <50
            004220   Hamilton College.......................             <50
            003509   UNIVERSITY OF MEMPHIS (THE)............             <50
            003131   UNIVERSITY OF TOLEDO...................             <50
            003510   MIDDLE TENNESSEE STATE UNIVERSITY......             <50
            041321   FASTTRAIN OF TAMPA.....................             <50
            031287   MT. SIERRA COLLEGE.....................             <50
            022741   LA' JAMES INTERNATIONAL COLLEGE--DES                <50
                      MOINES................................
            021493   SCS BUSINESS AND TECHNICAL INSTITUTE...             <50
            003652   UNIVERSITY OF HOUSTON..................             <50
            003273   HARRISBURG AREA COMMUNITY COLLEGE......             <50
            003184   UNIVERSITY OF OKLAHOMA.................             <50
            039733   SAE EXPRESSION COLLEGE.................             <50
            030911   ACT COLLEGE............................             <50
            021785   EAGLE GATE COLLEGE.....................             <50
            023013   PRISM CAREER INSTITUTE.................             <50
            008635   IBMC COLLEGE...........................             <50
            042279   MORTHLAND COLLEGE......................             <50
            002732   HOFSTRA UNIVERSITY.....................             <50
            002123   BECKER COLLEGE.........................             <50
            009230   WAYNE COUNTY COMMUNITY COLLEGE DISTRICT             <50
            003090   OHIO STATE UNIVERSITY (THE)............             <50
            001533   TALLAHASSEE COMMUNITY COLLEGE..........             <50
            025412   STRATFORD UNIVERSITY...................             <50
            022537   INTELLITEC COLLEGE.....................             <50
            003866   MILWAUKEE AREA TECHNICAL COLLEGE.......             <50
            002569   UNIVERSITY OF NEVADA--LAS VEGAS........             <50
            001500   BROWARD COLLEGE........................             <50
            001002   ALABAMA AGRICULTURAL & MECHANICAL                   <50
                      UNIVERSITY............................
            001005   ALABAMA STATE UNIVERSITY...............             <50
            034483   BUSINESS INDUSTRIAL RESOURCES..........             <50
            041232   INSTITUTE OF ALLIED MEDICAL PROFESSIONS             <50
            010142   TOURO UNIVERSITY.......................             <50
            002199   NORTHEASTERN UNIVERSITY................             <50
            001787   BETHEL UNIVERSITY......................             <50
            001536   UNIVERSITY OF MIAMI....................             <50
            005753   OWENS COMMUNITY COLLEGE................             <50
            004625   DELGADO COMMUNITY COLLEGE..............             <50
            001577   KENNESAW STATE UNIVERSITY..............             <50
            001758   SOUTHERN ILLINOIS UNIVERSITY AT                     <50
                      CARBONDALE............................
            001813   INDIANA UNIVERSITY--PURDUE UNIVERSITY               <50
                      INDIANAPOLIS..........................
            003594   UNIVERSITY OF NORTH TEXAS..............             <50
            037404   ATI COLLEGE............................             <50
            002823   SAINT JOHN'S UNIVERSITY................             <50
            030724   All-State Career School................             <50
            002259   EASTERN MICHIGAN UNIVERSITY............             <50
            001506   MIAMI DADE COLLEGE.....................             <50
            037633   MEDICAL PROFESSIONAL INSTITUTE.........             <50
            040743   HONDROS COLLEGE OF NURSING.............             <50
            001057   UNIVERSITY OF SOUTH ALABAMA............             <50
            001083   UNIVERSITY OF ARIZONA (THE)............             <50
            025476   FLORIDA NATIONAL UNIVERSITY............             <50
            004617   NATIONAL COLLEGE.......................             <50
            004866   STAUTZENBERGER COLLEGE.................             <50
            012627   THOMAS M. COOLEY LAW SCHOOL............             <50
            022539   Berks Technical Institute..............             <50
            002622   KEAN UNIVERSITY........................             <50
            001737   NORTHERN ILLINOIS UNIVERSITY...........             <50
            024911   BECKFIELD COLLEGE......................             <50
            031131   MARIC COLLEGE..........................             <50
            021283   INSTITUTE FOR BUSINESS & TECHNOLOGY....             <50
            020798   HEALD COLLEGE, SCHOOL OF BUSINESS......             <50
            001703   Kendall College........................             <50
            001733   NATIONAL LOUIS UNIVERSITY..............             <50
            008976   CLAYTON STATE UNIVERSITY...............             <50
            003630   PRAIRIE VIEW AGRICULTURAL & MECHANICAL              <50
                      UNIVERSITY............................
            003615   TEXAS STATE UNIVERSITY.................             <50
            003040   CUYAHOGA COMMUNITY COLLEGE.............             <50
            002617   MONTCLAIR STATE UNIVERSITY.............             <50
            002441   UNIVERSITY OF SOUTHERN MISSISSIPPI.....             <50
            002330   WESTERN MICHIGAN UNIVERSITY............             <50
            002410   JACKSON STATE UNIVERSITY...............             <50
            035643   INTERNATIONAL SCHOOL OF HEALTH, BEAUTY              <50
                      & TECHNOLOGY..........................
            041341   JERSEY COLLEGE.........................             <50
            021123   RIDLEY--LOWELL BUSINESS & TECHNICAL                 <50
                      INSTITUTE.............................
            002480   LINDENWOOD UNIVERSITY..................             <50
            002791   PACE UNIVERSITY........................             <50
            010881   STARK STATE COLLEGE....................             <50
            003612   UNIVERSITY OF HOUSTON--DOWNTOWN........             <50
            003896   UNIVERSITY OF WISCONSIN--MILWAUKEE.....             <50
            042087   COLORADO STATE UNIVERSITY--GLOBAL                   <50
                      CAMPUS................................
            003735   VIRGINIA COMMONWEALTH UNIVERSITY.......             <50
            003123   UNIVERSITY OF AKRON (THE)..............             <50
            002518   UNIVERSITY OF MISSOURI--KANSAS CITY....             <50
            002002   WESTERN KENTUCKY UNIVERSITY............             <50
            002950   NORTH CAROLINA CENTRAL UNIVERSITY......             <50
            041160   VIDEO SYMPHONY ENTERTRAINING...........             <50
            041279   TRIDENT UNIVERSITY INTERNATIONAL.......             <50
            025779   SANTA BARBARA BUSINESS COLLEGE.........             <50
            031150   ARIZONA COLLEGE........................             <50
            031081   SUMMIT COLLEGE.........................             <50
            030837   GALEN HEALTH INSTITUTES................             <50
            011117   ALLIANT INTERNATIONAL UNIVERSITY.......             <50
            009432   ESS COLLEGE OF BUSINESS................             <50
            002284   MARYGROVE COLLEGE......................             <50
            001479   EMBRY-RIDDLE AERONAUTICAL UNIVERSITY...             <50
            001535   UNIVERSITY OF FLORIDA..................             <50
            001520   SEMINOLE STATE COLLEGE OF FLORIDA......             <50
            001775   UNIVERSITY OF ILLINOIS URBANA-CHAMPAIGN             <50
            001544   ALBANY STATE UNIVERSITY................             <50
            041359   ORION COLLEGE..........................             <50
            038425   CAMBRIDGE COLLEGE OF HEALTHCARE &                   <50
                      TECHNOLOGY............................
            041323   INSTITUTE OF MEDICAL EDUCATION.........             <50
            013005   OLYMPIAN ACADEMY OF COSMETOLOGY........             <50
            025762   MID-CONTINENT UNIVERSITY...............             <50
            004579   INTERNATIONAL BUSINESS COLLEGE.........             <50
            003991   GREENVILLE TECHNICAL COLLEGE...........             <50
            003800   WASHINGTON STATE UNIVERSITY............             <50
            003712   TIDEWATER COMMUNITY COLLEGE............             <50
            003626   TARRANT COUNTY COLLEGE DISTRICT........             <50
            003100   OHIO UNIVERSITY........................             <50
            001154   SAN FRANCISCO STATE UNIVERSITY.........             <50
            001082   NORTHERN ARIZONA UNIVERSITY............             <50
            001052   UNIVERSITY OF ALABAMA AT BIRMINGHAM....             <50
            033674   COMMUNITY CARE COLLEGE.................             <50
            041618   BRANDMAN UNIVERSITY....................             <50
            009449   PENNCO TECH............................             <50
            023148   BALTIMORE INTERNATIONAL COLLEGE........             <50
            007518   APEX TECHNICAL SCHOOL..................             <50
            007405   WOOD TOBE--COBURN SCHOOL...............             <50
            003313   WIDENER UNIVERSITY.....................             <50
            020662   NEW SCHOOL, THE........................             <50
            001562   Georgia Perimeter College..............             <50
            010115   UNIVERSITY OF TEXAS AT SAN ANTONIO.....             <50
            003644   TEXAS TECH UNIVERSITY..................             <50
            002083   MORGAN STATE UNIVERSITY................             <50
            001561   COLUMBUS STATE UNIVERSITY..............             <50
            002923   EAST CAROLINA UNIVERSITY...............             <50
            002519   UNIVERSITY OF MISSOURI--SAINT LOUIS....             <50
            001776   UNIVERSITY OF ILLINOIS AT CHICAGO......             <50
            002006   GRAMBLING STATE UNIVERSITY.............             <50
            002657   NEW MEXICO STATE UNIVERSITY............             <50
            002243   CENTRAL MICHIGAN UNIVERSITY............             <50
            002270   HENRY FORD COLLEGE.....................             <50
            041697   UNITEK COLLEGE.........................             <50
            037893   UNITECH TRAINING ACADEMY...............             <50
            025215   LAMSON COLLEGE.........................             <50
            033484   MATTIA COLLEGE.........................             <50
            030897   CAREER INSTITUTE OF HEALTH AND                      <50
                      TECHNOLOGY............................
            020555   DELTA SCHOOL OF BUSINESS AND TECHNOLOGY             <50
            022949   INSTITUTE OF AUDIO RESEARCH............             <50
            008106   WESTERN TECHNICAL COLLEGE..............             <50
            007948   WILMINGTON UNIVERSITY..................             <50
            003420   BENEDICT COLLEGE.......................             <50
            011719   UNIVERSIDAD ANA G. MENDEZ--GURABO                   <50
                      CAMPUS................................
            009401   COLORADO CHRISTIAN UNIVERSITY..........             <50
            001497   JONES COLLEGE..........................             <50
            004846   Rasmussen College......................             <50
            001003   FAULKNER UNIVERSITY....................             <50
            001342   WHITTIER COLLEGE.......................             <50
            003728   OLD DOMINION UNIVERSITY................             <50
            007870   HILLSBOROUGH COMMUNITY COLLEGE.........             <50
            010286   SUNY EMPIRE STATE COLLEGE..............             <50
            010345   CINCINNATI STATE TECHNICAL & COMMUNITY              <50
                      COLLEGE...............................
            021775   RIO SALADO COMMUNITY COLLEGE...........             <50
            003152   UNIVERSITY OF CENTRAL OKLAHOMA.........             <50
            002663   UNIVERSITY OF NEW MEXICO...............             <50
            002613   NEW JERSEY CITY UNIVERSITY.............             <50
            001150   CALIFORNIA STATE UNIVERSITY--SACRAMENTO             <50
            036393   TRIAD EDUCATION........................             <50
            001101   UNIVERSITY OF ARKANSAS AT LITTLE ROCK..             <50
            030316   DPT BUSINESS SCHOOL....................             <50
            026009   AVEDA ARTS & SCIENCES INSTITUTE                     <50
                      COVINGTON.............................
            025868   HARRISON CAREER INSTITUTE-.............             <50
            011505   TRICOCI UNIVERSITY OF BEAUTY CULTURE...             <50
            022965   MASTERS INSTITUTE......................             <50
            004568   MIDSTATE COLLEGE.......................             <50
            009769   METROPOLITAN COLLEGE OF NEW YORK.......             <50
            010149   PEPPERDINE UNIVERSITY..................             <50
            001486   FLORIDA MEMORIAL UNIVERSITY............             <50
            001444   GEORGE WASHINGTON UNIVERSITY...........             <50
            003764   VIRGINIA STATE UNIVERSITY..............             <50
            003634   TEXAS STATE TECHNICAL COLLEGE..........             <50
            001360   METROPOLITAN STATE UNIVERSITY OF DENVER             <50
            003446   SOUTH CAROLINA STATE UNIVERSITY........             <50
            003249   COMMUNITY COLLEGE OF PHILADELPHIA......             <50
            002010   LOUISIANA STATE UNIVERSITY &                        <50
                      AGRICULTURAL & MECHANICAL COLLEGE.....
            039853   CDA TECHNICAL INSTITUTE................             <50
            001051   UNIVERSITY OF ALABAMA..................             <50
            023405   ST. LOUIS COLLEGE OF HEALTH CAREERS....             <50
            023190   COMPUTER LEARNING CENTERS,INC. CHICAGO.             <50
            022606   NUC UNIVERSITY.........................             <50
            030375   HODGES UNIVERSITY......................             <50
            003043   CHANCELLOR UNIVERSITY..................             <50
            006975   LINCOLN UNIVERSITY.....................             <50
            001210   HEALD INSTITUTE OF TECHNOLOGY..........             <50
            003765   NORFOLK STATE UNIVERSITY...............             <50
            009145   GOVERNORS STATE UNIVERSITY.............             <50
            001572   GEORGIA SOUTHERN UNIVERSITY............             <50
            001139   CALIFORNIA STATE UNIVERSITY, LONG BEACH             <50
            001475   DAYTONA STATE COLLEGE..................             <50
            001892   UNIVERSITY OF IOWA.....................             <50
            039153   CAREER QUEST LEARNING CENTERS..........             <50
            025399   STAR TECHNICAL INSTITUTE...............             <50
            030682   OHIO MEDIA SCHOOL......................             <50
            023385   GLENDALE CAREER COLLEGE................             <50
            031043   CAREER TECHNICAL INSTITUTE.............             <50
            030198   PCI HEALTH TRAINING CENTER.............             <50
            021066   AMERICAN INSTITUTE.....................             <50
            012846   LAWTON SCHOOL FOR MEDICAL AND DENTAL                <50
                      ASSISTANTS............................
            004730   MCINTOSH COLLEGE.......................             <50
            009268   KELSEY -JENNEY COLLEGE.................             <50
            002782   NEW YORK INSTITUTE OF TECHNOLOGY.......             <50
            007572   AMERICAN MUSICAL & DRAMATIC ACADEMY....             <50
            004072   NORTHWOOD UNIVERSITY...................             <50
            001767   BENEDICTINE UNIVERSITY.................             <50
            001363   REGIS UNIVERSITY.......................             <50
            001416   UNIVERSITY OF BRIDGEPORT...............             <50
            002130   BOSTON UNIVERSITY......................             <50
            001456   SOUTHEASTERN UNIVERSITY................             <50
            001749   ROOSEVELT UNIVERSITY...................             <50
            002975   UNIVERSITY OF NORTH CAROLINA--CHARLOTTE             <50
            002842   SUNY COLLEGE AT BUFFALO................             <50
            001989   UNIVERSITY OF KENTUCKY.................             <50
            003581   LAMAR UNIVERSITY.......................             <50
            002872   MONROE COMMUNITY COLLEGE...............             <50
            002407   HINDS COMMUNITY COLLEGE................             <50
            001137   CALIFORNIA STATE UNIVERSITY, FULLERTON.             <50
            001599   VALDOSTA STATE UNIVERSITY..............             <50
            001428   DELAWARE STATE UNIVERSITY..............             <50
            001827   PURDUE UNIVERSITY NORTHWEST............             <50
            002303   OAKLAND COMMUNITY COLLEGE..............             <50
            023220   COMPUTER LEARNING CENTERS, INC. SAN                 <50
                      FRANCISCO.............................
            034685   MDT COLLEGE OF HEALTH SCIENCES.........             <50
            030642   COMPUTER LEARNING CENTER OF ANAHEIM....             <50
            025964   SPARTAN COLLEGE OF AERONAUTICS &                    <50
                      TECHNOLOGY............................
            013016   OGLE SCHOOL HAIR SKIN NAILS............             <50
            035134   APEX SCHOOL OF THEOLOGY................             <50
            009618   TULSA WELDING SCHOOL...................             <50
            009043   ELMIRA BUSINESS INSTITUTE..............             <50
            010831   NEW COLLEGE OF CALIFORNIA..............             <50
            001710   LOYOLA UNIVERSITY CHICAGO..............             <50
            003827   WEST VIRGINIA UNIVERSITY...............             <50
            003648   TYLER JUNIOR COLLEGE...................             <50
            009841   UNIVERSITY OF NORTH FLORIDA............             <50
            002837   STATE UNIVERSITY OF NEW YORK AT BUFFALO             <50
            002362   MINNEAPOLIS COMMUNITY AND TECHNICAL                 <50
                      COLLEGE...............................
            003213   PORTLAND COMMUNITY COLLEGE.............             <50
            002031   UNIVERSITY OF LOUISIANA AT LAFAYETTE...             <50
            003316   CALIFORNIA UNIVERSITY OF PENNSYLVANIA..             <50
            002609   ROWAN UNIVERSITY.......................             <50
            002396   ALCORN STATE UNIVERSITY................             <50
            001590   SAVANNAH STATE UNIVERSITY..............             <50
            002307   OAKLAND UNIVERSITY.....................             <50
            041157   REGINA'S COLLEGE OF BEAUTY.............             <50
            041848   VANTAGE COLLEGE........................             <50
            037563   ANAMARC COLLEGE........................             <50
            038663   GALIANO CAREER ACADEMY.................             <50
            025982   UNIVERSITY OF SOUTHERNMOST FLORIDA.....             <50
            012425   STONE ACADEMY..........................             <50
            021483   MANHATTAN BEAUTY SCHOOL................             <50
            009407   LINCOLN COLLEGE OF NEW ENGLAND.........             <50
            031085   EVERGLADES UNIVERSITY..................             <50
            002722   FORDHAM UNIVERSITY.....................             <50
            003938   INTER AMERICAN UNIVERSITY OF PUERTO                 <50
                      RICO--SAN GERMAN CAMPUS...............
            002077   JOHNS HOPKINS UNIVERSITY...............             <50
            022779   ROSS UNIVERSITY SCHOOL OF VETERINARY                <50
                      MEDICINE..............................
            001325   UNIVERSITY OF SAN FRANCISCO............             <50
            007933   FRONT RANGE COMMUNITY COLLEGE..........             <50
            003646   TEXAS WOMANS UNIVERSITY................             <50
            003955   UNIVERSITY OF WEST FLORIDA (THE).......             <50
            003448   UNIVERSITY OF SOUTH CAROLINA--COLUMBIA.             <50
            002835   STATE UNIVERSITY OF NEW YORK AT ALBANY.             <50
            003478   AUSTIN PEAY STATE UNIVERSITY...........             <50
            001140   CALIFORNIA STATE UNIVERSITY, LOS                    <50
                      ANGELES...............................
            003032   CLEVELAND STATE UNIVERSITY.............             <50
            001807   INDIANA STATE UNIVERSITY...............             <50
            003451   COASTAL CAROLINA UNIVERSITY............             <50
            002268   GRAND VALLEY STATE UNIVERSITY..........             <50
            002424   MISSISSIPPI VALLEY STATE UNIVERSITY....             <50
            002278   LANSING COMMUNITY COLLEGE..............             <50
            040383   ATA COLLEGE............................             <50
            040803   ASPEN UNIVERSITY.......................             <50
            036253   PERFORMANCE TRAINING INSTITUTE.........             <50
            001090   ARKANSAS STATE UNIVERSITY..............             <50
            025318   PAUL MITCHELL THE SCHOOL COSTA MESA....             <50
            021440   BEAUTY INSTITUTE (THE).................             <50
            008655   GENESIS CAREER COLLEGE.................             <50
            007814   BROOKSTONE COLLEGE OF BUSINESS.........             <50
            010351   PSI INSTITUTE..........................             <50
            003739   SAINT PAUL'S COLLEGE...................             <50
            004484   JOHN F. KENNEDY UNIVERSITY.............             <50
            012300   PALMER COLLEGE OF CHIROPRACTIC.........             <50
            001842   VALPARAISO UNIVERSITY..................             <50
            001580   MERCER UNIVERSITY......................             <50
            002211   SPRINGFIELD COLLEGE....................             <50
            001117   AZUSA PACIFIC UNIVERSITY...............             <50
            002165   MCPHS UNIVERSITY.......................             <50
            001468   SAINT THOMAS UNIVERSITY................             <50
            004076   KIRKWOOD COMMUNITY COLLEGE.............             <50
            004920   TRIDENT TECHNICAL COLLEGE..............             <50
            003078   WRIGHT STATE UNIVERSITY................             <50
            002905   NORTH CAROLINA AGRICULTURAL AND                     <50
                      TECHNICAL STATE UNIVERSITY............
            002873   NASSAU COMMUNITY COLLEGE...............             <50
            001809   INDIANA UNIVERSITY--BLOOMINGTON........             <50
            002928   FAYETTEVILLE STATE UNIVERSITY..........             <50
            002260   FERRIS STATE UNIVERSITY................             <50
            003216   PORTLAND STATE UNIVERSITY..............             <50
            001441   UNIVERSITY OF THE DISTRICT OF COLUMBIA.             <50
            002516   UNIVERSITY OF MISSOURI--COLUMBIA.......             <50
            041826   HCI COLLEGE............................             <50
            007648   DENVER TECHNICAL COLLEGE...............             <50
            030913   REGENT UNIVERSITY......................             <50
            007401   MANDL SCHOOL...........................             <50
            002632   SETON HALL UNIVERSITY..................             <50
            003309   PEIRCE COLLEGE.........................             <50
            010509   HALLMARK UNIVERSITY....................             <50
            001044   STILLMAN COLLEGE.......................             <50
            001216   UNIVERSITY OF LA VERNE.................             <50
            001433   WESLEY COLLEGE.........................             <50
            001445   GEORGETOWN UNIVERSITY..................             <50
            037303   BATON ROUGE COMMUNITY COLLEGE..........             <50
            004508   UNIVERSITY OF COLORADO DENVER..........             <50
            009763   TULSA COMMUNITY COLLEGE................             <50
            003632   TEXAS A&M UNIVERSITY...................             <50
            004838   GUILFORD TECHNICAL COMMUNITY COLLEGE...             <50
            003749   GEORGE MASON UNIVERSITY................             <50
            021922   THOMAS EDISON STATE UNIVERSITY.........             <50
            003969   UNIVERSITY OF MINNESOTA--TWIN CITIES...             <50
            003773   CLARK COLLEGE..........................             <50
            002976   UNIVERSITY OF NORTH CAROLINA -                      <50
                      GREENSBORO............................
            001963   EASTERN KENTUCKY UNIVERSITY............             <50
            003145   YOUNGSTOWN STATE UNIVERSITY............             <50
            002325   UNIVERSITY OF MICHIGAN.................             <50
            001999   UNIVERSITY OF LOUISVILLE...............             <50
            002327   UNIVERSITY OF MICHIGAN--FLINT..........             <50
            003119   SINCLAIR COMMUNITY COLLEGE.............             <50
            001825   PURDUE UNIVERSITY......................             <50
            001869   IOWA STATE UNIVERSITY OF SCIENCE &                  <50
                      TECHNOLOGY............................
            001616   BOISE STATE UNIVERSITY.................             <50
            001020   JACKSONVILLE STATE UNIVERSITY..........             <50
            041194   AVEDA INSTITUTE--SOUTH FLORIDA.........             <50
            041390   MIDWESTERN CAREER COLLEGE..............             <50
            030716   CBT TECHNOLOGY INSTITUTE...............             <50
            031258   PREMIERE CAREER COLLEGE................             <50
            031100   ACADEMY OF HEALING ARTS................             <50
            025801   IVERSON INSTITUTE......................             <50
            034023   METROPOLITAN COMMUNITY COLLEGE.........             <50
            025590   UNIVERSITY OF ADVANCING COMPUTER                    <50
                      TECHNOLOGY............................
            031268   PACIFICA GRADUATE INSTITUTE............             <50
            021280   SUPERIOR TRAINING SERVICES.............             <50
            022452   MTI COLLEGE OF BUSINESS AND TECHNOLOGY.             <50
            020912   ELEGANCE INTERNATIONAL.................             <50
            021107   CLEVELAND INSTITUTE OF DENTAL--MEDICAL              <50
                      ASSISTANTS............................
            012912   MTI COLLEGE............................             <50
            010279   HICKEY COLLEGE.........................             <50
            004297   WATTERSON COLLEGE......................             <50
            003046   FRANKLIN UNIVERSITY....................             <50
            003010   ANTIOCH UNIVERSITY.....................             <50
            003499   LANE COLLEGE...........................             <50
            003388   VILLANOVA UNIVERSITY...................             <50
            002482   MARYVILLE UNIVERSITY OF SAINT LOUIS....             <50
            006942   MID-AMERICA CHRISTIAN UNIVERSITY.......             <50
            003357   POINT PARK UNIVERSITY..................             <50
            022444   AMERICAN UNIVERSITY OF THE CARIBBEAN...             <50
            002114   AMERICAN INTERNATIONAL COLLEGE.........             <50
            001397   UNIVERSITY OF NEW HAVEN................             <50
            003798   UNIVERSITY OF WASHINGTON...............             <50
            003727   NORTHERN VIRGINIA COMMUNITY COLLEGE....             <50
            002099   TOWSON UNIVERSITY......................             <50
            002503   MISSOURI STATE UNIVERSITY..............             <50
            001155   SAN JOSE STATE UNIVERSITY..............             <50
            002222   UNIVERSITY OF MASSACHUSETTS AT BOSTON..             <50
            003277   INDIANA UNIVERSITY OF PENNSYLVANIA.....             <50
            001786   BALL STATE UNIVERSITY..................             <50
            003223   UNIVERSITY OF OREGON...................             <50
            003018   BOWLING GREEN STATE UNIVERSITY.........             <50
            001601   UNIVERSITY OF WEST GEORGIA.............             <50
            002875   ONONDAGA COMMUNITY COLLEGE.............             <50
            001151   SAN DIEGO STATE UNIVERSITY.............             <50
            001024   UNIVERSITY OF WEST ALABAMA.............             <50
            042065   MYCOMPUTERCAREER.COM...................             <50
            001076   GLENDALE COMMUNITY COLLEGE.............             <50
            001086   UNIVERSITY OF ARKANSAS AT PINE BLUFF...             <50
            041414   LAURUS COLLEGE.........................             <50
            033943   REMINGTON COLLEGE--SAN DIEGO CAMPUS....             <50
            023112   AMERICAN SCHOOL OF TECHNOLOGY..........             <50
            030399   FREMONT UNIVERSITY.....................             <50
            022552   PENNSYLVANIA SCHOOL OF BUSINESS........             <50
            004825   TAYLOR BUSINESS INSTITUTE..............             <50
            010061   BRYANT AND STRATTON COLLEGE -VIRGINIA               <50
                      BEACH CAMPUS..........................
            007050   BELLUS ACADEMY.........................             <50
            010503   WICHITA TECHNICAL INSTITUTE............             <50
            009022   ASSOCIATED TECHNICAL COLLEGE...........             <50
            021686   EAST-WEST UNIVERSITY...................             <50
            006731   CASA LOMA COLLEGE......................             <50
            007845   NEW ENGLAND INSTITUTE OF TECHNOLOGY....             <50
            002498   PARK UNIVERSITY........................             <50
            008849   PALM BEACH ATLANTIC UNIVERSITY.........             <50
            002342   ST. CATHERINE UNIVERSITY...............             <50
            001371   UNIVERSITY OF DENVER...................             <50
            003631   TARLETON STATE UNIVERSITY..............             <50
            020753   UNIVERSITY OF ARKANSAS--PULASKI                     <50
                      TECHNICAL COLLEGE.....................
            010362   COLLEGE OF SOUTHERN NEVADA.............             <50
            005622   GEORGIA PIEDMONT TECHNICAL COLLEGE.....             <50
            006961   JEFFERSON COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            009542   COMMUNITY COLLEGE OF DENVER............             <50
            007120   DES MOINES AREA COMMUNITY COLLEGE......             <50
            023614   COLLIN COUNTY COMMUNITY COLLEGE                     <50
                      DISTRICT..............................
            002423   MISSISSIPPI STATE UNIVERSITY...........             <50
            001417   UNIVERSITY OF CONNECTICUT..............             <50
            003565   TEXAS A&M UNIVERSITY--COMMERCE.........             <50
            002625   WILLIAM PATERSON UNIVERSITY OF NEW                  <50
                      JERSEY................................
            003593   NAVARRO COLLEGE........................             <50
            003026   CENTRAL STATE UNIVERSITY...............             <50
            001566   FORT VALLEY STATE UNIVERSITY...........             <50
            002691   CUNY BOROUGH OF MANHATTAN COMMUNITY                 <50
                      COLLEGE...............................
            001815   INDIANA UNIVERSITY--NORTHWEST..........             <50
            002026   SOUTHERN UNIVERSITY AT NEW ORLEANS.....             <50
            002261   CHARLES STEWART MOTT COMMUNITY COLLEGE.             <50
            001315   UNIVERSITY OF CALIFORNIA, LOS ANGELES..             <50
            038123   OMNITECH INSTITUTE.....................             <50
            041317   SOUTHWEST UNIVERSITY AT EL PASO........             <50
            001077   MESA COMMUNITY COLLEGE.................             <50
            025408   GLOBE INSTITUTE OF TECHNOLOGY..........             <50
            025389   INTERNATIONAL BUSINESS COLLEGE-........             <50
            022708   JOYCE UNIVERSITY OF NURSING AND HEALTH              <50
                      SCIENCES..............................
            020741   CAPITOL CITY TRADE & TECHNICAL SCHOOL..             <50
            022025   NEW ENGLAND TRACTOR TRAILER TRAINING                <50
                      SCHOOL OF CONN........................
            021274   YTI CAREER INSTITUTE...................             <50
            022342   KEYSTONE TECHNICAL INSTITUTE...........             <50
            003965   BAY STATE COLLEGE......................             <50
            009479   ST. PAUL'S SCHOOL OF NURSING...........             <50
            005007   WEST VIRGINIA JUNIOR COLLEGE...........             <50
            004645   MINNEAPOLIS BUSINESS COLLEGE...........             <50
            007469   HUSSIAN COLLEGE........................             <50
            021829   CAMBRIDGE COLLEGE......................             <50
            002604   FAIRLEIGH DICKINSON UNIVERSITY.........             <50
            003199   MARYLHURST UNIVERSITY..................             <50
            003985   ORAL ROBERTS UNIVERSITY................             <50
            002962   SHAW UNIVERSITY........................             <50
            001937   OTTAWA UNIVERSITY......................             <50
            001243   MOUNT SAINT MARY'S UNIVERSITY..........             <50
            005244   BLUEGRASS COMMUNITY & TECHNICAL COLLEGE             <50
            004844   WAKE TECHNICAL COMMUNITY COLLEGE.......             <50
            003815   MARSHALL UNIVERSITY....................             <50
            007022   CUNY LEHMAN COLLEGE....................             <50
            021163   PUEBLO COMMUNITY COLLEGE...............             <50
            007191   NORTHAMPTON COUNTY AREA COMMUNITY                   <50
                      COLLEGE...............................
            003661   UNIVERSITY OF TEXAS AT EL PASO.........             <50
            008145   NASHVILLE STATE COMMUNITY COLLEGE......             <50
            001512   PALM BEACH STATE COLLEGE...............             <50
            002690   CUNY QUEENS COLLEGE....................             <50
            002267   GRAND RAPIDS COMMUNITY COLLEGE.........             <50
            002274   JACKSON COLLEGE........................             <50
            002986   WINSTON-SALEM STATE UNIVERSITY.........             <50
            001948   UNIVERSITY OF KANSAS...................             <50
            001693   NORTHEASTERN ILLINOIS UNIVERSITY.......             <50
            001350   COLORADO STATE UNIVERSITY..............             <50
            002068   COPPIN STATE UNIVERSITY................             <50
            002015   UNIVERSITY OF NEW ORLEANS (THE)........             <50
            002360   MINNESOTA STATE UNIVERSITY, MANKATO....             <50
            037063   HOLLYWOOD INSTITUTE....................             <50
            041245   MYCOMPUTERCAREER AT COLUMBUS...........             <50
            037974   CAREER CARE INSTITUTE..................             <50
            041327   HEALTHCARE CAREER COLLEGE..............             <50
            025354   SKYLINE COLLEGE--RICHMOND..............             <50
            025400   TENNESSEE ACADEMY OF COSMETOLOGY.......             <50
            026095   CAREER TRAINING ACADEMY................             <50
            031724   CALIBER TRAINING INSTITUTE.............             <50
            021618   MUSICIANS INSTITUTE....................             <50
            020543   TRUMBULL BUSINESS COLLEGE..............             <50
            030725   WORLD MEDICINE INSTITUTE...............             <50
            009520   NATIONAL ACADEMY OF BEAUTY ARTS........             <50
            009892   DULUTH BUSINESS UNIVERSITY.............             <50
            022425   BASTYR UNIVERSITY......................             <50
            005208   COLLEGE OF WESTCHESTER (THE)...........             <50
            002707   COLUMBIA UNIVERSITY IN THE CITY OF NEW              <50
                      YORK..................................
            003297   MERCYHURST UNIVERSITY..................             <50
            003714   HAMPTON UNIVERSITY.....................             <50
            003367   SAINT JOSEPH'S UNIVERSITY..............             <50
            003837   CARDINAL STRITCH UNIVERSITY............             <50
            001893   UPPER IOWA UNIVERSITY..................             <50
            001821   MARIAN UNIVERSITY......................             <50
            001125   CALIFORNIA BAPTIST UNIVERSITY..........             <50
            001543   Darton State College...................             <50
            001087   ARKANSAS BAPTIST COLLEGE...............             <50
            001434   AMERICAN UNIVERSITY (THE)..............             <50
            002029   TULANE UNIVERSITY......................             <50
            008545   Rockford Career College................             <50
            022288   Lincoln Technical Institute--East                   <50
                      Windsor...............................
            007640   FAYETTEVILLE TECHNICAL COMMUNITY                    <50
                      COLLEGE...............................
            008037   GATEWAY COMMUNITY COLLEGE..............             <50
            007993   CALIFORNIA STATE UNIVERSITY,                        <50
                      BAKERSFIELD...........................
            004852   CLARK STATE COLLEGE....................             <50
            004736   BERGEN COMMUNITY COLLEGE...............             <50
            008543   ATLANTA TECHNICAL COLLEGE..............             <50
            030830   OZARKS TECHNICAL COMMUNITY COLLEGE.....             <50
            001470   EASTERN FLORIDA STATE COLLEGE..........             <50
            001828   PURDUE UNIVERSITY FORT WAYNE...........             <50
            001313   UNIVERSITY OF CALIFORNIA, DAVIS........             <50
            001674   EASTERN ILLINOIS UNIVERSITY............             <50
            001610   UNIVERSITY OF HAWAII AT MANOA..........             <50
            001692   ILLINOIS STATE UNIVERSITY..............             <50
            001654   CITY COLLEGES OF CHICAGO--KENNEDY KING              <50
                      COLLEGE...............................
            001780   WESTERN ILLINOIS UNIVERSITY............             <50
            002454   UNIVERSITY OF CENTRAL MISSOURI.........             <50
            002314   SAGINAW VALLEY STATE UNIVERSITY........             <50
            001977   MURRAY STATE UNIVERSITY................             <50
            002326   UNIVERSITY OF MICHIGAN--DEARBORN.......             <50
            002005   NICHOLLS STATE UNIVERSITY..............             <50
            001370   UNIVERSITY OF COLORADO BOULDER.........             <50
            002021   NORTHWESTERN STATE UNIVERSITY..........             <50
            001316   UNIVERSITY OF CALIFORNIA, RIVERSIDE....             <50
            002102   UNIVERSITY OF BALTIMORE................             <50
            001519   SANTA FE COLLEGE.......................             <50
            002440   UNIVERSITY OF MISSISSIPPI..............             <50
            002838   STATE UNIVERSITY OF NEW YORK AT STONY               <50
                      BROOK.................................
            041698   GURNICK ACADEMY OF MEDICAL ARTS........             <50
            034275   UNIVERSITY OF ANTELOPE VALLEY..........             <50
            031226   EASTERN INTERNATIONAL COLLEGE..........             <50
            023491   HAIR FASHIONS BY KAYE BEAUTY COLLEGE...             <50
            033083   BRISTOL UNIVERSITY.....................             <50
            022053   SAVANNAH RIVER COLLEGE.................             <50
            025875   UNIVERSIDAD ANA G. MENDEZ--CUPEY CAMPUS             <50
            030673   METROPOLITAN COLLEGE...................             <50
            007229   WESTERN BEAUTY INSTITUTE...............             <50
            007791   WILFRED ACADEMY OF HAIR & BEAUTY                    <50
                      CULTURE...............................
            009989   CALIFORNIA AERONAUTICAL UNIVERSITY.....             <50
            007439   FOUNTAINHEAD COLLEGE OF TECHNOLOGY.....             <50
            003820   SALEM UNIVERSITY.......................             <50
            041633   COMPASS COLLEGE OF CINEMATIC ARTS......             <50
            008682   ACADEMY OF HAIR DESIGN.................             <50
            012393   THOMAS JEFFERSON UNIVERSITY............             <50
            010923   UNION INSTITUTE & UNIVERSITY...........             <50
            002949   UNIVERSITY OF MOUNT OLIVE..............             <50
            002709   CONCORDIA COLLEGE......................             <50
            010998   PENNSYLVANIA INSTITUTE OF TECHNOLOGY...             <50
            002397   BELHAVEN UNIVERSITY....................             <50
            002936   JOHNSON C. SMITH UNIVERSITY............             <50
            002790   NYACK COLLEGE..........................             <50
            001983   ST. CATHARINE COLLEGE..................             <50
            001050   TUSKEGEE UNIVERSITY....................             <50
            001707   LEWIS UNIVERSITY.......................             <50
            001556   BRENAU UNIVERSITY......................             <50
            002208   SIMMONS UNIVERSITY.....................             <50
            002218   SUFFOLK UNIVERSITY.....................             <50
            001028   MILES COLLEGE..........................             <50
            022769   COMMUNITY COLLEGE OF AURORA CENTRETECH              <50
                      CAMPUS................................
            007273   CUNY BERNARD M. BARUCH COLLEGE.........             <50
            003775   EASTERN WASHINGTON UNIVERSITY..........             <50
            006804   LAKELAND COMMUNITY COLLEGE.............             <50
            005533   SAINT PAUL COLLEGE--A COMMUNITY &                   <50
                      TECHNICAL COLLEGE.....................
            003992   PIEDMONT TECHNICAL COLLEGE.............             <50
            004452   MONTGOMERY COUNTY COMMUNITY COLLEGE....             <50
            007266   PIMA COUNTY COMMUNITY COLLEGE..........             <50
            009741   UNIVERSITY OF TEXAS AT DALLAS..........             <50
            003624   STEPHEN F AUSTIN STATE UNIVERSITY......             <50
            005317   FORSYTH TECHNICAL COMMUNITY COLLEGE....             <50
            003523   TENNESSEE TECHNOLOGICAL UNIVERSITY.....             <50
            001477   FLORIDA SOUTHWESTERN STATE COLLEGE.....             <50
            003210   OREGON STATE UNIVERSITY................             <50
            002554   UNIVERSITY OF NEBRASKA AT OMAHA........             <50
            002106   UNIVERSITY OF MARYLAND--EASTERN SHORE..             <50
            001581   MIDDLE GEORGIA STATE UNIVERSITY........             <50
            002063   COMMUNITY COLLEGE OF BALTIMORE COUNTY..             <50
            002621   NEW JERSEY INSTITUTE OF TECHNOLOGY.....             <50
            003231   COMMUNITY COLLEGE OF ALLEGHENY COUNTY..             <50
            002693   CUNY JOHN JAY COLLEGE OF CRIMINAL                   <50
                      JUSTICE...............................
            003379   UNIVERSITY OF PITTSBURGH...............             <50
            001147   CALIFORNIA STATE UNIVERSITY, FRESNO....             <50
            003487   EAST TENNESSEE STATE UNIVERSITY........             <50
            002954   UNIVERSITY OF NORTH CAROLINA AT                     <50
                      PEMBROKE..............................
            003590   MCLENNAN COMMUNITY COLLEGE.............             <50
            003077   MIAMI UNIVERSITY.......................             <50
            001092   UNIVERSITY OF CENTRAL ARKANSAS.........             <50
            039394   CENTURA INSTITUTE......................             <50
            001055   UNIVERSITY OF ALABAMA IN HUNTSVILLE....             <50
            041625   HOLLYWOOD INSTITUTE OF BEAUTY CAREERS..             <50
            001108   UNIVERSITY OF ARKANSAS.................             <50
            032423   CAREER NETWORKS INSTITUTE..............             <50
            023251   KEY COLLEGE............................             <50
            030427   LAURUS TECHNICAL INSTITUTE.............             <50
            023124   LA COLLEGE INTERNATIONAL...............             <50
            025812   CC'S COSMETOLOGY COLLEGE...............             <50
            025910   WRIGHT BUSINESS SCHOOL.................             <50
            030277   PACIFIC COLLEGE OF HEALTH AND SCIENCE..             <50
            012561   FIVE TOWNS COLLEGE.....................             <50
            020924   RIDLEY-LOWELL SCHOOL OF BUSINESS.......             <50
            021585   OHIO BUSINESS COLLEGE..................             <50
            022417   PJ'S COLLEGE OF COSMETOLOGY............             <50
            020651   REMINGTON COLLEGE--NEW ORLEANS CAMPUS..             <50
            004894   ERIE BUSINESS CENTER...................             <50
            025929   HEALD COLLEGE-SCHOOL OF TECHNOLOGY.....             <50
            009246   PACIFIC COAST COLLEGE..................             <50
            008575   SALON PROFESSIONAL ACADEMY (THE).......             <50
            003029   CINCINNATI CHRISTIAN UNIVERSITY........             <50
            002666   ADELPHI UNIVERSITY.....................             <50
            003645   TEXAS WESLEYAN UNIVERSITY..............             <50
            003545   BAYLOR UNIVERSITY......................             <50
            002506   SAINT LOUIS UNIVERSITY.................             <50
            003578   UNIVERSITY OF THE INCARNATE WORD.......             <50
            002628   RIDER UNIVERSITY.......................             <50
            003584   LETOURNEAU UNIVERSITY..................             <50
            003693   SOUTHERN VERMONT COLLEGE...............             <50
            003354   Philadelphia University................             <50
            002032   XAVIER UNIVERSITY OF LOUISIANA.........             <50
            010040   Ivy Tech Community College of Indiana--             <50
                      Region 1..............................
            003675   UNIVERSITY OF UTAH.....................             <50
            011161   TEXAS A&M UNIVERSITY--CORPUS CHRISTI...             <50
            003793   SPOKANE COMMUNITY COLLEGE..............             <50
            041429   GEORGIA GWINNETT COLLEGE...............             <50
            003771   CENTRAL WASHINGTON UNIVERSITY..........             <50
            003812   FAIRMONT STATE UNIVERSITY..............             <50
            003658   UNIVERSITY OF TEXAS--AUSTIN............             <50
            009345   STOCKTON UNIVERSITY....................             <50
            004509   UNIVERSITY OF COLORADO COLORADO SPRINGS             <50
            005752   CLOVER PARK TECHNICAL COLLEGE..........             <50
            011462   UNIVERSITY OF ALASKA ANCHORAGE.........             <50
            003998   CHATTANOOGA STATE COMMUNITY COLLEGE....             <50
            020554   BOSSIER PARISH COMMUNITY COLLEGE.......             <50
            004007   MADISON AREA TECHNICAL COLLEGE.........             <50
            022884   GWINNETT TECHNICAL COLLEGE.............             <50
            004027   UTAH VALLEY UNIVERSITY.................             <50
            010388   READING AREA COMMUNITY COLLEGE.........             <50
            001504   STATE COLLEGE OF FLORIDA, MANATEE-                  <50
                      SARASOTA..............................
            003530   UNIVERSITY OF TENNESSEE................             <50
            002471   SAINT LOUIS COMMUNITY COLLEGE..........             <50
            001493   INDIAN RIVER STATE COLLEGE.............             <50
            002103   UNIVERSITY OF MARYLAND, COLLEGE PARK...             <50
            001232   AMERICAN RIVER COLLEGE.................             <50
            001431   UNIVERSITY OF DELAWARE.................             <50
            003196   LANE COMMUNITY COLLEGE.................             <50
            003328   WEST CHESTER UNIVERSITY OF PENNSYLVANIA             <50
            003599   UNIVERSITY OF TEXAS RIO GRANDE VALLEY..             <50
            001138   CALIFORNIA STATE UNIVERSITY, EAST BAY..             <50
            001571   GEORGIA MILITARY COLLEGE...............             <50
            001575   GORDON STATE COLLEGE...................             <50
            001406   SOUTHERN CONNECTICUT STATE UNIVERSITY..             <50
            001620   IDAHO STATE UNIVERSITY.................             <50
            001378   CENTRAL CONNECTICUT STATE UNIVERSITY...             <50
            001759   SOUTHERN ILLINOIS UNIVERSITY                        <50
                      EDWARDSVILLE..........................
            001141   CALIFORNIA STATE UNIVERSITY, DOMINGUEZ              <50
                      HILLS.................................
            038753   MCI INSTITUTE OF TECHNOLOGY............             <50
            001078   PHOENIX COLLEGE........................             <50
            041900   RADIANS COLLEGE........................             <50
            026215   CAREER COLLEGE OF NORTHERN NEVADA......             <50
            026089   PINNACLE COLLEGE.......................             <50
            030235   CAMELOT COLLEGE........................             <50
            031444   AMERICAN COLLEGE OF HEALTHCARE AND                  <50
                      TECHNOLOGY............................
            030780   MIAMI MEDIA SCHOOL.....................             <50
            025383   DELTA COLLEGE OF ARTS & TECHNOLOGY.....             <50
            023214   TONI & GUY HAIRDRESSING ACADEMY........             <50
            031713   UNIVERSITY OF ST. AUGUSTINE FOR HEALTH              <50
                      SCIENCES..............................
            033163   LINCOLN TECHNICAL INSTITUTE--HARTFORD..             <50
            031090   SCHOOL OF COMMUNICATION ARTS OF NORTH               <50
                      CAROLINA..............................
            030777   DECKER COLLEGE.........................             <50
            011118   SAWYER COLLEGE OF BUSINESS.............             <50
            022896   CONSOLIDATED SCHOOL OF BUSINESS........             <50
            021884   SIERRA VALLEY COLLEGE OF COURT                      <50
                      REPORTING.............................
            020609   BROWN COLLEGE OF COURT REPORTING.......             <50
            021691   DAVIS COLLEGE..........................             <50
            004890   CENTRAL PENN COLLEGE...................             <50
            004947   WEST TENNESSEE BUSINESS COLLEGE........             <50
            009078   CAPRI INSTITUTE OF HAIR DESIGN.........             <50
            004893   DUBOIS BUSINESS COLLEGE................             <50
            003296   MARYWOOD UNIVERSITY....................             <50
            010813   AMERICAN ACADEMY MCALLISTER INSTITUTE..             <50
            002942   LIVINGSTONE COLLEGE....................             <50
            003537   ABILENE CHRISTIAN UNIVERSITY...........             <50
            007279   HAWAII PACIFIC UNIVERSITY..............             <50
            003501   LEMOYNE-OWEN COLLEGE...................             <50
            002883   UTICA UNIVERSITY.......................             <50
            003613   SOUTHERN METHODIST UNIVERSITY..........             <50
            002968   SAINT AUGUSTINE'S UNIVERSITY...........             <50
            003030   OHIO CHRISTIAN UNIVERSITY..............             <50
            003560   DALLAS BAPTIST UNIVERSITY..............             <50
            002415   MISSISSIPPI COLLEGE....................             <50
            002155   HARVARD UNIVERSITY.....................             <50
            001179   NOTRE DAME DE NAMUR UNIVERSITY.........             <50
            001211   HEALD BUSINESS COLLEGE.................             <50
            010847   Arizona Automotive Institute...........             <50
            002143   CURRY COLLEGE..........................             <50
            001229   SOUTHERN CALIFORNIA UNIVERSITY OF                   <50
                      HEALTH SCIENCES.......................
            001205   GOLDEN GATE UNIVERSITY.................             <50
            022333   ST. GEORGE'S UNIVERSITY, SCHOOL OF                  <50
                      MEDICINE..............................
            002347   CONCORDIA UNIVERSITY--SAINT PAUL.......             <50
            001164   CHAPMAN UNIVERSITY.....................             <50
            003133   Urbana University......................             <50
            001804   UNIVERSITY OF INDIANAPOLIS.............             <50
            011711   UNIVERSITY OF HOUSTON-CLEAR LAKE.......             <50
            003754   VIRGINIA POLYTECHNIC INSTITUTE & STATE              <50
                      UNIVERSITY............................
            030633   NORTHWEST ARKANSAS COMMUNITY COLLEGE...             <50
            007686   SOUTHERN UNIVERSITY AT SHREVEPORT--                 <50
                      BOSSIER CITY..........................
            003627   TEMPLE COLLEGE.........................             <50
            005220   SALT LAKE COMMUNITY COLLEGE............             <50
            007109   SUNY COLLEGE AT OLD WESTBURY...........             <50
            002405   EAST MISSISSIPPI COMMUNITY COLLEGE.....             <50
            002089   PRINCE GEORGE'S COMMUNITY COLLEGE......             <50
            002210   UNIVERSITY OF MASSACHUSETTS--DARTMOUTH.             <50
            001317   UNIVERSITY OF CALIFORNIA, SAN DIEGO....             <50
            001619   COLLEGE OF SOUTHERN IDAHO..............             <50
            001314   UNIVERSITY OF CALIFORNIA, IRVINE.......             <50
            001157   CALIFORNIA STATE UNIVERSITY, STANISLAUS             <50
            003318   CLARION UNIVERSITY OF PENNSYLVANIA.....             <50
            001144   CALIFORNIA STATE POLYTECHNIC                        <50
                      UNIVERSITY, POMONA....................
            003320   EAST STROUDSBURG UNIVERSITY OF                      <50
                      PENNSYLVANIA..........................
            002984   UNIVERSITY OF NORTH CAROLINA AT                     <50
                      WILMINGTON (THE)......................
            003321   EDINBORO UNIVERSITY OF PENNSYLVANIA....             <50
            002183   BRIDGEWATER STATE UNIVERSITY...........             <50
            002062   BOWIE STATE UNIVERSITY.................             <50
            002417   MISSISSIPPI GULF COAST COMMUNITY                    <50
                      COLLEGE...............................
            002871   MOHAWK VALLEY COMMUNITY COLLEGE--SUNY               <50
                      OFFICE OF COMMUNITY COLLEGES..........
            038094   MICROPOWER CAREER INSTITUTE............             <50
            041379   BRENSTEN EDUCATION.....................             <50
            041274   DIGITAL MEDIA ARTS COLLEGE.............             <50
            041893   ALLIED AMERICAN UNIVERSITY.............             <50
            041203   HEALTH AND STYLE INSTITUTE.............             <50
            038893   STANBRIDGE UNIVERSITY..................             <50
            037634   BOLD BEAUTY ACADEMY....................             <50
            039653   NEW ENGLAND COLLEGE OF BUSINESS AND                 <50
                      FINANCE...............................
            041378   AVEDA INSTITUTE COLUMBUS...............             <50
            037503   PROSPECT COLLEGE.......................             <50
            034003   QUEST COLLEGE..........................             <50
            023265   INTERFACE COLLEGE......................             <50
            030258   DAWN CAREER INSTITUTE..................             <50
            030951   GRETNA CAREER COLLEGE..................             <50
            024980   NEW WAVE HAIR ACADEMY..................             <50
            023608   PROVO COLLEGE..........................             <50
            034254   CENTRAL FLORIDA INSTITUTE..............             <50
            021208   YORKTOWNE BUSINESS INSTITUTE...........             <50
            022612   G SKIN & BEAUTY INSTITUTE..............             <50
            022843   INTERACTIVE COLLEGE OF TECHNOLOGY......             <50
            021802   METRO BUSINESS COLLEGE.................             <50
            021049   SUMNER COLLEGE.........................             <50
            021122   GREAT LAKES INSTITUTE OF TECHNOLOGY....             <50
            012670   BEL--REA INSTITUTE OF ANIMAL TECHNOLOGY             <50
            021662   ITI TECHNICAL COLLEGE..................             <50
            004889   CAMBRIA-ROWE BUSINESS COLLEGE..........             <50
            004932   DRAUGHONS COLLEGE......................             <50
            007203   SALON SUCCESS ACADEMY..................             <50
            007549   COYNE COLLEGE..........................             <50
            007649   ROCKY MOUNTAIN COLLEGE OF ART + DESIGN.             <50
            007931   PACIFIC TRAVEL TRADE SCHOOL--MAIN                   <50
                      CAMPUS................................
            006136   NATIONAL AVIATION ACADEMY--NEW ENGLAND.             <50
            002929   GARDNER--WEBB UNIVERSITY...............             <50
            002579   NEW ENGLAND COLLEGE....................             <50
            003663   WAYLAND BAPTIST UNIVERSITY--PLAINVIEW               <50
                      CAMPUS................................
            003436   LIMESTONE UNIVERSITY...................             <50
            003127   UNIVERSITY OF DAYTON...................             <50
            002825   ST. JOSEPH'S UNIVERSITY NEW YORK.......             <50
            002616   MONMOUTH UNIVERSITY....................             <50
            007304   CULINARY INSTITUTE OF AMERICA..........             <50
            003259   EASTERN UNIVERSITY.....................             <50
            003636   TEXAS CHRISTIAN UNIVERSITY.............             <50
            003455   VOORHEES UNIVERSITY....................             <50
            011649   LOYOLA MARYMOUNT UNIVERSITY............             <50
            003963   AMERICAN INSTITUTE OF BUSINESS.........             <50
            003258   DUQUESNE UNIVERSITY OF THE HOLY SPIRIT.             <50
            002798   PRATT INSTITUTE........................             <50
            002206   REGIS COLLEGE..........................             <50
            001218   LOMA LINDA UNIVERSITY..................             <50
            001582   MOREHOUSE COLLEGE......................             <50
            001591   SHORTER UNIVERSITY.....................             <50
            002160   LESLEY UNIVERSITY......................             <50
            001546   Armstrong State University.............             <50
            002345   UNIVERSITY OF SAINT THOMAS.............             <50
            008906   MACOMB COMMUNITY COLLEGE...............             <50
            010391   OKLAHOMA CITY COMMUNITY COLLEGE........             <50
            007118   PARKLAND COLLEGE.......................             <50
            003826   WEST VIRGINIA STATE UNIVERSITY.........             <50
            007871   GEORGE C. WALLACE STATE COMMUNITY                   <50
                      COLLEGE-MAIN CAMPUS...................
            006871   THOMAS NELSON COMMUNITY COLLEGE........             <50
            010652   PASCO--HERNANDO STATE COLLEGE..........             <50
            006911   MONTGOMERY COLLEGE.....................             <50
            005273   GATEWAY COMMUNITY AND TECHNICAL COLLEGE             <50
            004453   DALLAS COLLEGE.........................             <50
            010491   HENNEPIN TECHNICAL COLLEGE -...........             <50
            013231   UNIVERSITY OF HOUSTON--VICTORIA........             <50
            025083   SOUTHEAST COMMUNITY COLLEGE............             <50
            003993   MIDLANDS TECHNICAL COLLEGE--AIRPORT                 <50
                      CAMPUS................................
            030646   TEXAS SOUTHMOST COLLEGE................             <50
            003895   UNIVERSITY OF WISCONSIN--MADISON.......             <50
            032553   FLORIDA GULF COAST UNIVERSITY..........             <50
            003606   SAM HOUSTON STATE UNIVERSITY...........             <50
            003721   JAMES MADISON UNIVERSITY...............             <50
            003926   UNIVERSITY OF WISCONSIN--WHITEWATER....             <50
            006760   UNIVERSITY OF MAINE--AUGUSTA...........             <50
            002488   MISSOURI SOUTHERN STATE UNIVERSITY.....             <50
            003209   WESTERN OREGON UNIVERSITY..............             <50
            001471   COLLEGE OF CENTRAL FLORIDA.............             <50
            001346   ARAPAHOE COMMUNITY COLLEGE.............             <50
            003407   RHODE ISLAND COLLEGE...................             <50
            001928   KANSAS STATE UNIVERSITY................             <50
            001321   UNIVERSITY OF CALIFORNIA, SANTA CRUZ...             <50
            002974   UNIVERSITY OF NORTH CAROLINA--CHAPEL                <50
                      HILL..................................
            003549   BLINN COLLEGE..........................             <50
            002221   UNIVERSITY OF MASSACHUSETTS--AMHERST...             <50
            002868   HUDSON VALLEY COMMUNITY COLLEGE........             <50
            001514   POLK STATE COLLEGE.....................             <50
            002328   WASHTENAW COMMUNITY COLLEGE............             <50
            001949   WASHBURN UNIVERSITY--TOPEKA............             <50
            002104   UNIVERSITY OF MARYLAND, BALTIMORE......             <50
            003317   CHEYNEY UNIVERSITY OF PENNSYLVANIA.....             <50
            001650   CITY COLLEGES OF CHICAGO--MALCOLM X                 <50
                      COLLEGE...............................
            002565   UNIVERSITY OF NEBRASKA.................             <50
            003170   OKLAHOMA STATE UNIVERSITY..............             <50
            002589   UNIVERSITY OF NEW HAMPSHIRE............             <50
            001349   UNIVERSITY OF NORTHERN COLORADO........             <50
            002024   SOUTHEASTERN LOUISIANA UNIVERSITY......             <50
            002624   OCEAN COUNTY COLLEGE...................             <50
            002866   FASHION INSTITUTE OF TECHNOLOGY........             <50
            001380   WESTERN CONNECTICUT STATE UNIVERSITY...             <50
            041004   TAFT UNIVERSITY SYSTEM (THE)...........             <50
            041188   NEW YORK FILM ACADEMY..................             <50
            038333   AMERICAN ACADEMY OF TRADITIONAL CHINESE             <50
                      MEDICINE..............................
            036764   HEALTHY HAIR ACADEMY...................             <50
            001009   AUBURN UNIVERSITY......................             <50
            040573   ASHER COLLEGE..........................             <50
            030927   SKYLINE COLLEGE........................             <50
            030891   GEORGIA INSTITUTE OF COSMETOLOGY.......             <50
            030308   AMERICAN BROADCASTING SCHOOL...........             <50
            030658   OHIO INSTITUTE OF HEALTH CAREERS.......             <50
            030054   GEORGIA CAREER INSTITUTE...............             <50
            023209   TIDEWATER TECH.........................             <50
            022863   CAROLINA BEAUTY COLLEGE................             <50
            022774   SOUTH COAST COLLEGE....................             <50
            022378   SPECS HOWARD SCHOOL OF MEDIA ARTS......             <50
            011131   SAWYER SCHOOL-SAWYER SCHOOL............             <50
            021789   JOLIE HEALTH AND BEAUTY ACADEMY........             <50
            012879   PAT GOINS BENTON ROAD BEAUTY SCHOOL....             <50
            021211   MIDWEST INSTITUTE......................             <50
            022060   HUNTER BUSINESS SCHOOL.................             <50
            022586   AVALON SCHOOL OF COSMETOLOGY...........             <50
            011745   OHIO TECHNICAL COLLEGE.................             <50
            010859   BARCLAY CAREER SCHOOL..................             <50
            012047   MTA SCHOOL, RESIDENT SCHOOL............             <50
            020683   DOUGLAS EDUCATION CENTER...............             <50
            021088   WARDS CORNER BEAUTY ACADEMY............             <50
            012462   EASTWICK COLLEGE--HACKENSACK CAMPUS....             <50
            022229   INTERNATIONAL AIR & HOSPITALITY ACADEMY             <50
            010877   AMERICAN BUSINESS INSTITUTE............             <50
            020603   MIAT COLLEGE OF TECHNOLOGY.............             <50
            022472   MEDSPA CAREERS INSTITUTE...............             <50
            023053   PARKER UNIVERSITY......................             <50
            009418   CENTURY COLLEGE........................             <50
            008601   SAWYER COLLEGE.........................             <50
            004463   DRAUGHONS JUNIOR COLLEGE...............             <50
            010035   SOUTHERN COLLEGE.......................             <50
            032503   CBD COLLEGE............................             <50
            003147   BACONE COLLEGE.........................             <50
            002705   COLLEGE OF SAINT ROSE..................             <50
            002449   AVILA UNIVERSITY.......................             <50
            007294   HEALD COLLEGE-SCHOOL OF BUSINESS.......             <50
            003424   CLAFLIN UNIVERSITY.....................             <50
            003777   HERITAGE UNIVERSITY....................             <50
            003527   TUSCULUM UNIVERSITY....................             <50
            007484   NEWBURY COLLEGE........................             <50
            003585   LON MORRIS COLLEGE.....................             <50
            002882   SYRACUSE UNIVERSITY....................             <50
            002775   MOLLOY COLLEGE.........................             <50
            007893   FLAGLER COLLEGE........................             <50
            002913   CAMPBELL UNIVERSITY....................             <50
            001722   MCKENDREE UNIVERSITY...................             <50
            008147   UNIVERSIDAD AUTONOMA DE GUADALAJARA....             <50
            042401   AMERICAN UNIVERSITY OF ANTIGUA COLLEGE              <50
                      OF MEDICINE...........................
            001478   EDWARD WATERS UNIVERSITY...............             <50
            001212   HUMPHREYS UNIVERSITY...................             <50
            001403   SACRED HEART UNIVERSITY................             <50
            001826   Purdue University--North Central.......             <50
            001833   SAINT JOSEPH'S COLLEGE.................             <50
            001329   UNIVERSITY OF THE PACIFIC..............             <50
            011075   LE CORDON BLEU.........................             <50
            034165   Dallas Nursing Institute...............             <50
            002004   DILLARD UNIVERSITY.....................             <50
            002226   WESTERN NEW ENGLAND UNIVERSITY.........             <50
            012346   Dover Business College.................             <50
            001538   UNIVERSITY OF TAMPA (THE)..............             <50
            006865   CAMDEN COUNTY COLLEGE..................             <50
            005763   CENTRAL GEORGIA TECHNICAL COLLEGE......             <50
            003809   BLUEFIELD STATE COLLEGE................             <50
            003780   GREEN RIVER COLLEGE....................             <50
            010997   EAST GEORGIA STATE COLLEGE.............             <50
            004925   HORRY GEORGETOWN TECHNICAL COLLEGE.....             <50
            003732   RADFORD UNIVERSITY.....................             <50
            008896   PIKES PEAK COMMUNITY COLLEGE...........             <50
            010374   METROPOLITAN STATE UNIVERSITY..........             <50
            009163   SAN ANTONIO COLLEGE....................             <50
            006656   COLLEGE OF DUPAGE......................             <50
            009226   FRANCIS MARION UNIVERSITY..............             <50
            006810   LEHIGH CARBON COMMUNITY COLLEGE........             <50
            009275   NORTHERN KENTUCKY UNIVERSITY...........             <50
            003639   TEXAS A&M UNIVERSITY--KINGSVILLE.......             <50
            004595   HAWKEYE COMMUNITY COLLEGE..............             <50
            010176   WESTMORELAND COUNTY COMMUNITY COLLEGE..             <50
            007110   DELAWARE COUNTY COMMUNITY COLLEGE......             <50
            002403   DELTA STATE UNIVERSITY.................             <50
            003414   UNIVERSITY OF RHODE ISLAND.............             <50
            003239   BUCKS COUNTY COMMUNITY COLLEGE.........             <50
            002643   UNION COUNTY COLLEGE...................             <50
            002530   MONTANA STATE UNIVERSITY--BILLINGS.....             <50
            002205   QUINCY COLLEGE.........................             <50
            003218   CHEMEKETA COMMUNITY COLLEGE............             <50
            002697   QUEENSBOROUGH COMMUNITY COLLEGE-CUNY...             <50
            003325   MILLERSVILLE UNIVERSITY OF PENNSYLVANIA             <50
            001728   MORTON COLLEGE.........................             <50
            002496   NORTHWEST MISSOURI STATE UNIVERSITY....             <50
            002860   ADIRONDACK COMMUNITY COLLEGE--SUNY                  <50
                      OFFICE OF COMMUNITY COLLEGES..........
            001558   COLLEGE OF COASTAL GEORGIA.............             <50
            001113   ANTELOPE VALLEY COLLEGE................             <50
            001811   INDIANA UNIVERSITY--EAST...............             <50
            002878   SUFFOLK COUNTY COMMUNITY COLLEGE.......             <50
            003219   SOUTHERN OREGON UNIVERSITY.............             <50
            002981   WESTERN CAROLINA UNIVERSITY............             <50
            002058   ANNE ARUNDEL COMMUNITY COLLEGE.........             <50
            002013   LOUISIANA STATE UNIVERSITY IN                       <50
                      SHREVEPORT............................
            003395   PENNSYLVANIA COLLEGE OF TECHNOLOGY.....             <50
            001906   BUTLER COUNTY COMMUNITY COLLEGE........             <50
            003428   COLLEGE OF CHARLESTON..................             <50
            002017   MCNEESE STATE UNIVERSITY...............             <50
            001843   VINCENNES UNIVERSITY...................             <50
            002020   UNIVERSITY OF LOUISIANA AT MONROE......             <50
            003529   UNIVERSITY OF TENNESSEE--CHATTANOOGA...             <50
            003150   CAMERON UNIVERSITY.....................             <50
            003172   OKLAHOMA STATE UNIVERSITY INSTITUTE OF              <50
                      TECHNOLOGY--OKMULGEE..................
            002590   KEENE STATE COLLEGE....................             <50
            041400   GLOBAL HEALTH COLLEGE..................             <50
            001008   ATHENS STATE UNIVERSITY................             <50
            038525   CIT COLLEGE OF INFOMEDICAL TECHNOLOGY..             <50
            035954   ANGLEY COLLEGE.........................             <50
            038743   CAMBRIDGE JUNIOR COLLEGE...............             <50
            042281   HIGH DESERT MEDICAL COLLEGE............             <50
            042178   BOCA BEAUTY ACADEMY....................             <50
            041628   PAUL MITCHELL THE SCHOOL MODESTO.......             <50
            036506   PC AGE.................................             <50
            042293   MEDQUEST COLLEGE.......................             <50
            001060   COASTAL ALABAMA COMMUNITY COLLEGE......             <50
            037773   PAUL MITCHELL THE SCHOOL GASTONIA......             <50
            041660   MANHATTAN INSTITUTE (THE)..............             <50
            037813   PITC INSTITUTE.........................             <50
            038303   SAE INSTITUTE OF TECHNOLOGY............             <50
            041345   SAN DIEGO COLLEGE......................             <50
            041574   NATIONAL PARALEGAL COLLEGE.............             <50
            030654   PROFESSIONAL CAREERS INSTITUTE.........             <50
            023577   PAUL MITCHELL THE SCHOOL HOUSTON.......             <50
            025423   NATIONAL HOLISTIC INSTITUTE............             <50
            031136   SOUTHERN CALIFORNIA INSTITUTE OF                    <50
                      TECHNOLOGY............................
            023268   MERIDIAN COLLEGE.......................             <50
            025561   ETI SCHOOL OF SKILLED TRADES...........             <50
            023178   AMERICAN INSTITUTE OF TRUCKING.........             <50
            025212   ARLINGTON CAREER INSTITUTE.............             <50
            022602   DIESEL DRIVING ACADEMY.................             <50
            022895   PACE INSTITUTE.........................             <50
            010858   AVALON INSTITUTE.......................             <50
            022042   CHATTANOOGA COLLEGE--MEDICAL, DENTAL                <50
                      AND TECHNICAL CAREERS.................
            022151   HALLMARK INSTITUTE OF PHOTOGRAPHY......             <50
            021526   MTI BUSINESS COLLEGE...................             <50
            022960   PRINCE INSTITUTE--SOUTHEAST............             <50
            012358   PLAZA COLLEGE..........................             <50
            020775   MOUNTAIN STATES TECHNICAL INSTITUTE....             <50
            021151   BUTLER BUSINESS SCHOOL.................             <50
            012262   USA TRAINING ACADEMY HOME STUDY........             <50
            022540   NEW ENGLAND CULINARY INSTITUTE.........             <50
            020537   EASTWICK COLLEGE.......................             <50
            021253   NASHVILLE COLLEGE OF MEDICAL CAREERS...             <50
            021206   SAYBROOK UNIVERSITY....................             <50
            030908   LAKE ERIE COLLEGE OF OSTEOPATHIC                    <50
                      MEDICINE..............................
            009077   UTICA SCHOOL OF COMMERCE...............             <50
            008263   AWARD BEAUTY SCHOOL....................             <50
            008270   WILFRED ACADEMY........................             <50
            007372   AUSTIN'S SCHOOL OF SPA TECHNOLOGY......             <50
            003528   UNION UNIVERSITY.......................             <50
            002665   VAUGHN COLLEGE OF AERONAUTICS AND                   <50
                      TECHNOLOGY............................
            003854   LAKELAND UNIVERSITY....................             <50
            003863   MARQUETTE UNIVERSITY...................             <50
            003014   BALDWIN WALLACE UNIVERSITY.............             <50
            003245   CHESTNUT HILL COLLEGE..................             <50
            002737   IONA COLLEGE...........................             <50
            002916   CHOWAN UNIVERSITY......................             <50
            002777   MEDAILLE COLLEGE.......................             <50
            003724   MARYMOUNT UNIVERSITY...................             <50
            002638   SAINT PETER'S UNIVERSITY...............             <50
            002464   FONTBONNE UNIVERSITY...................             <50
            002820   SAINT FRANCIS COLLEGE..................             <50
            002941   LENOIR-RHYNE UNIVERSITY................             <50
            003024   CASE WESTERN RESERVE UNIVERSITY........             <50
            002477   A. T. STILL UNIVERSITY OF HEALTH                    <50
                      SCIENCES..............................
            013022   CITY UNIVERSITY OF SEATTLE.............             <50
            003359   ROBERT MORRIS UNIVERSITY...............             <50
            007012   SAMUEL MERRITT UNIVERSITY..............             <50
            003033   MOUNT ST. JOSEPH UNIVERSITY............             <50
            004703   LOGAN UNIVERSITY.......................             <50
            003141   WILBERFORCE UNIVERSITY.................             <50
            004861   UNIVERSITY OF NORTHWESTERN OHIO........             <50
            003353   UNIVERSITY OF THE SCIENCES IN                       <50
                      PHILADELPHIA..........................
            001768   SAINT XAVIER UNIVERSITY................             <50
            001495   JACKSONVILLE UNIVERSITY................             <50
            023518   UNIVERSIDAD IBEROAMERICANA (UNIBE).....             <50
            009924   Ivy Tech Community College of Indiana--             <50
                      Region 6..............................
            010832   Western State University College of Law             <50
            001785   ANDERSON UNIVERSITY....................             <50
            001698   John Marshall Law School (The).........             <50
            001505   LYNN UNIVERSITY........................             <50
            008423   Ivy Tech Community College of Indiana--             <50
                      Region 2..............................
            009926   Ivy Tech Community College of Indiana-              <50
                      Region 3..............................
            001709   LINCOLN COLLEGE........................             <50
            001664   UNIVERSITY OF ST. FRANCIS..............             <50
            003524   Tennessee Temple University............             <50
            001422   UNIVERSITY OF HARTFORD.................             <50
            001753   SCHOOL OF THE ART INSTITUTE OF CHICAGO.             <50
            010977   UNIVERSIDAD CENTRAL DEL ESTE...........             <50
            006951   UNIVERSITY OF SOUTH CAROLINA UPSTATE...             <50
            005320   CAPE FEAR COMMUNITY COLLEGE............             <50
            004003   CENTRAL TEXAS COLLEGE..................             <50
            005601   ALBANY TECHNICAL COLLEGE...............             <50
            005389   GATEWAY TECHNICAL COLLEGE..............             <50
            004742   CENTRAL NEW MEXICO COMMUNITY COLLEGE...             <50
            008310   AUBURN UNIVERSITY MONTGOMERY...........             <50
            007532   FINGER LAKES COMMUNITY COLLEGE--SUNY                <50
                      OFFICE OF COMMUNITY COLLEGES..........
            003665   WEST TEXAS A&M UNIVERSITY..............             <50
            009185   ROSE STATE COLLEGE.....................             <50
            012165   ATLANTA METROPOLITAN STATE COLLEGE.....             <50
            007954   NORMANDALE COMMUNITY COLLEGE...........             <50
            004075   EASTERN IOWA COMMUNITY COLLEGE DISTRICT             <50
            003920   UNIVERSITY OF WISCONSIN--OSHKOSH.......             <50
            030113   CALIFORNIA STATE UNIVERSITY, SAN MARCOS             <50
            005301   NORTHEAST WISCONSIN TECHNICAL COLLEGE..             <50
            042118   COLLEGE OF WESTERN IDAHO...............             <50
            037894   RIVER PARISHES COMMUNITY COLLEGE.......             <50
            010097   CUNY MEDGAR EVERS COLLEGE..............             <50
            009767   OLIVE-HARVEY COLLEGE...................             <50
            002926   ELIZABETH CITY STATE UNIVERSITY........             <50
            001773   TRITON COLLEGE.........................             <50
            002687   CUNY BROOKLYN COLLEGE..................             <50
            002997   NORTH DAKOTA STATE UNIVERSITY--FARGO...             <50
            001156   SONOMA STATE UNIVERSITY................             <50
            003580   KILGORE COLLEGE........................             <50
            002188   SALEM STATE UNIVERSITY.................             <50
            002174   NORTHERN ESSEX COMMUNITY COLLEGE.......             <50
            001950   WICHITA STATE UNIVERSITY...............             <50
            002335   RIVERLAND COMMUNITY COLLEGE............             <50
            001968   KENTUCKY STATE UNIVERSITY..............             <50
            002161   UNIVERSITY OF MASSACHUSETTS--LOWELL....             <50
            002501   SOUTHEAST MISSOURI STATE UNIVERSITY....             <50
            002698   COLLEGE OF STATEN ISLAND/CUNY..........             <50
            001865   IOWA CENTRAL COMMUNITY COLLEGE.........             <50
            001425   EASTERN CONNECTICUT STATE UNIVERSITY...             <50
            002858   STATE UNIVERSITY OF NEW YORK AT                     <50
                      FARMINGDALE...........................
            002836   BINGHAMTON UNIVERSITY..................             <50
            002054   UNIVERSITY OF SOUTHERN MAINE...........             <50
            003157   LANGSTON UNIVERSITY....................             <50
            001817   INDIANA UNIVERSITY SOUTHEAST...........             <50
            001149   CALIFORNIA STATE POLYTECHNIC                        <50
                      UNIVERSITY, HUMBOLDT..................
            001142   CALIFORNIA STATE UNIVERSITY, SAN                    <50
                      BERNARDINO............................
            001640   PRAIRIE STATE COLLEGE..................             <50
            001976   MOREHEAD STATE UNIVERSITY..............             <50
            003204   MT. HOOD COMMUNITY COLLEGE.............             <50
            002688   CITY COLLEGE OF NEW YORK--CUNY.........             <50
            002841   SUNY COLLEGE AT BROCKPORT..............             <50
            002184   FITCHBURG STATE UNIVERSITY.............             <50
            001146   CALIFORNIA STATE UNIVERSITY, CHICO.....             <50
            002276   KELLOGG COMMUNITY COLLEGE..............             <50
            001312   UNIVERSITY OF CALIFORNIA, BERKELEY.....             <50
            001219   LONG BEACH CITY COLLEGE................             <50
            001541   ABRAHAM BALDWIN AGRICULTURAL COLLEGE...             <50
            002849   STATE UNIVERSITY OF NEW YORK COLLEGE AT             <50
                      PLATTSBURGH...........................
            001623   NORTH IDAHO COLLEGE....................             <50
            001808   UNIVERSITY OF SOUTHERN INDIANA.........             <50
            041874   JOHN AMICO SCHOOL OF HAIR DESIGN.......             <50
            041676   FINGER LAKES SCHOOL OF MASSAGE (THE)...             <50
            038383   NIGHTINGALE COLLEGE....................             <50
            040563   CAREER COLLEGE OF CALIFORNIA...........             <50
            041723   ETERNITY COSMETOLOGY SCHOOL, CORP......             <50
            041145   VALLEY COLLEGE OF MEDICAL CAREERS......             <50
            001013   CALHOUN COMMUNITY COLLEGE..............             <50
            041348   AVEDA INSTITUTE--TALLAHASSEE...........             <50
            001085   UNIVERSITY OF ARKANSAS AT MONTICELLO...             <50
            041493   PARK WEST BARBER SCHOOL................             <50
            041528   PAUL MITCHELL THE SCHOOL SACRAMENTO....             <50
            032753   COSMETOLOGY CAREER INSTITUTE...........             <50
            031087   ROYAL BEAUTY CAREERS...................             <50
            023041   WILSHIRE COMPUTER COLLEGE..............             <50
            025228   FOX COLLEGE............................             <50
            031249   PAUL MITCHELL THE SCHOOL--LITTLE ROCK..             <50
            030790   ETI TECHNICAL COLLEGE OF NILES.........             <50
            025283   TDDS TECHNICAL INSTITUTE...............             <50
            026094   VALLEY COLLEGE.........................             <50
            031733   ATLANTA'S JOHN MARSHALL LAW SCHOOL.....             <50
            021634   NEW YORK CAREER INSTITUTE..............             <50
            022859   UCAS UNIVERSITY OF COSMETOLOGY ARTS &               <50
                      SCIENCES..............................
            012496   EVERGREEN BEAUTY AND BARBER COLLEGE....             <50
            020923   EASTWICK COLLEGE--NUTLEY CAMPUS........             <50
            022724   EASTERN COLLEGE OF HEALTH VOCATIONS....             <50
            012850   INTERNATIONAL SALON AND SPA ACADEMY....             <50
            008217   PAUL MITCHELL THE SCHOOL GREEN BAY.....             <50
            009104   TONI&GUY HAIRDRESSING ACADEMY..........             <50
            009032   EMPIRE COLLEGE.........................             <50
            035904   NTMA TRAINING CENTERS OF SOUTHERN                   <50
                      CALIFORNIA............................
            031155   ADVENTHEALTH UNIVERSITY................             <50
            001177   UNIVERSITY OF SILICON VALLEY...........             <50
            031070   SONORAN UNIVERSITY OF HEALTH SCIENCES..             <50
            001895   WALDORF UNIVERSITY.....................             <50
            009034   CATHERINE COLLEGE......................             <50
            021474   CLEVELAND CHIROPRACTIC COLLEGE.........             <50
            009284   BRITTANY BEAUTY SCHOOL.................             <50
            007305   PORTER AND CHESTER INSTITUTE OF HAMDEN.             <50
            009784   NATIONAL EDUCATION CENTER-BAUDER                    <50
                      COLLEGE CAMPUS........................
            007466   LIM COLLEGE............................             <50
            007468   SCHOOL OF VISUAL ARTS..................             <50
            003638   TEXAS COLLEGE..........................             <50
            012183   BURLINGTON COLLEGE.....................             <50
            002951   NORTH CAROLINA WESLEYAN COLLEGE........             <50
            003244   CHATHAM UNIVERSITY.....................             <50
            003502   LINCOLN MEMORIAL UNIVERSITY............             <50
            002575   FRANKLIN PIERCE UNIVERSITY.............             <50
            003752   VIRGINIA INTERMONT COLLEGE.............             <50
            003270   GWYNEDD MERCY UNIVERSITY...............             <50
            002712   D'YOUVILLE UNIVERSITY..................             <50
            003272   HARCUM COLLEGE.........................             <50
            003494   HIWASSEE COLLEGE.......................             <50
            003276   IMMACULATA UNIVERSITY..................             <50
            002806   ROCHESTER INSTITUTE OF TECHNOLOGY......             <50
            002765   MARIST COLLEGE.........................             <50
            002909   BARBER-SCOTIA COLLEGE..................             <50
            002769   MARYMOUNT MANHATTAN COLLEGE............             <50
            003988   NEUMANN UNIVERSITY.....................             <50
            002597   BLOOMFIELD COLLEGE.....................             <50
            002439   TOUGALOO COLLEGE.......................             <50
            003410   ROGER WILLIAMS UNIVERSITY..............             <50
            010395   UNIVERSITY OF SAN DIEGO................             <50
            003417   ALLEN UNIVERSITY.......................             <50
            003479   BELMONT UNIVERSITY.....................             <50
            003557   CONCORDIA UNIVERSITY TEXAS.............             <50
            010039   Ivy Tech Community College of Indiana--             <50
                      Region 4..............................
            002318   SPRING ARBOR UNIVERSITY................             <50
            001940   SOUTHWESTERN COLLEGE...................             <50
            039003   MEDICAL UNIVERSITY OF THE AMERICAS.....             <50
            001046   TALLADEGA COLLEGE......................             <50
            002050   UNIVERSITY OF NEW ENGLAND..............             <50
            001531   STETSON UNIVERSITY.....................             <50
            001295   SOUTHWESTERN LAW SCHOOL................             <50
            007440   Nashville Auto-Diesel College..........             <50
            002107   STEVENSON UNIVERSITY...................             <50
            011074   Bainbridge State College...............             <50
            001033   OAKWOOD UNIVERSITY.....................             <50
            001258   PACIFIC UNION COLLEGE..................             <50
            001169   CLAREMONT GRADUATE UNIVERSITY..........             <50
            001262   POINT LOMA NAZARENE UNIVERSITY.........             <50
            001374   ALBERTUS MAGNUS COLLEGE................             <50
            026214   Asher School of Business...............             <50
            001253   FRESNO PACIFIC UNIVERSITY..............             <50
            001972   LINDSEY WILSON COLLEGE.................             <50
            002146   EMERSON COLLEGE........................             <50
            001293   VANGUARD UNIVERSITY OF SOUTHERN                     <50
                      CALIFORNIA............................
            002150   FISHER COLLEGE.........................             <50
            037405   Art Institute of Tucson (The)..........             <50
            007728   Macon State College....................             <50
            001460   TRINITY WASHINGTON UNIVERSITY..........             <50
            001657   MIDWESTERN UNIVERSITY..................             <50
            007764   SOUTHEAST TECHNICAL COLLEGE............             <50
            008404   BROOKDALE COMMUNITY COLLEGE............             <50
            009647   OKLAHOMA STATE UNIVERSITY--OKLAHOMA                 <50
                      CITY..................................
            010684   ERIE COMMUNITY COLLEGE.................             <50
            009344   RAMAPO COLLEGE OF NEW JERSEY...........             <50
            003915   UNIVERSITY OF WISCONSIN--STOUT.........             <50
            003796   TACOMA COMMUNITY COLLEGE...............             <50
            009744   FOX VALLEY TECHNICAL COLLEGE...........             <50
            009256   MORAINE PARK TECHNICAL COLLEGE.........             <50
            008304   SCOTTSDALE COMMUNITY COLLEGE...........             <50
            006949   KALAMAZOO VALLEY COMMUNITY COLLEGE.....             <50
            011163   UNIVERSITY OF TEXAS AT TYLER...........             <50
            003677   UTAH STATE UNIVERSITY..................             <50
            007350   ANOKA TECHNICAL COLLEGE................             <50
            005757   LAKE SUPERIOR COLLEGE..................             <50
            039563   SOUTH LOUISIANA COMMUNITY COLLEGE......             <50
            003776   EVERETT COMMUNITY COLLEGE..............             <50
            012015   AUSTIN COMMUNITY COLLEGE...............             <50
            003996   YORK TECHNICAL COLLEGE.................             <50
            003990   FLORENCE--DARLINGTON TECHNICAL COLLEGE.             <50
            007283   CENTRAL ARIZONA COLLEGE................             <50
            004598   IOWA WESTERN COMMUNITY COLLEGE--COUNCIL             <50
                      BLUFFS................................
            003471   SOUTH DAKOTA STATE UNIVERSITY..........             <50
            003408   COMMUNITY COLLEGE OF RHODE ISLAND......             <50
            003540   AMARILLO COLLEGE.......................             <50
            001621   LEWIS-CLARK STATE COLLEGE..............             <50
            003435   LANDER UNIVERSITY......................             <50
            002315   SCHOOLCRAFT COLLEGE....................             <50
            002532   MONTANA STATE UNIVERSITY BOZEMAN.......             <50
            002848   SUNY COLLEGE AT OSWEGO.................             <50
            001699   JOLIET JUNIOR COLLEGE..................             <50
            003222   UMPQUA COMMUNITY COLLEGE...............             <50
            003425   CLEMSON UNIVERSITY.....................             <50
            002408   HOLMES COMMUNITY COLLEGE...............             <50
            002377   ST. CLOUD STATE UNIVERSITY.............             <50
            002411   JONES COUNTY JUNIOR COLLEGE............             <50
            002862   SUNY BROOME COMMUNITY COLLEGE..........             <50
            002694   KINGSBOROUGH COMMUNITY COLLEGE/CUNY....             <50
            002551   UNIVERSITY OF NEBRASKA--KEARNEY........             <50
            001358   COLORADO MESA UNIVERSITY...............             <50
            002302   NORTHWESTERN MICHIGAN COLLEGE..........             <50
            001626   UNIVERSITY OF IDAHO....................             <50
            002651   EASTERN NEW MEXICO UNIVERSITY..........             <50
            003315   BLOOMSBURG UNIVERSITY OF PENNSYLVANIA..             <50
            001569   GEORGIA INSTITUTE OF TECHNOLOGY........             <50
            002011   LOUISIANA STATE UNIVERSITY AT                       <50
                      ALEXANDRIA............................
            002919   DAVIDSON-DAVIE COMMUNITY COLLEGE.......             <50
            002427   NORTHWEST MISSISSIPPI COMMUNITY COLLEGE             <50
            001915   FORT HAYS STATE UNIVERSITY.............             <50
            003068   LORAIN COUNTY COMMUNITY COLLEGE........             <50
            001602   GEORGIA COLLEGE & STATE UNIVERSITY.....             <50
            001320   UNIVERSITY OF CALIFORNIA, SANTA BARBARA             <50
            003474   UNIVERSITY OF SOUTH DAKOTA.............             <50
            002468   JEFFERSON COLLEGE......................             <50
            002385   NORTHLAND COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            003322   KUTZTOWN UNIVERSITY OF PENNSYLVANIA....             <50
            002175   QUINSIGAMOND COMMUNITY COLLEGE.........             <50
            003323   LOCK HAVEN UNIVERSITY OF PENNSYLVANIA..             <50
            003531   UNIVERSITY OF TENNESSEE--MARTIN........             <50
            002850   STATE UNIVERSITY OF NEW YORK COLLEGE AT             <50
                      POTSDAM...............................
            001991   ELIZABETHTOWN COMMUNITY AND TECHNICAL               <50
                      COLLEGE...............................
            001290   SIERRA COLLEGE.........................             <50
            001280   SAN JOAQUIN DELTA COLLEGE..............             <50
            002072   FROSTBURG STATE UNIVERSITY.............             <50
            003592   MIDWESTERN STATE UNIVERSITY............             <50
            002859   SUNY COLLEGE OF AGRICULTURE &                       <50
                      TECHNOLOGY AT MORRISVILLE.............
            002490   MISSOURI WESTERN STATE UNIVERSITY......             <50
            002370   NORTH HENNEPIN COMMUNITY COLLEGE.......             <50
            039104   NATIONAL POLYTECHNIC COLLEGE...........             <50
            037276   AUGUSTE ESCOFFIER SCHOOL OF CULINARY                <50
                      ARTS..................................
            042546   MEDICAL PREP INSTITUTE OF TAMPA BAY....             <50
            039523   NATIONAL MASSAGE THERAPY INSTITUTE.....             <50
            041632   TENAJ SALON INSTITUTE..................             <50
            041470   PAUL MITCHELL THE SCHOOL ATLANTA.......             <50
            041752   PAUL MITCHELL THE SCHOOL EAST BAY......             <50
            041480   NEW LIFE BUSINESS INSTITUTE............             <50
            039393   WOLFORD COLLEGE........................             <50
            040033   BLAKE AUSTIN COLLEGE...................             <50
            001110   UNIVERSITY OF ARKANSAS AT FORT SMITH...             <50
            036813   CALIFORNIA HEALING ARTS COLLEGE........             <50
            030185   BENE'S CAREER ACADEMY..................             <50
            025838   SCS BUSINESS & TECHNICAL INSTITUTE.....             <50
            026047   CENTER FOR ADVANCED LEGAL STUDIES......             <50
            033243   CENTRAL CAREER SCHOOL..................             <50
            026220   SOUTHWEST ACUPUNCTURE COLLEGE..........             <50
            033326   DELTA COLLEGE..........................             <50
            023314   NORTHWEST HAIR ACADEMY.................             <50
            030653   PAUL MITCHELL THE SCHOOL TINLEY PARK...             <50
            030359   NATIONAL AVIATION ACADEMY..............             <50
            025844   NEW ENGLAND TRACTOR TRAILER TRAINING                <50
                      SCHOOL OF MASSACHUSETTS...............
            031018   ILLINOIS MEDIA SCHOOL..................             <50
            024987   DEMARGE COLLEGE........................             <50
            032054   JOLIE HAIR AND BEAUTY ACADEMY..........             <50
            023330   HAIR ACADEMY...........................             <50
            023342   SOUTHEASTERN ACADEMY...................             <50
            023043   PLATT COLLEGE, SAN DIEGO...............             <50
            025782   NOSSI COLLEGE OF ART...................             <50
            023141   SCHILLER INTERNATIONAL UNIVERSITY......             <50
            022049   AMERICAN ACADEMY OF HAIR DESIGN........             <50
            021578   AMERICAN HI-TECH BUSINESS TECHNOLOGY...             <50
            010934   GRIFFIN COLLEGE........................             <50
            012350   PHAGANS' SCHOOL OF HAIR DESIGN.........             <50
            010836   PIVOT POINT ACADEMY....................             <50
            021286   ART INSTITUTE OF CINCINNATI (THE)......             <50
            022948   CAPITOL CITY CAREERS...................             <50
            021886   AUSTIN BUSINESS COLLEGE................             <50
            022343   FASHION CAREERS OF CALIFORNIA COLLEGE..             <50
            012090   ROBERT FIANCE BEAUTY SCHOOLS...........             <50
            021975   BATON ROUGE SCHOOL OF COMPUTERS........             <50
            022697   AVEDA INSTITUTE MARYLAND...............             <50
            021700   SWEDISH INSTITUTE......................             <50
            023040   MISSOURI TECHNICAL SCHOOL..............             <50
            021408   MARTIN UNIVERSITY......................             <50
            026037   OREGON COLLEGE OF ORIENTAL MEDICINE....             <50
            021175   NAROPA UNIVERSITY......................             <50
            023584   COMMONWEALTH INTERNATIONAL UNIVERSITY..             <50
            040653   ROSEMAN UNIVERSITY OF HEALTH SCIENCES..             <50
            007522   CONTINENTAL SCHOOL OF BEAUTY CULTURE...             <50
            041425   TOURO UNIVERSITY WORLDWIDE.............             <50
            022372   PHILLIPS GRADUATE UNIVERSITY...........             <50
            009047   HUNTINGTON JUNIOR COLLEGE OF BUSINESS..             <50
            033463   ACADEMY FOR NURSING AND HEALTH                      <50
                      OCCUPATIONS...........................
            007187   NORTH ADRIAN'S COLLEGE OF BEAUTY.......             <50
            007839   TRIANGLE TECH..........................             <50
            009511   INTERNATIONAL ACADEMY..................             <50
            040883   WESTMED COLLEGE........................             <50
            010076   COMPUTER PROCESSING INST...............             <50
            003169   OKLAHOMA JUNIOR COLLEGE OF BUSINESS &               <50
                      TECHNOLOGY............................
            010551   NEW YORK SCHOOL FOR MEDICAL & DENTAL                <50
                      ASSISTANTS............................
            010724   ALBIZU UNIVERSITY......................             <50
            002599   CENTENARY UNIVERSITY...................             <50
            003936   PONTIFICAL CATHOLIC UNIVERSITY OF                   <50
                      PUERTO RICO (THE).....................
            003500   LEE UNIVERSITY.........................             <50
            007540   MISSOURI BAPTIST UNIVERSITY............             <50
            002805   ROBERTS WESLEYAN COLLEGE...............             <50
            003496   KING UNIVERSITY........................             <50
            002778   MOUNT SAINT MARY COLLEGE...............             <50
            003294   MANOR COLLEGE..........................             <50
            003526   TREVECCA NAZARENE UNIVERSITY...........             <50
            002703   COLLEGE OF MOUNT SAINT VINCENT.........             <50
            003225   WARNER PACIFIC UNIVERSITY..............             <50
            003241   CABRINI UNIVERSITY.....................             <50
            002739   ITHACA COLLEGE.........................             <50
            003089   OHIO NORTHERN UNIVERSITY...............             <50
            003598   OUR LADY OF THE LAKE UNIVERSITY........             <50
            002447   WILLIAM CAREY UNIVERSITY...............             <50
            003616   SOUTHWESTERN ASSEMBLIES OF GOD                      <50
                      UNIVERSITY............................
            003948   SAN FRANCISCO ART INSTITUTE............             <50
            003165   OKLAHOMA CHRISTIAN UNIVERSITY..........             <50
            006324   LABOURE COLLEGE OF HEALTHCARE..........             <50
            003378   UNIVERSITY OF PENNSYLVANIA.............             <50
            002957   QUEENS UNIVERSITY OF CHARLOTTE.........             <50
            003687   GREEN MOUNTAIN COLLEGE.................             <50
            003467   PRESENTATION COLLEGE...................             <50
            003702   AVERETT UNIVERSITY.....................             <50
            008848   WARNER UNIVERSITY......................             <50
            003183   SAINT GREGORY'S UNIVERSITY.............             <50
            003212   PACIFIC UNIVERSITY.....................             <50
            003392   WESTMINSTER COLLEGE....................             <50
            003085   NOTRE DAME COLLEGE OF OHIO.............             <50
            003283   LACKAWANNA COLLEGE.....................             <50
            002735   HILBERT COLLEGE........................             <50
            003766   VIRGINIA UNION UNIVERSITY..............             <50
            012277   NORTHEAST COLLEGE OF HEALTH SCIENCES...             <50
            003838   CARROLL UNIVERSITY.....................             <50
            002650   UNIVERSITY OF THE SOUTHWEST............             <50
            003623   ST. MARY'S UNIVERSITY..................             <50
            012088   Sullivan College of Technology and                  <50
                      Design................................
            001343   WOODBURY UNIVERSITY....................             <50
            001029   UNIVERSITY OF MOBILE...................             <50
            001641   BRADLEY UNIVERSITY.....................             <50
            001429   GOLDEY-BEACOM COLLEGE..................             <50
            002126   BERKLEE COLLEGE OF MUSIC...............             <50
            002016   LOYOLA UNIVERSITY NEW ORLEANS..........             <50
            008504   Richland College.......................             <50
            001588   PIEDMONT UNIVERSITY....................             <50
            001402   QUINNIPIAC UNIVERSITY..................             <50
            001605   CHAMINADE UNIVERSITY OF HONOLULU.......             <50
            001255   PACIFIC OAKS COLLEGE...................             <50
            010041   Ivy Tech Community College of Indiana--             <50
                      Region 5..............................
            001547   POINT UNIVERSITY.......................             <50
            002007   LOUISIANA COLLEGE......................             <50
            010109   Ivy Tech Community College of Indiana--             <50
                      Region 13.............................
            002246   CLEARY UNIVERSITY......................             <50
            001302   SAINT MARY'S COLLEGE OF CALIFORNIA.....             <50
            001587   PAINE COLLEGE..........................             <50
            001900   WILLIAM PENN UNIVERSITY................             <50
            002323   UNIVERSITY OF DETROIT MERCY............             <50
            009292   Andover College........................             <50
            001594   SPELMAN COLLEGE........................             <50
            001578   LAGRANGE COLLEGE.......................             <50
            002201   PINE MANOR COLLEGE.....................             <50
            001238   MILLS COLLEGE..........................             <50
            008611   HOSTOS COMMUNITY COLLEGE OF THE CITY                <50
                      UNIVERSITY OF NEW YORK................
            003994   SPARTANBURG COMMUNITY COLLEGE..........             <50
            005621   SOUTHERN CRESCENT TECHNICAL COLLEGE....             <50
            003688   NORTHERN VERMONT UNIVERSITY............             <50
            030722   CHANDLER--GILBERT COMMUNITY COLLEGE....             <50
            003671   DIXIE STATE UNIVERSITY.................             <50
            021466   SOUTH MOUNTAIN COMMUNITY COLLEGE.......             <50
            003784   OLYMPIC COLLEGE........................             <50
            003769   BELLEVUE COLLEGE.......................             <50
            007598   HOCKING TECHNICAL COLLEGE..............             <50
            010387   EL PASO COUNTY COMMUNITY COLLEGE                    <50
                      DISTRICT..............................
            008244   JOHNSON COUNTY COMMUNITY COLLEGE.......             <50
            003897   UNIVERSITY OF WISCONSIN COLLEGES.......             <50
            003759   J SARGEANT REYNOLDS COMMUNITY COLLEGE..             <50
            005015   UNIVERSITY OF WISCONSIN--PARKSIDE......             <50
            009914   ROANE STATE COMMUNITY COLLEGE..........             <50
            004926   TRI-COUNTY TECHNICAL COLLEGE...........             <50
            006835   DYERSBURG STATE COMMUNITY COLLEGE......             <50
            006960   MAYSVILLE COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            005541   MINNESOTA STATE COMMUNITY AND TECHNICAL             <50
                      COLLEGE...............................
            008596   WEST LOS ANGELES COLLEGE...............             <50
            040385   PIERPONT COMMUNITY & TECHNICAL COLLEGE.             <50
            005294   WAUKESHA COUNTY TECHNICAL COLLEGE......             <50
            003921   UNIVERSITY OF WISCONSIN--PLATTEVILLE...             <50
            003680   WEBER STATE UNIVERSITY.................             <50
            012693   PELLISSIPPI STATE COMMUNITY COLLEGE....             <50
            003995   CENTRAL CAROLINA TECHNICAL COLLEGE.....             <50
            007730   ROWAN COLLEGE AT BURLINGTON COUNTY.....             <50
            009507   GEORGIA HIGHLANDS COLLEGE..............             <50
            003816   EASTERN WEST VIRGINIA COMMUNITY &                   <50
                      TECHNICAL COLLEGE.....................
            003932   UNIVERSITY OF WYOMING..................             <50
            007316   WESTERN IOWA TECH COMMUNITY COLLEGE....             <50
            006931   WAUBONSEE COMMUNITY COLLEGE............             <50
            009942   SHAWNEE STATE UNIVERSITY...............             <50
            010027   JAMES A. RHODES STATE COLLEGE..........             <50
            006785   SCHENECTADY COUNTY COMMUNITY COLLEGE...             <50
            003423   CITADEL, THE MILITARY COLLEGE OF SOUTH              <50
                      CAROLINA..............................
            002173   NORTH SHORE COMMUNITY COLLEGE..........             <50
            003456   WINTHROP UNIVERSITY....................             <50
            001994   HOPKINSVILLE COMMUNITY COLLEGE.........             <50
            001598   UNIVERSITY OF GEORGIA..................             <50
            002906   APPALACHIAN STATE UNIVERSITY...........             <50
            003449   UNIVERSITY OF SOUTH CAROLINA--AIKEN....             <50
            002185   FRAMINGHAM STATE UNIVERSITY............             <50
            002393   MINNESOTA STATE COLLEGE SOUTHEAST......             <50
            001848   SOUTHEASTERN COMMUNITY COLLEGE.........             <50
            002870   JEFFERSON COMMUNITY COLLEGE............             <50
            002988   BISMARCK STATE COLLEGE.................             <50
            003327   SLIPPERY ROCK UNIVERSITY...............             <50
            002994   MINOT STATE UNIVERSITY.................             <50
            002847   SUNY COLLEGE AT ONEONTA................             <50
            001226   LOS ANGELES PIERCE COLLEGE.............             <50
            002388   UNIVERSITY OF MINNESOTA DULUTH.........             <50
            003161   NORTHEASTERN STATE UNIVERSITY..........             <50
            002855   SUNY COLLEGE OF TECHNOLOGY AT CANTON...             <50
            003168   ROGERS STATE UNIVERSITY................             <50
            002861   CAYUGA COMMUNITY COLLEGE...............             <50
            002591   PLYMOUTH STATE UNIVERSITY OF THE                    <50
                      UNIVERSITY SYSTEM OF NEW HAMPSHIRE....
            003553   CISCO COLLEGE..........................             <50
            001925   KANSAS CITY KANSAS COMMUNITY COLLEGE...             <50
            002664   WESTERN NEW MEXICO UNIVERSITY..........             <50
            002301   NORTHERN MICHIGAN UNIVERSITY...........             <50
            001022   JEFFERSON STATE COMMUNITY COLLEGE......             <50
            042440   CALIFORNIA INTERCONTINENTAL UNIVERSITY.             <50
            042063   FVI SCHOOL OF NURSING AND TECHNOLOGY...             <50
            037834   ABDILL CAREER COLLEGE..................             <50
            041529   STUDIO ACADEMY OF BEAUTY (THE).........             <50
            041298   MEDIATECH INSTITUTE....................             <50
            041280   MILLENNIUM TRAINING INSTITUTE..........             <50
            041687   PELOTON COLLEGE........................             <50
            042289   MCDOUGLE TECHNICAL INSTITUTE...........             <50
            041330   BIOHEALTH COLLEGE......................             <50
            001089   ARKANSAS TECH UNIVERSITY...............             <50
            041302   INSTITUTE OF PRODUCTION AND RECORDING               <50
                      (THE).................................
            001016   UNIVERSITY OF NORTH ALABAMA............             <50
            041812   SOUTHERN CALIFORNIA HEALTH INSTITUTE                <50
                      (SOCHI)...............................
            041365   PCCENTER...............................             <50
            038033   HEALTHCARE TRAINING INSTITUTE..........             <50
            035933   SOUTHWEST INSTITUTE OF HEALING ARTS....             <50
            040583   HEALTH OPPORTUNITY TECHNICAL CENTER....             <50
            001109   UNIVERSITY OF ARKANSAS FOR MEDICAL                  <50
                      SCIENCES..............................
            034557   CORTIVA INSTITUTE--CHICAGO.............             <50
            031152   MOTORING TECHNICAL TRAINING INSTITUTE..             <50
            033563   MEDICAL TRAINING COLLEGE...............             <50
            023257   LABARON HAIRDRESSING ACADEMY...........             <50
            026059   TESST COLLEGE OF TECHNOLOGY............             <50
            033923   CHASE COLLEGE..........................             <50
            034903   PAUL MITCHELL THE SCHOOL CHICAGO.......             <50
            030670   ANTONELLI MEDICAL & PROFESSIONAL                    <50
                      INSTITUTE.............................
            030104   CRESCENT CITY SCHOOL OF GAMING &                    <50
                      BARTENDING............................
            023182   KD CONSERVATORY COLLEGE OF FILM AND                 <50
                      DRAMATIC ARTS.........................
            034297   EAST WEST COLLEGE OF NATURAL MEDICINE..             <50
            025681   TEXAS BARBER COLLEGE...................             <50
            030947   KRS COMPUTER AND BUSINESS SCHOOL.......             <50
            031275   ADVANCED TECHNOLOGY INSTITUTE..........             <50
            025548   VANGUARD COLLEGE OF COSMETOLOGY A PAUL              <50
                      MITCHELL PARTNER SCHOOLMETAIRIE.......
            023322   HAIR PROFESSIONALS CAREER COLLEGE......             <50
            023382   BAY STATE SCHOOL OF TECHNOLOGY.........             <50
            032993   PACIFIC COLLEGE........................             <50
            026107   SHIRLEY BAKER CAREER INSTITUTE.........             <50
            023424   ACADEMY OF RADIO & TV BROADCASTING.....             <50
            026128   LOS ANGELES RECORDING SCHOOL...........             <50
            026010   AMERICAN SCHOOL OF BUSINESS............             <50
            021506   COSMETOLOGY AND SPA ACADEMY............             <50
            021928   WALNUT HILL COLLEGE....................             <50
            021641   MTI BUSINESS SCHOOLS (CLOSED)..........             <50
            013087   CAPRI BEAUTY COLLEGE...................             <50
            022702   INTERNATIONAL AVIATION AND TRAVEL                   <50
                      ACADEMY...............................
            020618   ROMAN ACADEMY OF BEAUTY CULTURE........             <50
            011911   BRICK COMPUTER SCIENCE INSTITUTE.......             <50
            020932   WATTERSON COLLEGE PACIFIC..............             <50
            021650   ELDORADO COLLEGE.......................             <50
            021010   NORTHWEST COLLEGE SCHOOL OF BEAUTY.....             <50
            022676   SOFIA UNIVERSITY.......................             <50
            011631   D'JAY'S INSTITUTE OF COSMETOLOGY AND                <50
                      ESTHIOLOGY............................
            011129   NATIONAL EDUCATION CENTER BRYMAN CAMPUS             <50
            010930   SUBURBAN TECHNICAL SCHOOL..............             <50
            021604   WILFRED ACADEMY OF HAIR DESIGN & BEAUTY             <50
                      CULTURE...............................
            004902   PENN COMMERCIAL BUSINESS/TECHNICAL                  <50
                      SCHOOL................................
            008544   CAREER COLLEGES OF CHICAGO.............             <50
            005008   MOUNTAIN STATE COLLEGE.................             <50
            023269   SUNSTATE ACADEMY.......................             <50
            009283   MIDWAY PARIS BEAUTY SCHOOL.............             <50
            021830   ORLEANS TECHNICAL COLLEGE..............             <50
            021642   FOREST INSTITUTE OF PROFESSIONAL                    <50
                      PSYCHOLOGY............................
            010424   SUMMIT SALON ACADEMY...................             <50
            008328   ALVAREITA'S COLLEGE OF COSMETOLOGY.....             <50
            010631   ALBERT MERRILL SCHOOL..................             <50
            004847   INTERSTATE BUSINESS COLLEGE............             <50
            038744   COMMUNITY CHRISTIAN COLLEGE............             <50
            021636   WILLIAM JAMES COLLEGE..................             <50
            030763   BEULAH HEIGHTS UNIVERSITY..............             <50
            009739   GLEN DOW ACADEMY OF HAIR DESIGN &                   <50
                      SALONS................................
            024827   WESTERN UNIVERSITY OF HEALTH SCIENCES..             <50
            010098   NEUMONT COLLEGE OF COMPUTER SCIENCE....             <50
            007926   TRAVEL & TRADE CAREER INSTITUTE........             <50
            025034   AMRIDGE UNIVERSITY.....................             <50
            003083   UNIVERSITY OF MOUNT UNION..............             <50
            002369   NORTH CENTRAL UNIVERSITY...............             <50
            003737   SHENANDOAH UNIVERSITY..................             <50
            003399   YORK COLLEGE OF PENNSYLVANIA...........             <50
            002779   NAZARETH COLLEGE OF ROCHESTER..........             <50
            003790   SEATTLE UNIVERSITY.....................             <50
            003235   ARCADIA UNIVERSITY.....................             <50
            003797   UNIVERSITY OF PUGET SOUND..............             <50
            012500   RANKEN TECHNICAL COLLEGE...............             <50
            003818   UNIVERSITY OF CHARLESTON...............             <50
            003287   LA SALLE UNIVERSITY....................             <50
            003819   OHIO VALLEY UNIVERSITY.................             <50
            003045   UNIVERSITY OF FINDLAY (THE)............             <50
            003832   ALVERNO COLLEGE........................             <50
            003684   CHAMPLAIN COLLEGE......................             <50
            002639   STEVENS INSTITUTE OF TECHNOLOGY........             <50
            012050   ROSEDALE TECHNICAL COLLEGE.............             <50
            003243   CEDAR CREST COLLEGE....................             <50
            003282   KINGS COLLEGE..........................             <50
            002473   KANSAS CITY ART INSTITUTE..............             <50
            002985   WINGATE UNIVERSITY.....................             <50
            002927   ELON UNIVERSITY........................             <50
            007465   AMERICAN ACADEMY OF DRAMATIC ARTS......             <50
            002788   NIAGARA UNIVERSITY.....................             <50
            002527   UNIVERSITY OF PROVIDENCE...............             <50
            003940   INTER AMERICAN UNIVERSITY OF PUERTO                 <50
                      RICO--METROPOLITAN CAMPUS.............
            013103   CALIFORNIA WESTERN SCHOOL OF LAW.......             <50
            003422   SOUTHERN WESLEYAN UNIVERSITY...........             <50
            002542   CREIGHTON UNIVERSITY...................             <50
            003979   TEACHERS COLLEGE, COLUMBIA UNIVERSITY..             <50
            003490   FISK UNIVERSITY........................             <50
            003577   HUSTON--TILLOTSON UNIVERSITY...........             <50
            003360   ROSEMONT COLLEGE.......................             <50
            002463   EVANGEL UNIVERSITY.....................             <50
            003497   KNOXVILLE COLLEGE......................             <50
            002821   SAINT JOHN FISHER COLLEGE..............             <50
            003720   UNIVERSITY OF LYNCHBURG................             <50
            003591   MCMURRY UNIVERSITY.....................             <50
            003144   XAVIER UNIVERSITY......................             <50
            002953   WILLIAM PEACE UNIVERSITY...............             <50
            012399   LEWIS COLLEGE OF BUSINESS..............             <50
            002586   RIVIER UNIVERSITY......................             <50
            003303   CARLOW UNIVERSITY......................             <50
            003602   PAUL QUINN COLLEGE.....................             <50
            003166   OKLAHOMA CITY UNIVERSITY...............             <50
            003635   TEXAS CHIROPRACTIC COLLEGE.............             <50
            002903   YESHIVA UNIVERSITY.....................             <50
            002122   BAY PATH UNIVERSITY....................             <50
            001784   ANCILLA DOMINI COLLEGE.................             <50
            001724   MILLIKIN UNIVERSITY....................             <50
            008510   Eastfield College......................             <50
            001946   TABOR COLLEGE..........................             <50
            001097   HARDING UNIVERSITY.....................             <50
            002354   HAMLINE UNIVERSITY.....................             <50
            001103   PHILANDER SMITH COLLEGE................             <50
            001739   NORTHWESTERN UNIVERSITY................             <50
            001183   HOLY NAMES UNIVERSITY..................             <50
            001929   KANSAS WESLEYAN UNIVERSITY.............             <50
            001215   LA SIERRA UNIVERSITY...................             <50
            001962   UNIVERSITY OF THE CUMBERLANDS..........             <50
            008276   Bryant & Stratton Business Institute--              <50
                      Syracuse..............................
            002334   AUGSBURG UNIVERSITY....................             <50
            001252   HOPE INTERNATIONAL UNIVERSITY..........             <50
            031005   Virginia College at Pensacola..........             <50
            001322   UNIVERSITY OF REDLANDS.................             <50
            001734   NORTH CENTRAL COLLEGE..................             <50
            039063   ATA Career Education...................             <50
            001741   OLIVET NAZARENE UNIVERSITY.............             <50
            011708   Hair Design School, The................             <50
            001847   BUENA VISTA UNIVERSITY.................             <50
            042066   SAE Institute of Technology--Atlanta...             <50
            020695   Akron Institute of Herzing University..             <50
            010264   South College-Asheville................             <50
            001959   CAMPBELLSVILLE UNIVERSITY..............             <50
            001563   EMMANUEL COLLEGE.......................             <50
            002067   WASHINGTON ADVENTIST UNIVERSITY........             <50
            001624   NORTHWEST NAZARENE UNIVERSITY..........             <50
            002282   MADONNA UNIVERSITY.....................             <50
            001634   AURORA UNIVERSITY......................             <50
            008547   Ivy Tech Community College of Indiana--             <50
                      Region 7..............................
            001717   MACMURRAY COLLEGE......................             <50
            010182   ROGUE COMMUNITY COLLEGE................             <50
            008133   ZANE STATE COLLEGE.....................             <50
            005006   WALLA WALLA COMMUNITY COLLEGE..........             <50
            006787   CLINTON COMMUNITY COLLEGE..............             <50
            003899   UNIVERSITY OF WISCONSIN--GREEN BAY.....             <50
            007582   AIMS COMMUNITY COLLEGE.................             <50
            031153   GENESEE-LIVINGSTON-STEUBEN-WYOMING                  <50
                      BOCES.................................
            006791   SUNY COLLEGE AT PURCHASE...............             <50
            041143   NEVADA STATE COLLEGE...................             <50
            009314   GREAT FALLS COLLEGE MONTANA STATE                   <50
                      UNIVERSITY............................
            009930   UNIVERSITY OF TEXAS OF THE PERMIAN                  <50
                      BASIN.................................
            011046   CENTRAL OHIO TECHNICAL COLLEGE.........             <50
            004878   CLACKAMAS COMMUNITY COLLEGE............             <50
            009333   UNIVERSITY OF ILLINOIS AT SPRINGFIELD..             <50
            003823   WEST LIBERTY UNIVERSITY................             <50
            003813   GLENVILLE STATE UNIVERSITY.............             <50
            004502   CITY COLLEGE OF SAN FRANCISCO..........             <50
            005277   EASTERN MAINE COMMUNITY COLLEGE........             <50
            003925   UNIVERSITY OF WISCONSIN--SUPERIOR......             <50
            006811   LUZERNE COUNTY COMMUNITY COLLEGE.......             <50
            003611   SOUTH PLAINS COLLEGE...................             <50
            003747   UNIVERSITY OF VIRGINIA'S COLLEGE AT                 <50
                      WISE (THE)............................
            004788   HERKIMER COUNTY COMMUNITY COLLEGE--SUNY             <50
                      OFFICE OF COMMUNITY COLLEGES..........
            011678   STATE UNIVERSITY OF NEW YORK                        <50
                      POLYTECHNIC INSTITUTE.................
            004062   PITT COMMUNITY COLLEGE.................             <50
            009544   SPOKANE FALLS COMMUNITY COLLEGE........             <50
            003816   SOUTHERN WEST VIRGINIA COMMUNITY AND                <50
                      TECHNICAL COLLEGE.....................
            003961   HARPER COLLEGE.........................             <50
            005697   NORTHWEST--SHOALS COMMUNITY COLLEGE....             <50
            004024   GEORGIA NORTHWESTERN TECHNICAL COLLEGE.             <50
            030686   SPECIAL SCHOOL DISTRICT OF ST. LOUIS                <50
                      COUNTY................................
            003791   SHORELINE COMMUNITY COLLEGE............             <50
            003802   WESTERN WASHINGTON UNIVERSITY..........             <50
            006901   ROWAN COLLEGE OF SOUTH JERSEY..........             <50
            005754   ROWAN-CABARRUS COMMUNITY COLLEGE.......             <50
            004759   CUNY YORK COLLEGE......................             <50
            005001   EDMONDS COLLEGE........................             <50
            005525   SOUTHERN MAINE COMMUNITY COLLEGE.......             <50
            039573   BLUE RIDGE COMMUNITY AND TECHNICAL                  <50
                      COLLEGE...............................
            020995   CENTRAL COMMUNITY COLLEGE..............             <50
            040414   MOUNTWEST COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            008038   MIDDLESEX COMMUNITY COLLEGE............             <50
            010487   WEST GEORGIA TECHNICAL COLLEGE.........             <50
            009912   VOLUNTEER STATE COMMUNITY COLLEGE......             <50
            003782   LOWER COLUMBIA COLLEGE.................             <50
            021661   ELAINE P. NUNEZ COMMUNITY COLLEGE......             <50
            003600   PANOLA COLLEGE.........................             <50
            003005   UNIVERSITY OF NORTH DAKOTA.............             <50
            002008   LOUISIANA TECH UNIVERSITY..............             <50
            002696   NEW YORK CITY COLLEGE OF TECHNOLOGY OF              <50
                      THE CITY UNIVERSITY OF NEW YORK.......
            001890   UNIVERSITY OF NORTHERN IOWA............             <50
            001348   COLORADO SCHOOL OF MINES...............             <50
            002531   MONTANA TECHNOLOGICAL UNIVERSITY.......             <50
            002689   CUNY HUNTER COLLEGE....................             <50
            001292   SOLANO COMMUNITY COLLEGE...............             <50
            002972   NORTH CAROLINA STATE UNIVERSITY........             <50
            002877   ROCKLAND COMMUNITY COLLEGE.............             <50
            001816   INDIANA UNIVERSITY--SOUTH BEND.........             <50
            001902   COWLEY COUNTY COMMUNITY COLLEGE & AREA              <50
                      VOCATIONAL TECHNICAL SCHOOL...........
            002856   SUNY COLLEGE OF AGRICULTURE &                       <50
                      TECHNOLOGY AT COBLESKILL..............
            001233   SACRAMENTO CITY COLLEGE................             <50
            001193   CYPRESS COLLEGE........................             <50
            002581   NHTI--CONCORD'S COMMUNITY COLLEGE......             <50
            002091   SALISBURY UNIVERSITY...................             <50
            002277   LAKE MICHIGAN COLLEGE..................             <50
            001266   LANEY COLLEGE..........................             <50
            002053   UNIVERSITY OF MAINE....................             <50
            001246   MT. SAN JACINTO COLLEGE................             <50
            002876   ORANGE COUNTY COMMUNITY COLLEGE........             <50
            002845   SUNY COLLEGE AT GENESEO................             <50
            003179   SOUTHEASTERN OKLAHOMA STATE UNIVERSITY.             <50
            003450   UNIVERSITY OF SOUTH CAROLINA BEAUFORT..             <50
            003181   SOUTHWESTERN OKLAHOMA STATE UNIVERSITY.             <50
            001285   SANTA BARBARA CITY COLLEGE.............             <50
            002176   BRISTOL COMMUNITY COLLEGE..............             <50
            002881   SUNY WESTCHESTER COMMUNITY COLLEGE.....             <50
            002189   WESTFIELD STATE UNIVERSITY.............             <50
            003558   NORTH CENTRAL TEXAS COLLEGE............             <50
            002317   SOUTHWESTERN MICHIGAN COLLEGE..........             <50
            001585   UNIVERSITY OF NORTH GEORGIA............             <50
            001345   ADAMS STATE UNIVERSITY.................             <50
            041174   MILWAUKEE CAREER COLLEGE...............             <50
            042058   SAE INSTITUTE OF TECHNOLOGY, LOS                    <50
                      ANGELES...............................
            041791   VERVE COLLEGE..........................             <50
            037485   DURHAM BEAUTY ACADEMY..................             <50
            042211   NEW HORIZONS MEDICAL INSTITUTE.........             <50
            040143   P&A SCHOLARS BEAUTY SCHOOL.............             <50
            001072   COCHISE COLLEGE........................             <50
            037593   STELLAR CAREER COLLEGE.................             <50
            041093   ACADEMY OF BARBERING ARTS (THE)........             <50
            036114   FLORIDA BARBER ACADEMY.................             <50
            038063   LAKE COLLEGE...........................             <50
            040165   AMERICAN INSTITUTE OF BEAUTY...........             <50
            037013   MEMPHIS INSTITUTE OF BARBERING.........             <50
            041387   PAUL MITCHELL THE SCHOOL--PASADENA.....             <50
            038163   ARTISTIC NAILS & BEAUTY ACADEMY........             <50
            040213   AUGUSTA SCHOOL OF MASSAGE..............             <50
            037233   CULINARY INSTITUTE LENOTRE.............             <50
            041477   LAKE LANIER SCHOOL OF MASSAGE..........             <50
            041800   CINTA AVEDA INSTITUTE..................             <50
            039396   DAYTONA COLLEGE........................             <50
            042047   PAUL MITCHELL THE SCHOOL RALEIGH.......             <50
            001107   SOUTHERN ARKANSAS UNIVERSITY...........             <50
            041156   MAYFIELD COLLEGE.......................             <50
            041587   HOLLYWOOD BEAUTY COLLEGE...............             <50
            042106   ADVANCED COMPUTING INSTITUTE...........             <50
            037833   BLUE CLIFF CAREER COLLEGE..............             <50
            042245   TRENZ BEAUTY ACADEMY...................             <50
            040823   PROFESSIONAL CAREER TRAINING INSTITUTE.             <50
            042476   NEW BEGINNINGS BEAUTY ACADEMY..........             <50
            040894   CCI TRAINING CENTER....................             <50
            042779   HOUSTON SCHOOL OF CARPENTRY............             <50
            041670   PAUL MITCHELL THE SCHOOL TEMECULA......             <50
            041211   ELEVATE SALON INSTITUTE................             <50
            040963   CHARLESTON SCHOOL OF LAW...............             <50
            038385   NORTHWEST CAREER COLLEGE...............             <50
            036984   CALIFORNIA COLLEGE OF VOCATIONAL                    <50
                      CAREERS...............................
            041784   VOGUE COLLEGE OF COSMETOLOGY...........             <50
            041732   TAYLOR ANDREWS ACADEMY OF HAIR DESIGN..             <50
            034453   HDS TRUCK DRIVING INSTITUTE............             <50
            033273   HAIR ACADEMY II........................             <50
            024925   DELAWARE VALLEY ACADEMY OF MEDICAL &                <50
                      DENTAL ASSISTANTS.....................
            025410   ALASKA CAREER COLLEGE..................             <50
            033963   OKLAHOMA HEALTH ACADEMY................             <50
            023110   PAUL MITCHELL THE SCHOOL PORTLAND......             <50
            030819   YTI CAREER INSTITUTE--ALTOONA..........             <50
            025536   DIVERSIFIED VOCATIONAL COLLEGE.........             <50
            031973   INSTITUTE FOR HEALTH EDUCATION (THE)...             <50
            025619   BRILLARE HAIRDRESSING ACADEMY..........             <50
            033615   WILLSEY INSTITUTE......................             <50
            023067   FORT WORTH BEAUTY SCHOOL...............             <50
            025200   INTERNATIONAL SCHOOL OF SKIN AND                    <50
                      NAILCARE..............................
            025827   CORTIVA INSTITUTE--TUCSON..............             <50
            023529   AMERICAN BUSINESS INSTITUTE (CLOSED)...             <50
            026031   CRAVE BEAUTY ACADEMY,LLC...............             <50
            023183   AMERICAN CAREER ACADEMY................             <50
            023398   SOUTHERN INSTITUTE OF COSMETOLOGY......             <50
            031513   SUCCESS INSTITUTE OF BUSINESS..........             <50
            026158   COLLEGE OF COURT REPORTING.............             <50
            032183   UNIVERSITY OF THE POTOMAC..............             <50
            026161   JEAN MADELINE AVEDA INSTITUTE..........             <50
            033413   SOUTHWESTERN PROFESSIONAL INSTITUTE....             <50
            023411   KENNETH SHULER SCHOOL OF COSMETOLOGY &              <50
                      NAILS.................................
            023198   BEAUTY INSTITUTE SCHWARZKOPF                        <50
                      PROFESSIONAL (THE)....................
            030079   GALLIPOLIS CAREER COLLEGE..............             <50
            034183   GWINNETT COLLEGE-SANDY SPRINGS.........             <50
            023438   MONTGOMERY BEAUTY SCHOOL...............             <50
            030327   COOPER CAREER INSTITUTE................             <50
            030634   MODERN TECHNOLOGY SCHOOL...............             <50
            021654   TRAINCO BUS SCHOOL.....................             <50
            022546   CONCHO CAREER INSTITUTE................             <50
            022183   SOUTHWEST SCHOOL OF BUSINESS &                      <50
                      TECHNICAL CAREERS.....................
            020925   LAUREL TECHNICAL INSTITUTE.............             <50
            022959   AMERICAN CAREER TRAINING TRAVEL SCHOOL.             <50
            012932   TINT SCHOOL OF MAKEUP & COSMETOLOGY....             <50
            020860   VIDEO TECHNICAL INSTITUTE..............             <50
            011519   JOSEPH'S COLLEGE COSMETOLOGY...........             <50
            022385   CENTRAL OKLAHOMA COLLEGE...............             <50
            021026   ROYAL BUSINESS SCHOOL (CLOSED).........             <50
            022880   PROFESSIONAL BUSINESS SCHOOL...........             <50
            011617   CENTER FOR ALLIED HEALTH EDUCATION.....             <50
            023014   EAST OHIO COLLEGE......................             <50
            021178   AVEDA ARTS & SCIENCES INSTITUTE                     <50
                      LAFAYETTE.............................
            012027   GALEN COLLEGE OF CALIFORNIA............             <50
            011744   NATIONAL BEAUTY COLLEGE................             <50
            022021   CULINARY SCHOOL OF WASHINGTON..........             <50
            021232   AVEDA ARTS & SCIENCES INSTITUTE                     <50
                      MINNEAPOLIS...........................
            022340   CAMERON COLLEGE........................             <50
            021499   PAUL MITCHELL THE SCHOOL JACKSONVILLE..             <50
            022475   ARIZONA INSTITUTE OF ELECTROLYSIS DIV               <50
                      UNIF SCHOOL OF AM.....................
            020551   HAWAII BUSINESS COLLEGE................             <50
            022776   INTERNATIONAL BARBER & STYLE COLLEGE...             <50
            011844   INTERNATIONAL TECHNICAL INSTITUTE......             <50
            022952   UNITED SCHOOLS.........................             <50
            021544   BEAU MONDE ACADEMY OF BARBERING AND                 <50
                      COSMETOLOGY...........................
            012896   NORTH COAST COLLEGE, THE...............             <50
            023015   CAMBRIDGE TECHL INST...................             <50
            012982   BORDER INSTITUTE OF TECHNOLOGY.........             <50
            021877   CROWN BUSINESS INSTITUTE MIAMI.........             <50
            025994   NEW YORK COLLEGE OF HEALTH PROFESSIONS.             <50
            042183   MIDWIVES COLLEGE OF UTAH...............             <50
            040943   ROBERT B. MILLER COLLEGE (THE).........             <50
            042788   LOS ANGELES PACIFIC UNIVERSITY.........             <50
            021102   COLUMBIA COLLEGE HOLLYWOOD.............             <50
            008123   ADVANCED CAREER TRAINING...............             <50
            009435   PHILLIPS JUNIOR COLLEGE AT BIRMINGHAM..             <50
            020882   JORDAN COLLEGE.........................             <50
            009890   VALLEY COMMERCIAL COLLEGE..............             <50
            042213   PHILADELPHIA TECHNICIAN TRAINING                    <50
                      INSTITUTE.............................
            010372   ADELPHI BUSINESS COLLEGE...............             <50
            008486   NATIONAL EDUCATION CENTER NATIONAL                  <50
                      INSTITUTE OF TECHNOLOGY CAMPUS........
            007253   FEDERICO BEAUTY INSTITUTE..............             <50
            036124   VALLEY GRANDE INSTITUTE FOR ACADEMIC                <50
                      STUDIES...............................
            002134   BURDETT COLLEGE -- MAIN CAMPUS.........             <50
            008568   VET TECH INSTITUTE.....................             <50
            030888   WATKINS COLLEGE OF ART, DESIGN & FILM..             <50
            031062   FRANCISCAN MISSIONARIES OF OUR LADY                 <50
                      UNIVERSITY............................
            007389   MIDLAND CAREER INSTITUTE...............             <50
            036914   AVE MARIA SCHOOL OF LAW................             <50
            034403   BAPTIST MEMORIAL COLLEGE OF HEALTH                  <50
                      SCIENCES..............................
            025340   NATIONAL UNIVERSITY OF NATURAL MEDICINE             <50
            021446   KILIAN COMMUNITY COLLEGE...............             <50
            004630   DRAUGHON TRAINING INSTITUTE............             <50
            007853   NATIONAL EDUCATION CENTER KEE BUSINESS              <50
                      COLLEGE CAMPUS........................
            036523   METROPOLITAN LEARNING INSTITUTE........             <50
            007387   LONG ISLAND BEAUTY SCHOOL..............             <50
            007430   ANTONELLI INSTITUTE....................             <50
            003376   THIEL COLLEGE..........................             <50
            002598   CALDWELL UNIVERSITY....................             <50
            003035   OHIO DOMINICAN UNIVERSITY..............             <50
            003302   MOUNT ALOYSIUS COLLEGE.................             <50
            012580   SAINT LOUIS CHRISTIAN COLLEGE..........             <50
            002899   WAGNER COLLEGE.........................             <50
            003012   ASHLAND UNIVERSITY.....................             <50
            002603   DREW UNIVERSITY........................             <50
            002783   NEW YORK LAW SCHOOL....................             <50
            003723   MARY BALDWIN UNIVERSITY................             <50
            002760   MANHATTANVILLE COLLEGE.................             <50
            003439   MORRIS COLLEGE.........................             <50
            003298   MESSIAH UNIVERSITY.....................             <50
            002795   PAUL SMITH'S COLLEGE OF ARTS & SCIENCES             <50
            003571   HARDIN-SIMMONS UNIVERSITY..............             <50
            003742   SWEET BRIAR COLLEGE....................             <50
            002610   FELICIAN UNIVERSITY....................             <50
            003767   VIRGINIA WESLEYAN UNIVERSITY...........             <50
            003066   LAKE ERIE COLLEGE......................             <50
            002910   BELMONT ABBEY COLLEGE..................             <50
            002744   KEUKA COLLEGE..........................             <50
            003481   CARSON--NEWMAN UNIVERSITY..............             <50
            012031   SAN DIEGO CHRISTIAN COLLEGE............             <50
            003486   LIPSCOMB UNIVERSITY....................             <50
            002461   DRURY UNIVERSITY.......................             <50
            002911   BENNETT COLLEGE........................             <50
            002817   ST. BONAVENTURE UNIVERSITY.............             <50
            003831   WHEELING UNIVERSITY....................             <50
            002699   CLARKSON UNIVERSITY....................             <50
            003498   LAMBUTH UNIVERSITY.....................             <50
            002608   GEORGIAN COURT UNIVERSITY..............             <50
            003280   KEYSTONE COLLEGE.......................             <50
            003575   HOWARD PAYNE UNIVERSITY................             <50
            002502   SOUTHWEST BAPTIST UNIVERSITY...........             <50
            003384   UNIVERSITY OF SCRANTON.................             <50
            003941   UNIVERSIDAD ANA G. MENDEZ--CAROLINA                 <50
                      CAMPUS................................
            002713   DOMINICAN UNIVERSITY NEW YORK..........             <50
            002931   GUILFORD COLLEGE.......................             <50
            003586   LUBBOCK CHRISTIAN UNIVERSITY...........             <50
            003507   MEMPHIS COLLEGE OF ART.................             <50
            003069   LOURDES UNIVERSITY.....................             <50
            002935   JOHN WESLEY UNIVERSITY.................             <50
            010554   CONCORDIA COLLEGE ALABAMA..............             <50
            003987   LA ROCHE UNIVERSITY....................             <50
            010771   GUPTON-JONES COLLEGE OF FUNERAL SERVICE             <50
            003247   MISERICORDIA UNIVERSITY................             <50
            003110   OTTERBEIN UNIVERSITY...................             <50
            002520   WASHINGTON UNIVERSITY IN ST. LOUIS.....             <50
            003411   SALVE REGINA UNIVERSITY................             <50
            002681   CANISIUS COLLEGE.......................             <50
            012328   NORTHWESTERN HEALTH SCIENCES UNIVERSITY             <50
            002944   MARS HILL UNIVERSITY...................             <50
            003651   UNIVERSITY OF DALLAS...................             <50
            003369   SUSQUEHANNA UNIVERSITY.................             <50
            003149   SOUTHERN NAZARENE UNIVERSITY...........             <50
            006873   MARIAN COURT COLLEGE...................             <50
            007032   MIDAMERICA NAZARENE UNIVERSITY.........             <50
            021449   Delaware Technical Community College...             <50
            001824   OAKLAND CITY UNIVERSITY................             <50
            002225   WENTWORTH INSTITUTE OF TECHNOLOGY......             <50
            008491   Nebraska College of Business...........             <50
            001867   GRAND VIEW UNIVERSITY..................             <50
            021849   Palmer College of Chiropractic West....             <50
            001158   UNITED STATES INTERNATIONAL UNIV.......             <50
            001379   CONNECTICUT COLLEGE....................             <50
            002266   CORNERSTONE UNIVERSITY.................             <50
            021887   Prince Institute--Rocky Mountains......             <50
            001850   CENTRAL COLLEGE........................             <50
            003561   Cedar Valley College...................             <50
            001887   SIMPSON COLLEGE........................             <50
            001023   JUDSON COLLEGE.........................             <50
            001918   FRIENDS UNIVERSITY.....................             <50
            001488   FLORIDA SOUTHERN COLLEGE...............             <50
            001196   DOMINICAN UNIVERSITY OF CALIFORNIA.....             <50
            022087   San Diego Golf Academy.................             <50
            002239   AQUINAS COLLEGE........................             <50
            001540   WEBBER INTERNATIONAL UNIVERSITY........             <50
            002322   FINLANDIA UNIVERSITY...................             <50
            001545   ANDREW COLLEGE.........................             <50
            001839   TRINE UNIVERSITY.......................             <50
            001557   BREWTON PARKER COLLEGE.................             <50
            001866   GRACELAND UNIVERSITY...................             <50
            001564   EMORY UNIVERSITY.......................             <50
            001871   IOWA WESLEYAN UNIVERSITY...............             <50
            001625   BRIGHAM YOUNG UNIVERSITY--IDAHO........             <50
            001891   UNIVERSITY OF DUBUQUE..................             <50
            012470   Bryant & Stratton Business Institute--              <50
                      Rochester.............................
            001903   BAKER UNIVERSITY.......................             <50
            001691   ILLINOIS INSTITUTE OF TECHNOLOGY.......             <50
            001132   CALIFORNIA INSTITUTE OF THE ARTS.......             <50
            001716   GENERATIONS COLLEGE....................             <50
            004721   Lincoln School of Commerce.............             <50
            001725   MONMOUTH COLLEGE.......................             <50
            002144   DEAN COLLEGE...........................             <50
            010037   Ivy Tech Community College of Indiana--             <50
                      Region 9..............................
            002236   ALMA COLLEGE...........................             <50
            001116   ART CENTER COLLEGE OF DESIGN...........             <50
            002265   GRACE CHRISTIAN UNIVERSITY.............             <50
            001750   DOMINICAN UNIVERSITY...................             <50
            002279   LAWRENCE TECHNOLOGICAL UNIVERSITY......             <50
              #N/A   (blank)................................             <50
            001121   BETHANY UNIVERSITY OF THE ASSEMBLIES OF             <50
                      GOD...................................
            001774   UNIVERSITY OF CHICAGO (THE)............             <50
            011210   BUNKER HILL COMMUNITY COLLEGE-.........             <50
            033723   NORTHWEST VISTA COLLEGE................             <50
            026236   PARADISE VALLEY COMMUNITY COLLEGE......             <50
            003625   SUL ROSS STATE UNIVERSITY..............             <50
            004069   UNIVERSITY OF MINNESOTA--CROOKSTON.....             <50
            004480   DE ANZA COMMUNITY COLLEGE..............             <50
            003999   CLEVELAND STATE COMMUNITY COLLEGE......             <50
            003917   UNIVERSITY OF WISCONSIN--EAU CLAIRE....             <50
            031013   GRANITE STATE COLLEGE..................             <50
            007536   COSUMNES RIVER COLLEGE.................             <50
            006789   COLUMBIA--GREENE COMMUNITY COLLEGE--                <50
                      SUNY OFFICE OF CMNTY COLLEGES.........
            007644   LAKE LAND COLLEGE......................             <50
            005537   SOUTH CENTRAL COLLEGE..................             <50
            007692   MORAINE VALLEY COMMUNITY COLLEGE.......             <50
            012652   ONONDAGA CORTLAND MADISON BOCES........             <50
            003928   CASPER COLLEGE.........................             <50
            022781   SANTA FE COMMUNITY COLLEGE.............             <50
            008073   BUTTE COLLEGE..........................             <50
            030665   SOUTHEASTERN TECHNICAL COLLEGE.........             <50
            008129   ADULT & COMMUNITY EDUCATION, COLUMBUS               <50
                      CITY SCHOOLS..........................
            032343   CHARTER OAK STATE COLLEGE..............             <50
            004999   BELLINGHAM TECHNICAL COLLEGE...........             <50
            006788   TOMPKINS CORTLAND COMMUNITY COLLEGE....             <50
            005000   PIERCE COLLEGE.........................             <50
            042421   UNIVERSITY OF NORTH TEXAS AT DALLAS....             <50
            008403   INDIAN HILLS COMMUNITY COLLEGE.........             <50
            005535   PINE TECHNICAL AND COMMUNITY COLLEGE...             <50
            008558   BEAUFORT COUNTY COMMUNITY COLLEGE......             <50
            011167   COMMUNITY COLLEGE OF VERMONT...........             <50
            008659   LAUREL RIDGE COMMUNITY COLLEGE.........             <50
            012105   NATIONAL PARK COLLEGE..................             <50
            005252   RIDGEWATER COLLEGE.....................             <50
            003745   UNIVERSITY OF VIRGINIA.................             <50
            005258   HAWAII COMMUNITY COLLEGE...............             <50
            021921   BUTLER TECHNOLOGY AND CAREER                        <50
                      DEVELOPMENT SCHOOLS...................
            005304   CHIPPEWA VALLEY TECHNICAL COLLEGE......             <50
            023413   PALO ALTO COLLEGE......................             <50
            005318   CATAWBA VALLEY COMMUNITY COLLEGE.......             <50
            003608   SAINT PHILIP'S COLLEGE.................             <50
            010060   VERNON COLLEGE.........................             <50
            030838   HEARTLAND COMMUNITY COLLEGE............             <50
            042485   TEXAS A&M UNIVERSITY-SAN ANTONIO.......             <50
            031563   ESTRELLA MOUNTAIN COMMUNITY COLLEGE....             <50
            005390   BLACKHAWK TECHNICAL COLLEGE............             <50
            032603   CALIFORNIA STATE UNIVERSITY, MONTEREY               <50
                      BAY...................................
            010364   WHATCOM COMMUNITY COLLEGE..............             <50
            034283   KLAMATH COMMUNITY COLLEGE..............             <50
            010453   WASHINGTON STATE COMMUNITY COLLEGE.....             <50
            040386   BRIDGEVALLEY COMMUNITY AND TECHNICAL                <50
                      COLLEGE...............................
            010641   SOUTHERN WESTCHESTER BOCES.............             <50
            006807   COMMUNITY COLLEGE OF BEAVER COUNTY.....             <50
            003981   UNIVERSITY OF NORTH CAROLINA SCHOOL OF              <50
                      THE ARTS..............................
            010674   TEXAS TECH UNIVERSITY HEALTH SCIENCES               <50
                      CENTER................................
            003662   VICTORIA COLLEGE.......................             <50
            002568   UNIVERSITY OF NEVADA , RENO............             <50
            001143   CALIFORNIA POLYTECHNIC STATE UNIVERSITY             <50
            001365   COLORADO STATE UNIVERSITY-PUEBLO.......             <50
            003220   SOUTHWESTERN OREGON COMMUNITY COLLEGE..             <50
            001910   COFFEYVILLE COMMUNITY COLLEGE..........             <50
            003221   TREASURE VALLEY COMMUNITY COLLEGE......             <50
            002292   MICHIGAN TECHNOLOGICAL UNIV............             <50
            001705   ILLINOIS VALLEY COMMUNITY COLLEGE......             <50
            002171   MASSACHUSETTS BAY COMMUNITY COLLEGE....             <50
            001926   PITTSBURG STATE UNIVERSITY.............             <50
            001206   GOLDEN WEST COLLEGE....................             <50
            003153   CONNORS STATE COLLEGE..................             <50
            001573   GEORGIA SOUTHWESTERN STATE UNIVERSITY..             <50
            003154   EAST CENTRAL UNIVERSITY................             <50
            003186   BLUE MOUNTAIN COMMUNITY COLLEGE........             <50
            002536   UNIVERSITY OF MONTANA (THE)............             <50
            002295   MONTCALM COMMUNITY COLLEGE.............             <50
            003160   NORTHEASTERN OKLAHOMA A & M COLLEGE....             <50
            002170   HOLYOKE COMMUNITY COLLEGE..............             <50
            001197   EL CAMINO COLLEGE......................             <50
            003541   ANGELO STATE UNIVERSITY................             <50
            001652   HAROLD WASHINGTON COLLEGE..............             <50
            003554   CLARENDON COLLEGE......................             <50
            002692   CUNY BRONX COMMUNITY COLLEGE...........             <50
            003573   HILL COLLEGE...........................             <50
            002915   CENTRAL PIEDMONT COMMUNITY COLLEGE.....             <50
            002846   STATE UNIVERSITY OF NEW YORK AT NEW                 <50
                      PALTZ.................................
            001187   COLLEGE OF THE SISKIYOUS...............             <50
            002105   UNIVERSITY OF MARYLAND--BALTIMORE                   <50
                      COUNTY................................
            003163   NORTHWESTERN OKLAHOMA STATE UNIVERSITY.             <50
            002879   SULLIVAN COUNTY COMMUNITY COLLEGE--SUNY             <50
                      OFFICE OF COMMUNITY COLLEGES..........
            001615   UNIVERSITY OF HAWAII MAUI COLLEGE......             <50
            002596   ATLANTIC CAPE COMMUNITY COLLEGE........             <50
            002336   BEMIDJI STATE UNIVERSITY...............             <50
            001877   NORTH IOWA AREA COMMUNITY COLLEGE......             <50
            002430   PEARL RIVER COMMUNITY COLLEGE..........             <50
            002857   SUNY COLLEGE OF TECHNOLOGY AT DELHI....             <50
            001579   AUGUSTA UNIVERSITY.....................             <50
            001979   WEST KENTUCKY COMMUNITY AND TECHNICAL               <50
                      COLLEGE...............................
            001523   SAINT JOHNS RIVER STATE COLLEGE........             <50
            001997   SOMERSET COMMUNITY COLLEGE.............             <50
            001223   LOS ANGELES CITY COLLEGE...............             <50
            002517   MISSOURI UNIVERSITY OF SCIENCE AND                  <50
                      TECHNOLOGY............................
            001814   INDIANA UNIVERSITY--KOKOMO.............             <50
            003546   COASTAL BEND COLLEGE...................             <50
            002367   MINNESOTA STATE UNIVERSITY MOORHEAD....             <50
            001227   LOS ANGELES TRADE-TECHNICAL COLLEGE....             <50
            001294   SOUTHWESTERN COMMUNITY COLLEGE DISTRICT             <50
            002874   NIAGARA COUNTY COMMUNITY COLLEGE.......             <50
            002373   ROCHESTER COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            003572   TRINITY VALLEY COMMUNITY COLLEGE.......             <50
            002843   SUNY COLLEGE AT CORTLAND...............             <50
            001923   HUTCHINSON COMMUNITY COLLEGE...........             <50
            003174   OKLAHOMA PANHANDLE STATE UNIVERSITY....             <50
            002422   MISSISSIPPI UNIVERSITY FOR WOMEN.......             <50
            001490   GULF COAST STATE COLLEGE...............             <50
            002177   MASSASOIT COMMUNITY COLLEGE............             <50
            002057   ALLEGANY COLLEGE OF MARYLAND...........             <50
            002394   WINONA STATE UNIVERSITY................             <50
            041523   GEORGIA BEAUTY ACADEMY.................             <50
            041204   PAUL MITCHELL THE SCHOOL MIAMI.........             <50
            041582   PAUL MITCHELL THE SCHOOL SHERMAN OAKS..             <50
            040053   UNITED STATES UNIVERSITY...............             <50
            039655   HAIR EXPRESSIONS--PAUL MITCHELL PARTNER             <50
                      SCHOOL................................
            036703   TIGI HAIRDRESSING ACADEMY LEGACY.......             <50
            041173   DAYTON SCHOOL OF MEDICAL MASSAGE.......             <50
            041671   AVEDA INSTITUTE DENVER.................             <50
            038143   TURNING POINT BEAUTY COLLEGE...........             <50
            041423   AVEDA ARTS & SCIENCES INSTITUTE CORPUS              <50
                      CHRISTI...............................
            038393   AVEDA ARTS & SCIENCES INSTITUTE NEW                 <50
                      YORK..................................
            041431   PROFESSIONAL HANDS INSTITUTE...........             <50
            042151   CALIFORNIA CAREER INSTITUTE............             <50
            037863   ADVANCED COLLEGE.......................             <50
            038105   MID CITY COLLEGE.......................             <50
            041710   ADVANCED TRAINING INSTITUTE............             <50
            039013   PACIFIC COAST TRADE SCHOOL.............             <50
            041013   CAROLINA SCHOOL OF BROADCASTING........             <50
            036274   JACKSONVILLE BEAUTY INSTITUTE..........             <50
            041265   COAST CAREER INSTITUTE.................             <50
            041192   EAGLE ROCK COLLEGE.....................             <50
            041043   ACADEMY DI CAPELLI.....................             <50
            041601   TRINITY SCHOOL OF HEALTH AND ALLIED                 <50
                      SCIENCES..............................
            041753   PENROSE ACADEMY........................             <50
            036454   RUDY & KELLY ACADEMY, A PAUL MITCHELL               <50
                      PARTNER SCHOOL........................
            041454   OXFORD ACADEMY OF HAIR DESIGN..........             <50
            039073   PAUL MITCHELL THE SCHOOL GREAT LAKES...             <50
            041455   SKIN SCIENCE INSTITUTE OF LASER &                   <50
                      ESTHETICS.............................
            041505   PREFERRED COLLEGE OF NURSING, LOS                   <50
                      ANGELES...............................
            041796   ENTOURAGE INSTITUTE OF BEAUTY AND                   <50
                      ESTHETICS.............................
            040384   AVI CAREER TRAINING....................             <50
            041468   SOUTH TEXAS TRAINING CENTER............             <50
            042349   AMG COLLEGE............................             <50
            041063   PALM BEACH ACADEMY OF HEALTH & BEAUTY..             <50
            042449   SONORAN DESERT INSTITUTE...............             <50
            037534   MICHAEL'S SCHOOL OF BEAUTY.............             <50
            039554   MIDWEST INSTITUTE OF MASSAGE THERAPY...             <50
            041869   INTERNATIONAL COLLEGE OF BEAUTY, ARTS &             <50
                      SCIENCES..............................
            001004   UNIVERSITY OF MONTEVALLO...............             <50
            039633   INSTITUTE OF HEALTH AND TECHNOLOGY.....             <50
            001007   CENTRAL ALABAMA COMMUNITY COLLEGE......             <50
            041878   CYBERTEX INSTITUTE OF TECHNOLOGY.......             <50
            041584   L'ESPRIT ACADEMY.......................             <50
            041944   AMERICAN COLLEGE OF HEALTHCARE SCIENCES             <50
            037143   TREND BARBER COLLEGE...................             <50
            041948   VELVET TOUCH ACADEMY OF COSMETOLOGY....             <50
            035844   COLORADO SCHOOL OF HEALING ARTS........             <50
            042045   ELAINE STERLING INSTITUTE(THE).........             <50
            041624   PAUL MITCHELL THE SCHOOL ALBUQUERQUE...             <50
            041326   DAVINES PROFESSIONAL ACADEMY OF BEAUTY              <50
                      AND BUSINESS..........................
            035773   COBA ACADEMY...........................             <50
            036803   JAY'S TECHNICAL INSTITUTE..............             <50
            040144   PALLADIUM TECHNICAL ACADEMY............             <50
            041284   MIAMI REGIONAL UNIVERSITY..............             <50
            001098   HENDERSON STATE UNIVERSITY.............             <50
            041494   GARY MANUEL AVEDA INSTITUTE............             <50
            041340   JOHN PAOLO'S XTREME BEAUTY INSTITUTE,               <50
                      GOLDWELL PRODUCTS ARTISTRY............
            041503   RWM FIBER OPTICS.......................             <50
            041580   METRO BEAUTY ACADEMY...................             <50
            033073   CSC INSTITUTE..........................             <50
            031384   AMERICAN COLLEGE OF MEDICAL TECHNOLOGY.             <50
            026196   COLLEGE FOR EARLY CHILDHOOD EDUCATORS..             <50
            030161   SOUTHWESTERN COLLEGE OF BUSINESS.......             <50
            025454   NORTH AMERICAN TRADE SCHOOLS...........             <50
            023243   CAREERCOM COLLEGE OF BUSINESS..........             <50
            025044   VOCATIONAL INSTITUTE...................             <50
            030288   AMERICAN NATIONAL COLLEGE..............             <50
            030020   HAIRMASTERS INSTITUTE OF COSMETOLOGY...             <50
            025420   SIERRA ACADEMY OF AERONAUTICS-AIRLINE               <50
                      TRAINING CENTER.......................
            024984   NATIONAL CAREER INSTITUTE..............             <50
            030344   CONSERVATORY OF RECORDING ARTS &                    <50
                      SCIENCES..............................
            032383   FLORIDA COLLEGE OF INTEGRATIVE MEDICINE             <50
            030541   ROYALE COLLEGE OF BEAUTY AND BARBERING.             <50
            025647   ELAINE STEVEN BEAUTY COLLEGE...........             <50
            025863   FLORIDA INSTITUTE OF TRADITIONAL                    <50
                      CHINESE MEDICINE......................
            033673   PROFESSIONAL GOLFERS CAREER COLLEGE....             <50
            023208   MAGNOLIA COLLEGE OF COSMETOLOGY........             <50
            025184   NATIONAL HISPANIC UNIVERSITY (THE).....             <50
            023044   YTI CAREER INSTITUTE--CAPITAL REGION...             <50
            034404   MARIAN HEALTH CAREERS CENTER...........             <50
            023545   SOUTHEASTERN BEAUTY SCHOOLS............             <50
            026063   PAUL MITCHELL THE SCHOOL WICHITA.......             <50
            026021   NORTHWEST COLLEGE OF ART & DESIGN......             <50
            026071   PAUL MITCHELL THE SCHOOL BOISE.........             <50
            030906   COBB BEAUTY COLLEGE....................             <50
            032243   NEW PROFESSIONS TECHNICAL INSTITUTE....             <50
            023601   PROFESSIONAL CAREER COLLEGE............             <50
            032533   PAUL MITCHELL THE SCHOOL MEMPHIS.......             <50
            023602   STENOTYPE INSTITUTE OF SPRINGFIELD.....             <50
            026146   SUMMIT INSTITUTE.......................             <50
            030977   CENTRAL CALIFORNIA SCHOOL OF CONTINUING             <50
                      EDUCATION.............................
            033553   GHENT BEAUTY ACADEMY...................             <50
            030978   CARSTEN INSTITUTE OF COSMETOLOGY.......             <50
            025696   SEARCY BEAUTY COLLEGE..................             <50
            030990   CORTIVA INSTITUTE--SEATTLE.............             <50
            025135   MARJON SCHOOL OF BEAUTY................             <50
            025574   STAR COLLEGE OF COSMETOLOGY............             <50
            025706   CAREERCOM JUNIOR COLLEGE OF BUSINESS...             <50
            031111   NEW YORK PARALEGAL SCHOOL..............             <50
            034145   ACUPUNCTURE AND MASSAGE COLLEGE........             <50
            023377   PROFESSIONAL SKILLS INSTITUTE..........             <50
            025754   INTERNATIONAL CULINARY CENTER..........             <50
            031161   VOGUE BEAUTY AND BARBER SCHOOL.........             <50
            030144   SOUTHERN CALIFORNIA INTERNATIONAL                   <50
                      COLLEGE...............................
            024947   BALTIMORE STUDIO OF HAIR DESIGN........             <50
            030650   PAUL MITCHELL THE SCHOOL RICHLAND......             <50
            030439   NEWSCHOOL OF ARCHITECTURE AND DESIGN...             <50
            022675   GLENWOOD BEAUTY ACADEMY................             <50
            020503   ACADEMY COLLEGE........................             <50
            022847   CHICAGO INSTITUTE OF TECHNOLOGY........             <50
            011690   PHILLIPS COLLEGE OF ATLANTA............             <50
            022515   TREND SETTERS' ACADEMY OF BEAUTY                    <50
                      CULTURE...............................
            011193   STRATFORD SCHOOL.......................             <50
            011481   DIVERS INSTITUTE OF TECHNOLOGY.........             <50
            011256   UNITED ELECTRONICS INST................             <50
            020523   UNIVERSITY OF WEST LOS ANGELES.........             <50
            020937   LONG ISLAND BUSINESS INSTITUTE.........             <50
            022430   SOUTHWEST COLLEGE......................             <50
            021664   NATIONAL UNIVERSITY COLLEGE-IBC                     <50
                      INSTITUTE.............................
            011816   GREAT LAKES TECHL INST.................             <50
            012901   DOMINION COLLEGE.......................             <50
            022694   EASTERN HILLS ACADEMY OF HAIR DESIGN...             <50
            021059   BRITTANY BEAUTY ACADEMY................             <50
            022732   INSTITUTE OF COMPUTER SCIENCE..........             <50
            021858   MOLER BARBER COLLEGE...................             <50
            022879   RAPHAEL'S SCHOOL OF BEAUTY CULTURE.....             <50
            021250   CAREER ACADEMY OF BEAUTY...............             <50
            022980   DESIGN INSTITUTE OF SAN DIEGO..........             <50
            011000   BAILIE SCHOOL OF BROADCAST.............             <50
            020564   CAPRI COSMETOLOGY LEARNING CENTER......             <50
            010903   RIZZIERI AVEDA SCHOOL FOR BEAUTY AND                <50
                      WELLNESS..............................
            021448   VET TECH INSTITUTE OF HOUSTON..........             <50
            021256   MICHIGAN COLLEGE OF BEAUTY-TROY........             <50
            012483   PAUL MITCHELL THE SCHOOL DALLAS........             <50
            012064   ORION TECHNICAL COLLEGE................             <50
            022584   AVEDA ARTS & SCIENCES INSTITUTE BATON               <50
                      ROUGE.................................
            022041   NEW ENGLAND TRACTOR TRAILER TRAINING                <50
                      SCHOOL................................
            020772   ROSS TECHNICAL INSTITUTE...............             <50
            022050   COLLEGE OF WILMINGTON..................             <50
            022695   WESTERN HILLS SCHOOL OF BEAUTY & HAIR               <50
                      DESIGN................................
            012092   KENNETH SHULER SCHOOL OF COSMETOLOGY...             <50
            020837   VOCATIONAL TRAINING CENTER.............             <50
            022127   LANCASTER SCHOOL OF COSMETOLOGY &                   <50
                      THERAPEUTIC BODYWORK..................
            020936   SOUTHWEST INSTITUTE OF TECHNOLOGY......             <50
            022173   NORTH AMERICAN COLLEGE.................             <50
            022855   CREATIVE CIRCUS........................             <50
            021284   CERTIFIED WELDING & TRADE SCHOOL.......             <50
            021139   KATHERINE GIBBS SCHOOL.................             <50
            022197   CORTEZ W PETERS BUSINESS COLLEGE OF                 <50
                      CHICAGO...............................
            011866   LU ROSS ACADEMY........................             <50
            021318   JEFFERSON BUSINESS COLLEGE (CLOSED)....             <50
            022999   A BUSINESS CAREER INSTITUTE............             <50
            022346   SHORE BEAUTY SCHOOL....................             <50
            011896   ACADEMY OF BEAUTY CULTURE..............             <50
            022362   MAY TECHNICAL COLLEGE..................             <50
            021436   RETS ELECTRONIC INSTITUTE..............             <50
            021782   CHARLESTON SCHOOL OF BEAUTY CULTURE....             <50
            041432   HULT INTERNATIONAL BUSINESS SCHOOL.....             <50
            021706   UNITED STATES SPORTS ACADEMY...........             <50
            007779   LANSDALE SCHOOL OF BUSINESS............             <50
            004490   PATTEN UNIVERSITY......................             <50
            010063   DELTA CAREER COLLEGE...................             <50
            008552   STEVENS--THE INSTITUTE OF BUSINESS &                <50
                      ARTS..................................
            007391   BEAUTY SCHOOL OF MIDDLETOWN............             <50
            004924   FORREST COLLEGE........................             <50
            009708   ELITE ACADEMY OF COSMETOLOGY...........             <50
            025703   LOS ANGELES ORT TECHNICAL INSTITUTE....             <50
            032353   MASSACHUSETTS SCHOOL OF LAW AT ANDOVER.             <50
            022220   AMERICAN FILM INSTITUTE CONSERVATORY...             <50
            040673   SELMA UNIVERSITY.......................             <50
            008958   STENOGRAPH INSTITUTE OF TEXAS..........             <50
            010447   PLAZA BEAUTY SCHOOL....................             <50
            007515   ROBERT FIANCE HAIR DESIGN INST.........             <50
            008494   HOHOKUS SCHOOL OF TRADE AND TECHNICAL               <50
                      SCIENCES..............................
            004991   COMMONWEALTH COLLEGE, NORFOLK..........             <50
            009523   LA'JAMES INTERNATIONAL COLLEGE.........             <50
            004621   AYERS CAREER COLLEGE...................             <50
            030088   BRILLARE BEAUTY INSTITUTE..............             <50
            005204   BEAL UNIVERSITY........................             <50
            020961   FIELDING GRADUATE UNIVERSITY...........             <50
            009223   MBTI BUSINESS TRAINING INSTITUTE.......             <50
            041565   GEORGIA CHRISTIAN UNIVERSITY...........             <50
            007595   WILFRED ACADEMY OF HAIR AND BEAUTY                  <50
                      CULTURE...............................
            041933   SHEPHERD UNIVERSITY....................             <50
            025240   JONES TECHNICAL INSTITUTE..............             <50
            010161   LORAINES ACADEMY & SPA.................             <50
            009363   EMPIRE TECHNICAL SCHOOL................             <50
            041497   HOMESTEAD SCHOOLS......................             <50
            007617   CARNEGIE INSTITUTE.....................             <50
            010463   NATIONAL TECHNICAL SCHOOLS.............             <50
            006606   BAPTIST HEALTH SYSTEM SCHOOL OF HEALTH              <50
                      PROFESSIONS...........................
            010577   UNITED COLLEGE OF BUSINESS.............             <50
            009447   WEBSTER CAREER COLLEGE.................             <50
            009482   MANSFIELD BUSINESS COLLEGE.............             <50
            007397   CENTER FOR THE MEDIA ARTS..............             <50
            002955   PFEIFFER UNIVERSITY....................             <50
            003142   WILMINGTON COLLEGE.....................             <50
            004071   WALSH COLLEGE OF ACCOUNTANCY & BUSINESS             <50
                      ADMINISTRATION........................
            003848   EDGEWOOD COLLEGE.......................             <50
            002808   DAEMEN UNIVERSITY......................             <50
            002894   UNIVERSITY OF ROCHESTER................             <50
            010618   MID-AMERICA COLLEGE OF FUNERAL SERVICE.             <50
            003850   HOLY FAMILY COLLEGE....................             <50
            002763   MARIA COLLEGE..........................             <50
            003198   LINFIELD UNIVERSITY....................             <50
            003637   JARVIS CHRISTIAN UNIVERSITY............             <50
            002908   BARTON COLLEGE.........................             <50
            002816   SIENA COLLEGE..........................             <50
            003869   MOUNT MARY UNIVERSITY..................             <50
            003084   MUSKINGUM UNIVERSITY...................             <50
            002992   UNIVERSITY OF MARY.....................             <50
            003518   SOUTHERN ADVENTIST UNIVERSITY..........             <50
            003911   VITERBO UNIVERSITY.....................             <50
            010880   CHATFIELD COLLEGE......................             <50
            002748   LE MOYNE COLLEGE.......................             <50
            003134   URSULINE COLLEGE.......................             <50
            003937   UNIVERSIDAD DEL SAGRADO CORAZON........             <50
            003762   VIRGINIA UNIVERSITY OF LYNCHBURG.......             <50
            003576   HOUSTON BAPTIST UNIVERSITY.............             <50
            002685   CAZENOVIA COLLEGE......................             <50
            002749   NEW YORK COLLEGE OF PODIATRIC MEDICINE.             <50
            012574   RINGLING COLLEGE OF ART AND DESIGN.....             <50
            002534   ROCKY MOUNTAIN COLLEGE.................             <50
            013029   BORICUA COLLEGE........................             <50
            003025   CEDARVILLE UNIVERSITY..................             <50
            003288   LEBANON VALLEY COLLEGE.................             <50
            002540   COLLEGE OF SAINT MARY..................             <50
            003986   DESALES UNIVERSITY.....................             <50
            003431   CONVERSE UNIVERSITY....................             <50
            003811   DAVIS & ELKINS COLLEGE.................             <50
            003366   SAINT FRANCIS UNIVERSITY...............             <50
            003402   BRYANT UNIVERSITY......................             <50
            008880   MORRISON INSTITUTE OF TECHNOLOGY.......             <50
            003229   ALBRIGHT COLLEGE.......................             <50
            003783   NORTHWEST UNIVERSITY...................             <50
            002544   DOANE UNIVERSITY.......................             <50
            009109   RIVERSIDE SCHOOL OF AERONUTICS.........             <50
            011113   MAHARISHI INTERNATIONAL UNIVERSITY.....             <50
            009117   MILWAUKEE COLLEGE OF BUSINESS..........             <50
            002555   NEBRASKA WESLEYAN UNIVERSITY...........             <50
            003504   MARTIN METHODIST COLLEGE...............             <50
            002474   KANSAS CITY UNIVERSITY.................             <50
            002412   MARY HOLMES COLLEGE....................             <50
            002489   MISSOURI VALLEY COLLEGE................             <50
            003685   COLLEGE OF SAINT JOSEPH................             <50
            003352   PHILADELPHIA COLLEGE OF OSTEOPATHIC                 <50
                      MEDICINE..............................
            003048   HEIDELBERG UNIVERSITY..................             <50
            003275   HOLY FAMILY UNIVERSITY.................             <50
            009800   RUSH UNIVERSITY........................             <50
            002886   ALBANY LAW SCHOOL OF UNION UNIVERSITY..             <50
            003966   BOSTON ARCHITECTURAL COLLEGE...........             <50
            003242   CARNEGIE MELLON UNIVERSITY.............             <50
            003266   GANNON UNIVERSITY......................             <50
            003669   WILEY COLLEGE..........................             <50
            003306   UNIVERSITY OF VALLEY FORGE.............             <50
            003670   BRIGHAM YOUNG UNIVERSITY...............             <50
            010266   RANDALL UNIVERSITY.....................             <50
            010365   CHARLES R. DREW UNIVERSITY OF MEDICINE              <50
                      AND SCIENCE...........................
            007085   MOUNT VERNON NAZARENE UNIVERSITY.......             <50
            003351   CAIRN UNIVERSITY.......................             <50
            002241   CALVIN UNIVERSITY......................             <50
            001975   MIDWAY UNIVERSITY......................             <50
            039883   SAE Institute of Technology, New York..             <50
            001326   SANTA CLARA UNIVERSITY.................             <50
            002132   BRADFORD COLLEGE.......................             <50
            001036   SAMFORD UNIVERSITY.....................             <50
            001889   SAINT AMBROSE UNIVERSITY...............             <50
            031823   New Hampshire Institute of Art.........             <50
            030501   STUDIO ARTS COLLEGE INTERNATIONAL......             <50
            001568   INTERDENOMINATIONAL THEOLOGICAL CENTER.             <50
            001291   SIMPSON UNIVERSITY.....................             <50
            012184   International Academy of Hair Design...             <50
            012766   NATIONAL UNIVERSITY OF IRELAND, GALWAY.             <50
            001589   REINHARDT UNIVERSITY...................             <50
            008981   Marinello Schools of Beauty............             <50
            041956   Tribeca Flashpoint College.............             <50
            001917   BARCLAY COLLEGE........................             <50
            001041   SPRING HILL COLLEGE....................             <50
            006191   Saint Vincent's College................             <50
            003689   Northern Vermont University Lyndon.....             <50
            001965   KENTUCKY CHRISTIAN UNIVERSITY..........             <50
            006740   University of Colorado at Denver.......             <50
            002001   THOMAS MORE UNIVERSITY.................             <50
            001676   ELMHURST UNIVERSITY....................             <50
            002109   MCDANIEL COLLEGE.......................             <50
            001251   OTIS COLLEGE OF ART AND DESIGN.........             <50
            009423   ROYAL COLLEGE OF ART...................             <50
            001070   THUNDERBIRD SCHOOL OF GLOBAL MANAGEMENT             <50
            002238   ANDREWS UNIVERSITY.....................             <50
            001093   CENTRAL BAPTIST COLLEGE................             <50
            001555   THOMAS UNIVERSITY......................             <50
            001094   UNIVERSITY OF THE OZARKS...............             <50
            001281   WILLIAM JESSUP UNIVERSITY..............             <50
            001732   NATIONAL UNIVERSITY OF HEALTH SCIENCES              <50
                      (THE).................................
            001904   BETHANY COLLEGE........................             <50
            001409   UNIVERSITY OF SAINT JOSEPH.............             <50
            001133   CALIFORNIA LUTHERAN UNIVERSITY.........             <50
            001745   QUINCY UNIVERSITY......................             <50
            001954   BELLARMINE UNIVERSITY..................             <50
            010038   Ivy Tech Community College of Indiana--             <50
                      Region 10.............................
            001960   SPALDING UNIVERSITY....................             <50
            001426   YALE UNIVERSITY........................             <50
            001964   GEORGETOWN COLLEGE.....................             <50
            009923   Ivy Tech Community College of Indiana--             <50
                      Region 11.............................
            001969   KENTUCKY WESLEYAN COLLEGE..............             <50
            001772   TRINITY INTERNATIONAL UNIVERSITY.......             <50
            001988   UNION COLLEGE..........................             <50
            001236   MENLO COLLEGE..........................             <50
            002043   HUSSON UNIVERSITY......................             <50
            001793   EARLHAM COLLEGE........................             <50
            002080   MARYLAND INSTITUTE COLLEGE OF ART......             <50
            009925   Ivy Tech Community College of Indiana--             <50
                      Region 12.............................
            002118   ASSUMPTION UNIVERSITY..................             <50
            001437   CATHOLIC UNIVERSITY OF AMERICA (THE)...             <50
            002148   ENDICOTT COLLEGE.......................             <50
            001838   TAYLOR UNIVERSITY......................             <50
            002219   TUFTS UNIVERSITY.......................             <50
            004648   Rasmussen College--Eagan...............             <50
            002234   ADRIAN COLLEGE.........................             <50
            011686   Rasmussen College--Eden Prairie........             <50
            033343   UNIVERSIDAD CATOLICA NORDESTANA........             <50
            001854   COE COLLEGE............................             <50
            033353   MEDICAL UNIVERSITY OF SILESIA (THE)....             <50
            025033   Rasmussen College--Mankato.............             <50
            008503   Mountain View College..................             <50
            008080   STATE FAIR COMMUNITY COLLEGE...........             <50
            041522   CARTHAGE R-9 SCHOOL DISTRICT/CARTHAGE               <50
                      TECHNICAL CENTER......................
            031004   COCONINO COUNTY COMMUNITY COLLEGE......             <50
            009010   MADISONVILLE COMMUNITY COLLEGE.........             <50
            003805   YAKIMA VALLEY COLLEGE..................             <50
            009054   WEST VIRGINIA NORTHERN COMMUNITY                    <50
                      COLLEGE-WHEELING CAMPUS...............
            006725   UNIVERSITY OF TENNESSEE HEALTH SCIENCE              <50
                      CENTER................................
            004711   STATE TECHNICAL COLLEGE OF MISSOURI....             <50
            006782   GENESEE COMMUNITY COLLEGE..............             <50
            004713   THREE RIVERS COLLEGE...................             <50
            012954   HUDSON COUNTY COMMUNITY COLLEGE........             <50
            009194   LAKESHORE TECHNICAL COLLEGE............             <50
            022260   EAST LOS ANGELES COLLEGE...............             <50
            005271   SOUTHCENTRAL KENTUCKY COMMUNITY AND                 <50
                      TECHNICAL COLLEGE.....................
            023502   INDIANA COUNTY TECHNOLOGY CENTER.......             <50
            007275   EASTERN GATEWAY COMMUNITY COLLEGE......             <50
            006753   ILLINOIS CENTRAL COLLEGE...............             <50
            005313   NORTH CENTRAL STATE COLLEGE............             <50
            008308   CECIL COLLEGE..........................             <50
            003787   SEATTLE CENTRAL COLLEGE................             <50
            007170   LINCOLN LAND COMMUNITY COLLEGE.........             <50
            003760   VIRGINIA WESTERN COMMUNITY COLLEGE.....             <50
            008727   CHICAGO CITY-WIDE COLLEGE..............             <50
            009651   TEXAS A&M INTERNATIONAL UNIVERSITY.....             <50
            020635   COASTLINE COMMUNITY COLLEGE............             <50
            009740   INVER HILLS COMMUNITY COLLEGE..........             <50
            021702   ALBANY SCHOHARIE SCHENECTADY SARATOGA               <50
                      BOCES PRACTICAL NURSING PROGRAM.......
            003956   DALTON STATE COLLEGE...................             <50
            022637   MIAMI VALLEY CAREER TECHNOLOGY CENTER..             <50
            009764   TUNXIS COMMUNITY COLLEGE...............             <50
            023120   BERGEN COUNTY TECHNICAL SCHOOLS........             <50
            005363   DENMARK TECHNICAL COLLEGE..............             <50
            025395   IRVINE VALLEY COLLEGE..................             <50
            005378   NORTHEAST STATE COMMUNITY COLLEGE......             <50
            030345   OWENSBORO COMMUNITY & TECHNICAL COLLEGE             <50
            009941   BELMONT COLLEGE........................             <50
            006768   MID MICHIGAN COLLEGE...................             <50
            009994   PASSAIC COUNTY COMMUNITY COLLEGE.......             <50
            008284   MITCHELL TECHNICAL COLLEGE.............             <50
            010014   GARRETT COLLEGE........................             <50
            007111   NORTH COUNTRY COMMUNITY COLLEGE........             <50
            004740   MERCER COUNTY COMMUNITY COLLEGE........             <50
            003609   SAN JACINTO COMMUNITY COLLEGE DISTRICT.             <50
            005387   NORTHCENTRAL TECHNICAL COLLEGE.........             <50
            041301   LOUISIANA DELTA COMMUNITY COLLEGE......             <50
            003919   UNIVERSITY OF WISCONSIN--LACROSSE......             <50
            007171   KIRTLAND COMMUNITY COLLEGE.............             <50
            003779   GRAYS HARBOR COLLEGE...................             <50
            012870   SOUTHERN STATE COMMUNITY COLLEGE.......             <50
            010338   EASTERN VIRGINIA MEDICAL SCHOOL........             <50
            005624   COLUMBUS TECHNICAL COLLEGE.............             <50
            005448   DURHAM TECHNICAL COMMUNITY COLLEGE.....             <50
            021077   TRUCKEE MEADOWS COMMUNITY COLLEGE......             <50
            006815   ORANGEBURG--CALHOUN TECHNICAL COLLEGE..             <50
            003696   UNIVERSITY OF VERMONT AND STATE                     <50
                      AGRICULTURAL COLLEGE..................
            005489   CENTRAL LOUISIANA TECHNICAL COMMUNITY               <50
                      COLLEGE...............................
            008078   SPRINGFIELD TECHNICAL COMMUNITY COLLEGE             <50
            005498   WICHITA STATE UNIVERSITY CAMPUS OF                  <50
                      APPLIED SCIENCES AND TECHNOLOGY.......
            022456   WARREN COUNTY CAREER CENTER............             <50
            010402   DAKOTA COUNTY TECHNICAL COLLEGE........             <50
            005761   L. E. FLETCHER TECHNICAL COMMUNITY                  <50
                      COLLEGE...............................
            007555   LAKES REGION COMMUNITY COLLEGE.........             <50
            023108   LANCASTER COUNTY CAREER AND TECHNOLOGY              <50
                      CENTER................................
            003792   SKAGIT VALLEY COLLEGE..................             <50
            006962   HAZARD COMMUNITY AND TECHNICAL COLLEGE.             <50
            006938   LINN-BENTON COMMUNITY COLLEGE..........             <50
            023528   POLARIS CAREER CENTER--ADULT EDUCATION              <50
                      DEPARTMENT............................
            007684   KISHWAUKEE COLLEGE.....................             <50
            008132   TOLEDO PUBLIC SCHOOLS ADULT AND                     <50
                      CONTINUING EDUCATION..................
            004513   HOUSATONIC COMMUNITY COLLEGE...........             <50
            030300   OGEECHEE TECHNICAL COLLEGE.............             <50
            007729   COUNTY COLLEGE OF MORRIS...............             <50
            004952   UNIVERSITY OF TEXAS MEDICAL BRANCH AT               <50
                      GALVESTON.............................
            010710   CAPITAL AREA CAREER CENTER.............             <50
            004972   GALVESTON COLLEGE......................             <50
            003923   UNIVERSITY OF WISCONSIN--RIVER FALLS...             <50
            008155   EVERGREEN STATE COLLEGE (THE)..........             <50
            003924   UNIVERSITY OF WISCONSIN--STEVENS POINT.             <50
            008278   TERRA STATE COMMUNITY COLLEGE..........             <50
            003781   HIGHLINE COLLEGE.......................             <50
            007108   UNIVERSITY OF PUERTO RICO--RIO PIEDRAS              <50
                      CAMPUS................................
            003719   LONGWOOD UNIVERSITY....................             <50
            003774   COLUMBIA BASIN COLLEGE.................             <50
            011824   NORTHWOOD TECHNICAL COLLEGE............             <50
            036273   LAMAR INSTITUTE OF TECHNOLOGY..........             <50
            011864   MOHAVE COMMUNITY COLLEGE...............             <50
            038713   FOLSOM LAKE COLLEGE....................             <50
            004549   LEEWARD COMMUNITY COLLEGE..............             <50
            003601   PARIS JUNIOR COLLEGE...................             <50
            003668   WHARTON COUNTY JUNIOR COLLEGE..........             <50
            003935   UNIVERSITY OF GUAM.....................             <50
            012182   CHATTAHOOCHEE VALLEY COMMUNITY COLLEGE.             <50
            006799   CRAVEN COMMUNITY COLLEGE...............             <50
            012293   VEEB NASSAU COUNTY SCHOOL OF PRACTICAL              <50
                      NURSING...............................
            003678   SOUTHERN UTAH UNIVERSITY...............             <50
            003930   NORTHERN WYOMING COMMUNITY COLLEGE                  <50
                      DISTRICT..............................
            042295   TEXAS A&M UNIVERSITY--CENTRAL TEXAS....             <50
            004951   UNIVERSITY OF TEXAS HEALTH SCIENCE                  <50
                      CENTER AT HOUSTON.....................
            008903   COLLEGE OF THE CANYONS.................             <50
            012750   EDISON STATE COMMUNITY COLLEGE.........             <50
            005534   ST. CLOUD TECHNICAL AND COMMUNITY                   <50
                      COLLEGE...............................
            001636   SOUTHWESTERN ILLINOIS COLLEGE..........             <50
            001592   SOUTH GEORGIA STATE COLLEGE............             <50
            002566   WAYNE STATE COLLEGE....................             <50
            001124   CABRILLO COLLEGE.......................             <50
            001502   LAKE SUMTER STATE COLLEGE..............             <50
            001510   NORTHWEST FLORIDA STATE COLLEGE........             <50
            001649   RICHARD J DALEY COLLEGE-CITY COLLEGES               <50
                      OF CHICAGO............................
            001217   LASSEN COLLEGE.........................             <50
            003463   DAKOTA STATE UNIVERSITY................             <50
            002459   CROWDER COLLEGE........................             <50
            003156   REDLANDS COMMUNITY COLLEGE.............             <50
            002466   HARRIS--STOWE STATE UNIVERSITY.........             <50
            001201   FULLERTON COLLEGE......................             <50
            001275   SAN DIEGO MESA COLLEGE.................             <50
            003193   EASTERN OREGON UNIVERSITY..............             <50
            001190   CONTRA COSTA COLLEGE...................             <50
            002559   PERU STATE COLLEGE.....................             <50
            002332   ANOKA-RAMSEY COMMUNITY COLLEGE.........             <50
            003146   WESTERN OKLAHOMA STATE COLLEGE.........             <50
            001611   UNIVERSITY OF HAWAII AT HILO...........             <50
            001287   SANTA ROSA JUNIOR COLLEGE..............             <50
            002491   MOBERLY AREA COMMUNITY COLLEGE.........             <50
            003155   EASTERN OKLAHOMA STATE COLLEGE.........             <50
            001242   MONTEREY PENINSULA COLLEGE.............             <50
            003158   MURRAY STATE COLLEGE...................             <50
            001185   COLLEGE OF THE REDWOODS................             <50
            002180   MASSACHUSETTS COLLEGE OF ART AND DESIGN             <50
            002980   WAYNE COMMUNITY COLLEGE................             <50
            001202   GAVILAN COLLEGE........................             <50
            001675   ELGIN COMMUNITY COLLEGE................             <50
            003189   CLATSOP COMMUNITY COLLEGE..............             <50
            002983   WILKES COMMUNITY COLLEGE...............             <50
            002642   COLLEGE OF NEW JERSEY (THE)............             <50
            001681   HIGHLAND COMMUNITY COLLEGE.............             <50
            003438   MEDICAL UNIVERSITY OF SOUTH CAROLINA...             <50
            002514   NORTH CENTRAL MISSOURI COLLEGE.........             <50
            001307   FRESNO CITY COLLEGE....................             <50
            001513   PENSACOLA STATE COLLEGE................             <50
            002293   LAKE SUPERIOR STATE UNIVERSITY.........             <50
            002993   MAYVILLE STATE UNIVERSITY..............             <50
            001199   FOOTHILL COLLEGE.......................             <50
            002012   LOUISIANA STATE UNIVERSITY AT EUNICE...             <50
            003466   NORTHERN STATE UNIVERSITY..............             <50
            002995   DAKOTA COLLEGE AT BOTTINEAU............             <50
            001747   ROCK VALLEY COLLEGE....................             <50
            003326   SHIPPENSBURG UNIVERSITY OF PENNSYLVANIA             <50
            003483   COLUMBIA STATE COMMUNITY COLLEGE.......             <50
            002996   NORTH DAKOTA STATE COLLEGE OF SCIENCE..             <50
            001250   ORANGE COAST COLLEGE...................             <50
            001353   FORT LEWIS COLLEGE.....................             <50
            002409   ITAWAMBA COMMUNITY COLLEGE.............             <50
            001245   MOUNT SAN ANTONIO COLLEGE..............             <50
            002867   SUNY FULTON-MONTGOMERY COMMUNITY                    <50
                      COLLEGE...............................
            002014   LOUISIANA STATE UNIVERSITY HEALTH                   <50
                      SCIENCES CENTER.......................
            002413   MERIDIAN COMMUNITY COLLEGE.............             <50
            002375   SOUTHWEST MINNESOTA STATE UNIVERSITY...             <50
            002615   MIDDLESEX COLLEGE......................             <50
            001118   BAKERSFIELD COLLEGE....................             <50
            001864   IOWA LAKES COMMUNITY COLLEGE...........             <50
            001286   SANTA MONICA COLLEGE...................             <50
            003563   DEL MAR COLLEGE........................             <50
            002533   MONTANA STATE UNIVERSITY--NORTHERN.....             <50
            001273   SAN DIEGO CITY COLLEGE.................             <50
            001938   PRATT COMMUNITY COLLEGE................             <50
            003574   HOWARD COUNTY JUNIOR COLLEGE DISTRICT..             <50
            002537   UNIVERSITY OF MONTANA WESTERN (THE)....             <50
            002426   NORTHEAST MISSISSIPPI COMMUNITY COLLEGE             <50
            002539   CHADRON STATE COLLEGE..................             <50
            001875   MARSHALLTOWN COMMUNITY COLLEGE.........             <50
            002172   MOUNT WACHUSETT COMMUNITY COLLEGE......             <50
            002653   NEW MEXICO HIGHLANDS UNIVERSITY........             <50
            001261   PASADENA CITY COLLEGE..................             <50
            002355   HIBBING COMMUNITY COLLEGE..............             <50
            035883   IRENE'S MYOMASSOLOGY INSTITUTE.........             <50
            042335   MED-LIFE INSTITUTE.....................             <50
            041731   LAB PAUL MITCHELL PARTNER SCHOOL (THE).             <50
            041254   PAUL MITCHELL THE SCHOOL AUSTIN........             <50
            042504   FOSBRE ACADEMY OF HAIR DESIGN..........             <50
            041257   CUT BEAUTY SCHOOL (THE)................             <50
            041707   PAUL MITCHELL THE SCHOOL ST LOUIS......             <50
            041264   CHAMPION INSTITUTE OF COSMETOLOGY......             <50
            042283   PAUL MITCHELL THE SCHOOL SCHENECTADY...             <50
            041822   HAWAII MEDICAL COLLEGE.................             <50
            040983   TECHSKILLS--CHARLOTTE..................             <50
            041845   CHRISTINE VALMY INTERNATIONAL SCHOOL OF             <50
                      ESTHETICS & COSMETOLOGY...............
            042697   UR BEAUTY & BARBER ACADEMY.............             <50
            041476   AVEDA INSTITUTE LAS VEGAS..............             <50
            041364   AMERICAN INSTITUTE OF MEDICAL SCIENCES              <50
                      & EDUCATION...........................
            041855   BEVERLY HILLS DESIGN INSTITUTE.........             <50
            041714   AVEDA INSTITUTE PORTLAND...............             <50
            041863   PAUL MITCHELL THE SCHOOL LAS VEGAS.....             <50
            041758   JRENEE COLLEGE.........................             <50
            039143   CALC, INSTITUTE OF TECHNOLOGY..........             <50
            040014   MOJAVE BARBER COLLEGE..................             <50
            041872   NEW BEGINNING COLLEGE OF COSMETOLOGY...             <50
            035983   PAUL MITCHELL THE SCHOOL SANTA BARBARA.             <50
            039704   WELLSPRING SCHOOL OF ALLIED HEALTH.....             <50
            042460   MICHAEL K. GALVIN BEAUTY & BUSINESS                 <50
                      ACADEMY...............................
            041483   DENVER COLLEGE OF NURSING..............             <50
            041337   NEW YORK MEDICAL CAREER TRAINING CENTER             <50
            041879   JOE BLASCO MAKEUP ARTIST TRAINING                   <50
                      CENTER................................
            042777   CALIFORNIA COLLEGE OF BARBERING AND                 <50
                      COSMETOLOGY...........................
            041883   FLORIDA ACADEMY........................             <50
            041349   ORANGE PARK INTERNATIONAL SCHOOL OF                 <50
                      BEAUTY................................
            038043   BELLEFONTE ACADEMY OF BEAUTY...........             <50
            041703   BEAUTY ACADEMY OF SOUTH FLORIDA........             <50
            041896   STATE CAREER SCHOOL....................             <50
            041385   HOUSTON INTERNATIONAL COLLEGE                       <50
                      CARDIOTECH ULTRASOUND SCHOOL..........
            041919   PAUL MITCHELL THE SCHOOL SPOKANE.......             <50
            036543   EASTERN VIRGINIA CAREER COLLEGE........             <50
            041927   BARBER SCHOOL (THE) BY TIM HITE........             <50
            040434   ALPINE COLLEGE.........................             <50
            041485   MEDICAL INSTITUTE OF PALM BEACH........             <50
            041443   INSTITUTE OF CULINARY EDUCATION........             <50
            041945   AVEDA INSTITUTE TUCSON.................             <50
            035573   NORTH FLORIDA COSMETOLOGY INSTITUTE....             <50
            041491   PAUL MITCHELL THE SCHOOL CINCINNATI....             <50
            042304   PAUL MITCHELL THE SCHOOL LANSING.......             <50
            041976   FLORIDA INSTITUTE OF RECORDING, SOUND               <50
                      AND TECHNOLOGY........................
            042342   CENTER FOR ULTRASOUND RESEARCH &                    <50
                      EDUCATION.............................
            042031   PAUL MITCHELL THE SCHOOL RENO..........             <50
            042369   K&G 5 STAR BARBER COLLEGE..............             <50
            036614   SOUTH FLORIDA INSTITUTE OF TECHNOLOGY..             <50
            037573   ADVANCE SCIENCE INTERNATIONAL COLLEGE..             <50
            041288   BRANFORD ACADEMY OF HAIR & COSMETOLOGY.             <50
            041187   AMERICAN BUSINESS & TECHNOLOGY                      <50
                      UNIVERSITY............................
            041153   COACHELLA VALLEY BEAUTY COLLEGE........             <50
            042537   SACRAMENTO ULTRASOUND INSTITUTE........             <50
            039203   INSTITUTE OF HAIR DESIGN...............             <50
            042646   HOGAN INSTITUTE OF COSMETOLOGY AND                  <50
                      ESTHETICS.............................
            041518   TEMPLE (THE): A PAUL MITCHELL PARTNER               <50
                      SCHOOL................................
            042700   URBAN BARBER COLLEGE...................             <50
            041304   SHEAR EXCELLENCE HAIR ACADEMY..........             <50
            041003   DENMARK COLLEGE........................             <50
            042135   SHARP EDGEZ BARBER INSTITUTE...........             <50
            039333   MUELLER COLLEGE........................             <50
            037003   REGENCY BEAUTY INSTITUTE--CLEVELAND....             <50
            039353   CALIFORNIA NURSES EDUCATIONAL INSTITUTE             <50
            042160   UNIVERSAL TRAINING INSTITUTE...........             <50
            041210   MYCOMPUTERCAREER AT INDIANAPOLIS.......             <50
            042166   AZURE COLLEGE..........................             <50
            036276   FLORIDA EDUCATION INSTITUTE............             <50
            042182   PAUL MITCHELL THE SCHOOL--JERSEY SHORE.             <50
            001040   SOUTHERN UNION STATE COMMUNITY COLLEGE.             <50
            042189   ROCKY VISTA UNIVERSITY.................             <50
            001063   UNIVERSITY OF ALASKA FAIRBANKS.........             <50
            042192   ACE COSMETOLOGY AND BARBER TRAINING                 <50
                      CENTER................................
            041023   NEW AGE TRAINING.......................             <50
            040924   MAKE-UP DESIGNORY......................             <50
            001079   YAVAPAI COLLEGE........................             <50
            042212   BLY'S SCHOOL OF COSMETOLOGY............             <50
            041407   AVEDA INSTITUTE CHAPEL HILL............             <50
            042219   CALIFORNIA TECHNICAL ACADEMY...........             <50
            041241   ELITE COLLEGE OF COSMETOLOGY...........             <50
            042226   HEALTHCARE INSTITUTE (THE).............             <50
            041782   VOGUE COLLEGE--SAN ANTONIO.............             <50
            042237   BAY AREA MEDICAL ACADEMY...............             <50
            041053   NIGHTINGALE MEDICAL INSTITUTE..........             <50
            041533   PAUL MITCHELL THE SCHOOL COLUMBUS......             <50
            041708   UNITY COSMETOLOGY COLLEGE..............             <50
            026211   PTC CAREER INSTITUE OF WASHINGTON......             <50
            025530   MODERN COLLEGE OF DESIGN (THE).........             <50
            023326   METROPOLITAN TECHNICAL INSTITUTE &                  <50
                      BUSINESS COLLEGE......................
            025882   DOUGLAS J AVEDA INSTITUTE..............             <50
            026181   BUSINESS AND BANKING INSTITUTE.........             <50
            025891   AMERICAN COLLEGE OF BUSINESS...........             <50
            030050   SAFFORD COLLEGE OF BEAUTY CULTURE......             <50
            023472   BRANELL INSTITUTE......................             <50
            034793   PCI COLLEGE............................             <50
            025258   LEES SCHOOL OF COSMETOLOGY.............             <50
            031784   CORAL RIDGE TRAINING SCHOOL............             <50
            035373   NEW YORK AUTOMOTIVE & DIESEL INSTITUTE.             <50
            025738   L'ACADEMIE DE CUISINE..................             <50
            025906   UNIVERSITY OF SARASOTA-................             <50
            026238   CORTIVA INSTITUTE--SCOTTSDALE..........             <50
            030614   ASCENSION COLLEGE......................             <50
            025183   LASALLE TECH...........................             <50
            025908   AMERICAN TELLER SCHOOLS OF ARIZONA.....             <50
            030261   POLYTECHNIC INSTITUTE..................             <50
            025586   MR RICH'S BEAUTY COLLEGE...............             <50
            031313   FIVE BRANCHES UNIVERSITY...............             <50
            023517   PAUL MITCHELL THE SCHOOL--LOUISVILLE...             <50
            031643   CREATIVE CENTER (THE)..................             <50
            030667   AILANO SCHOOL OF COSMETOLOGY...........             <50
            026166   SHEAR EGO INTERNATIONAL SCHOOL OF HAIR              <50
                      DESIGN................................
            025950   HAIR ACADEMY THE.......................             <50
            032364   L T INTERNATIONAL BEAUTY SCHOOL........             <50
            023537   FEDERAL TRUCK DRIVING SCHOOL...........             <50
            032623   DAVID DEMUTH INSTITUTE OF COSMETOLOGY..             <50
            026002   OCEAN CORPORATION (THE)................             <50
            025018   DELTA COLLEGE OF BUSINESS & TECHNOLOGY.             <50
            023555   NATIONAL CAREER COLLEGE................             <50
            023266   ALASKA COMPUTER INSTITUTE..............             <50
            023566   CHARLESTON COSMETOLOGY INSTITUTE.......             <50
            023423   CAREER INSTITUTE (THE).................             <50
            025599   BNS TECHNICAL INSTITUTE................             <50
            025185   HAIR DYNAMICS EDUCATION CENTER.........             <50
            030882   CARSON CITY BEAUTY ACADEMY.............             <50
            025849   FIRST INSTITUTE........................             <50
            030885   NEW YORK INTERNATIONAL BEAUTY SCHOOL...             <50
            034543   TENNESSEE CAREER COLLEGE...............             <50
            030894   SCHOOL OF HAIR DESIGN..................             <50
            035344   AMERICAN INSTITUTE OF ALTERNATIVE                   <50
                      MEDICINE..............................
            030902   APOLLO COLLEGE.........................             <50
            023237   PAT WILSON'S BEAUTY COLLEGE............             <50
            026023   CENTRAL COAST COLLEGE..................             <50
            031564   AOMA GRADUATE SCHOOL OF INTEGRATIVE                 <50
                      MEDICINE..............................
            025438   PARIS II EDUCATIONAL CENTER............             <50
            025729   BUSINESS INFORMATICS CENTER............             <50
            025633   KANKAKEE ACADEMY OF HAIR DESIGN........             <50
            031795   TEXAS HEALTH AND SCIENCE UNIVERSITY....             <50
            025329   BUSINESS SKILLS INSTITUTE..............             <50
            026171   BATON ROUGE COLLEGE....................             <50
            025656   CABOT COLLEGE..........................             <50
            032253   AMERICAN UNIVERSITY OF HEALTH SCIENCES.             <50
            026085   DELTA CAREER INSTITUTE.................             <50
            032374   FARIS TECHNICAL INSTITUTE..............             <50
            031082   FRANCOIS D. COLLEGE OF HAIR SKIN &                  <50
                      NAILS.................................
            026204   UNIFIED SCHOOLS OF AMERICA-COMPTON                  <50
                      CAMPUS................................
            026108   COURT REPORTING INSTITUTE..............             <50
            024997   CAREER DEVELOPMENT INSTITUTE...........             <50
            023635   ARTHUR'S BEAUTY COLLEGE................             <50
            025013   TREBAS INSTITUTE OF REC ARTS...........             <50
            031096   NATIONAL INSTITUTE OF TECHNOLOGY.......             <50
            025372   PALOMAR INSTITUTE OF COSMETOLOGY.......             <50
            031109   ACADEMY OF BEAUTY PROFESSIONALS........             <50
            023417   CAREER ACADEMY OF HAIR DESIGN..........             <50
            025685   GRABBER SCHOOL OF HAIR DESIGN..........             <50
            030047   MUNDUS INSTITUTE.......................             <50
            023185   CENTURY SCHOOLS........................             <50
            030051   ARKANSAS BEAUTY SCHOOL- LITTLE ROCK....             <50
            031147   PRAXIS INSTITUTE.......................             <50
            025568   PAUL MITCHELL THE SCHOOL SALT LAKE CITY             <50
            026127   SALON PROFESSIONAL ACADEMY--MELBOURNE,              <50
                      THE...................................
            023429   ELSA COOPER INSTITUTE OF COURT                      <50
                      REPORTING.............................
            026136   OKLAHOMA JUNIOR COLLEGE................             <50
            034096   BENNETT CAREER INSTITUTE...............             <50
            024944   COMPUTER DYNAMICS INSTITUTE............             <50
            023337   AMERICAN BARTENDERS SCHOOL.............             <50
            031240   NORTHWESTERN TECHNOLOGICAL INSTITUTE...             <50
            030255   MECH TECH COLLEGE......................             <50
            031244   VALDOSTA ACADEMY OF BEAUTY CULTURE.....             <50
            025205   NATIONAL CAREER ACADEMY................             <50
            026139   COMPUTER BUSINESS COLLEGE..............             <50
            030285   LAWTON CAREER INSTITUTE................             <50
            031256   MIAMI AD SCHOOL........................             <50
            035193   MISSOURI COLLEGE OF COSMETOLOGY NORTH..             <50
            024948   CR'U INSTITUTE OF COSMETOLOGY AND                   <50
                      BARBERING.............................
            023104   NEVADA CAREER SCHOOL...................             <50
            024971   MEDICAL CAREERS INSTITUTE..............             <50
            023474   MOORE CAREER COLLEGE...................             <50
            022858   CAREER TECHL INST......................             <50
            010716   TOBE-COBURN SCHOOL FOR FASHION CAREERS.             <50
            020639   ROYALE BEAUTY COLLEGE..................             <50
            020926   PTC CAREER INSTITUTE...................             <50
            011126   GARCES COMMERCIAL COLLEGE..............             <50
            013024   RILEY COLLEGE..........................             <50
            021904   SCHILLING--DOUGLAS SCHOOL OF HAIR                   <50
                      DESIGN................................
            021044   SPA TECH INSTITUTE.....................             <50
            022039   ERIE INSTITUTE OF TECHNOLOGY...........             <50
            021094   ROBERT FIANCE INSTITUTE OF FLORIDA.....             <50
            010808   BRANELL INST...........................             <50
            011621   AUTOMOTIVE TRAINING CENTER.............             <50
            022755   PAUL MITCHELL THE SCHOOL KNOXVILLE.....             <50
            013088   CAPRI OAK FOREST BEAUTY COLLEGE........             <50
            022939   VOLUNTEER BEAUTY ACADEMY...............             <50
            013132   INTERNATIONAL COLLEGE OF BROADCASTING..             <50
            020620   ABC TECHNICAL & TRADE SCHOOLS..........             <50
            011689   REFRIGERATION SCHOOL (THE).............             <50
            022032   CAREER POINT BUSINESS SCHOOL...........             <50
            013165   CLIMATE CONTROL INSTITUTE..............             <50
            022092   DORSEY SCHOOL OF BEAUTY................             <50
            011709   CINCINNATI METROPOLITAN COLLEGE........             <50
            011034   LONG BEACH COLLEGE OF BUSINESS.........             <50
            021267   BAY AREA LEGAL ACADEMY.................             <50
            022551   INST OF SECURITY & TECHLGY.............             <50
            021268   DIESEL INSTITUTE OF AMERICA............             <50
            022627   DELAWARE COUNTY INSTITUTE OF TRAINING..             <50
            011751   PHOENIX INSTITUTE OF TECHNOLOGY........             <50
            022824   NATIONAL TECHNICAL COLLEGE.............             <50
            021282   BRIDGES BEAUTY COLLEGE.................             <50
            013008   SUMMIT SALON ACADEMY--PORTLAND.........             <50
            020508   AMERICAN BUSINESS COLLEGE..............             <50
            022978   PAUL MITCHELL THE SCHOOL RAPID CITY....             <50
            021390   CRAFT INSTITUTE (THE)..................             <50
            021924   MR. JOHN'S SCHOOL OF COSMETOLOGY,                   <50
                      ESTHETICS & NAILS.....................
            021451   SCOTT COLLEGE OF COSMETOLOGY...........             <50
            010909   CONCORDE CAREER INST...................             <50
            020528   COUNTY SCHOOLS HOME STUDY..............             <50
            022022   STYLEMASTERS COLLEGE OF HAIR DESIGN....             <50
            021492   TEXCEL CAREER CENTER...................             <50
            022033   GENE JUAREZ BEAUTY SCHOOLS.............             <50
            021514   COASTAL TRAINING INSTITUTE.............             <50
            012072   PHILLIPS HAIRSTYLING INSTITUTE.........             <50
            011865   CALIFORNIA HAIR DESIGN ACADEMY.........             <50
            022149   COMPUTER PROCESSING INSTITUTE..........             <50
            021535   OAKBRIDGE ACADEMY OF ARTS..............             <50
            022196   OMEGA INSTITUTE........................             <50
            021586   MR. BELA'S SCHOOL OF COSMETOLOGY.......             <50
            022381   MINNESOTA SCHOOL OF COSMETOLOGY........             <50
            021635   NEW ENGLAND SCHOOL OF PHOTOGRAPHY......             <50
            020765   OREGON POLYTECHNIC INSTITUTE...........             <50
            020565   MITCHELL'S ACADEMY.....................             <50
            010821   AMERICAN COLLEGE.......................             <50
            021658   NATIONAL TRAINING SYSTEMS--                         <50
                      CORRESPONDENCE SCHOOL.................
            012562   CALIFORNIA PARAMEDICAL AND TECHNICAL                <50
                      COLLEGE...............................
            021668   JOHN AMICO'S SCHOOL OF HAIR DESIGN.....             <50
            010827   DAVID PRESSLEY PROFESSIONAL SCHOOL OF               <50
                      COSMETOLOGY...........................
            021718   SABINA'S BEAUTY ACADEMY................             <50
            020797   COLLEGE OF HAIR DESIGN.................             <50
            021760   CHERYL FELL'S SCHOOL OF BUSINESS.......             <50
            020801   UNITED COLLEGE.........................             <50
            021763   SPENCER BUSINESS & TECHNICAL INSTITUTE.             <50
            022878   NATIONAL TRACTOR TRAILER SCHOOL........             <50
            021780   HARGEST VOCATIONAL TECHNICAL COLLEGE...             <50
            022902   GENERAL COMMUNICATIONS.................             <50
            011979   BLAKE BUSINESS SCHOOL..................             <50
            012848   MOLER HOLLYWOOD BEAUTY ACADEMY.........             <50
            011221   NATIONAL EDUCATION CENTER, BRYMAN                   <50
                      CAMPUS................................
            021814   MSTA BUSINESS COLLEGE (CLOSED).........             <50
            021964   CUTTING EDGE HAIRSTYLING ACADEMY.......             <50
            004567   METROPOLITAN BUSINESS COLLEGE..........             <50
            031091   ASPIRA CITY COLLEGE....................             <50
            002034   MID STATE COLLEGE......................             <50
            004857   HAMMEL COLLEGE.........................             <50
            022704   SOUTHEASTERN BIBLE COLLEGE.............             <50
            021064   O'MORE COLLEGE OF DESIGN...............             <50
            010347   STAGE ONE, THE HAIR SCHOOL.............             <50
            004872   DRAUGHON COLLEGE.......................             <50
            008873   PAUL MITCHELL THE SCHOOL DANBURY.......             <50
            004879   TREND COLLEGE..........................             <50
            031105   CITY COLLEGE OF COLORADO SPRINGS.......             <50
            004901   NEWPORT BUSINESS INSTITUTE.............             <50
            036663   PILLAR COLLEGE.........................             <50
            036894   FAITH INTERNATIONAL UNIVERSITY.........             <50
            034743   AVE MARIA COLLEGE......................             <50
            004935   EDMONDSON JUNIOR COLLEGE...............             <50
            033813   CONNECTICUT TRAINING CENTER............             <50
            005186   LAMSON JUNIOR COLLEGE..................             <50
            038853   EMPLOYMENT SOLUTIONS...................             <50
            005202   FRANKLIN COLLEGE.......................             <50
            008939   CANNELLA SCHOOL OF HAIR DESIGN.........             <50
            033274   ACUPUNCTURE AND INTEGRATIVE MEDICINE                <50
                      COLLEGE, BERKELEY.....................
            009035   PHILLIPS COLLEGE OF CHICAGO............             <50
            006666   LUTHERAN SCHOOL OF NURSING.............             <50
            009221   PHILLIPS COLLEGES......................             <50
            007142   LYLE'S COLLEGE OF BEAUTY...............             <50
            035163   KING'S UNIVERSITY (THE)................             <50
            041806   APPALACHIAN COLLEGE OF PHARMACY........             <50
            009607   HOUSE OF HEAVILIN BEAUTY COLLEGE.......             <50
            007318   CDI CAREER DEVELOPMENT INST............             <50
            036673   FAITH THEOLOGICAL SEMINARY.............             <50
            036964   SABER COLLEGE..........................             <50
            010246   FLEET BUSINESS SCHOOL..................             <50
            021943   NORTHEAST INSTITUTE OF EDUCATION.......             <50
            010421   NATIONAL EDUCATION CENTER-SAWYER CAMPUS             <50
            010634   NATIONAL EDUCATION CENTER--ARKANSAS                 <50
                      COLLEGE OF TECHNOLOGY CAMPUS..........
            004839   PHILLIPS JUNIOR COLLEGE HARDBARGER                  <50
                      CAMPUS................................
            007375   ISLAND DRAFTING & TECHNICAL INSTITUTE..             <50
            036353   CARVER BIBLE COLLEGE...................             <50
            037093   EDWARD VIA VIRGINIA COLLEGE OF                      <50
                      OSTEOPATHIC MEDICINE..................
            031052   BAPTIST HEALTH COLLEGE LITTLE ROCK.....             <50
            022027   OZARK CHRISTIAN COLLEGE................             <50
            021068   BRAMSON ORT COLLEGE MAIN CAMPUS-01.....             <50
            022141   OAK POINT UNIVERSITY...................             <50
            003421   BOB JONES UNIVERSITY...................             <50
            022285   LIFE CHIROPRACTIC COLLEGE WEST.........             <50
            025308   POLITECHNICAL INSTITUTE OF FLORIDA.....             <50
            007508   PLAZA SCHOOL OF TECHNOLOGY.............             <50
            025326   LANDMARK COLLEGE.......................             <50
            022310   WOMEN'S TECHL INSTITUTE................             <50
            039483   HARRISBURG UNIVERSITY OF SCIENCE AND                <50
                      TECHNOLOGY............................
            007546   CDI CAREER DEVELOPMENT INSTITUTE.......             <50
            004462   GADSDEN BUSINESS COLLEGE...............             <50
            022316   MGH INSTITUTE OF HEALTH PROFESSIONS....             <50
            009279   EDUTEK PROFESSIONAL COLLEGES...........             <50
            007588   CAPRI COLLEGE..........................             <50
            009409   CENTRAL CITY BUSINESS INSTITUTE........             <50
            007752   JON LOUIS SCHOOL OF BEAUTY.............             <50
            004504   BARNES BUSINESS COLLEGE................             <50
            007798   WILFRED ACADEMY OF HAIR & BEAUTY                    <50
                      CULTURE...............................
            009687   PHILLIPS JUNIOR COLLEGE CONDIE CAMPUS..             <50
            038533   KECK GRADUATE INSTITUTE OF APPLIED LIFE             <50
                      SCIENCES..............................
            025784   MARYLAND UNIVERSITY OF INTEGRATIVE                  <50
                      HEALTH................................
            030970   MERCY COLLEGE OF OHIO..................             <50
            025799   NORTH CENTRAL OPPORTUNITIES                         <50
                      INDUSTRIALIZATION CENTER..............
            021000   UNIVERSIDAD POLITECNICA DE PUERTO RICO.             <50
            010211   KINYON-CAMPBELL BUSINESS SCHOOL........             <50
            031009   LUTHER RICE COLLEGE & SEMINARY.........             <50
            010251   NATIONAL EDUCATION CENTER--CAPITOL HILL             <50
                      CAMPUS................................
            021404   ST. JOSEPH SCHOOL OF NURSING...........             <50
            041184   CHICAGO ORT TECHNICAL INSTITUTE........             <50
            001628   AMERICAN ACADEMY OF ART COLLEGE........             <50
            023315   GRAND ISLAND COLLEGE...................             <50
            025000   SAN JOAQUIN COLLEGE OF LAW.............             <50
            038724   DIVINE MERCY UNIVERSITY................             <50
            003289   LEHIGH UNIVERSITY......................             <50
            020653   PRESCOTT COLLEGE.......................             <50
            003535   VANDERBILT UNIVERSITY..................             <50
            003362   SETON HILL UNIVERSITY..................             <50
            003799   WALLA WALLA UNIVERSITY.................             <50
            003185   UNIVERSITY OF TULSA (THE)..............             <50
            011917   DRAKE SCHOOL OF MANHATTAN..............             <50
            003194   GEORGE FOX UNIVERSITY..................             <50
            002504   UNIVERSITY OF HEALTH SCIENCES AND                   <50
                      PHARMACY IN ST. LOUIS.................
            004712   NORTHWEST MISSOURI COMMUNITY COLLEGE...             <50
            003072   MALONE UNIVERSITY......................             <50
            003604   WILLIAM MARSH RICE UNIVERSITY..........             <50
            002948   MONTREAT COLLEGE.......................             <50
            006305   MAINE COLLEGE OF HEALTH PROFESSIONS....             <50
            002567   YORK COLLEGE...........................             <50
            003610   SCHREINER UNIVERSITY...................             <50
            003300   MOORE COLLEGE OF ART AND DESIGN........             <50
            006445   BILL AND SANDRA POMEROY COLLEGE OF                  <50
                      NURSING AT CROUSE HOSPITAL............
            002525   WILLIAM WOODS UNIVERSITY...............             <50
            006467   SAINT JOSEPH'S COLLEGE OF NURSING AT ST             <50
                      JOSEPH'S HOSPITAL HEALTH CENTE........
            003164   OKLAHOMA BAPTIST UNIVERSITY............             <50
            006487   AULTMAN COLLEGE OF NURSING AND HEALTH               <50
                      SCIENCES..............................
            002677   BROOKLYN LAW SCHOOL....................             <50
            003197   LEWIS & CLARK COLLEGE..................             <50
            002553   MIDLAND UNIVERSITY.....................             <50
            006771   COLLEGE FOR CREATIVE STUDIES...........             <50
            002946   METHODIST UNIVERSITY...................             <50
            006858   UNITY COLLEGE..........................             <50
            003112   PENN OHIO COLLEGE......................             <50
            002914   CATAWBA COLLEGE........................             <50
            002741   AMERICAN JEWISH UNIVERSITY.............             <50
            003621   ST. EDWARD'S UNIVERSITY................             <50
            011673   MAINE COLLEGE OF ART...................             <50
            003023   CAPITAL UNIVERSITY.....................             <50
            011934   VERMONT LAW SCHOOL.....................             <50
            002512   STEPHENS COLLEGE.......................             <50
            012154   CALIFORNIA INSTITUTE OF INTEGRAL                    <50
                      STUDIES...............................
            003385   URSINUS COLLEGE........................             <50
            012309   UNIVERSITY OF WESTERN STATES...........             <50
            002920   DUKE UNIVERSITY........................             <50
            002526   CARROLL COLLEGE........................             <50
            007113   ARIZONA CHRISTIAN UNIVERSITY...........             <50
            003982   CLEVELAND INSTITUTE OF ART (THE).......             <50
            003391   WAYNESBURG UNIVERSITY..................             <50
            002759   MANHATTAN SCHOOL OF MUSIC..............             <50
            003641   TEXAS LUTHERAN UNIVERSITY..............             <50
            020681   ADLER UNIVERSITY.......................             <50
            003227   WILLAMETTE UNIVERSITY..................             <50
            003482   CHRISTIAN BROTHERS UNIVERSITY..........             <50
            003394   WILKES UNIVERSITY......................             <50
            003788   SEATTLE PACIFIC UNIVERSITY.............             <50
            002513   TARKIO COLLEGE.........................             <50
            002945   MEREDITH COLLEGE.......................             <50
            007462   COLLEGE OF VISUAL ARTS.................             <50
            010624   LIGHTHOUSE CAREER INSTITUTE............             <50
            003401   BROWN UNIVERSITY.......................             <50
            010761   DALLAS INSTITUTE OF FUNERAL SERVICE....             <50
            003233   ALVERNIA UNIVERSITY....................             <50
            002371   UNIVERSITY OF NORTHWESTERN- ST PAUL....             <50
            002499   ROCKHURST UNIVERSITY...................             <50
            003116   UNIVERSITY OF RIO GRANDE...............             <50
            002718   ELMIRA COLLEGE.........................             <50
            003293   LYCOMING COLLEGE.......................             <50
            002933   HIGH POINT UNIVERSITY..................             <50
            003506   MEHARRY MEDICAL COLLEGE................             <50
            003036   FRANCISCAN UNIVERSITY OF STEUBENVILLE..             <50
            002896   VILLA MARIA COLLEGE OF BUFFALO.........             <50
            003691   MIDDLEBURY COLLEGE.....................             <50
            003525   TENNESSEE WESLEYAN UNIVERSITY..........             <50
            008174   ART INSTITUTE OF BOSTON................             <50
            011918   DRAKE SCHOOL OF THE BRONX..............             <50
            003692   NORWICH UNIVERSITY.....................             <50
            003135   WALSH UNIVERSITY.......................             <50
            003039   COLUMBUS COLLEGE OF ART & DESIGN.......             <50
            012059   TRINITY BIBLE COLLEGE AND GRADUATE                  <50
                      SCHOOL................................
            002600   SAINT ELIZABETH UNIVERSITY.............             <50
            003301   MORAVIAN UNIVERSITY....................             <50
            002547   GRACE UNIVERSITY.......................             <50
            002956   CAROLINA UNIVERSITY....................             <50
            009089   HANNIBAL--LAGRANGE UNIVERSITY..........             <50
            012315   CORNISH COLLEGE OF THE ARTS............             <50
            003427   COKER UNIVERSITY.......................             <50
            003143   WITTENBERG UNIVERSITY..................             <50
            003252   DELAWARE VALLEY UNIVERSITY.............             <50
            003311   SALUS UNIVERSITY.......................             <50
            002939   LEES-MCRAE COLLEGE.....................             <50
            002758   MANHATTAN COLLEGE......................             <50
            003049   HIRAM COLLEGE..........................             <50
            013007   NAZARENE BIBLE COLLEGE.................             <50
            003441   NORTH GREENVILLE UNIVERSITY............             <50
            002803   RENSSELAER POLYTECHNIC INSTITUTE.......             <50
            003050   JOHN CARROLL UNIVERSITY................             <50
            003175   PHILLIPS UNIVERSITY....................             <50
            003465   MOUNT MARTY UNIVERSITY.................             <50
            002433   RUST COLLEGE...........................             <50
            003262   ELIZABETHTOWN COLLEGE..................             <50
            003588   UNIVERSITY OF MARY HARDIN-BAYLOR.......             <50
            002734   HOUGHTON COLLEGE.......................             <50
            003419   CHARLESTON SOUTHERN UNIVERSITY.........             <50
            031277   Southern New England School of Law.....             <50
            002197   NICHOLS COLLEGE........................             <50
            002119   ATLANTIC UNION COLLEGE.................             <50
            001635   BARAT COLLEGE..........................             <50
            004922   Columbia Junior College................             <50
            003825   West Virginia University Institute of               <50
                      Technology............................
            001803   HUNTINGTON UNIVERSITY..................             <50
            001570   Southern Polytechnic State University..             <50
            021002   Brookhaven College.....................             <50
            004948   Texas A&M University System Health                  <50
                      Science Center........................
            037803   SABA UNIVERSITY SCHOOL OF MEDICINE.....             <50
            001735   NORTH PARK UNIVERSITY..................             <50
            010228   UNIVERSITY OF STIRLING.................             <50
            040473   Bridgemont Community and Technical                  <50
                      College...............................
            002311   KUYPER COLLEGE.........................             <50
            040533   Clemens College........................             <50
            002117   ANNA MARIA COLLEGE.....................             <50
            001288   CLAREMONT SCHOOL OF THEOLOGY...........             <50
            002124   BENTLEY UNIVERSITY.....................             <50
            001105   SHORTER COLLEGE........................             <50
            001832   UNIVERSITY OF SAINT FRANCIS............             <50
            001414   TRINITY COLLEGE........................             <50
            035183   EUROPEAN GRADUATE SCHOOL (EGS).........             <50
            006622   Jefferson College of Health Sciences...             <50
            001846   BRIAR CLIFF UNIVERSITY.................             <50
            042079   SAE Institute of Technology--Miami.....             <50
            009786   Illinois Eastern Community Colleges--               <50
                      Lincoln Trail College.................
            001659   ROSALIND FRANKLIN UNIVERSITY OF                     <50
                      MEDICINE AND SCIENCE..................
            001542   AGNES SCOTT COLLEGE....................             <50
            005034   AMERICAN UNIVERSITY IN CAIRO (THE).....             <50
            002288   ROCHESTER UNIVERSITY...................             <50
            001943   UNIVERSITY OF SAINT MARY...............             <50
            001019   HUNTINGDON COLLEGE.....................             <50
            001748   ROCKFORD UNIVERSITY....................             <50
            001708   LINCOLN CHRISTIAN UNIVERSITY...........             <50
            001952   ASBURY UNIVERSITY......................             <50
            035213   Ivy Tech Community College of Indiana--             <50
                      Region 14.............................
            010394   University of Medicine & Dentistry of               <50
                      New Jersey............................
            004779   Long Island University--Brooklyn.......             <50
            001958   BRESCIA UNIVERSITY.....................             <50
            001552   Augusta State University...............             <50
            005889   University of Oklahoma Health Sciences              <50
                      Center................................
            002145   EASTERN NAZARENE COLLEGE...............             <50
            025086   Middle Georgia Technical College.......             <50
            002158   LASELL UNIVERSITY......................             <50
            001606   BRIGHAM YOUNG UNIVERSITY--HAWAII.......             <50
            009085   KING'S COLLEGE LONDON..................             <50
            001678   EUREKA COLLEGE.........................             <50
            001339   CORBAN UNIVERSITY......................             <50
            001617   COLLEGE OF IDAHO (THE).................             <50
            002233   WORCESTER POLYTECHNIC INSTITUTE........             <50
            001436   CAPITOL TECHNOLOGY UNIVERSITY..........             <50
            002235   ALBION COLLEGE.........................             <50
            023563   UNIVERSIDAD FEDERICO HENRIQUEZ Y                    <50
                      CARDAJAL..............................
            001127   CALIFORNIA COLLEGE OF THE ARTS.........             <50
            001980   UNIVERSITY OF PIKEVILLE................             <50
            020533   CENTRO DE ESTUDIOS UNIVERSITARIOS                   <50
                      XOCHICALCO............................
            001788   BUTLER UNIVERSITY......................             <50
            002262   KETTERING UNIVERSITY...................             <50
            001586   OGLETHORPE UNIVERSITY..................             <50
            001860   DRAKE UNIVERSITY.......................             <50
            001795   UNIVERSITY OF EVANSVILLE...............             <50
            030917   POZNAN UNIVERSITY OF MEDICAL SCIENCES..             <50
            002052   THOMAS COLLEGE.........................             <50
            002308   OLIVET COLLEGE.........................             <50
            002065   NOTRE DAME OF MARYLAND UNIVERSITY......             <50
            002316   SIENA HEIGHTS UNIVERSITY...............             <50
            001800   GRACE COLLEGE AND THEOLOGICAL SEMINARY.             <50
            002078   LOYOLA UNIVERSITY MARYLAND.............             <50
            002353   GUSTAVUS ADOLPHUS COLLEGE..............             <50
            022527   Hair Design School (The)...............             <50
            001880   MOUNT MERCY UNIVERSITY.................             <50
            001696   ILLINOIS WESLEYAN UNIVERSITY...........             <50
            005330   FAYETTE COUNTY CAREER & TECHNICAL                   <50
                      INSTITUTE.............................
            004004   JOHN TYLER COMMUNITY COLLEGE...........             <50
            021963   COLLINS CAREER TECHNICAL CENTER........             <50
            009928   PIEDMONT VIRGINIA COMMUNITY COLLEGE....             <50
            009509   CHARLES A. JONES CAREER AND EDUCATION               <50
                      CENTER................................
            007986   HALIFAX COMMUNITY COLLEGE..............             <50
            042544   ARKANSAS STATE UNIVERSITY--MOUNTAIN                 <50
                      HOME..................................
            003929   EASTERN WYOMING COLLEGE................             <50
            005267   NORTHWEST KANSAS TECHNICAL COLLEGE.....             <50
            005380   MID-STATE TECHNICAL COLLEGE............             <50
            030192   SI TANKA UNIVERSITY....................             <50
            003707   RICHARD BLAND COLLEGE..................             <50
            031555   OCONEE FALL LINE TECHNICAL COLLEGE.....             <50
            010006   GREATER JOHNSTOWN AREA VOCATIONAL                   <50
                      TECHNICAL SCHOOL -....................
            041949   TILLAMOOK BAY COMMUNITY COLLEGE........             <50
            006819   BLUE RIDGE COMMUNITY COLLEGE...........             <50
            021728   DUTCHESS BOCES SCHOOL OF PRACTICAL                  <50
                      NURSING...............................
            010019   UNIVERSITY OF TEXAS SOUTHWESTERN                    <50
                      MEDICAL CENTER (THE)..................
            022825   LENAPE TECHNICAL SCHOOL................             <50
            010020   LEWIS AND CLARK COMMUNITY COLLEGE......             <50
            009236   NASHUA COMMUNITY COLLEGE...............             <50
            010051   CUNY LAGUARDIA COMMUNITY COLLEGE.......             <50
            009259   LARAMIE COUNTY COMMUNITY COLLEGE.......             <50
            010056   AIKEN TECHNICAL COLLEGE................             <50
            003786   PENINSULA COLLEGE......................             <50
            003761   WYTHEVILLE COMMUNITY COLLEGE...........             <50
            031229   YORK COUNTY COMMUNITY COLLEGE..........             <50
            003828   WEST VIRGINIA UNIVERSITY--PARKERSBURG..             <50
            004608   BARTON COUNTY COMMUNITY COLLEGE........             <50
            006973   CANADA COLLEGE.........................             <50
            004033   ASHEVILLE BUNCOMBE TECHNICAL COMMUNITY              <50
                      COLLEGE...............................
            010147   WESTERN SUFFOLK BOCES..................             <50
            009910   TECHNICAL COLLEGE OF THE LOWCOUNTRY--               <50
                      BEAUFORT CAMPUS.......................
            005424   SOUTH CENTRAL CAREER CENTER............             <50
            021582   WASHINGTON SARATOGA WARREN HAMILTON                 <50
                      ESSEX BOCES...........................
            005429   ROLLA TECHNICAL INSTITUTE CENTER.......             <50
            021794   EASTERN SUFFOLK BOCES..................             <50
            010323   HANNAH E MULLINS SCHOOL OF PRACTICAL                <50
                      NURSING...............................
            042817   COMPTON COLLEGE........................             <50
            010340   LOS MEDANOS COLLEGE....................             <50
            023047   TRI-RIVERS CAREER CENTER...............             <50
            010363   WESTERN NEVADA COLLEGE.................             <50
            004600   NORTHWEST IOWA COMMUNITY COLLEGE.......             <50
            005467   SOWELA TECHNICAL COMMUNITY COLLEGE.....             <50
            003944   UNIVERSITY OF PUERTO RICO--MAYAGUEZ....             <50
            007107   ESSEX COUNTY COLLEGE...................             <50
            024978   GREENE COUNTY CAREER CENTER............             <50
            008175   HOWARD COMMUNITY COLLEGE...............             <50
            026038   LORAIN COUNTY JVS ADULT CAREER CENTER..             <50
            005500   MANHATTAN AREA TECHNICAL COLLEGE.......             <50
            009336   JOHNSTON COMMUNITY COLLEGE.............             <50
            005532   CAPE GIRARDEAU CAREER AND TECHNOLOGY                <50
                      CENTER................................
            005306   BATES TECHNICAL COLLEGE................             <50
            007570   HELENA COLLEGE UNIVERSITY OF MONTANA...             <50
            007742   FT LAUDERDALE SCHOOL OF ALLIED HEALTH               <50
                      CAREERS...............................
            004765   CUNY GRADUATE SCHOOL & UNIVERSITY                   <50
                      CENTER................................
            031284   DELAWARE COUNTY TECHNICAL SCHOOL.......             <50
            010736   MARION TECHNICAL COLLEGE...............             <50
            006777   FLATHEAD VALLEY COMMUNITY COLLEGE......             <50
            010879   RICHLAND COMMUNITY COLLEGE.............             <50
            007916   FRANKLIN COUNTY CAREER AND TECHNOLOGY               <50
                      CENTER................................
            007635   CAPITAL COMMUNITY COLLEGE..............             <50
            039603   NEW RIVER COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            003664   WEATHERFORD COLLEGE....................             <50
            009826   KENNEBEC VALLEY COMMUNITY COLLEGE......             <50
            005544   ALEXANDRIA TECHNICAL AND COMMUNITY                  <50
                      COLLEGE...............................
            009895   ALBERT EINSTEIN COLLEGE OF MEDICINE....             <50
            005599   AUGUSTA TECHNICAL COLLEGE..............             <50
            021515   CENTRAL SUSQUEHANNA LPN CAREER CENTER..             <50
            011245   WEST VIRGINIA SCHOOL OF OSTEOPATHIC                 <50
                      MEDICINE..............................
            021562   TECHNICAL COLLEGE OF THE ROCKIES.......             <50
            003628   TEXARKANA COLLEGE......................             <50
            003942   UNIVERSITY OF PUERTO RICO--CENTRAL                  <50
                      ADMINISTRATION........................
            011667   NORTHEAST COMMUNITY COLLEGE............             <50
            005759   NORTHWEST TECHNICAL COLLEGE--BEMIDJI...             <50
            005618   SAVANNAH TECHNICAL COLLEGE.............             <50
            007690   KANKAKEE COMMUNITY COLLEGE.............             <50
            011727   DELAWARE TECHNICAL COMMUNITY COLLEGE...             <50
            003705   COLLEGE OF WILLIAM & MARY..............             <50
            008557   NASH COMMUNITY COLLEGE.................             <50
            005263   MINNESOTA WEST COMMUNITY AND TECHNICAL              <50
                      COLLEGE...............................
            005620   CHATTAHOOCHEE TECHNICAL COLLEGE........             <50
            003810   CONCORD UNIVERSITY.....................             <50
            003933   WESTERN WYOMING COMMUNITY COLLEGE......             <50
            023062   VENANGO COUNTY AREA VOCATIONAL                      <50
                      TECHNICAL SCHOOL......................
            012123   UNIVERSITY OF PUERTO RICO--AGUADILLA...             <50
            023154   NORTHEAST TEXAS COMMUNITY COLLEGE......             <50
            007669   SOUTHWEST WISCONSIN TECHNICAL COLLEGE..             <50
            023485   LAMAR STATE COLLEGE--PORT ARTHUR.......             <50
            003683   CASTLETON UNIVERSITY...................             <50
            023515   NORTHERN CAREER INSTITUTE..............             <50
            012407   SCHUYLER STEUBEN CHEMUNG TIOGA ALLEGANY             <50
                      BOCES.................................
            023582   LAMAR STATE COLLEGE--ORANGE............             <50
            012550   LOS ANGELES MISSION COLLEGE............             <50
            024544   NORTHEAST OHIO MEDICAL UNIVERSITY......             <50
            012589   ERIE 1 BOARD OF COOPERATIVE EDUCATIONAL             <50
                      SERVICES..............................
            025039   WARREN COUNTY COMMUNITY COLLEGE........             <50
            008660   GERMANNA COMMUNITY COLLEGE.............             <50
            025864   TRUMBULL CAREER AND TECHNICAL CENTER-               <50
                      ADULT TRAINING CENTER.................
            008677   NORTHWEST STATE COMMUNITY COLLEGE......             <50
            005276   CENTRAL MAINE COMMUNITY COLLEGE........             <50
            004835   CALDWELL COMMUNITY COLLEGE & TECHNICAL              <50
                      INSTITUTE.............................
            003947   UNIVERSITY OF CALIFORNIA, HASTINGS                  <50
                      COLLEGE OF THE LAW....................
            012813   JOHN WOOD COMMUNITY COLLEGE............             <50
            030514   AUBURN CAREER CENTER...................             <50
            012860   ARKANSAS NORTHEASTERN COLLEGE..........             <50
            007731   RARITAN VALLEY COMMUNITY COLLEGE.......             <50
            008862   EAST CENTRAL COLLEGE...................             <50
            006756   NORTHSHORE TECHNICAL COMMUNITY COLLEGE.             <50
            008863   WALTERS STATE COMMUNITY COLLEGE........             <50
            009543   RED ROCKS COMMUNITY COLLEGE............             <50
            020522   BLACK RIVER TECHNICAL COLLEGE..........             <50
            031060   MISSOURI STATE UNIVERSITY--WEST PLAINS.             <50
            020735   UNIVERSITY OF ARKANSAS COMMUNITY                    <50
                      COLLEGE AT BATESVILLE.................
            031279   OSCEOLA TECHNICAL COLLEGE..............             <50
            020746   SOUTH ARKANSAS COMMUNITY COLLEGE.......             <50
            031291   FOND DU LAC TRIBAL & COMMUNITY COLLEGE.             <50
            005707   SOUTHEAST ARKANSAS COLLEGE.............             <50
            009549   WESTERN TEXAS COLLEGE..................             <50
            020839   NORTHERN NEW MEXICO COLLEGE............             <50
            004845   WILSON COMMUNITY COLLEGE...............             <50
            020870   OZARKA COLLEGE.........................             <50
            035353   HUNTINGDON COUNTY CAREER AND TECHNOLOGY             <50
                      CENTER................................
            003746   UNIVERSITY OF MARY WASHINGTON..........             <50
            003603   RANGER COLLEGE.........................             <50
            021078   UNIVERSITY OF HAWAII--WEST OAHU........             <50
            038763   CULPEPER COSMETOLOGY TRAINING CENTER...             <50
            021099   JAMES MARTIN ADULT HEALTH OCCUPATIONS..             <50
            007950   WEST SHORE COMMUNITY COLLEGE...........             <50
            021113   CUYAMACA COLLEGE.......................             <50
            041271   UNIVERSITY OF CALIFORNIA, MERCED.......             <50
            021169   UPPER VALLEY CAREER CENTER.............             <50
            003679   SNOW COLLEGE...........................             <50
            021263   MADISON ONEIDA BOCES PRACTICAL NURSING              <50
                      PROGRAM...............................
            042034   ARKANSAS STATE UNIVERSITY--NEWPORT.....             <50
            021407   CANTON CITY SCHOOL DISTRICT ADULT                   <50
                      CAREER & TECHNICAL EDUCATION..........
            009903   VANCE--GRANVILLE COMMUNITY COLLEGE.....             <50
            021460   WAYNE--FINGER LAKES BOCES..............             <50
            005372   SOUTH PUGET SOUND COMMUNITY COLLEGE....             <50
            003614   SOUTHWEST TEXAS JUNIOR COLLEGE.........             <50
            005373   LAKE WASHINGTON INSTITUTE OF TECHNOLOGY             <50
            003464   HURON UNIVERSITY.......................             <50
            001993   HENDERSON COMMUNITY COLLEGE............             <50
            003570   GRAYSON COLLEGE........................             <50
            001909   CLOUD COUNTY COMMUNITY COLLEGE.........             <50
            001162   CHABOT COLLEGE.........................             <50
            001267   MERRITT COLLEGE........................             <50
            002982   WESTERN PIEDMONT COMMUNITY COLLEGE.....             <50
            001228   LOS ANGELES VALLEY COLLEGE.............             <50
            002190   WORCESTER STATE UNIVERSITY.............             <50
            002339   CENTRAL LAKES COLLEGE..................             <50
            001181   COLLEGE OF SAN MATEO...................             <50
            003596   ODESSA COLLEGE.........................             <50
            003454   UNIVERSITY OF SOUTH CAROLINA--                      <50
                      SALKEHATCHIE..........................
            001911   COLBY COMMUNITY COLLEGE................             <50
            001335   VICTOR VALLEY COMMUNITY COLLEGE........             <50
            002654   NEW MEXICO INSTITUTE OF MINING &                    <50
                      TECHNOLOGY............................
            001166   CITRUS COLLEGE.........................             <50
            001208   GROSSMONT COLLEGE......................             <50
            001308   REEDLEY COLLEGE........................             <50
            002074   HAGERSTOWN COMMUNITY COLLEGE...........             <50
            002486   MINERAL AREA COLLEGE...................             <50
            002075   HARFORD COMMUNITY COLLEGE..............             <50
            001996   BIG SANDY COMMUNITY AND TECHNICAL                   <50
                      COLLEGE...............................
            001176   WEST HILLS COMMUNITY COLLEGE...........             <50
            002880   ULSTER COUNTY COMMUNITY COLLEGE........             <50
            001913   DODGE CITY COMMUNITY COLLEGE...........             <50
            001284   SANTA ANA COLLEGE......................             <50
            001289   SHASTA COLLEGE.........................             <50
            003459   BLACK HILLS STATE UNIVERSITY...........             <50
            002095   SAINT MARY'S COLLEGE OF MARYLAND.......             <50
            001372   WESTERN COLORADO UNIVERSITY............             <50
            001916   FORT SCOTT COMMUNITY COLLEGE...........             <50
            001851   IOWA WESTERN COMMUNITY COLLEGE.........             <50
            003162   NORTHERN OKLAHOMA COLLEGE..............             <50
            002991   LAKE REGION STATE COLLEGE..............             <50
            001919   GARDEN CITY COMMUNITY COLLEGE..........             <50
            001338   WEST VALLEY COLLEGE....................             <50
            003167   UNIVERSITY OF SCIENCE & ARTS OF                     <50
                      OKLAHOMA..............................
            003008   VALLEY CITY STATE UNIVERSITY...........             <50
            001924   INDEPENDENCE COMMUNITY COLLEGE.........             <50
            001901   ALLEN COUNTY COMMUNITY COLLEGE.........             <50
            001742   ILLINOIS EASTERN COMMUNITY COLLEGES....             <50
            002869   JAMESTOWN COMMUNITY COLLEGE............             <50
            003176   CARL ALBERT STATE COLLEGE..............             <50
            001282   SAN JOSE CITY COLLEGE..................             <50
            003178   SEMINOLE STATE COLLEGE.................             <50
            001161   CERRITOS COMMUNITY COLLEGE.............             <50
            002402   COPIAH-LINCOLN COMMUNITY COLLEGE.......             <50
            002240   BAY DE NOC COMMUNITY COLLEGE...........             <50
            001239   MIRACOSTA COLLEGE......................             <50
            001368   TRINIDAD STATE COLLEGE.................             <50
            003188   CENTRAL OREGON COMMUNITY COLLEGE.......             <50
            001998   SOUTHEAST KENTUCKY COMMUNITY AND                    <50
                      TECHNICAL COLLEGE.....................
            002404   EAST CENTRAL COMMUNITY COLLEGE.........             <50
            002907   UNIVERSITY OF NORTH CAROLINA ASHEVILLE.             <50
            001752   SAUK VALLEY COMMUNITY COLLEGE..........             <50
            003453   UNIVERSITY OF SOUTH CAROLINA--LANCASTER             <50
            001930   LABETTE COMMUNITY COLLEGE..............             <50
            001643   SPOON RIVER COLLEGE....................             <50
            002844   SUNY AT FREDONIA.......................             <50
            001648   CITY COLLEGES OF CHICAGO HARRY S TRUMAN             <50
                      COLLEGE...............................
            003211   OREGON INSTITUTE OF TECHNOLOGY.........             <50
            002947   MITCHELL COMMUNITY COLLEGE.............             <50
            001612   HONOLULU COMMUNITY COLLEGE.............             <50
            001186   COLLEGE OF THE SEQUOIAS................             <50
            001613   KAPIOLANI COMMUNITY COLLEGE............             <50
            001260   PALOMAR COLLEGE........................             <50
            002853   SUNY MARITIME COLLEGE..................             <50
            001857   SOUTHWESTERN COMMUNITY COLLEGE.........             <50
            002854   SUNY COLLEGE OF TECHNOLOGY AT ALFRED...             <50
            001655   WILBUR WRIGHT COLLEGE..................             <50
            001269   RIO HONDO COMMUNITY COLLEGE............             <50
            002582   MANCHESTER COMMUNITY COLLEGE...........             <50
            001319   UNIVERSITY OF CALIFORNIA, SAN FRANCISCO             <50
            002310   ST. CLAIR COUNTY COMMUNITY COLLEGE.....             <50
            002181   MASSACHUSETTS MARITIME ACADEMY.........             <50
            003568   FRANK PHILLIPS COLLEGE.................             <50
            002187   MASSACHUSETTS COLLEGE OF LIBERAL ARTS..             <50
            001413   THAMES VALLEY STATE TECHNICAL COLLEGE..             <50
            002863   CORNING COMMUNITY COLLEGE--SUNY OFFICE              <50
                      OF COMMUNITY COLLEGES.................
            002040   UNIVERSITY OF MAINE--FARMINGTON........             <50
            002864   DUTCHESS COMMUNITY COLLEGE.............             <50
            003583   LEE COLLEGE............................             <50
            001485   COLLEGE OF THE FLORIDA KEYS (THE)......             <50
            001270   RIVERSIDE CITY COLLEGE.................             <50
            003324   MANSFIELD UNIVERSITY OF PENNSYLVANIA...             <50
            001990   ASHLAND COMMUNITY AND TECHNICAL COLLEGE             <50
            042417   SAINT JOSEPH'S SCHOOL OF NURSING.......             <50
            001071   ARIZONA WESTERN COLLEGE................             <50
            042759   ANOTHER LEVEL BARBERING AND COSMETOLOGY             <50
                      SCHOOL................................
            041742   ALL BEAUTY COLLEGE.....................             <50
            041179   CHAMPION BEAUTY COLLEGE................             <50
            041748   AMERICAN TRADE SCHOOL..................             <50
            042531   ALLIED HEALTH CAREERS INSTITUTE........             <50
            041749   ESTELLE INTERNATIONAL..................             <50
            041659   PAUL MITCHELL THE SCHOOL FRESNO........             <50
            041751   PAUL MITCHELL THE SCHOOL HONOLULU......             <50
            041736   NOTTER SCHOOL OF PASTRY ARTS...........             <50
            037764   ORION INSTITUTE........................             <50
            041589   FLAIR BEAUTY COLLEGE...................             <50
            041402   MISSISSIPPI INSTITUTE OF AESTHETICS,                <50
                      NAILS, & COSMETOLOGY..................
            041622   AMERICAN ACADEMY OF HEALTH AND BEAUTY..             <50
            041754   ELITE COSMETOLOGY SCHOOL...............             <50
            042654   ANN WEBB SKIN INSTITUTE................             <50
            041756   PARK AVENUE SCHOOL OF COSMETOLOGY......             <50
            042853   HOLLYWOOD CULTURAL COLLEGE.............             <50
            038913   SOMA INSTITUTE--THE NATIONAL SCHOOL OF              <50
                      CLINICAL MASSAGE THERAPY..............
            001038   SNEAD STATE COMMUNITY COLLEGE..........             <50
            041772   REAL BARBERS COLLEGE (THE).............             <50
            041721   CCIC BEAUTY COLLEGE....................             <50
            041779   BUCKNER BARBER SCHOOL..................             <50
            037513   ESCUELA HOTELERA DE SAN JUAN...........             <50
            041781   CAROLINA COLLEGE OF HAIR DESIGN........             <50
            042328   JOHN PATRICK UNIVERSITY OF HEALTH AND               <50
                      APPLIED SCIENCES......................
            041409   INTERNATIONAL COSMETOLOGY ACADEMY......             <50
            042367   BLUSH SCHOOL OF MAKEUP.................             <50
            041410   DOUGLAS J AVEDA INSTITUTE-CHICAGO......             <50
            041602   ATLANTA BEAUTY & BARBER ACADEMY........             <50
            041789   ASHDOWN COLLEGE OF HEALTH SCIENCES.....             <50
            039873   TEXAS HEALTH SCHOOL....................             <50
            041411   FRENCH ACADEMY OF COSMETOLOGY..........             <50
            042556   INTERNATIONAL DIVING INSTITUTE.........             <50
            041413   SAN FRANCISCO INSTITUTE OF ESTHETICS &              <50
                      COSMETOLOGY...........................
            042733   VICTORY CAREER COLLEGE.................             <50
            036143   DAVID'S ACADEMY OF BEAUTY..............             <50
            042778   PRO BEAUTY ACADEMY (THE)...............             <50
            041417   HEALING HANDS SCHOOL OF HOLISTIC HEALTH             <50
            038113   EASTERN SCHOOL OF ACUPUNCTURE AND                   <50
                      TRADITIONAL MEDICINE..................
            041816   INTEGRITY COLLEGE OF HEALTH............             <50
            036103   MJ'S BEAUTY ACADEMY....................             <50
            038923   HARLEY'S BEAUTY & BARBER CAREER                     <50
                      INSTITUTE.............................
            038324   COSMETOLOGY SCHOOL OF ARTS & SCIENCES..             <50
            035744   CORTIVA INSTITUTE--SOMERSET SCHOOL OF               <50
                      MASSAGE THERAPY.......................
            037243   DIGIPEN INSTITUTE OF TECHNOLOGY........             <50
            041831   WASHINGTON BARBER COLLEGE..............             <50
            041239   LEXINGTON HEALING ARTS ACADEMY.........             <50
            041833   ABCOTT INSTITUTE.......................             <50
            042266   CAROLINA CAREER COLLEGE................             <50
            041836   SALON PROFESSIONAL ACADEMY OF KENOSHA               <50
                      (THE).................................
            036955   ARIZONA SCHOOL OF ACUPUNCTURE AND                   <50
                      ORIENTAL MEDICINE.....................
            041840   PAUL MITCHELL THE SCHOOL INDIANAPOLIS..             <50
            042319   ALAMO CITY BARBER COLLEGE..............             <50
            041842   TAYLOR ANDREWS ACADEMY-ST. GEORGE......             <50
            041588   THEATRE OF ARTS........................             <50
            039163   ECLIPS SCHOOL OF COSMETOLOGY AND                    <50
                      BARBERING.............................
            042359   BELLA COSMETOLOGY AND BARBER COLLEGE...             <50
            041847   PROTEGE ACADEMY........................             <50
            042385   TRAINING DOMAIN (THE)..................             <50
            037783   HEALTH WORKS INSTITUTE.................             <50
            042425   ASSOCIATED BARBER COLLEGE OF SAN DIEGO.             <50
            041851   NORTHEAST TECHNICAL INSTITUTE..........             <50
            041606   PAUL MITCHELL THE SCHOOL NORMAL........             <50
            040253   LAST MINUTE CUTS SCHOOL OF BARBERING                <50
                      AND COSMETOLOGY.......................
            042494   CENTER FOR NEUROSOMATIC STUDIES........             <50
            041856   MEDICAL ALLIED CAREER CENTER...........             <50
            042524   WORLDCLASS ACADEMY OF BEAUTY CAREERS...             <50
            041859   ELITE SCHOOL OF COSMETOLOGY............             <50
            041627   ERIC FISHER ACADEMY....................             <50
            041444   ACADEMY OF HAIR DESIGN (THE)...........             <50
            042604   CUTTING EDGE ACADEMY...................             <50
            041448   INTERNATIONAL ACADEMY OF STYLE.........             <50
            041338   SOUTHEAST CULINARY & HOSPITALITY                    <50
                      COLLEGE...............................
            041260   PAUL MITCHELL THE SCHOOL CLEVELAND.....             <50
            042742   INSTALLER INSTITUTE....................             <50
            040363   SOUTHEAST TEXAS CAREER INSTITUTE.......             <50
            042763   AMERICAN MASSAGE & BODYWORK INSTITUTE..             <50
            041877   CREVIER'S SCHOOL OF COSMETOLOGY........             <50
            042806   GOODFELLAS BARBER COLLEGE..............             <50
            041459   CELEBRITY SCHOOL OF BEAUTY.............             <50
            042911   COMMERCIAL DIVERS INTERNATIONAL........             <50
            039683   LAKEWOOD SCHOOL OF THERAPEUTIC MASSAGE.             <50
            041653   PAUL MITCHELL THE SCHOOL MILWAUKEE.....             <50
            041269   ACADEMY OF CAREER TRAINING.............             <50
            041669   COSMETIC ARTS INSTITUTE................             <50
            041275   CDE CAREER INSTITUTE...................             <50
            001030   BISHOP STATE COMMUNITY COLLEGE.........             <50
            041277   AMERICAN SENTINEL UNIVERSITY...........             <50
            038223   PAUL MITCHELL THE SCHOOL--MADISON......             <50
            041898   ACADEMY FOR SALON PROFESSIONALS........             <50
            039414   ELITE ACADEMY OF BEAUTY ARTS...........             <50
            041903   AMERICAN INSTITUTE OF MEDICAL                       <50
                      SONOGRAPHY............................
            041216   FILA ACADEMY (THE).....................             <50
            041905   NEW YORK SCHOOL OF ESTHETICS & DAY SPA.             <50
            041369   UNIVERSITY OF AESTHETICS & COSMETOLOGY.             <50
            041914   SCHOOL OF COURT REPORTING (THE)........             <50
            038684   LOS ANGELES COLLEGE OF MUSIC...........             <50
            039703   HANDS ON THERAPY.......................             <50
            041240   DOMINION SCHOOL OF HAIR DESIGN.........             <50
            041921   AMERICAN MEDICAL ACADEMY...............             <50
            042264   MT TRAINING CENTER.....................             <50
            041926   PALMETTO BEAUTY SCHOOL.................             <50
            036263   BROWN AVEDA INSTITUTE..................             <50
            041123   LOUISIANA CULINARY INSTITUTE...........             <50
            040723   AVEDA INSTITUTE PROVO..................             <50
            041930   RIO GRANDE VALLEY COLLEGE..............             <50
            042302   PAUL MITCHELL THE SCHOOL FARMINGTON                 <50
                      HILLS.................................
            038783   PROFESSIONAL MASSAGE TRAINING CENTER...             <50
            042305   PAUL MITCHELL THE SCHOOL GRAND RAPIDS..             <50
            040433   ACE INSTITUTE OF TECHNOLOGY............             <50
            042324   VANTAGE COLLEGE--SAN ANTONIO...........             <50
            041299   FLORIDA SCHOOL OF MASSAGE..............             <50
            042329   PREPARING PEOPLE BARBER STYLING COLLEGE             <50
            039034   AMERICAN BEAUTY SCHOOL.................             <50
            042337   CHRISTINE VALMY INTERNATIONAL SCHOOL                <50
                      FORESTHETICS, SKIN CARE & MAKE-UP.....
            042028   PANACHE ACADEMY OF BEAUTY..............             <50
            041597   AMERICAN MEDICAL SCIENCES CENTER.......             <50
            041495   A & W HEALTHCARE EDUCATORS.............             <50
            042364   SANDRA ACADEMY OF SALON SERVICES.......             <50
            042032   BOISE BARBER COLLEGE A D.MARTIN ACADEMY             <50
            035873   GENESIS VOCATIONAL TRAINING............             <50
            042035   AUSTIN KADE ACADEMY....................             <50
            042386   GOULD'S ACADEMY........................             <50
            042038   WOODRUFF MEDICAL AND WELLNESS TRAINING.             <50
            042423   DALTON INSTITUTE OF ESTHETICS AND                   <50
                      COSMETOLOGY...........................
            042040   ASPEN BEAUTY ACADEMY--LAUREL...........             <50
            042436   INTERNATIONAL HAIR AND BARBER ACADEMY..             <50
            041500   CENTRAL NURSING COLLEGE................             <50
            041604   ANGELES COLLEGE........................             <50
            042046   BEAUTY AND HEALTH INSTITUTE............             <50
            042467   LEARNING BRIDGE CAREER INSTITUTE.......             <50
            039745   CALIFORNIA CAREER COLLEGE..............             <50
            042490   MEDICAL CAREER AND TECHNICAL COLLEGE...             <50
            042052   WADE GORDON HAIRDRESSING ACADEMY.......             <50
            042498   DOLCE THE ACADEMY......................             <50
            042053   MITSU SATO HAIR ACADEMY................             <50
            042523   PREMIER BARBER INSTITUTE...............             <50
            041312   TOTAL IMAGE BEAUTY ACADEMY.............             <50
            042529   INTERNATIONAL BEAUTY EDUCATION CENTER..             <50
            042062   DIGITAL FILM ACADEMY...................             <50
            035683   LEON STUDIO ONE SCHOOL OF BEAUTY                    <50
                      KNOWLEDGE.............................
            041511   SUMMIT BEAUTY SCHOOL...................             <50
            042555   ALABAMA SCHOOL OF NAIL TECHNOLOGY &                 <50
                      COSMETOLOGY...........................
            041515   AMERICAN ACADEMY OF COSMETOLOGY........             <50
            042562   KENNY'S ACADEMY OF BARBERING...........             <50
            042073   SCHOOL FOR ALLIED HEALTH PROFESSIONALS.             <50
            039953   UNIVERSITY OF EAST-WEST MEDICINE.......             <50
            042075   MEDICAL CAREER INSTITUTE...............             <50
            041631   SUMMIT SALON ACADEMY--GAINESVILLE......             <50
            042088   GLORIA FRANCIS SCHOOL OF MAKE-UP                    <50
                      ARTISTRY..............................
            042716   AVENUE ACADEMY, A COSMETOLOGY INSTITUTE             <50
                      (THE).................................
            042096   INSTITUTE OF HEALTH SCIENCES...........             <50
            042735   WINONAH'S INTERNATIONAL SCHOOL OF                   <50
                      COSMETOLOGY...........................
            042098   HINTON BARBER AND BEAUTY COLLEGE.......             <50
            042751   ANOUSHEH SCHOOL OF HAIR................             <50
            041517   BELLA CAPELLI ACADEMY A PAUL MITCHELL               <50
                      PARTNER SCHOOL........................
            042760   GLITZ SCHOOL OF COSMETOLOGY............             <50
            042132   KAIZEN BEAUTY ACADEMY..................             <50
            041634   COSMO BEAUTY ACADEMY...................             <50
            041313   CORINTH ACADEMY OF COSMETOLOGY.........             <50
            041649   BARONE BEAUTY ACADEMY..................             <50
            039043   QUALITY COLLEGE OF CULINARY CAREERS....             <50
            042814   CALIFORNIA HEALTH SCIENCES UNIVERSITY..             <50
            042156   AMERICAN INSTITUTE OF PHARMACEUTICAL                <50
                      TECHNOLOGY............................
            042889   PEARLANDS INNOVATIVE SCHOOL OF BEAUTY..             <50
            042157   IBERO AMERICAN COLLEGE.................             <50
            042949   CTK HEALTHCARE & CAREER INSTITUTE......             <50
            037463   LEGRAND INSTITUTE OF COSMETOLOGY.......             <50
            041650   MERIDIAN INSTITUTE OF SURGICAL                      <50
                      ASSISTING.............................
            042165   CENTER FOR THE HEALING ARTS............             <50
            041655   ACAYDIA SPA AND SCHOOL OF AESTHETICS...             <50
            041166   TAYLOR COLLEGE.........................             <50
            038814   EUROPEAN MASSAGE THERAPY SCHOOL (THE)..             <50
            042176   SESSIONS COLLEGE FOR PROFESSIONAL                   <50
                      DESIGN................................
            040933   ACADEMY OF NATURAL THERAPY.............             <50
            038083   INSTITUTE OF BEAUTY AND WELLNESS (THE).             <50
            041347   INTERNATIONAL PROFESSIONAL SCHOOL OF                <50
                      BODYWORK..............................
            042180   UNITED MEDICAL AND BUSINESS INSTITUTE..             <50
            001031   NORTHEAST ALABAMA COMMUNITY COLLEGE....             <50
            041530   RENAISSANCE ACADEMIE...................             <50
            041685   SOLEX COLLEGE..........................             <50
            041169   DIGRIGOLI SCHOOL OF COSMETOLOGY........             <50
            036333   CALIFORNIA LEARNING CENTER.............             <50
            041548   DUVALL'S SCHOOL OF COSMETOLOGY.........             <50
            038857   HOUSTON'S TRAINING AND EDUCATION CENTER             <50
                      (H-TEC)...............................
            042209   NATIONAL PERSONAL TRAINING INSTITUTE OF             <50
                      COLUMBUS..............................
            001065   UNIVERSITY OF ALASKA SOUTHEAST.........             <50
            041551   INSTITUTE OF MEDICAL AND BUSINESS                   <50
                      CAREERS...............................
            039123   CREDENCE INSTITUTE OF BEAUTY...........             <50
            041559   AVEDA FREDRIC'S INSTITUTE..............             <50
            001111   ALLAN HANCOCK COLLEGE..................             <50
            041571   L3 COMMERCIAL TRAINING SOLUTIONS                    <50
                      AIRLINE ACADEMY.......................
            041711   PAUL MITCHELL THE SCHOOL--DELAWARE.....             <50
            042220   ARCLABS................................             <50
            041716   SALON PROFESSIONAL ACADEMY OF ELGIN                 <50
                      (THE).................................
            041572   LOVE BEAUTY SCHOOL.....................             <50
            037693   PC TECH LEARNING CENTER................             <50
            035564   KUSSAD INSTITUTE OF COURT REPORTING....             <50
            001104   PHILLIPS COMMUNITY COLLEGE OF THE                   <50
                      UNIVERSITY OF ARKANSAS................
            042239   MIND BODY INSTITUTE....................             <50
            035783   TRI-STATE COLLEGE......................             <50
            042241   COSMETOLOGY ACADEMY OF TEXARKANA.......             <50
            041392   UNIVERSAL BARBER COLLEGE...............             <50
            041575   ACCESS CAREERS.........................             <50
            042250   PARISIAN SPA INSTITUTE.................             <50
            041726   SALON 496 BARBER ACADEMY...............             <50
            025460   TRI-STATE COLLEGE OF ACUPUNCTURE.......             <50
            025860   INFINITY CAREER COLLEGE................             <50
            035514   STATE BEAUTY ACADEMY...................             <50
            023155   TOLEDO ACADEMY OF BEAUTY...............             <50
            031873   STENOTECH CAREER INSTITUTE.............             <50
            025275   HOUSTON TRAINING SCHOOLS...............             <50
            034334   NEW CONCEPT MASSAGE & BEAUTY SCHOOL....             <50
            026153   PSI INSTITUTE OF WASHINGTON............             <50
            025837   MUNICIPAL TRAINING CENTER..............             <50
            025330   WESTERN BUSINESS INSTITUTE.............             <50
            031533   AMERICAN COLLEGE OF ACUPUNCTURE &                   <50
                      ORIENTAL MEDICINE.....................
            025549   MICRO TECHNOLGY INSTITUTE..............             <50
            023350   PHILLIPS BUSINESS SCHOOL...............             <50
            026163   FRAN BROWN COLLEGE OF BEAUTY...........             <50
            023050   CAREER INSTITUTE OF AMERICA............             <50
            026165   VISIBLE CHANGES UNIVERSITY.............             <50
            034984   OMEGA INSTITUTE OF COSMETOLOGY.........             <50
            025553   PATSY AND ROB'S ACADEMY OF BEAUTY......             <50
            024824   PONCE HEALTH SCIENCES UNIVERSITY.......             <50
            025555   TECHNICAL CAREER INSTITUTE.............             <50
            023125   BROOKLYN TRAINING CENTER...............             <50
            025556   ELECTRONIC TECHNICAL INSTITUTE.........             <50
            023188   UNITED STATES TRUCK DRIVING SCHOOL.....             <50
            025337   WESTWOOD EDUCATIONAL...................             <50
            024989   NATIONAL BUSINESS SCHOOL AUTOMOTIVE                 <50
                      DIVISION..............................
            023409   FLORIDA ACADEMY OF COSMETOLOGY ARTS &               <50
                      SCIENCES..............................
            025937   RICHPORT TECHNICAL COLLEGE.............             <50
            025349   PONCE PARAMEDICAL COLLEGE (POPAC)......             <50
            033193   CREATIVE IMAGES INSTITUTE OF                        <50
                      COSMETOLOGY...........................
            023111   TRENDMASTERS ACADEMY OF COSMETOLOGY....             <50
            033713   TONI&GUY HAIRDRESSING ACADEMY I TIGI                <50
                      CREATIVE SCHOOL.......................
            025584   SAN ANTONIO COURT REPORTING INSTITUTE..             <50
            025189   BARRETT & CO SCHOOL OF HAIR DESIGN.....             <50
            030024   GRAHAM WEBB INTERNATIONAL ACADEMY OF                <50
                      HAIR..................................
            023386   CHARZANNE BEAUTY COLLEGE...............             <50
            025281   ZENZIS BEAUTY COLLEGE..................             <50
            025230   AVTECH INSTITUTE.......................             <50
            030049   AMERICAN NANNY COLLEGE.................             <50
            031068   HOUSTON ALLIED HEALTH CAREERS..........             <50
            023285   MOLER--PICKENS BEAUTY COLLEGE..........             <50
            023253   AMERICAN CENTER FOR TECHNICAL ARTS &                <50
                      SCIENCES..............................
            023299   FLORIDA INSTITUTE OF ULTRASOUND........             <50
            031208   KAY HARVEY HAIRDRESSING ACADEMY........             <50
            023066   NEW WORLD INSTITUTE....................             <50
            025419   BJ'S BEAUTY & BARBER COLLEGE...........             <50
            023159   CAPILO SCHOOL OF HAIR DESIGN...........             <50
            024959   MR JS HAIR ACADEMY.....................             <50
            030071   HOT SPRINGS BEAUTY COLLEGE.............             <50
            024974   ACADEMY OF PROFESSIONAL DEVELOPMENT....             <50
            023432   UNITED BUSINESS INSTITUTE..............             <50
            025893   AMERICAN TECHNICAL COLLEGE.............             <50
            023437   CHICAGO TECHNOLOGICAL COLLEGE..........             <50
            025446   MAGEE BROTHERS BEAUTY SCHOOL...........             <50
            030197   MIDWEST CAREER COLLEGE.................             <50
            032005   YOUNGSTOWN COLLEGE OF MASSOTHERAPY                  <50
                      (THE).................................
            030199   CAPSTONE COLLEGE.......................             <50
            024995   AMERICAN TRANSPORTATION EDUCATION                   <50
                      CENTERS...............................
            030213   TRISTATE TRAVEL SCHOOL.................             <50
            032793   MYOTHERAPY INSTITUTE...................             <50
            030234   ARKANSAS TECHNICAL SCHOOL..............             <50
            025019   CARS VOCATIONAL TRAINING SCHOOL........             <50
            030238   AIMS ACADEMY...........................             <50
            025049   BEAUTY ACADEMY.........................             <50
            030247   STILLWATER BEAUTY ACADEMY..............             <50
            033893   ACADEMY OF MASSAGE THERAPY.............             <50
            025382   TECHL EDUCATION IN CULINARY AND HEALTH.             <50
            025496   METROPLITAN BUSINESS COLLEGE...........             <50
            023448   SOUTHERN BUS SCHOOLS...................             <50
            034303   UNIVERSAL THERAPEUTIC MASSAGE INSTITUTE             <50
            025644   SOUTHERN COLLEGE OF TECHNOLOGY.........             <50
            026090   EMPEROR'S COLLEGE OF TRADITIONAL                    <50
                      ORIENTAL MEDICINE.....................
            025388   ALLEGIANCE BEAUTY SCHOOL...............             <50
            023056   NATIONAL BROADCASTING SCHOOL...........             <50
            030311   JGM COSMETOLOGY INSTITUTE..............             <50
            035194   LYNNDALE FUNDAMENTALS OF BEAUTY SCHOOL.             <50
            030313   XENON INTERNATIONAL ACADEMY IV.........             <50
            026112   NATIONAL CAREER SCHOOL.................             <50
            030322   ALADDIN BEAUTY COLLEGE #32.............             <50
            031057   NEWBRIDGE COLLEGE--MONTEREY PARK.......             <50
            025673   BRAXTON SCHOOL OF BUSINESS.............             <50
            023236   PONCE COLLEGE OF TECHNOLOGY............             <50
            025674   PRO DRIVE..............................             <50
            024917   CORTIVA INSTITUTE-- BOSTON.............             <50
            023487   CAREER BLAZERS LEARNING CENTER.........             <50
            025417   COASTAL COLLEGE........................             <50
            030520   MEREDITH MANOR INTERNATIONAL EQUESTRIAN             <50
                      CENTRE................................
            031207   NEW YORK CONSERVATORY FOR DRAMATIC ARTS             <50
                      (THE).................................
            023492   HEADMASTERS SCHOOL OF HAIR DESIGN......             <50
            023327   ROSSTON COLLEGE........................             <50
            030523   KENNETH SHULER SCHOOL OF COSMETOLOGY &              <50
                      HAIR DESIGN...........................
            031243   TODAY'S TRAINING CENTER................             <50
            030532   ASTRAL ACADEMY OF HAIR.................             <50
            031245   LOS ANGELES PACIFIC COLLEGE............             <50
            023240   COLLEGE OF THE PALM BEACHES............             <50
            031266   AMERICAN COLLEGE OF PROFESSIONAL                    <50
                      EDUCATION.............................
            030612   MIDWEST COLLEGE OF ORIENTAL MEDICINE...             <50
            031280   SANTA BARBARA COLLEGE OF ORIENTAL                   <50
                      MEDICINE..............................
            030649   AARON'S ACADEMY OF BEAUTY..............             <50
            025876   ORLO SCHOOL OF HAIR DESIGN AND                      <50
                      COSMETOLOGY (THE).....................
            023504   SOUTHEAST TEXAS TECHL INST.............             <50
            031505   A--TECHNICAL COLLEGE...................             <50
            023174   EMORY COLLEGE OF PUERTO RICO...........             <50
            025432   LOS ANGELES BROADCASTERS...............             <50
            030661   PTC CAREER INST CLEVELAND..............             <50
            025434   BROWNSON TECHNICAL SCHOOL..............             <50
            025702   DEE BOYA INSTITUTE OF FASHION..........             <50
            025307   SEBRING CAREER SCHOOLS.................             <50
            023524   VOGUE COLLEGE OF COSMETOLOGY #25.......             <50
            031853   PHAGANS' GRANTS PASS COLLEGE OF BEAUTY.             <50
            030677   RETS ELECTRONIC INSTITUTION............             <50
            023345   UNITED CAREER CENTER...................             <50
            025398   QUEEN CITY COLLEGE.....................             <50
            032053   MODERN BEAUTY SCHOOL...................             <50
            023541   DOOLIN TECHNICAL COLLEGE...............             <50
            025955   OMNI COLLEGE...........................             <50
            030720   AVALON VOCATIONAL TECHNICAL INSTITUTE..             <50
            023346   PAZAZZ HAIR SCHOOL.....................             <50
            030726   DCI CAREER INSTITUTE...................             <50
            032773   PATHWAY VOCATIONAL ACADEMY.............             <50
            025708   HOSPITALITY INSTITUTE..................             <50
            032804   CORTIVA INSTITUTE--CHARLOTTESVILLE.....             <50
            030741   WESTLAKE INSTITUTE OF TECHNOLOGY.......             <50
            033223   CULINARY INSTITUTE OF NEW ORLEANS......             <50
            030744   PHAGANS' NEWPORT ACADEMY OF COSMETOLOGY             <50
                      CAREERS...............................
            026011   OPELOUSAS SCHOOL OF COSMETOLOGY........             <50
            030745   EAST WEST COLLEGE OF THE HEALING ARTS..             <50
            025462   LAUREL BUSINESS INSTITUTE..............             <50
            025713   VISTA DEL MAR-SCHOOL OF COURT REPORTING             <50
            033703   AUDIO RECORDING TECHNOLOGY INSTITUTE...             <50
            023556   INTERNATIONAL INSTITUTE OF                          <50
                      TRANSPORATION RESOURCES...............
            025103   BEAUTY TECHNICAL COLLEGE...............             <50
            030784   CAMEO BEAUTY ACADEMY...................             <50
            025155   CALIFORNIA BUSINESS INSTITUTE..........             <50
            030802   LOUISIANA TRAINING CENTER..............             <50
            023235   METILS WELDING SCHOOL..................             <50
            030808   ACADEMY (THE)..........................             <50
            025499   CONSUMER ELECTRONICS TRAINING CENTER...             <50
            030879   LIBERTY ACADEMY OF BUSINESS............             <50
            026088   IADE AMERICAN SCHOOLS..................             <50
            023241   FLAGLER CAREER INSTITUTE...............             <50
            034313   ESI TECHNOLOGY TRAINING CENTER.........             <50
            023597   NORTHEAST CAREER SCHOOLS...............             <50
            023379   COLLEGE OF HAIR DESIGN CAREERS.........             <50
            030948   INDUSTRIAL MANAGEMENT & TRAINING                    <50
                      INSTITUTE.............................
            023146   CRESTWOOD CAREER ACADEMY...............             <50
            025747   WATTERSON SCHOOL OF BUSINESS AND                    <50
                      TECHNOLOGY............................
            034854   JAMES ALBERT SCHOOL OF COSMETOLOGY.....             <50
            030962   CHARLES STUART SCHOOL..................             <50
            034914   AMERICAN ADVANCED TECHNICIANS INSTITUTE             <50
            023100   RON THOMAS SCHOOL OF COSMETOLOGY.......             <50
            035165   EZELL'S COSMETOLOGY SCHOOL, LLC........             <50
            030985   ALLSTATE INSTITUTE OF TECHNOLOGY.......             <50
            035303   KEYSKILLS LEARNING.....................             <50
            023310   MARYLAND BEAUTY ACADEMY OF ESSEX.......             <50
            025524   ACADEMY OF HAIR TECHNOLOGY.............             <50
            031001   PARAMOUNT BEAUTY ACADEMY...............             <50
            023094   PARALEGAL INSTITUTE....................             <50
            023605   AMERICAN VOCATIONAL CENTER.............             <50
            031020   RIVERTOWN SCHOOL OF BEAUTY, BARBER,                 <50
                      SKIN CARE AND NAILS...................
            025770   PAUL MITCHELL THE SCHOOL--ESANI........             <50
            021563   MARGATE SCHOOL OF BEAUTY...............             <50
            022477   SOUTH WEST ACADEMY OF TECHNOLOGY.......             <50
            012351   PHAGANS' SCHOOL OF BEAUTY..............             <50
            011914   MIDTOWN SCHOOL OF BUSINESS.............             <50
            022622   NATIONAL ACADEMY FOR PARALEGAL STUDIES.             <50
            021162   COMMERCIAL PROGRAMMING UNLIMITED.......             <50
            021617   PACIFIC COAST TECHL INST...............             <50
            010926   BALIN INST OF TECHLGY..................             <50
            012403   MEADOWS BUSINESS COLLEGE...............             <50
            021644   INTERNATIONAL TRAINING.................             <50
            022548   TEXAS VOCATIONAL SCHOOL................             <50
            020584   GORDON PHILLIPS SCHOOL OF BEAUTY                    <50
                      CULTURE...............................
            021523   SCHOOL OF COMMUNICATION ARTS...........             <50
            020594   INTERNATIONAL BEAUTY ACADEMY...........             <50
            022922   NEBRASKA CUSTOM DIESEL DRIVERS TRAINING             <50
            021186   ULTISSMA BEAUTY INST BRENTWOOD.........             <50
            011484   ADVANCED INSTITUTE OF HAIR DESIGN......             <50
            011572   COLORADO SCHOOL OF TRADES..............             <50
            020717   ARIZONA CAREER COLLEGE (CLOSED)........             <50
            021687   JACKSONVILLE BUSINESS AND CAREERS                   <50
                      INSTITUTE.............................
            022411   SIMMONS SCHOOL.........................             <50
            011963   DELTA JUNIOR COLLEGE...................             <50
            020756   ANDOVER TRACTOR TRAILER SCHOOL HOME                 <50
                      STUDY DIVISION........................
            010910   CASCADE BUSINESS COLLEGE...............             <50
            012551   LAUREL BEAUTY ACADEMY..................             <50
            021743   KEITH METRO HAIR ACADEMY...............             <50
            022737   NATIONAL EDUCATION CENTER NATIONAL                  <50
                      INSTITUTE OF TECHNOLOGY...............
            011182   CLIFTON SCHOOL OF BUSINESS.............             <50
            022784   JETT COLLEGE OF COSMETOLOGY & BARBERING             <50
            021230   LAVONNES ACADEMY OF BEAUTY.............             <50
            022889   ACCUTECH CAREER INSTITUTE..............             <50
            013240   LYTLE'S REDWOOD EMPIRE BEAUTY COLLEGE..             <50
            011154   MERIT COLLEGE..........................             <50
            020596   AL TATE BEAUTY COLLEGE.................             <50
            022994   ALAMEDA TECHNICAL COLLEGE..............             <50
            021783   VOGUE SCHOOL OF HAIR DESIGN #6.........             <50
            011814   GATEWAY ELECTRONICS INST...............             <50
            010837   SIMMONS INSTITUTE OF FUNERAL SERVICE...             <50
            022313   CAGUAS COLLEGE OF TECHNOLOGY & SCIENCE.             <50
            021796   EMPIRE BEAUTY SCHOOLS..................             <50
            022359   ACADEMY OF HAIR DESIGN # 4.............             <50
            012020   VICTORIA BEAUTY AND BARBER COLLEGE.....             <50
            022387   HAIRSTYLING INSTITUTE OF CHARLOTTE.....             <50
            021257   HELENA DYE & FLANARY BEAUTY COLLEGE....             <50
            012460   APOLLO BUSINESS & TECHNICAL SCHOOL.....             <50
            021813   LONG TECHNICAL COLLEGE.................             <50
            010810   COMMERCIAL COLLEGE OF BATON ROUGE......             <50
            011596   SYLVAIN MELLOUL INTERNATIONAL HAIR                  <50
                      ACADEMY...............................
            022538   TEXAS SCHOOLS..........................             <50
            021831   BOJACK ACADEMY OF BEAUTY CULTURE.......             <50
            020766   PICCOLO SCHOOL OF HAIR DESIGN..........             <50
            021832   MED HELP TRAINING SCHOOL...............             <50
            011830   BERK TRADE & BUSINESS SCHOOL...........             <50
            021838   EASON'S INST OF TECHLGY................             <50
            022661   EASTERN JACKSON COUNTY COLLEGE OF                   <50
                      ALLIED HEALTH.........................
            021842   PAROBA COLLEGE OF COSMETOLOGY..........             <50
            022745   ACADEMY OF COSMETOLOGY.................             <50
            021844   JENKS BEAUTY COLLEGE...................             <50
            022760   FRANKLIN BEAUTY SCHOOL.................             <50
            021852   ILLINOIS SCHOOL OF COMMERCE............             <50
            012782   DEBBIES SCHOOL OF BEAUTY CULTURE.......             <50
            021864   MELBOURNE BEAUTY SCHOOL................             <50
            011219   COLUMBIA SCHOOL OF BROADCASTING, HOME               <50
                      STUDY.................................
            021870   LEONE SCHOOL OF TECHNOLOGY.............             <50
            020563   KENSINGTON BUSINESS INSTITUTE..........             <50
            021874   PARKS COLLEGE..........................             <50
            022943   TECHNICAL TRAINING CENTER..............             <50
            021888   SULLIVAN EDUCATIONAL CENTERS...........             <50
            013010   LANCASTER BEAUTY SCHOOL................             <50
            021891   CEM COLLEGE............................             <50
            022982   HEADQUARTERS ACADEMY OF HAIR DESIGN                 <50
                      (THE).................................
            021897   CREATIVE SCHOOL OF BEAUTY..............             <50
            023006   CONTINENTAL BEAUTY COLLEGE.............             <50
            021071   TEMPE TECHNICAL INSTITUTE..............             <50
            022225   CINCINNATI SCHOOL OF COURT REPORTING                <50
                      AND BUSINESS..........................
            021091   SOUTH CENTRAL CAREER COLLEGE...........             <50
            022238   ROMAR BEAUTY SCHOOL....................             <50
            011799   PAUL MITCHELL THE SCHOOL FAYETTEVILLE..             <50
            022281   STEVEN PAPAGEORGE HAIR ACADEMY.........             <50
            020959   GUTHRIE ACADEMY........................             <50
            022332   COSMETOLOGY CAREERS UNLIMITED..........             <50
            020921   MASSACHUSETTS SCHOOL OF BARBERING......             <50
            012381   CLASSIC BEAUTY COLLEGES................             <50
            023016   CASHIER TRAINING INSTITUTE.............             <50
            020724   PLAZA THREE ACADEMY....................             <50
            023023   ORLANDO ACADEMY OF BEAUTY CULTURE......             <50
            012920   ACADEMY OF SCIENTIFIC HAIR DESIGN......             <50
            011800   FREDERICK'S BEAUTY COLLEGE.............             <50
            011098   FLINT INSTITUTE OF BARBERING...........             <50
            011802   ARIZONA ACADEMY OF BEAUTY--NORTH.......             <50
            022443   MISSISSIPPI BARBER ACADEMY.............             <50
            012068   MANSFIELD BEAUTY SCHOOLS...............             <50
            011521   EDUCATION DYNAMICS INSTITUTE...........             <50
            022030   NATIONAL TRAINING......................             <50
            022481   AUSTIN SCHOOL OF BEAUTY CULTURE........             <50
            021098   MARYCREST COLLEGE......................             <50
            022513   D'OR SCHOOL OF COSMETOLOGY.............             <50
            021322   MCKIM TECHNICAL INSTITUTE..............             <50
            022517   FOSTER'S COSMETOLOGY AND BARBER COLLEGE             <50
            021329   MASSACHUSETTS SCHOOL OF BARBER & MENS               <50
                      HAIR..................................
            021461   CHAUFFEURS TRAINING SCHOOL.............             <50
            020657   CALIFORNIA BEAUTY COLLEGE..............             <50
            010747   ELECTRONIC COMPUTER PROGRAMMING INST...             <50
            021344   CONNECTICUT INSTITUTE OF ART...........             <50
            021491   PACE BUSINESS SCHOOL(THE)..............             <50
            011006   AMERICAN INSTITUTE OF DESIGN...........             <50
            021125   CALIFORNIA SCHOOL OF COURT REPORTING...             <50
            020661   OHIO STATE COLLEGE OF BARBER STYLING...             <50
            022621   HAIR PROFESSIONALS SCHOOL OF                        <50
                      COSMETOLOGY...........................
            022056   PALM BEACH BEAUTY & BARBER SCHOOL......             <50
            012929   SOUTH HILLS BEAUTY ACADEMY.............             <50
            012094   SOUTHWEST SCHOOL OF MEDICAL ASSISTANTS.             <50
            020791   MILE HIGH COLLEGE......................             <50
            022088   FIRST BUSINESS SCHOOL (THE)............             <50
            021127   NORTH HAVEN ACADEMY, LLC...............             <50
            022091   STAGE ONE THE HAIR SCHOOL..............             <50
            022752   PROFESSIONAL TRAINING INST (CLOSED)....             <50
            021346   GENERAL EDUCATION & TRAINING HOME STUDY             <50
            022759   MODERN WELDING SCHOOL, INC.............             <50
            022107   CAREER BEAUTY COLLEGE..................             <50
            011629   LEWIS INTERNATIONAL SCHOOL.............             <50
            022114   JAY TRUCK DRIVER TRAINING CENTER.......             <50
            021531   PAUL MITCHELL THE SCHOOL MURFREESBORO..             <50
            022119   CHEEKS BEAUTY ACADEMY..................             <50
            021003   MED-ASSIST SCHOOL OF HAWAII............             <50
            022132   UNIVERSAL ACADAMY OF HAIR DESIGN.......             <50
            012810   ASSOCIATED TECHNICAL INSTITUTE.........             <50
            010663   WILMA BOYD CAREER SCHOOLS..............             <50
            021581   GOLDEN STATE SCHOOL....................             <50
            012166   CAROUSEL BEAUTY COLLEGE................             <50
            012823   PAT GOINS RUSTON BEAUTY SCHOOL.........             <50
            022152   PHARR VOCATIONAL SCHOOL................             <50
            022920   DIESEL TRUCK DRIVER TRAIN SCHOOL.......             <50
            012202   GRIFFIN BELLEVUE BUSINESS COLLEGE......             <50
            021009   MEDICAL ARTS TRAINING CENTER...........             <50
            022168   CALIFORNIA INSTITUTE...................             <50
            012948   ROB ROY ACADEMY........................             <50
            021387   GROVE SCHOOL OF MUSIC..................             <50
            010887   CONNECTICUT BUSINESS INSTITUTE.........             <50
            011169   INTERNATIONAL TRAINING CENTER (CLOSED).             <50
            022975   OEHRLEIN SCHOOL OF COSMETOLOGY.........             <50
            020713   INTERNATIONAL CAREER INSTITUTE.........             <50
            020873   FIRST SCHOOL FOR CAREERS...............             <50
            022200   COLLEEN O'HARA'S BEAUTY ACADEMY........             <50
            022988   CONTINENTAL COLLEGE OF BEAUTY & BARBER              <50
                      STYLG.................................
            012295   JZ TREND ACADEMY PAUL MITCHELL PARTNER              <50
                      SCHOOL................................
            020878   ARTISTIC BEAUTY COLLEGE................             <50
            022204   CATHERINE HINDS INSTITUTE OF ESTHETICS.             <50
            023012   CHARLES ALLAN ACADEMY OF BEAUTY CULTURE             <50
            022206   BENEDICT SCHOOL OF LANGUAGES AND                    <50
                      COMMERCE..............................
            011912   NEW YORK BUSINESS SCHOOL...............             <50
            022216   DRET SCHOOL............................             <50
            023019   ALLIED MEDICAL AND TECHNICAL INSTITUTE.             <50
            021974   WOODBRIDGE BUSINESS INSTITUTE..........             <50
            022001   GUTI, THE PREMIER BEAUTY AND WELLNESS               <50
                      ACADEMY...............................
            021958   LICEO DE ARTE Y TECNOLOGIA.............             <50
            010150   FLORIDA BEAUTY COLLEGE.................             <50
            009567   TENNESSEE SCHOOL OF BEAUTY.............             <50
            004473   LOYOLA LAW SCHOOL......................             <50
            030073   OREGON COLLEGE OF ART & CRAFT..........             <50
            009877   HENRI'S SCHOOL OF HAIR DESIGN..........             <50
            042509   INTER AMERICAN UNIVERSITY OF PUERTO                 <50
                      RICO--SCHOOL OF LAW...................
            042501   SANTA BARBARA AND VENTURA COLLEGES OF               <50
                      LAW (THE).............................
            007550   NATIONAL EDUCATION CENTER KENTUCKY                  <50
                      COLLEGE OF TECHNOLOGY CAMPUS..........
            004493   SIERRA COLLEGE OF BUSINESS.............             <50
            005209   MILLER MOTTE BUSINESS COLLEGE..........             <50
            021187   LONG ISLAND COLLEGE HOSPITAL--SCHOOL OF             <50
                      NURSING...............................
            042527   PACIFIC RIM CHRISTIAN UNIVERSITY.......             <50
            036683   BIRTHINGWAY COLLEGE OF MIDWIFERY.......             <50
            007605   ACADEMY PACIFIC TRAVEL COLLEGE.........             <50
            042355   PRESIDIO GRADUATE SCHOOL...............             <50
            022345   BOISE BIBLE COLLEGE....................             <50
            041256   CAREER SCHOOL OF NY....................             <50
            042567   REFORMED UNIVERSITY....................             <50
            034224   COLLEGE OF BIBLICAL STUDIES-HOUSTON....             <50
            042609   MYSTROS BARBER ACADEMY.................             <50
            009515   J. MICHAEL HARROLD BEAUTY ACADEMY......             <50
            007619   MEDICAL INSTITUTE OF MINNESOTA.........             <50
            031805   EUGENIO MARIA DE HOSTOS SCHOOL OF LAW..             <50
            042655   ICOHS COLLEGE..........................             <50
            022747   MADISON SCHOOLS........................             <50
            007659   LA' JAMES COLLEGE OF HAIRSTYLING.......             <50
            007482   TAD TECHNICAL INSTITUTE................             <50
            007674   AMERICAN BEAUTY COLLEGE................             <50
            010122   PHAGANS' MEDFORD BEAUTY SCHOOL.........             <50
            005210   CLEVELAND INSTITUTE OF ELECTRONICS.....             <50
            023065   PROFESSIONAL BUSINESS COLLEGE..........             <50
            042771   YOUNG AMERICANS COLLEGE OF THE                      <50
                      PERFORMING ARTS (THE).................
            042415   WAVE LEADERSHIP COLLEGE................             <50
            007780   NEW CASTLE SCHOOL OF TRADES............             <50
            021597   NEW HOPE CHRISTIAN COLLEGE.............             <50
            007790   TRIPLE CITIES SCHOOL OF BEAUTY CULTURE.             <50
            021073   PENNSYLVANIA ACADEMY OF THE FINE ARTS..             <50
            037524   SUM BIBLE COLLEGE & THEOLOGICAL                     <50
                      SEMINARY..............................
            004487   CRISS COLLEGE..........................             <50
            030074   LAKESIDE SCHOOL OF MASSAGE THERAPY.....             <50
            009433   SHERMAN KENDALL'S ACADEMY OF BEAUTY                 <50
                      ARTS & SCIENCES.......................
            041285   SOUTHERN CATHOLIC COLLEGE..............             <50
            007459   PAIER COLLEGE OF ART...................             <50
            021689   KANSAS CHRISTIAN COLLEGE...............             <50
            025459   HYPNOSIS MOTIVATION INSTITUTE..........             <50
            006420   MONTCLAIR HOSPITAL LLC.................             <50
            009600   COSMETOLOGY CAREERS UNLIMITED COLLEGE               <50
                      OF HAIR, SKIN, AND NAILS..............
            007833   TRACEY-WARNER SCHOOL...................             <50
            009670   WRIGHT BEAUTY COLLEGE..................             <50
            021366   WISCONSIN LUTHERAN COLLEGE.............             <50
            009724   DELOUX SCHOOL OF COSMETOLOGY ESCONDIDO.             <50
            038553   ECCLESIA COLLEGE.......................             <50
            022749   VIRGINIA SCHOOLS.......................             <50
            007872   SAWYER COLLEGE AT PONOMA...............             <50
            009958   HICKS ACADEMY OF BEAUTY CULTURE........             <50
            007921   PAUL MITCHELL THE SCHOOL ARKANSAS......             <50
            034555   NATIONAL LABOR COLLEGE.................             <50
            001394   MORSE SCHOOL OF BUSINESS...............             <50
            004632   SPENCER COLLEGE........................             <50
            041545   STARTING POINTS........................             <50
            010130   WADE COLLEGE...........................             <50
            041212   INSTITUTE OF TAOIST EDUCATION AND                   <50
                      ACUPUNCTURE...........................
            025162   WESLEY BIBLICAL SEMINARY...............             <50
            008140   RICKERSON BEAUTY ACADEMY #5............             <50
            041433   ELLIS UNIVERSITY.......................             <50
            036953   COMMUNITY ENHANCEMENT SERVICES.........             <50
            032583   SOUTHERN METHODIST COLLEGE.............             <50
            008249   NATIONAL EDUCATION CENTER--BRYMAN                   <50
                      CAMPUS................................
            023164   INSTITUTO DE EDUCATION UNIVERSAL.......             <50
            008259   EDUCATORS OF BEAUTY COLLEGE OF                      <50
                      COSMETOLOGY...........................
            004710   KANSAS CITY BUSINESS COLLEGE...........             <50
            030282   TRINITY COLLEGE OF FLORIDA.............             <50
            010478   BLANTOS COLLEGE........................             <50
            007130   NEWBERRY SCHOOL OF BEAUTY..............             <50
            021601   GENEVA GENERAL HOSPITAL................             <50
            038565   FLORIDA SCHOOL OF TRADITIONAL MIDWIFERY             <50
            035033   WINNER INSTITUTE OF ARTS & SCIENCES....             <50
            022652   GLOBAL BUSINESS INSTITUTE..............             <50
            009380   NATIONAL EDUCATION CENTER TEMPLE SCHOOL             <50
                      CAMPUS................................
            008435   INTERBORO INSTITUTE....................             <50
            004962   DURHAM COLLEGE OF SAN ANTONIO..........             <50
            041331   CALIFORNIA UNIVERSITY OF MANAGEMENT AND             <50
                      SCIENCES..............................
            031163   OHIO COLLEGE OF MASSOTHERAPY...........             <50
            025054   ATLANTIC UNIVERSITY COLLEGE............             <50
            010643   NATIONAL SCHOOL OF HEALTH TECHNOLOGY...             <50
            041722   NORTHWESTERN INSTITUTE OF HEALTH AND                <50
                      TECHNOLOGY............................
            009457   GEORGE ROGERS CLARK COLLEGE............             <50
            008548   HICKOX SCHOOL OF INFORMATION TECHNOLOGY             <50
            004527   WASHINGTON SCHOOL OF SECRETARIES.......             <50
            008550   DRAUGHONS BUSINESS COLLEGE.............             <50
            031773   SAN JUAN BAUTISTA SCHOOL OF MEDICINE...             <50
            002543   DANA COLLEGE...........................             <50
            009535   STAUNTON SCHOOL OF COSMETOLOGY.........             <50
            030310   AMERICAN CENTER FOR CAREER TRAINING....             <50
            022740   BRANNON BUS INST.......................             <50
            031019   TRINITY BAPTIST COLLEGE................             <50
            037263   OHIO MID-WESTERN COLLEGE...............             <50
            034033   EPIC BIBLE COLLEGE.....................             <50
            009660   TIFFIN ACADEMY OF HAIR DESIGN..........             <50
            041795   NORTH AMERICAN UNIVERSITY..............             <50
            042236   ACADEMY OF INTERACTIVE ENTERTAINMENT...             <50
            003015   BLISS COLLEGE..........................             <50
            009713   ALASKA JUNIOR COLLEGE..................             <50
            008658   O'BRIENS AVEDA INSTITUTE...............             <50
            040733   JUNG TAO SCHOOL OF CLASSICAL CHINESE                <50
                      MEDICINE..............................
            038943   HUNTSVILLE BIBLE COLLEGE...............             <50
            023305   LAGUNA COLLEGE OF ART AND DESIGN.......             <50
            022664   CENTRAL CHRISTIAN COLLEGE OF THE BIBLE.             <50
            009831   MODEL COLLEGE OF HAIR DESIGN...........             <50
            007284   EDUTEK PROFESSIONAL COLLEGE............             <50
            004614   WICHITA BUSINESS COLLEGE...............             <50
            008885   FRANKLIN SCHOOL OF COSMELOTOGY & HAIR               <50
                      DESIGN................................
            022828   INTER AMERICAN UNIVERSITY OF PUERTO                 <50
                      RICO--FAJARDO CAMPUS..................
            030329   NORTHWEST INSTITUTE OF ACUPUNCTURE &                <50
                      ORIENTAL MEDICINE.....................
            020907   CLEVELAND UNIVERSITY-KANSAS CITY.......             <50
            008891   GORDON PHILLIPS BEAUTY SCHOOL..........             <50
            030070   FRONTIER NURSING UNIVERSITY............             <50
            007302   BUSINESS CAREER INSTITUTE..............             <50
            010078   ROSWELL COLLEGE OF COSMETOLOGY.........             <50
            008954   PITTSBURGH BEAUTY ACADEMY..............             <50
            010112   BRYAN INSTITUTE........................             <50
            041373   CAYCE/REILLY SCHOOL OF MASSAGE.........             <50
            010129   PHILLIPS JUNIOR COLLEGE OF SPARTANBURG.             <50
            008997   CDI CAREER DEVELOPEMENT INSTITUTE......             <50
            010145   ADVANCED BEAUTY COLLEGE................             <50
            041405   HORIZON UNIVERSITY.....................             <50
            010151   VINCENNES BEAUTY COLLEGE...............             <50
            039413   AVE MARIA UNIVERSITY...................             <50
            022230   CLAYTON UNIV...........................             <50
            004931   NETTLETON CAREER COLLEGE...............             <50
            010210   PROSPECT HALL SCHOOL OF BUSINESS.......             <50
            036763   FAMILY OF FAITH CHRISTIAN UNIVERSITY...             <50
            023357   BATON ROUGE GENERAL MEDICAL CENTER.....             <50
            021979   NORTH BENNET STREET SCHOOL.............             <50
            032513   BEACON UNIVERSITY......................             <50
            034114   INTERNATIONAL TRAINING CAREERS.........             <50
            007516   ULTISSMA BEAUTY INSTITUTE (CLOSED).....             <50
            004891   CHURCHMAN BUSINESS SCHOOL..............             <50
            010397   LAURENWOOD COLLEGE(CLOSED).............             <50
            030018   WELCH COLLEGE..........................             <50
            010406   JOSEF'S SCHOOL OF HAIR, SKIN & BODY....             <50
            009133   TEXAS INSTITUTE........................             <50
            021554   PENNSYLVANIA COLLEGE OF STRAIGHT                    <50
                      CHIROPRACTIC..........................
            009186   DEAN INSTITUTE OF TECHNOLOGY...........             <50
            010461   EDUCATION AMERICA-TOPEKA TECHNICAL                  <50
                      COLLEGE...............................
            041937   JOHN PAUL THE GREAT CATHOLIC UNIVERSITY             <50
            010465   LEARNING INSTITUTE FOR BEAUTY SCIENCES.             <50
            042171   RUDOLF STEINER COLLEGE.................             <50
            010500   DEBBIE'S SCHOOL OF BEAUTY CULTURE......             <50
            031121   DEWEY UNIVERSITY.......................             <50
            010571   CAPITOL BUSINESS COLLEGE...............             <50
            042174   HIGH TECH HIGH GRADUATE SCHOOL OF                   <50
                      EDUCATION.............................
            010622   BAILE SCHOOL OF BROADCASTING...........             <50
            010632   DEWOLFF HAIRSTYLING AND COSMETOLOGY                 <50
                      INSTITUTE.............................
            041440   FAIRFAX UNIVERSITY OF AMERICA..........             <50
            039823   VISIBLE MUSIC COLLEGE..................             <50
            007427   SOUTHWEST TECHNICAL COLLEGE............             <50
            032833   NORTHWEST HVAC/R ASSOCIATION & TRAINING             <50
            008860   SIT....................................             <50
            011941   AMERICAN UNIVERSITY OF PUERTO RICO.....             <50
            003694   SAINT MICHAEL'S COLLEGE................             <50
            003856   LAWRENCE UNIVERSITY....................             <50
            012744   SOUTHSIDE COLLEGE OF HEALTH SCIENCES...             <50
            003868   MILWAUKEE SCHOOL OF ENGINEERING........             <50
            009824   ROBERT MORRIS COLLEGE..................             <50
            003873   MOUNT SENARIO COLLEGE..................             <50
            003713   HAMPDEN SYDNEY COLLEGE.................             <50
            003875   NORTHLAND COLLEGE......................             <50
            003447   SPARTANBURG METHODIST COLLEGE..........             <50
            003892   ST NORBERT COLLEGE.....................             <50
            002644   UPSALA COLLEGE.........................             <50
            002587   SAINT ANSELM COLLEGE...................             <50
            003396   WILSON COLLEGE.........................             <50
            002930   GREENSBORO COLLEGE.....................             <50
            003406   PROVIDENCE COLLEGE.....................             <50
            002729   HARTWICK COLLEGE.......................             <50
            003704   BRIDGEWATER COLLEGE....................             <50
            003285   LANCASTER BIBLE COLLEGE................             <50
            011685   WENTWORTH TECHNICAL SCHOOL.............             <50
            003939   INTER AMERICAN UNIVERSITY OF PUERTO                 <50
                      RICO--AGUADILLA CAMPUS................
            012248   CENTRAL SCHOOL OF PRACTICAL NURSING....             <50
            002731   HOBART AND WILLIAM SMITH COLLEGES......             <50
            012525   CARIBBEAN UNIVERSITY...................             <50
            003109   OHIO WESLEYAN UNIVERSITY...............             <50
            003484   COVENANT COLLEGE.......................             <50
            003952   UNIVERSITY OF THE PACIFIC MCGEORGE                  <50
                      SCHOOL OF LAW.........................
            020771   MILWAUKEE INSTITUTE OF ART & DESIGN....             <50
            003505   MARYVILLE COLLEGE......................             <50
            003393   WESTMINSTER THEOLOGICAL SEMINARY.......             <50
            002453   CENTRAL METHODIST UNIVERSITY...........             <50
            003011   ART ACADEMY OF CINCINNATI..............             <50
            003511   MILLIGAN UNIVERSITY....................             <50
            003690   MARLBORO COLLEGE.......................             <50
            002380   SAINT MARY'S UNIVERSITY OF MINNESOTA...             <50
            002887   ALBANY MEDICAL COLLEGE.................             <50
            002668   ALFRED UNIVERSITY......................             <50
            002366   CROSSROADS COLLEGE.....................             <50
            002943   LOUISBURG COLLEGE......................             <50
            003709   EMORY & HENRY COLLEGE..................             <50
            004002   MCKENZIE COLLEGE.......................             <50
            003715   HOLLINS UNIVERSITY.....................             <50
            004181   ADVOCATE TRINITY HOSPITAL SCHOOL OF                 <50
                      RADIOLOGIC TECHNOLOGY.................
            011859   WORD OF LIFE BIBLE INSTITUTE...........             <50
            002812   TROCAIRE COLLEGE.......................             <50
            003440   NEWBERRY COLLEGE.......................             <50
            004529   TAMPA COLLEGE ST PETERSBURG CAMPUS.....             <50
            003785   PACIFIC LUTHERAN UNIVERSITY............             <50
            004641   DUNWOODY COLLEGE OF TECHNOLOGY.........             <50
            003804   WHITWORTH UNIVERSITY...................             <50
            003556   COMMONWEALTH INSTITUTE OF FUNERAL                   <50
                      SERVICE...............................
            002912   BREVARD COLLEGE........................             <50
            004886   ELECTRONIC INSTITUTES..................             <50
            003830   WEST VIRGINIA WESLEYAN COLLEGE.........             <50
            005029   INTER AMERICAN UNIVERSITY OF PUERTO                 <50
                      RICO--PONCE CAMPUS....................
            020637   SHERMAN COLLEGE OF STRAIGHT                         <50
                      CHIROPRACTIC..........................
            005310   PITTSBURGH INSTITUTE OF AERONAUTICS....             <50
            002717   ELIZABETH SETON COLLEGE................             <50
            006228   METHODIST COLLEGE......................             <50
            003389   WASHINGTON AND JEFFERSON COLLEGE.......             <50
            006257   SAINT ELIZABETH SCHOOL OF NURSING......             <50
            003647   TRINITY UNIVERSITY.....................             <50
            006273   MERCY COLLEGE OF HEALTH SCIENCES.......             <50
            003224   UNIVERSITY OF PORTLAND.................             <50
            006322   SIGNATURE HEALTHCARE BROCKTON HOSPITAL              <50
                      SCHOOL OF NURSING.....................
            009387   PERRY TECHNICAL INSTITUTE..............             <50
            002670   CLARKS SUMMIT UNIVERSITY...............             <50
            002572   COLBY-SAWYER COLLEGE...................             <50
            006389   GOLDFARB SCHOOL OF NURSING AT BARNES-               <50
                      JEWISH COLLEGE........................
            003686   GODDARD COLLEGE........................             <50
            006399   BRYAN COLLEGE OF HEALTH SCIENCES.......             <50
            010153   HELENE FULD COLLEGE OF NURSING.........             <50
            006404   NEBRASKA METHODIST COLLEGE OF NURSING &             <50
                      ALLIED HEALTH.........................
            003409   RHODE ISLAND SCHOOL OF DESIGN..........             <50
            006448   ELLIS MEDICINE, THE BELANGER SCHOOL OF              <50
                      NURSING...............................
            010501   LAKEVIEW COLLEGE OF NURSING............             <50
            006461   SAINT ELIZABETH MEDICAL CENTER.........             <50
            003695   TRINITY COLLEGE OF VERMONT.............             <50
            003564   EAST TEXAS BAPTIST UNIVERSITY..........             <50
            003703   BLUEFIELD COLLEGE......................             <50
            006477   CABARRUS COLLEGE OF HEALTH SCIENCES....             <50
            003708   EASTERN MENNONITE UNIVERSITY...........             <50
            002742   JUILLIARD SCHOOL (THE).................             <50
            003711   FERRUM COLLEGE.........................             <50
            006498   HURON SCHOOL OF NURSING................             <50
            003238   BUCKNELL UNIVERSITY....................             <50
            006612   COVENANT SCHOOL OF NURSING AND ALLIED               <50
                      HEALTH................................
            003733   RANDOLPH-MACON COLLEGE.................             <50
            002671   BARD COLLEGE...........................             <50
            011732   MAYO CLINIC COLLEGE OF MEDICINE AND                 <50
                      SCIENCE...............................
            003350   UNIVERSITY OF THE ARTS (THE)...........             <50
            011915   DRAKE BUSINESS SCHOOL..................             <50
            003151   OKLAHOMA WESLEYAN UNIVERSITY...........             <50
            002708   BARNARD COLLEGE........................             <50
            002458   COTTEY COLLEGE.........................             <50
            003778   GONZAGA UNIVERSITY.....................             <50
            002460   CULVER-STOCKTON COLLEGE................             <50
            002584   NOTRE DAME COLLEGE.....................             <50
            002960   SALEM COLLEGE..........................             <50
            003445   PRESBYTERIAN COLLEGE...................             <50
            007026   ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI             <50
            003041   DEFIANCE COLLEGE.......................             <50
            003180   SOUTHWESTERN CHRISTIAN UNIVERSITY......             <50
            003806   ALDERSON BROADDUS UNIVERSITY...........             <50
            003364   SAINT CHARLES BORROMEO SEMINARY........             <50
            002711   CORNELL UNIVERSITY.....................             <50
            007291   ST. LUKE'S COLLEGE.....................             <50
            003469   UNIVERSITY OF SIOUX FALLS..............             <50
            002832   SAINT THOMAS AQUINAS COLLEGE...........             <50
            003265   FRANKLIN & MARSHALL COLLEGE............             <50
            002978   WAKE FOREST UNIVERSITY.................             <50
            002450   CALVARY UNIVERSITY.....................             <50
            007330   CRANFORD COLLEGE.......................             <50
            020636   TAD TECHNICAL INSTITUTE KANSAS CITY....             <50
            002990   UNIVERSITY OF JAMESTOWN................             <50
            003839   CARTHAGE COLLEGE.......................             <50
            002524   WILLIAM JEWELL COLLEGE.................             <50
            020690   NEW YORK SCHOOL OF INTERIOR DESIGN.....             <50
            003206   MULTNOMAH UNIVERSITY...................             <50
            020758   SOUTHERN CALIFORNIA INSTITUTE OF                    <50
                      ARCHITECTURE (THE)....................
            003386   VALLEY FORGE MILITARY COLLEGE..........             <50
            003208   BUSHNELL UNIVERSITY....................             <50
            008843   ALASKA BIBLE COLLEGE...................             <50
            002275   KALAMAZOO COLLEGE......................             <50
            030954   BOND UNIVERSITY........................             <50
            002023   UNIVERSITY OF HOLY CROSS...............             <50
            001689   ILLINOIS COLLEGE OF OPTOMETRY..........             <50
            008920   UNIVERSITY OF NOTTINGHAM...............             <50
            011780   BRUNEL UNIVERSITY LONDON...............             <50
            001515   ROLLINS COLLEGE........................             <50
            001700   JUDSON UNIVERSITY......................             <50
            041527   Astrodome Career Centers...............             <50
            001704   KNOX COLLEGE...........................             <50
            009225   Texas State Technical College Harlingen             <50
            001706   LAKE FOREST COLLEGE....................             <50
            001604   YOUNG HARRIS COLLEGE...................             <50
            042439   University of Texas Health Science                  <50
                      Center at Tyler (The).................
            002343   COLLEGE OF SAINT SCHOLASTICA...........             <50
            012539   University of The Arts London IDO--                 <50
                      Central Saint Martins College.........
            001986   SUE BENNETT COLLEGE....................             <50
            002254   Michigan State University College of                <50
                      Law...................................
            012206   JAMES COOK UNIVERSITY..................             <50
            038073   ROSE BRUFORD COLLEGE OF THEATRE AND                 <50
                      PERFORMANCE...........................
            008373   TEL AVIV UNIVERSITY....................             <50
            001241   Monterey Institute of International                 <50
                      Studies...............................
            002133   BRANDEIS UNIVERSITY....................             <50
            001278   SAN FRANCISCO CONSERVATORY OF MUSIC....             <50
            002154   HELLENIC COLLEGE & HOLY CROSS GREEK                 <50
                      ORTHODOX SCHOOL OF THEOLOGY...........
            038463   PACIFIC LIFE BIBLE COLLEGE.............             <50
            003044   Trinity Lutheran Seminary..............             <50
            038974   INTERNATIONAL SPACE UNIVERSITY.........             <50
            010594   RICHMOND, THE AMERICAN INTERNATIONAL                <50
                      UNIVERSITY IN LONDON..................
            004749   Bryant & Stratton Business Institute-               <50
                      Albany................................
            010720   RYERSON UNIVERSITY.....................             <50
            040703   RAPHAEL RECANATI INTERNATIONAL SCHOOL,              <50
                      THE INTERDISCIPLINARY CENTER..........
            001688   ILLINOIS COLLEGE.......................             <50
            001305   STANFORD UNIVERSITY....................             <50
            005526   South Central Louisiana Technical                   <50
                      College...............................
            042188   REGENT'S UNIVERSITY LONDON.............             <50
            030333   MANCHESTER METROPOLITAN UNIVERSITY                  <50
                      (THE).................................
            025798   New England School of Acupuncture......             <50
            006839   UNIVERSITY OF EDINBURGH................             <50
            002228   Wheelock College.......................             <50
            001549   ATLANTA COLLEGE OF ART.................             <50
            021810   UNIVERSITY OF SOUTH AUSTRALIA..........             <50
            001122   BIOLA UNIVERSITY.......................             <50
            023393   ERASMUS UNIVERSITY ROTTERDAM (EUR).....             <50
            030843   UNIVERSITY OF LIMERICK.................             <50
            001341   WESTMONT COLLEGE.......................             <50
            011950   Corcoran College of Art and Design.....             <50
            001778   VANDERCOOK COLLEGE OF MUSIC............             <50
            002140   COLLEGE OF OUR LADY OF THE ELMS........             <50
            020774   North Lake College.....................             <50
            002151   BENJAMIN FRANKLIN INSTITUTE OF                      <50
                      TECHNOLOGY............................
            021019   ROEHAMPTON UNIVERSITY..................             <50
            008693   CITY, UNIVERSITY OF LONDON.............             <50
            003088   Ohio College of Podiatric Medicine.....             <50
            009249   UNIVERSITY OF LIVERPOOL (THE)..........             <50
            031273   Omaha School of Massage and Healthcare              <50
                      of Herzing University.................
            010188   UNIVERSITY COLLEGE DUBLIN, NATIONAL                 <50
                      UNIVERSITY OF IRELAND, DUBLIN.........
            038505   MEDICAL UNIVERSITY OF LODZ.............             <50
            001200   FULLER THEOLOGICAL SEMINARY............             <50
            001798   FRANKLIN COLLEGE OF INDIANA............             <50
            010709   Empire Beauty School-Lakewood..........             <50
            001799   GOSHEN COLLEGE.........................             <50
            024579   University of Kansas Medical Center....             <50
            001385   FAIRFIELD UNIVERSITY...................             <50
            002341   COLLEGE OF SAINT BENEDICT..............             <50
            021069   American Academy of Dramatic Arts-West.             <50
            002357   LUTHER SEMINARY........................             <50
            013094   Bellingham Beauty School...............             <50
            001099   HENDRIX COLLEGE........................             <50
            001823   ANABAPTIST MENNONITE BIBLICAL SEMINARY.             <50
            001100   JOHN BROWN UNIVERSITY..................             <50
            001834   CALUMET COLLEGE OF SAINT JOSEPH........             <50
            006688   UNIVERSITY OF TORONTO..................             <50
            001835   SAINT MARY OF THE WOODS COLLEGE........             <50
            030295   UNIVERSITY OF NORTHUMBRIA AT NEWCASTLE.             <50
            001012   BIRMINGHAM-SOUTHERN COLLEGE............             <50
            006692   UNIVERSITY OF LEEDS....................             <50
            021948   UNIVERSITY OF THE WEST OF ENGLAND,                  <50
                      BRISTOL...............................
            006697   QUEEN MARY UNIVERSITY OF LONDON........             <50
            001840   UNIVERSITY OF NOTRE DAME...............             <50
            002039   COLBY COLLEGE..........................             <50
            001852   CLARKE UNIVERSITY......................             <50
            009707   Lexington Community Community..........             <50
            001855   DES MOINES UNIVERSITY--OSTEOPATHIC                  <50
                      MEDICAL CENTER........................
            002073   GOUCHER COLLEGE........................             <50
            021567   Florida Christian College..............             <50
            030672   UNIVERSITY OF SYDNEY...................             <50
            001690   Dr William M Scholl College of                      <50
                      Podiatric Medicine at Finch University
            011808   Empire Beauty School--Flagstaff........             <50
            022164   TYNDALE UNIVERSITY.....................             <50
            002116   ANDOVER NEWTON THEOLOGICAL SCHOOL......             <50
            001876   MARYCREST INTERNATIONAL UNIVERSITY.....             <50
            002121   BABSON COLLEGE.........................             <50
            001879   MORNINGSIDE UNIVERSITY.................             <50
            008376   VRIJE UNIVERSITEIT AMSTERDAM...........             <50
            030219   EDIC College...........................             <50
            008450   KASTURBA MEDICAL COLLEGE...............             <50
            011881   California School of Professional                   <50
                      Psychology, Alameda...................
            002139   CLARK UNIVERSITY.......................             <50
            001894   VENNARD COLLEGE........................             <50
            008452   ABERYSTWYTH UNIVERSITY.................             <50
            001896   WARTBURG COLLEGE.......................             <50
            008461   UNIVERSITY OF SAINT ANDREWS............             <50
            039743   ST. GEORGE'S UNIVERSITY, SCHOOL OF                  <50
                      VETERINARY MEDICINE...................
            002153   GORDON COLLEGE.........................             <50
            001462   WASHINGTON BIBLE COLLEGE...............             <50
            008665   UNIVERSITY OF KENT.....................             <50
            001905   BETHEL COLLEGE.........................             <50
            008908   UNIVERSITY OF BIRMINGHAM (THE).........             <50
            001908   CENTRAL CHRISTIAN COLLEGE OF KANSAS....             <50
            009932   Texas State Technical College West                  <50
                      Texas.................................
            001914   DONNELLY COLLEGE.......................             <50
            010157   CARDIFF UNIVERSITY.....................             <50
            001567   Gainesville State College..............             <50
            001597   TRUETT MCCONNELL UNIVERSITY............             <50
            022736   QUEEN'S UNIVERSITY OF BELFAST (THE)....             <50
            001600   WESLEYAN COLLEGE.......................             <50
            007590   Lakeland Medical & Dental Academy......             <50
            033333   MEDICAL UNIVERSITY OF LUBLIN...........             <50
            001939   NEWMAN UNIVERSITY......................             <50
            002248   CRANBROOK ACADEMY OF ART...............             <50
            001061   ALASKA PACIFIC UNIVERSITY..............             <50
            002253   DAVENPORT UNIVERSITY--EASTERN REGION...             <50
            001062   SHELDON JACKSON COLLEGE................             <50
            034567   Crossroads Bible College...............             <50
            001945   STERLING COLLEGE.......................             <50
            010599   INSTITUT D'ETUDES POLITIQUES DE PARIS..             <50
            023473   UNIVERSIDAD DE CIENCIAS MEDICAS                     <50
                      (UCIMED)..............................
            020979   University of New Hampshire School of               <50
                      Law...................................
            001487   ECKERD COLLEGE.........................             <50
            033503   BOURNEMOUTH UNIVERSITY.................             <50
            001953   ASBURY THEOLOGICAL SEMINARY............             <50
            010816   KINGSTON UNIVERSITY....................             <50
            012732   Laurel Technical College...............             <50
            001684   GREENVILLE UNIVERSITY..................             <50
            025457   GLASGOW SCHOOL OF ART..................             <50
            001961   CENTRE COLLEGE OF KENTUCKY.............             <50
            030294   UNIVERSITY OF KEELE....................             <50
                    --------------------------------------------------------
                     Grand Total............................         201,900
    ------------------------------------------------------------------------

        Question. For each of the years 2016, 2017, 2018, 2019,
    2020, 2021, and 2022, 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. Information regarding the group discharge requests
    from attorneys general is provided in the enclosed file.

               Group Submissions by Attorneys General Seeking Relief for Constituents as of July 14, 2022
    ----------------------------------------------------------------------------------------------------------------
                           DIPLOMA PROGRAM(S) IF     ATTORNEY
     SCHOOL/SCHOOL GROUP         APPLICABLE           GENERAL          STATE          STATUS       SUBMISSION DATE
    ----------------------------------------------------------------------------------------------------------------
    American Career                               Maura Healy     Massachusetts   Granted                  7/20/2016
     Institute                                                                                             7/26/2016
                                                                                                            8/3/2016
                                                                                                           8/12/2016
                                                                                                          11/16/2016
                                                                                                          11/23/2016
                                                                                                            1/3/2017
    rrrrrrrrrrrrrrrrrrrrrr
    Anthem University                             Lori Swanson    Minnesota       Under                     5/3/2016
                                                                                   Consideratio            7/22/2016
                                                                                   n                      10/19/2016
                                                                                                           2/13/2017
                                                                                                            3/9/2017
                                                                                                            4/4/2017
    rrrrrrrrrrrrrrrrrrrrrr
    CEHE                   Submission for         Phillip J.      Colorado        Under                    6/30/2022
                            discharge for          Weiser                          Consideratio
                            students who                                           n
                            enrolled in Colorado
                            between 2006-2021
    rrrrrrrrrrrrrrrrrrrrrr
    Corinthian Colleges,                          Maura Healy     Massachusetts   Granted                 11/30/2015
     Inc.
    rrrrrrrrrrrrrrrrrrrrrr
    Corinthian Colleges,                          Brad Schimel    Wisconsin       Granted                   2/4/2016
     Inc.
    rrrrrrrrrrrrrrrrrrrrrr
    Corinthian Colleges,                          Lisa Madigan    Illinois        Granted                 12/16/2016
     Inc.                  Dental Assistant       Kwame Raoul                                               6/3/2019
                           Electrician
                           Massage Therapy
                           Medical
                            Administrative
                            Assistant
                           Medical Assistant
                           Medical Insurance
                            Billing and Coding
                           Pharmacy Technician
    rrrrrrrrrrrrrrrrrrrrrr
    Corinthian Colleges,                          Bob Ferguson    Washington      Granted                 12/20/2016
     Inc.
    rrrrrrrrrrrrrrrrrrrrrr
    Corinthian Colleges,   Submission for         Lisa Madigan    Illinois        Granted                   6/5/2017
     Inc.                   discharge for         Bob Ferguson    Washington
                            students enrolled at  Maura Healy     Massachusetts
                            programs covered by   Xavier Becerra  California
                            the Department's job  George Jepsen   Connecticut
                            placement rate        Matthew Dean    Delaware
                            misrepresentation     Douglas Chin    Hawaii
                            findings.             Tom Miller      Iowa
                                                  Andy Beshear    Kentucky
                                                  Brian E. Frosh  Maryland
                                                  Janet T. Mills  Maine
                                                  Lori Swanson    Minnesota
                                                  Jim Hodd        Mississippi
                                                  Hector          New Mexico
                                                   Balderas       New York
                                                  Eric T.         Oregon
                                                   Schneiderman   Pennsylvania
                                                  Ellen F.        Virginia
                                                   Rosenblum      District of
                                                  Josh Shapiro     Columbia
                                                  Mark R.
                                                   Herring
                                                  Karl A. Racine
    rrrrrrrrrrrrrrrrrrrrrr
    Court Reporting        Submission for         Bob Ferguson    Washington      Partially                 11/21/16
     Institute              discharge for                                          Granted
                            students enrolled at
                            CRI's Seattle and
                            Tacoma campuses.
    rrrrrrrrrrrrrrrrrrrrrr
    Education Corporation  Submission for         Josh Shapiro    Pennsylvania    Under                    4/28/2022
     of America (Virginia   discharge for         Brian E. Frosh  Maryland         Consideratio
     College, Brightwood,   students enrolled     Rob Bonta       California       n
     Brightwood Career      between June 2016     Phillip J.      Colorado
     Institute, Golf        and its closure in     Weiser         Virginia
     Academy of America     December 2018.        Jason Miyares   Alabama
     and Ecotech                                  Steve Marshall  ..............
     Institute)
    rrrrrrrrrrrrrrrrrrrrrr
    Globe University &                            Lori Swanson    Minnesota       Partially                 6/7/2016
     Minnesota School of                                                           Granted
     Business
    rrrrrrrrrrrrrrrrrrrrrr
    Illinois Institute of  Submission requests    Kwame Raoul     Illinois        Under                     6/3/2019
     Art and Art            students have any     Phil Weiser     Colorado         Consideratio
     Institute of           federal student loan                                   n
     Colorado               used to pay for
                            schooling at the
                            affected campuses
                            from January 1, 2018
                            onward discharged
                            and any amounts paid
                            on those loans
                            refunded.
    rrrrrrrrrrrrrrrrrrrrrr
    ITT Technical          Submission for         Phillip J.                      .............             4/1/2021
     Institute              discharge for all      Weiser         Colorado
                            borrowers who         Ellen F.        Oregon
                            enrolled at ITT        Rosenblum      Minnesota
                            between 2007 and      Keith Ellison   District of
                            2010 (or who assumed  Karl A. Racine   Columbia
                            federal loan debt     Bob Ferguson    Washington
                            for another person    Gurbir S.       New Jersey
                            who enrolled at ITT    Grewal         Vermont
                            between 2007 and      Thomas J.
                            2010). During this     Donovan, Jr.
                            time, ITT misled      Stephen H.
                            students about the     Levins         Hawaii
                            value of an ITT        (Executive     Maryland
                            degree using its       Director,      Idaho
                            Value Proposition      State of       Illinois
                            Document.              Hawaii Office  Pennsylvania
                                                   of Consumer    Iowa
                                                   Affairs)       Virginia
                                                  Brian E. Frosh  Maine
                                                  Lawrence G.     Kansas
                                                   Wasden         New Mexico
                                                  Kwame Raoul     North Carolina
                                                  Josh Shapiro    New York
                                                  Tom Miller      Massachusetts
                                                  Mark Herring    Nebraska
                                                  Aaron M. Frey   Wisconsin
                                                  Derek Schmidt   Connecticut
                                                  Hector          Nevada
                                                   Balderas       Tennessee
                                                  Josh Stein
                                                  Letitia James
                                                  Maura Healey
                                                  Douglas
                                                   Peterson
                                                  Joshua L. Kaul
                                                  William Tong
                                                  Aaron D. Ford
                                                  Herbert
                                                   Slatery, III
    rrrrrrrrrrrrrrrrrrrrrr
    Kaplan University      Medical Assistant      Maura Healy     Massachusetts   Under                     5/6/2016
                           Medical Billing and                                     Consideratio            5/31/2016
                            Coding                                                 n
    rrrrrrrrrrrrrrrrrrrrrr
    Lincoln Technical      Criminal Justice       Maura Healy     Massachusetts   Under                    1/14/2016
     Institute                                                                     Consideratio
                                                                                   n
    rrrrrrrrrrrrrrrrrrrrrr
    New England Institute  Submission for         Maura Healey    Massachusetts   Under                    3/25/2022
     of Art/EDMC            borrowers who                                          Consideratio
                            attended from 1999-                                    n
                            2015
    rrrrrrrrrrrrrrrrrrrrrr
    Premier Education      N/A                    Maura Healey    Massachusetts   Under              October 3, 2019
     Group                                                                         Consideratio    November 22, 2019
                                                                                   n
                                                                                  Under
                                                                                   Consideratio
                                                                                   n
    rrrrrrrrrrrrrrrrrrrrrr
    Westwood College       Criminal Justice       Lisa Madigan    Illinois        Under                   12/13/2016
                                                  Kwame Raoul                      Consideratio             6/3/2019
                                                                                   n
    rrrrrrrrrrrrrrrrrrrrrr
    Westwood College       N/A                    Phil Weiser     Colorado        Under              August 27, 2020
                                                                                   Consideratio
                                                                                   n
    ----------------------------------------------------------------------------------------------------------------
    The table provides a list of all attorneys general submissions related to groups of borrowers for which the
      attorneys general seek a borrower defense discharge as of April 12, 2021. The table includes the submission
      date, the attorneys general, the school, and the diploma program, if applicable. If a diploma program is not
      provided for a submission, the submission was not limited to a specific program.
    Please note that under the Department's regulations, it is within the Secretary's discretion to create a group
      discharge process and define the parameters of the group. The Department cannot provide the number of
      borrowers that will be included in a certain group unless and until a group is established and defined by the
      Secretary. However, individual applications submitted by attorneys general have been, and will continue to be,
      considered under the individual application review process.

        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. Please see the AG group submission list provided in (d).
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, 2021,
    and 2022, how many borrowers covered by a group discharge application
    are in default on their Federal student loans?
        Answer. (f) 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, 2021,
    and 2022, how many loans of the borrowers covered by a group discharge
    application have been certified by the Department of Education for
    Treasury offset? 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 16(f), above.
        Question. For each of the years 2016, 2017, 2018, 2019, 2020, 2021,
    and 2022, 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 16(f), above.
        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 March 31,
    2022, derived from LOC data recorded in the Department's eZ-Audit
    system and Postsecondary Education Participants System. As of March 31,
    2022, the Department held LOCs and other surety from 339 institutions,
    totaling approximately $587 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 March 31, 2022. The second tab
    provides the field definitions and descriptions of the reasons why a
    LOC was requested from a listed institution. The report does not
    provide historical context for the LOCs held as of March 31, 2022, 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.

    --------------------------------------------------------------------------------------------------------------------------------------------------------
                      Institution            Institution     Submission      LOC Request     LOC Reason    LOC Received                        LOC Percent
         OPE ID           Name       State      Type        Fiscal Year          Date        Requested         Date           LOC Amount         Funding
    --------------------------------------------------------------------------------------------------------------------------------------------------------
          04295000   Buckinghamshi          Foreign           05/07/2021       05/07/2021   Failed           06/25/2021         $180,026.00              50
                      re New                 Public                                          Numeric
                      University                                                             Test
    rrrrrrrrrrrrrrrr
          00836500   Concordia              Foreign           04/30/2020       05/10/2021   Failed           05/18/2021          889,100.00              50
                      University             Private                                         Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02235300   London                 Foreign           07/31/2019       10/21/2021   Failed           11/03/2021          581,702.00              50
                      Metropolitan           Private                                         Numeric
                      University                                                             Test
    rrrrrrrrrrrrrrrr
          03900300   Medical                Foreign For       04/30/2020       12/18/2020   Failed           02/04/2021        1,961,452.00              10
                      University             Profit                                          Numeric
                      of the                                                                 Test
                      Americas
    rrrrrrrrrrrrrrrr
          02180500   Middlesex              Foreign           07/31/2019       06/25/2020   Failed Past      08/27/2020           80,595.00              10
                      University             Private                                         Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          01276600   National               Foreign           09/30/2019                                     11/02/2021          179,609.00              10
                      University             Private
                      of Ireland,
                      Galway
    rrrrrrrrrrrrrrrr
          02087900   Oxford                 Foreign           07/31/2019                                     06/07/2021          650,557.00              50
                      Brookes                Private
                      University
    rrrrrrrrrrrrrrrr
          04075300   Quest                  Foreign           04/30/2020       04/15/2021   Failed           05/20/2021          278,835.00              50
                      University             Private                                         Numeric
                      Canada                                                                 Test
    rrrrrrrrrrrrrrrr
          01059400   Richmond, The          Foreign           07/31/2019       07/23/2020   Failed Past      01/11/2021          376,231.00              10
                      American               Private                                         Performanc
                      Internationa                                                           e
                      l University                                                           Requiremen
                      in London                                                              ts
    rrrrrrrrrrrrrrrr
          03824300   Royal                  Foreign           07/31/2020       03/12/2021   Failed Past      04/27/2021        1,555,221.00              10
                      Veterinary             Private                                         Performanc
                      College                                                                e
                      (The),                                                                 Requiremen
                      University                                                             ts
                      of London
    rrrrrrrrrrrrrrrr
          03780300   Saba                   Foreign For       04/30/2020       12/18/2020   Failed           02/04/2021        1,693,419.00              10
                      University             Profit                                          Numeric
                      School of                                                              Test
                      Medicine
    rrrrrrrrrrrrrrrr
          02233300   St. George's           Foreign For       06/30/2020       05/17/2021   Failed           06/15/2021       35,827,740.00              10
                      University,            Profit                                          Numeric
                      School of                                                              Test
                      Medicine
    rrrrrrrrrrrrrrrr
          03974300   St. George's           Foreign For       06/30/2020       05/17/2021   Failed           06/15/2021        4,517,661.00              10
                      University,            Profit                                          Numeric
                      School of                                                              Test
                      Veterinary
                      Medicine
    rrrrrrrrrrrrrrrr
          03764300   St. Matthew's          Foreign For       04/30/2020       12/18/2020   Failed           02/04/2021          854,655.00              10
                      University             Profit                                          Numeric
                      School of                                                              Test
                      Medicine
    rrrrrrrrrrrrrrrr
          04275700   Staffordshire          Foreign           04/30/2020       03/01/2021   Failed           06/29/2021          240,744.00              50
                      University             Private                                         Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00858600   Swansea                Foreign           07/31/2019       07/24/2020   Failed Past      09/28/2020          110,772.00              10
                      University             Private                                         Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00670400   University             Foreign           09/30/2019                                     08/07/2020          150,509.00              10
                      College Cork           Private
    rrrrrrrrrrrrrrrr
          01018800   University             Foreign           09/30/2019       03/06/2020   Failed Past      08/28/2020        1,300,626.00              10
                      College                Private                                         Performanc
                      Dublin,                                                                e
                      National                                                               Requiremen
                      University                                                             ts
                      of Ireland,
                      Dublin
    rrrrrrrrrrrrrrrr
          03728300   University of          Foreign           07/31/2018       03/28/2019   Failed Past      03/28/2019           38,262.00              10
                      Derby                  Private                                         Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00684200   University of          Foreign           09/30/2019                                     07/23/2021          429,909.00              10
                      Dublin                 Private
                      Trinity
                      College
    rrrrrrrrrrrrrrrr
          03045000   University of          Foreign           07/31/2019       01/14/2021   Failed Past      03/05/2021          375,189.00              10
                      East London            Private                                         Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00868700   University of          Foreign           07/31/2019       07/15/2020   Failed Past      08/25/2020          312,501.00              10
                      Essex                  Private                                         Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          01045600   University of          Foreign           09/30/2018       03/01/2018   Failed Past      05/01/2018           25,862.00              10
                      Haifa                  Private                                         Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02229100   University of          Foreign           07/31/2020       05/15/2021   Failed           07/09/2021          326,390.00              50
                      Leicester              Private                                         Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03084300   University of          Foreign           09/28/2021                                     09/28/2021          167,476.00              10
                      Limerick               Private
    rrrrrrrrrrrrrrrr
          00669400   University of          Foreign           07/31/2019       08/10/2020   Failed           06/15/2021          372,092.00              10
                      London--Scho           Private                                         Numeric
                      ol of                                                                  Test
                      Oriental &
                      African
                      Studies
    rrrrrrrrrrrrrrrr
          04230700   University of          Foreign           07/31/2020       03/22/2021   Failed           04/28/2021          173,766.00              50
                      the                    Private                                         Numeric
                      Highlands                                                              Test
                      and Islands
    rrrrrrrrrrrrrrrr
          03945300   University of          Foreign           07/31/2020       05/15/2021   Failed           05/18/2021          314,737.00              50
                      West London            Private                                         Numeric
                      (The)                                                                  Test
    rrrrrrrrrrrrrrrr
          04138600   Alaska            AK   Non Profit        05/31/2020       05/17/2021   Failed Past      06/29/2021           69,945.00              10
                      Christian                                                              Performanc
                      College                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02341000   Fortis            AL   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        2,351,760.00              15
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03361400   Fortis            AL   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021          540,768.00              15
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00105000   Tuskegee          AL   Non Profit        06/30/2019       09/29/2020   Untimely         11/17/2020            8,126.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          00109500   Crowley's         AR   Non Profit        06/30/2020                                     12/21/2021          170,000.00              10
                      Ridge
                      College
    rrrrrrrrrrrrrrrr
          04233100   Arizona           AZ   Proprietary       04/30/2019                                     09/14/2020          278,992.00              25
                      School of
                      Integrative
                      Studies
    rrrrrrrrrrrrrrrr
          04175300   Penrose           AZ   Proprietary       12/31/2020       02/09/2022   New Owner        02/16/2022          512,893.00              25
                      Academy                                                                Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          01168900   Refrigeration     AZ   Proprietary       09/30/2020       12/15/2021   Failed           12/28/2021        4,800,032.00              10
                      School (The)                                                           Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04244900   Sonoran           AZ   Proprietary       12/31/2020       03/09/2022   Failed           02/24/2022        2,896,951.00              27
                      Desert                                                                 Numeric
                      Institute                                                              Test
    rrrrrrrrrrrrrrrr
          03736300   Advance             CA Proprietary       12/31/2019       07/07/2020   Untimely         07/20/2020           11,428.00              25
                      Beauty                                                                 Refunds
                      College
    rrrrrrrrrrrrrrrr
          04206800   Advance             CA Proprietary       12/31/2020       06/29/2021   Failed Past      08/04/2021          140,477.00              15
                      Beauty Techs                                                           Performanc
                      Academy                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04206800   Advance             CA Proprietary       12/31/2020       06/29/2021   Failed Past      12/27/2018           48,145.00               5
                      Beauty Techs                                                           Performanc
                      Academy                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04243100   Alhambra            CA Proprietary       12/31/2019       02/02/2022   Failed Past      03/01/2022           35,770.00              10
                      Medical                                                                Performanc
                      University                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04227100   America             CA Non Profit        06/30/2020       02/05/2021   Failed Past      03/09/2021            9,132.00              10
                      Evangelical                                                            Performanc
                      University                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04265600   American            CA Proprietary       12/31/2019       04/22/2021   Failed           09/21/2021           14,243.00              10
                      Fitness and                                                            Numeric
                      Nutrition                                                              Test
                      Academy
    rrrrrrrrrrrrrrrr
          04159700   American            CA Proprietary       12/31/2019       01/07/2021   Failed           04/27/2021           90,942.00              10
                      Medical                                                                Numeric
                      Sciences                                                               Test
                      Center
    rrrrrrrrrrrrrrrr
          03532400   ATA College         CA Proprietary       12/31/2020       01/05/2022   Failed           03/10/2022           68,626.00              10
                                                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03740400   ATI College         CA Proprietary       12/31/2020       05/19/2021   Failed Past      06/11/2021           52,565.00              10
                                                                                             Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04223700   Bay Area            CA Proprietary       12/31/2020       12/29/2021   Failed           01/04/2022          172,069.00              15
                      Medical                                                                Numeric
                      Academy                                                                Test
    rrrrrrrrrrrrrrrr
          02218800   Brookline           CA Proprietary                        07/31/2020   New Owner        08/25/2020        8,497,839.00              25
                      College                                                                Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04277700   California          CA Proprietary       12/31/2020                                     12/29/2020           18,027.00              25
                      College of
                      Barbering
                      and
                      Cosmetology
    rrrrrrrrrrrrrrrr
          03097700   Central             CA Proprietary       12/31/2019       10/09/2020   Untimely         11/17/2020           13,329.00              25
                      California                                                             Refunds
                      School of
                      Continuing
                      Education
    rrrrrrrrrrrrrrrr
          00116500   Church              CA Non Profit        06/30/2019                                     08/18/2021          254,189.00              50
                      Divinity
                      School of
                      the Pacific
    rrrrrrrrrrrrrrrr
          00128800   Claremont           CA Non Profit        06/30/2020       08/16/2021   Failed           09/27/2021          988,781.00              50
                      School of                                                              Numeric
                      Theology                                                               Test
    rrrrrrrrrrrrrrrr
          03874400   Community           CA Non Profit        06/30/2019       11/09/2020   Failed           02/02/2021          294,114.00              50
                      Christian                                                              Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          04175400   Elite               CA Proprietary       03/31/2021                                     05/07/2020           15,201.00              25
                      Cosmetology
                      School
    rrrrrrrrrrrrrrrr
          00120000   Fuller              CA Non Profit        06/30/2020       05/25/2021   Untimely         06/22/2021           37,792.00              25
                      Theological                                                            Refunds
                      Seminary
    rrrrrrrrrrrrrrrr
          04141700   Healing Hands       CA Proprietary       12/31/2019       05/17/2021   Untimely         07/16/2021            8,979.00              25
                      School of                                                              Refunds
                      Holistic
                      Health
    rrrrrrrrrrrrrrrr
          04217500   J D Academy         CA Proprietary       12/31/2019       10/09/2020   New Owner        12/15/2020          192,562.00              25
                      of Salon and                                                           Missing 2
                      Spa                                                                    yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04001300   Los Angeles         CA Proprietary                        02/28/2022   New Owner        03/22/2022          161,819.00              25
                      College of                                                             Missing 2
                      Aesthetics                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04037300   Los Angeles         CA Proprietary       12/31/2020       12/10/2021   Untimely         01/18/2021          713,469.00              25
                      Film School                                                            Refunds
                      (The)
    rrrrrrrrrrrrrrrr
          01186600   Lu Ross             CA Proprietary       12/31/2020       09/29/2021   Failed           11/29/2021          729,205.00              50
                      Academy                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02161800   Musicians           CA Proprietary       09/30/2020       08/01/2021   Failed           08/24/2021        1,187,454.00              10
                      Institute                                                              Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03027700   Pacific             CA Proprietary       12/31/2020       09/01/2021   Untimely         10/18/2021           30,649.00              25
                      College of                                                             Refunds
                      Health and
                      Science
    rrrrrrrrrrrrrrrr
          00125800   Pacific Union       CA Non Profit        06/30/2019       12/14/2021   Failed           02/16/2022        4,565,247.00              25
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03973300   SAE                 CA Proprietary       06/30/2021       01/04/2022   Failed           02/08/2022        1,002,608.00              25
                      Expression                                                             Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          00130200   Saint Mary's        CA Non Profit        06/30/2020       09/17/2020   Untimely         10/13/2020            9,175.00              25
                      College of                                                             Refunds
                      California
    rrrrrrrrrrrrrrrr
          01203100   San Diego           CA Non Profit        06/30/2020       02/22/2022   Failed           03/08/2022          634,624.00              11
                      Christian                                                              Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          00394800   San Francisco       CA Non Profit        06/30/2019       07/02/2021   Other            02/18/2022           26,465.00              10
                      Art
                      Institute
    rrrrrrrrrrrrrrrr
          02267600   Sofia               CA Proprietary       06/30/2020       03/02/2021   Failed           04/20/2021          497,455.00              17
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02267600   Sofia               CA Proprietary       06/30/2020       03/02/2021   Failed           04/20/2021          248,757.00               9
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02267600   Sofia               CA Proprietary       06/30/2020       03/02/2021   Failed           04/20/2021          690,540.00              24
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04298200   Southern            CA Proprietary       12/31/2020       07/01/2021   Failed           07/30/2021          219,925.00              50
                      California                                                             Numeric
                      College of                                                             Test
                      Barber and
                      Beauty
    rrrrrrrrrrrrrrrr
          02596400   Spartan             CA Proprietary       12/31/2020       01/04/2022   Failed           01/25/2022          938,422.00              10
                      College of                                                             Numeric
                      Aeronautics                                                            Test
                      & Technology
    rrrrrrrrrrrrrrrr
          04195400   Unitek              CA Proprietary       12/31/2020                                     09/21/2021        1,433,089.00              25
                      College
    rrrrrrrrrrrrrrrr
          04169700   Unitek              CA Proprietary       12/31/2020                                     09/21/2021        7,099,499.00              25
                      College
    rrrrrrrrrrrrrrrr
          03995300   University of       CA Proprietary       12/31/2019       11/01/2021   Failed           11/16/2021           29,162.00              10
                      East-West                                                              Numeric
                      Medicine                                                               Test
    rrrrrrrrrrrrrrrr
          03171300   University of       CA Proprietary       12/31/2020       01/12/2022   Failed           01/25/2022       16,242,055.00              10
                      St.                                                                    Numeric
                      Augustine                                                              Test
                      for Health
                      Sciences
    rrrrrrrrrrrrrrrr
          04114500   Valley              CA Proprietary       12/31/2020       07/14/2021   Other            08/30/2021          113,101.00              10
                      College of
                      Medical
                      Careers
    rrrrrrrrrrrrrrrr
          04249600   Westcliff           CA Proprietary       12/31/2019       06/29/2021   Untimely         07/13/2021           23,499.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          04249600   Westcliff           CA Proprietary       12/31/2020                                     09/28/2021          688,744.00              10
                      University
    rrrrrrrrrrrrrrrr
          04093300   Academy of          CO Proprietary       12/31/2019       01/25/2021   Failed           02/17/2021           48,071.00              10
                      Natural                                                                Numeric
                      Therapy                                                                Test
    rrrrrrrrrrrrrrrr
          04185000   Colorado            CO Proprietary       12/31/2019       04/19/2021   Failed           07/28/2021          106,744.00              12
                      Academy of                                                             Numeric
                      Veterinary                                                             Test
                      Technology
    rrrrrrrrrrrrrrrr
          04185000   Colorado            CO Proprietary       12/31/2019       04/19/2021   Failed           12/20/2018           66,996.00               7
                      Academy of                                                             Numeric
                      Veterinary                                                             Test
                      Technology
    rrrrrrrrrrrrrrrr
          04185000   Colorado            CO Proprietary       12/31/2019       04/19/2021   Failed           12/20/2018           53,160.00               6
                      Academy of                                                             Numeric
                      Veterinary                                                             Test
                      Technology
    rrrrrrrrrrrrrrrr
          01157200   Colorado            CO Proprietary                        06/02/2021   New Owner        06/08/2021          242,682.00              25
                      School of                                                              Missing 2
                      Trades                                                                 yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04148300   Denver              CO Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        1,485,152.00              15
                      College of                                                             Numeric
                      Nursing                                                                Test
    rrrrrrrrrrrrrrrr
          03006300   IBMC College        CO Proprietary       12/31/2020       09/27/2021   Untimely         12/01/2021          140,520.00              25
                                                                                             Refunds
    rrrrrrrrrrrrrrrr
          04299100   National            CO Non Profit        06/30/2020       01/04/2022   Failed           01/13/2022          162,375.00              50
                      Institute                                                              Numeric
                      for Medical                                                            Test
                      Assistant
                      Advancement
    rrrrrrrrrrrrrrrr
          04218900   Rocky Vista         CO Proprietary       06/30/2020       05/17/2021   Failed           06/15/2021        6,887,740.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04218900   Rocky Vista         CO Proprietary       06/30/2021                                     03/01/2022      116,774,424.00              50
                      University
    rrrrrrrrrrrrrrrr
          00729700   Spartan             CO Proprietary       12/31/2020       09/08/2021   Untimely         09/16/2021            9,529.00              25
                      College of                                                             Refunds
                      Aeronautics
                      and
                      Technology
    rrrrrrrrrrrrrrrr
          00729700   Spartan             CO Proprietary       12/31/2020       01/04/2022   Failed           01/25/2022          398,789.00              10
                      College of                                                             Numeric
                      Aeronautics                                                            Test
                      and
                      Technology
    rrrrrrrrrrrrrrrr
          04279000   American            CT Proprietary                        06/11/2021   New Owner        06/15/2021          117,036.00              25
                      Institute of                                                           Missing 2
                      Healthcare &                                                           yrs of
                      Technology                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          00730300   Lincoln             CT Proprietary       12/31/2020       12/29/2021   Untimely         12/29/2021          106,360.00              25
                      Technical                                                              Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          00140100   Post                CT Proprietary       06/30/2020       05/26/2021   Untimely         07/09/2021        1,575,859.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          04148400   TIGI                CT Proprietary       12/31/2017       12/21/2018   New Owner        04/26/2019           51,168.00              25
                      Hairdressing                                                           Missing 2
                      Academy                                                                yrs of
                      Guilford                                                               Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04142700   Pontifical         DC  Non Profit        12/31/2020       12/06/2021   Other            12/14/2021          122,204.00              50
                      John Paul II
                      Institute
                      for Studies
                      on Marriage
                      and Family
    rrrrrrrrrrrrrrrr
          03702300   Delaware          DE   Proprietary       12/31/2020       05/06/2021   Failed           06/15/2021           58,627.00              10
                      Learning                                                               Numeric
                      Institute of                                                           Test
                      Cosmetology
    rrrrrrrrrrrrrrrr
          00143300   Wesley            DE   Non Profit        06/30/2019       02/12/2021   Going            04/07/2021        2,784,000.00              20
                      College                                                                Concern
    rrrrrrrrrrrrrrrr
          03816300   Artistic          FL   Proprietary       12/31/2019       06/21/2021   Untimely         07/09/2021           14,437.00              25
                      Nails &                                                                Refunds
                      Beauty
                      Academy
    rrrrrrrrrrrrrrrr
          03801400   Beauty            FL   Proprietary                        06/02/2021   New Owner        08/03/2021            7,583.00              10
                      Institute                                                              Missing 1
                      (The)                                                                  yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04217800   Boca Beauty       FL   Proprietary                        08/12/2021   New Owner        08/16/2021          686,954.00              25
                      Academy                                                                Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04217800   Boca Beauty       FL   Proprietary                        02/25/2022   Failed           03/30/2022          411,810.00              10
                      Academy                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04249400   Center for        FL   Proprietary       12/31/2019       06/10/2021   Failed Past      08/11/2021            7,571.00              10
                      Neurosomatic                                                           Performanc
                      Studies                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03434300   Fortis            FL   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021          812,903.00              15
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02188900   Hobe Sound        FL   Non Profit        06/30/2019                                     11/22/2021           74,766.00              10
                      Bible
                      College
    rrrrrrrrrrrrrrrr
          01016100   Loraines          FL   Proprietary       12/31/2020       09/15/2021   Other            01/06/2022           73,577.00              10
                      Academy &
                      Spa
    rrrrrrrrrrrrrrrr
          04220200   More Tech         FL   Proprietary       12/31/2020       11/10/2021   Failed Past      02/16/2022           52,455.00              10
                      Institute                                                              Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04106300   Palm Beach        FL   Proprietary       12/31/2018       08/29/2019   New Owner        09/19/2019          330,565.00              25
                      Academy of                                                             Missing 2
                      Health &                                                               yrs of
                      Beauty                                                                 Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04106300   Palm Beach        FL   Proprietary       12/31/2018       09/29/2020   Untimely         12/29/2020           88,470.00              25
                      Academy of                                                             Refunds
                      Health &
                      Beauty
    rrrrrrrrrrrrrrrr
          04120400   Paul Mitchell     FL   Proprietary                        09/03/2021   New Owner        09/07/2021          214,750.00              25
                      The School                                                             Missing 2
                      Miami                                                                  yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04254300   Pets              FL   Proprietary                        02/19/2020   New Owner        02/20/2020           10,000.00             100
                      Playground                                                             Missing 2
                      Grooming                                                               yrs of
                      School                                                                 Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          02314100   Schiller          FL   Proprietary                        02/14/2020   New Owner        03/03/2020          383,948.00              25
                      Internationa                                                           Missing 2
                      l University                                                           yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          03264300   South Florida     FL   Non Profit        06/30/2020       11/16/2021   Other            01/06/2022          446,558.00              50
                      Bible
                      College and
                      Theological
                      Seminary
    rrrrrrrrrrrrrrrr
          03549300   Ultimate          FL   Non Profit        12/31/2020       09/01/2021   Failed           10/26/2021       32,190,088.00              10
                      Medical                                                                Numeric
                      Academy                                                                Test
    rrrrrrrrrrrrrrrr
          00884800   Warner            FL   Non Profit        06/30/2020       03/11/2022   Failed           03/22/2022          966,762.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03173300   Atlanta's         GA   Proprietary       07/31/2020       09/23/2021   Failed Past      09/23/2021        1,400,451.00              10
                      John                                                                   Performanc
                      Marshall Law                                                           e
                      School                                                                 Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04021300   Augusta           GA   Proprietary       12/31/2019       02/08/2021   Failed           04/13/2021           54,753.00              50
                      School of                                                              Numeric
                      Massage                                                                Test
    rrrrrrrrrrrrrrrr
          04260000   Institute of      GA   Proprietary       12/31/2019       01/05/2022   Failed Past      03/01/2022           38,341.00              10
                      Medical                                                                Performanc
                      Ultrasound                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00158700   Paine College     GA   Non Profit        06/30/2020       10/19/2021   Other            10/19/2021        1,071,831.00              10
    rrrrrrrrrrrrrrrr
          04147000   Paul Mitchell     GA   Proprietary       12/31/2020       08/06/2020   Other            10/05/2021          349,860.00              10
                      the School
                      Atlanta
    rrrrrrrrrrrrrrrr
          03438300   Pacific           GU   Non Profit        06/30/2019                                     01/18/2022           85,991.00              24
                      Islands
                      University
    rrrrrrrrrrrrrrrr
          04182200   Hawaii            HI   Proprietary       12/31/2020                                     03/15/2022           63,486.00              25
                      Medical
                      College
    rrrrrrrrrrrrrrrr
          00184600   Briar Cliff       IA   Non Profit        05/31/2020       09/02/2021   Untimely         11/17/2020           10,090.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          00186600   Graceland         IA   Non Profit        05/31/2019       08/26/2020   Untimely         10/20/2020           42,623.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          00187100   Iowa Wesleyan     IA   Non Profit        05/31/2020       06/11/2021   Failed           09/28/2021          514,898.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00794100   Salon             IA   Proprietary       12/31/2020       11/15/2021   Failed Past      12/21/2021           69,275.00              10
                      Professional                                                           Performanc
                      Academy                                                                e
                      (The)                                                                  Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00162500   Brigham Young     ID   Non Profit        12/31/2020       06/15/2020   Untimely         07/28/2020          168,817.00              25
                      University--                                                           Refunds
                      Idaho
    rrrrrrrrrrrrrrrr
          04168600   College of        ID   Proprietary                        03/14/2022   New Owner        03/30/2022           31,000.00              25
                      Massage                                                                Missing 2
                      Therapy                                                                yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04150600   Urban 113         ID   Proprietary                        08/12/2020   New Owner        08/25/2020           43,762.00              25
                      School of                                                              Missing 2
                      Cosmetology                                                            yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          00162800   American          IL   Proprietary       12/31/2020       10/22/2021   Failed           12/21/2021          301,614.00              10
                      Academy of                                                             Numeric
                      Art College                                                            Test
    rrrrrrrrrrrrrrrr
          03914300   CALC,             IL   Proprietary                        01/07/2022   New Owner        03/22/2022          160,000.00              25
                      Institute of                                                           Missing 2
                      Technology                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          03078400   Cameo Beauty      IL   Proprietary       12/31/2020       07/19/2021   Going            01/14/2022          325,827.00              50
                      Academy                                                                Concern
    rrrrrrrrrrrrrrrr
          02349500   Cannella          IL   Proprietary       12/31/2019       03/25/2021   New Owner        05/12/2021           16,953.00              10
                      School of                                                              Missing 1
                      Hair Design                                                            yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          02202600   Cannella          IL   Proprietary       12/31/2019       03/25/2021   New Owner        05/12/2021           14,081.00              10
                      School of                                                              Missing 1
                      Hair Design                                                            yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          02556100   ETI School of     IL   Proprietary       12/31/2018       11/21/2019   Failed Past      03/06/2020          248,658.00              10
                      Skilled                                                                Performanc
                      Trades                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02556600   John Amico        IL   Proprietary       12/31/2019       09/04/2019   Failed Past      09/25/2019           12,802.00              10
                      School of                                                              Performanc
                      Hair Design                                                            e
                      2                                                                      Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00170000   Judson            IL   Non Profit        05/31/2020       06/28/2021   Failed           08/11/2021        1,001,479.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00171200   Lutheran          IL   Non Profit        06/30/2020       07/13/2021   Failed           10/26/2021          175,456.00              50
                      School of                                                              Numeric
                      Theology at                                                            Test
                      Chicago
    rrrrrrrrrrrrrrrr
          03368300   Midwest           IL   Proprietary       12/31/2020       10/19/2021   Failed           12/21/2021        3,760,272.00              10
                      Technical                                                              Numeric
                      Institute                                                              Test
    rrrrrrrrrrrrrrrr
          03128500   National          IL   Non Profit        06/30/2018       07/08/2019   Failed Past      09/27/2019           15,509.00              10
                      Latino                                                                 Performanc
                      Education                                                              e
                      Institute                                                              Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          01236200   Northwestern      IL   Proprietary       07/31/2020       05/18/2021   Failed           09/18/2020        1,162,580.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02185400   Saint             IL   Non Profit        06/30/2020       06/16/2021   Failed           09/14/2021        2,034,307.00              50
                      Augustine                                                              Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          04189200   Salon             IL   Proprietary       12/31/2019       05/20/2021   Going            06/10/2021          113,170.00              20
                      Professional                                                           Concern
                      Academy
                      (The)
    rrrrrrrrrrrrrrrr
          00166300   Spertus           IL   Non Profit        06/30/2020       05/20/2021   Failed           08/11/2021            1,158.00              10
                      College of                                                             Numeric
                      Judaica                                                                Test
    rrrrrrrrrrrrrrrr
          01181000   Taylor            IL   Proprietary       12/31/2020       10/15/2021   Failed           11/02/2021           39,664.00              10
                      Business                                                               Numeric
                      Institute                                                              Test
    rrrrrrrrrrrrrrrr
          00178300   Worsham           IL   Proprietary       12/31/2020       10/29/2021   Failed           12/01/2021          700,000.00              50
                      College of                                                             Numeric
                      Mortuary                                                               Test
                      Science
    rrrrrrrrrrrrrrrr
          04258200   Christina and     IN   Proprietary       12/31/2018       09/05/2019   Failed Past      12/19/2019            2,291.00              10
                      Company                                                                Performanc
                      Education                                                              e
                      Center                                                                 Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04256100   Indiana           IN   Proprietary       12/31/2019       03/24/2021   Failed           06/14/2021           83,432.00              10
                      College of                                                             Numeric
                      Sports &                                                               Test
                      Medical
                      Massage
    rrrrrrrrrrrrrrrr
          04246600   Textures          IN   Proprietary       12/31/2017       03/07/2019   Failed Past      04/05/2019           26,800.00              10
                      Institute of                                                           Performanc
                      Cosmetology                                                            e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00190400   Bethany           KS   Non Profit        06/30/2020       10/14/2021   Failed           10/20/2021          788,371.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00190800   Central           KS   Non Profit        06/30/2020       09/27/2021   Failed           10/05/2021          692,002.00              10
                      Christian                                                              Numeric
                      College of                                                             Test
                      Kansas
    rrrrrrrrrrrrrrrr
          02168900   Kansas            KS   Non Profit        06/30/2020       12/07/2021   Failed           12/07/2021          127,799.00              10
                      Christian                                                              Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          04205300   Mitsu Sato        KS   Proprietary       12/31/2020       08/17/2021   Failed Past      08/31/2021           75,279.00              10
                      Hair Academy                                                           Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00194000   Southwestern      KS   Non Profit        06/30/2020       07/11/2021   Failed           07/29/2021        1,290,263.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          01050300   Wichita           KS   Proprietary       12/31/2019       08/26/2020   Untimely         09/18/2020           28,966.00              25
                      Technical                                                              Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          04038300   ATA College       KY   Proprietary       09/30/2021       04/14/2022   Failed Past      03/15/2022        2,072,183.00              12
                                                                                             Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03083700   Galen Health      KY   Proprietary                        03/03/2021   Other            07/28/2021       42,455,916.00              40
                      Institutes
    rrrrrrrrrrrrrrrr
          03083700   Galen Health      KY   Proprietary                        12/31/2021   Other            03/01/2022        8,115,412.00              10
                      Institutes
    rrrrrrrrrrrrrrrr
          02526100   Jenny Lea         KY   Proprietary                        09/14/2021   New Owner        11/16/2021           25,341.00              25
                      Academy of                                                             Missing 2
                      Cosmetology                                                            yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04249000   Medical           KY   Proprietary       06/30/2016       08/28/2017   Failed Past      09/11/2017           62,711.00              10
                      Career and                                                             Performanc
                      Technical                                                              e
                      College                                                                Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03294300   Blue Cliff        LA   Proprietary       12/31/2020       01/10/2022   Failed           01/25/2022        2,900,674.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03480300   Fortis            LA   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        2,520,238.00              15
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02554800   Vanguard          LA   Proprietary                        10/01/2021   New Owner        10/12/2021          596,463.00              25
                      College of                                                             Missing 2
                      Cosmetology                                                            yrs of
                      A Paul                                                                 Audited
                      Mitchell                                                               Financial
                      Partner                                                                Statement
                      SchoolMetair
                      ie
    rrrrrrrrrrrrrrrr
          00215100   Benjamin          MA   Non Profit        06/30/2019       08/04/2020   Failed           10/06/2020          480,760.00              10
                      Franklin                                                               Numeric
                      Institute of                                                           Test
                      Technology
    rrrrrrrrrrrrrrrr
          03248300   Boston            MA   Non Profit        06/30/2020       01/18/2022   Failed           01/13/2020           77,165.00              25
                      Baptist                                                                Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          02274300   Conway School     MA   Non Profit        06/30/2019       12/14/2020   Failed Past      09/16/2019           37,915.00              10
                      of Landscape                                                           Performanc
                      Design                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04116900   DiGrigoli         MA   Proprietary       12/31/2020       11/05/2021   Failed Past      12/22/2021           26,673.00              10
                      School of                                                              Performanc
                      Cosmetology                                                            e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00215400   Hellenic          MA   Non Profit        06/30/2019       11/12/2020   Failed Past      10/18/2018          189,199.00              15
                      College &                                                              Performanc
                      Holy Cross                                                             e
                      Greek                                                                  Requiremen
                      Orthodox                                                               ts
                      School of
                      Theology
    rrrrrrrrrrrrrrrr
          00220100   Pine Manor        MA   Non Profit        06/30/2020       11/16/2021   Other            12/21/2021          526,683.00              15
                      College
    rrrrrrrrrrrrrrrr
          00632200   Signature         MA   Non Profit        09/30/2019       06/12/2020   Failed           11/17/2020          194,922.00              10
                      Healthcare                                                             Numeric
                      Brockton                                                               Test
                      Hospital
                      School of
                      Nursing
    rrrrrrrrrrrrrrrr
          03130500   Urban College     MA   Non Profit        08/31/2017       08/27/2018   Failed Past      12/07/2018          165,364.00              10
                      of Boston                                                              Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03493300   All-State         MD   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        2,717,579.00              15
                      Career                                                                 Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          01031900   Fortis            MD   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        8,198,786.00              15
                      Institute--T                                                           Numeric
                      owson                                                                  Test
    rrrrrrrrrrrrrrrr
          03822400   Maple Springs     MD   Non Profit        06/30/2013   ...............  ...........      01/21/2015            7,000.00              10
                      Baptist
                      Bible
                      College &
                      Seminary
    rrrrrrrrrrrrrrrr
          00223400   Adrian            MI   Non Profit        06/30/2021       03/02/2022   Failed           11/02/2021        1,886,250.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03005700   Detroit           MI   Proprietary       06/30/2021       01/07/2022   New Owner        01/25/2022          162,627.00              10
                      Business                                                               Missing 1
                      Institute--D                                                           yr of
                      ownriver                                                               Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          02588200   Douglas J         MI   Proprietary       12/31/2020       09/28/2021   Untimely         10/06/2021           36,674.00              25
                      Aveda                                                                  Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          00232200   Finlandia         MI   Non Profit        06/30/2020       10/26/2021   Failed           12/07/2021          445,938.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04280000   Great Lakes       MI   Non Profit        12/31/2019       02/25/2021   Failed           03/15/2021           26,688.00              50
                      Boat                                                                   Numeric
                      Building                                                               Test
                      School
    rrrrrrrrrrrrrrrr
          03588300   Irene's           MI   Proprietary       08/31/2019       07/22/2020   Untimely         08/25/2020           19,940.00              25
                      Myomassology                                                           Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          01321800   M.J. Murphy       MI   Proprietary       12/31/2018       12/04/2019   Failed Past      11/25/2019           29,075.00              10
                      Beauty                                                                 Performanc
                      College                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00228200   Madonna           MI   Non Profit        06/30/2020       09/27/2021   Untimely         10/13/2021           23,813.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          00894600   Port Huron        MI   Proprietary       12/31/2019       11/05/2020   Failed           03/04/2021           20,964.00              10
                      Cosmetology                                                            Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          00228800   Rochester         MI   Non Profit        05/31/2020       02/11/2021   Failed           03/02/2021          774,750.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04138400   Salon             MI   Proprietary       12/31/2020       04/08/2021   Failed Past      06/01/2021           45,492.00              10
                      Professional                                                           Performanc
                      Academy                                                                e
                      (The)                                                                  Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04255100   U.S. Truck        MI   Proprietary       12/31/2018       09/05/2019   Failed           10/15/2019           21,296.00              10
                      Driver                                                                 Numeric
                      Training                                                               Test
                      School
    rrrrrrrrrrrrrrrr
          00983100   Model College     MN   Proprietary       12/31/2018       08/20/2019   Failed Past      11/06/2019           59,787.00              10
                      of Hair                                                                Performanc
                      Design                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00869400   Rasmussen         MN   Proprietary       09/30/2020       04/02/2021   Failed           05/10/2021       23,071,270.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02504200   Walden            MN   Proprietary       12/31/2020       12/01/2021   Failed           12/16/2021       83,962,403.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03110900   Academy of        MO   Proprietary                        03/01/2021   New Owner        03/16/2021           28,076.00              25
                      Beauty                                                                 Missing 2
                      Professional                                                           yrs of
                      s                                                                      Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          03110900   Academy of        MO   Proprietary       06/30/2020       05/21/2021   Failed           07/09/2021           29,118.00               1
                      Beauty                                                                 Numeric
                      Professional                                                           Test
                      s
    rrrrrrrrrrrrrrrr
          04295100   AESTHETICS        MO   Non Profit        12/31/2020       04/16/2021   Failed           05/04/2021          223,920.00              50
                      INSTITUTE                                                              Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04118700   American          MO   Proprietary       12/31/2020       11/30/2021   Failed           12/14/2021          101,305.00              60
                      Business &                                                             Numeric
                      Technology                                                             Test
                      University
    rrrrrrrrrrrrrrrr
          04174800   American          MO   Proprietary       12/31/2019       11/29/2021   Failed Past      01/25/2022           98,180.00              10
                      Trade School                                                           Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04174800   American          MO   Proprietary       12/31/2020       07/28/2021   Failed           07/28/2021          556,307.00              50
                      Trade School                                                           Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00244900   Avila             MO   Non Profit        06/30/2019       01/14/2020   Untimely         01/29/2020           26,368.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          00246300   Evangel           MO   Non Profit        04/30/2020       06/09/2021   Failed           06/29/2021        1,718,200.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04173900   Evolve Beauty     MO   Proprietary       12/31/2017       11/06/2018   Failed Past      01/22/2019           28,533.00              15
                      Academy                                                                Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00908900   Hannibal--LaG     MO   Non Profit        06/30/2020       08/09/2021   Failed           10/19/2021          604,329.00              10
                      range                                                                  Numeric
                      University                                                             Test
    rrrrrrrrrrrrrrrr
          04130600   Healing Arts      MO   Proprietary       12/31/2020       01/28/2022   Other            03/22/2022          294,503.00              50
                      Center
    rrrrrrrrrrrrrrrr
          02277500   House of          MO   Proprietary       06/30/2020       05/21/2021   Failed           07/09/2021          192,873.00               8
                      Heavilin                                                               Numeric
                      Beauty                                                                 Test
                      College
    rrrrrrrrrrrrrrrr
          00960700   House of          MO   Proprietary       06/30/2020       05/21/2021   Failed           07/09/2021           25,902.00               1
                      Heavilin                                                               Numeric
                      Beauty                                                                 Test
                      College
    rrrrrrrrrrrrrrrr
          03519300   Missouri          MO   Proprietary       12/31/2020       02/10/2022   Failed           03/30/2022           43,601.00              10
                      College of                                                             Numeric
                      Cosmetology                                                            Test
                      North
    rrrrrrrrrrrrrrrr
          00639200   Research          MO   Proprietary       12/31/2019       11/04/2020   Failed           11/23/2020          443,967.00              50
                      Medical                                                                Numeric
                      Center                                                                 Test
    rrrrrrrrrrrrrrrr
          04282700   Urshan            MO   Non Profit        06/30/2020       12/06/2021   Failed Past      02/22/2022          137,065.00              10
                      College                                                                Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03970400   WellSpring        MO   Proprietary       06/30/2020       04/07/2021   Failed           06/17/2021           49,277.00               1
                      School of                                                              Numeric
                      Allied                                                                 Test
                      Health
    rrrrrrrrrrrrrrrr
          03970400   WellSpring        MO   Proprietary       06/30/2020       04/07/2021   Failed           06/15/2021          188,709.00               4
                      School of                                                              Numeric
                      Allied                                                                 Test
                      Health
    rrrrrrrrrrrrrrrr
          03970400   WellSpring        MO   Proprietary       06/30/2020       04/07/2021   Failed           06/22/2021          463,821.00              10
                      School of                                                              Numeric
                      Allied                                                                 Test
                      Health
    rrrrrrrrrrrrrrrr
          04131300   Corinth           MS   Proprietary       12/31/2020       09/30/2021   Untimely         09/30/2021           15,452.00              25
                      Academy of                                                             Refunds
                      Cosmetology
    rrrrrrrrrrrrrrrr
          00243500   Southeastern      MS   Non Profit        06/30/2018       07/17/2017   Failed Past      10/04/2017           12,157.00              13
                      Baptist                                                                Performanc
                      College                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04282400   Vaughn Beauty     MS   Proprietary       06/30/2020       04/22/2021   Failed           06/22/2021           51,725.00              50
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02621300   Academy of        MT   Proprietary       12/31/2019       09/11/2020   Failed Past      12/28/2018           13,285.00              10
                      Cosmetology                                                            Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04163700   Bitterroot        MT   Proprietary       12/31/2020                                     10/12/2021           20,574.00              10
                      School of
                      Cosmetology
    rrrrrrrrrrrrrrrr
          04249900   Yellowstone       MT   Non Profit        06/30/2019       02/24/2020   Failed           05/08/2020          133,500.00              50
                      Christian                                                              Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          03570300   Carolina           NC  Non Profit        06/30/2019       11/06/2020   Going            01/12/2021           49,200.00               5
                      Christian                                                              Concern
                      College
    rrrrrrrrrrrrrrrr
          03570300   Carolina           NC  Non Profit        06/30/2019       08/01/2021   Going            08/14/2021           51,861.00               5
                      Christian                                                              Concern
                      College
    rrrrrrrrrrrrrrrr
          00292700   Elon               NC  Non Profit        05/31/2019       08/03/2020   Untimely         08/14/2020           93,621.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          00294800   Montreat           NC  Non Profit        06/30/2019       06/25/2020   Failed           08/03/2021          849,790.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          01179900   Paul Mitchell      NC  Proprietary       09/30/2020       09/27/2021   Failed           12/21/2021        3,501,787.00              50
                      The School                                                             Numeric
                      Fayetteville                                                           Test
    rrrrrrrrrrrrrrrr
          00295500   Pfeiffer           NC  Non Profit        06/30/2020       09/01/2021   Failed           11/09/2021        7,111,351.00              50
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00296000   Salem College      NC  Non Profit        06/30/2016       06/21/2017   Failed Past      09/06/2017          961,226.00              10
                                                                                             Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04173000   Shepherds          NC  Non Profit        06/30/2020       04/02/2021   Failed           06/01/2021           59,667.00              50
                      Theological                                                            Numeric
                      Seminary                                                               Test
    rrrrrrrrrrrrrrrr
          04139400   Hair Academy      ND   Proprietary                        02/09/2022   New Owner        02/10/2022          110,700.00              25
                      (The)                                                                  Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          01040600   Josef's           ND   Proprietary       12/31/2019       09/18/2020   Failed           03/16/2021          126,640.00              10
                      School of                                                              Numeric
                      Hair, Skin &                                                           Test
                      Body
    rrrrrrrrrrrrrrrr
          04234400   American          NJ   Proprietary       12/31/2019       01/24/2021   Failed Past      03/03/2022            5,000.00              59
                      Institute of                                                           Performanc
                      Alternative                                                            e
                      Medicine                                                               Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04181400   Best Care         NJ   Proprietary       12/31/2020       01/14/2022   Failed Past      02/25/2022          145,156.00              10
                      College                                                                Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02132300   Fortis            NJ   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        2,504,992.00              15
                      Institute                                                              Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          01246100   Lincoln           NJ   Proprietary       12/31/2020       12/29/2021   Untimely         12/29/2021          493,660.00              25
                      Technical                                                              Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          04271600   Avenue            NM   Proprietary       12/31/2019       05/18/2021   Failed           07/09/2021           60,207.00              10
                      Academy, A                                                             Numeric
                      Cosmetology                                                            Test
                      Institute
                      (The)
    rrrrrrrrrrrrrrrr
          04259300   Burrell           NM   Proprietary       06/30/2021       02/10/2022   New Owner        02/22/2022        4,515,149.00              25
                      College of                                                             Missing 2
                      Osteopathic                                                            yrs of
                      Medicine                                                               Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          02622000   Southwest         NM   Proprietary       12/31/2020       12/10/2021   Failed Past      12/21/2021           65,081.00              10
                      Acupuncture                                                            Performanc
                      College                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04156000   Academy of        NY   Proprietary                        09/08/2021   New Owner        09/15/2021           86,134.00              25
                      Cosmetology                                                            Missing 2
                      & Esthetics                                                            yrs of
                      NYC (The)                                                              Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          03903400   American          NY   Proprietary                        06/16/2021   New Owner        09/28/2021          229,906.00              25
                      Beauty                                                                 Missing 2
                      School                                                                 yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          00751800   Apex              NY   Proprietary                        10/20/2020   New Owner        10/06/2020        1,078,463.00              10
                      Technical                                                              Missing 1
                      School                                                                 yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04223100   ARROJO            NY   Proprietary       12/31/2019       06/21/2021   Going            07/27/2021           97,509.00              10
                      Cosmetology                                                            Concern
                      School
    rrrrrrrrrrrrrrrr
          04234200   Center for        NY   Proprietary       12/31/2018       10/25/2019   Failed Past      02/14/2020           61,654.00              10
                      Ultrasound                                                             Performanc
                      Research &                                                             e
                      Education                                                              Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04282800   Glasgow           NY   Non Profit        07/31/2018       04/08/2019   Failed           05/29/2019          410,000.00              50
                      Caledonian                                                             Numeric
                      New York                                                               Test
                      College
    rrrrrrrrrrrrrrrr
          01302600   Machzikei         NY   Non Profit        12/31/2019       05/03/2021   Failed Past      06/29/2021           80,744.00              10
                      Hadath                                                                 Performanc
                      Rabbinical                                                             e
                      College                                                                Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02182200   New School        NY   Proprietary       12/31/2019       03/22/2021   Failed           05/04/2021          177,029.00              50
                      Center for                                                             Numeric
                      Media                                                                  Test
    rrrrrrrrrrrrrrrr
          03203300   New York          NY   Proprietary       12/31/2020       02/10/2022   Untimely         03/03/2022           10,670.00              25
                      Institute of                                                           Refunds
                      Massage
    rrrrrrrrrrrrrrrr
          01055100   New York          NY   Proprietary       06/30/2019       03/26/2021   Untimely         05/20/2021           25,593.00              25
                      School for                                                             Refunds
                      Medical &
                      Dental
                      Assistants
    rrrrrrrrrrrrrrrr
          04190500   New York          NY   Proprietary                        02/23/2022   New Owner        02/25/2022          122,502.00              25
                      School of                                                              Missing 2
                      Esthetics &                                                            yrs of
                      Day Spa                                                                Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          00267400   New York          NY   Non Profit        06/30/2020       11/09/2021   Failed           11/09/2021          311,847.00              10
                      Theological                                                            Numeric
                      Seminary                                                               Test
    rrrrrrrrrrrrrrrr
          00279000   Nyack College     NY   Non Profit        06/30/2020       04/29/2021   Failed           10/26/2021        1,870,252.00              12
                                                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00643800   Phillips          NY   Non Profit        12/31/2019       04/13/2021   Failed           06/01/2021          999,946.00              50
                      School of                                                              Numeric
                      Nursing at                                                             Test
                      Mount Sinai
                      Beth Israel
    rrrrrrrrrrrrrrrr
          00397800   Rabbinical        NY   Non Profit        12/31/2019       01/20/2021   Failed           04/27/2021          140,735.00              50
                      Seminary of                                                            Numeric
                      America                                                                Test
    rrrrrrrrrrrrrrrr
          00646100   Saint             NY   Non Profit        12/31/2019       04/09/2021   Failed           05/04/2021          176,583.00              10
                      Elizabeth                                                              Numeric
                      Medical                                                                Test
                      Center
    rrrrrrrrrrrrrrrr
          02556700   Seminar           NY   Non Profit        08/31/2019       08/09/2021   Failed Past      01/17/2022          138,347.00              10
                      L'Moros Bais                                                           Performanc
                      Yaakov                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04179800   Sotheby's         NY   Proprietary       08/31/2019       12/16/2021   Other            02/16/2022          418,333.00              50
                      Institute of
                      Art--NY
    rrrrrrrrrrrrrrrr
          01236400   St. Paul's        NY   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        1,279,712.00              15
                      School of                                                              Numeric
                      Nursing                                                                Test
    rrrrrrrrrrrrrrrr
          00947900   St. Paul's        NY   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        1,240,355.00              15
                      School of                                                              Numeric
                      Nursing                                                                Test
    rrrrrrrrrrrrrrrr
          02170000   Swedish           NY   Proprietary       12/31/2020       01/12/2022   Failed           01/31/2022        1,397,089.00              10
                      Institute                                                              Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          01224800   Central           OH   Non Profit        12/31/2019       01/14/2021   Failed           03/02/2021          361,667.00              50
                      School of                                                              Numeric
                      Practical                                                              Test
                      Nursing
    rrrrrrrrrrrrrrrr
          01090600   Cincinnati        OH   Non Profit        06/30/2019       03/29/2021   Disclaimer       05/12/2021           99,022.00              10
                      College of
                      Mortuary
                      Science
    rrrrrrrrrrrrrrrr
          04254900   Cincinnati        OH   Proprietary       12/31/2020       11/22/2021   Failed Past      12/28/2021           17,492.00              10
                      School of                                                              Performanc
                      Barbering &                                                            e
                      Hair Design                                                            Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04206700   Elite Welding     OH   Proprietary       09/30/2017                                     10/22/2018           72,824.00              10
                      Academy
    rrrrrrrrrrrrrrrr
          00941200   Fortis            OH   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        2,510,293.00              15
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          02190700   Fortis            OH   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        2,634,376.00              15
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00953000   Gerber Akron      OH   Proprietary       06/30/2020       04/22/2020   Failed Past      07/14/2017           28,613.00              10
                      Beauty                                                                 Performanc
                      School                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00307200   Malone            OH   Non Profit        06/30/2018       07/03/2019   Failed Past      09/06/2019        1,600,931.00              10
                      University                                                             Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02328500   Moler--Picken     OH   Proprietary       12/31/2019       04/08/2021   Failed Past      03/03/2020           38,116.00              10
                      s Beauty                                                               Performanc
                      College                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          01284800   Moler             OH   Proprietary       12/31/2019       04/08/2021   Failed Past      03/03/2020           46,452.00              10
                      Hollywood                                                              Performanc
                      Beauty                                                                 e
                      Academy                                                                Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03583300   Ohio              OH   Non Profit        06/30/2019       02/05/2020   Failed Past      06/18/2020           33,286.00              10
                      Institute of                                                           Performanc
                      Allied                                                                 e
                      Health                                                                 Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02287900   Raphael's         OH   Proprietary       12/31/2020       01/20/2022   Untimely         03/01/2022           40,533.00              25
                      School of                                                              Refunds
                      Beauty
                      Culture
    rrrrrrrrrrrrrrrr
          02315500   Toledo            OH   Proprietary       08/31/2019       04/12/2021   New Owner        06/01/2021           30,433.00              10
                      Academy of                                                             Missing 1
                      Beauty                                                                 yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          00311600   University of     OH   Non Profit        06/30/2020       08/20/2021   Failed           09/14/2021          949,000.00              10
                      Rio Grande                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00314100   Wilberforce       OH   Non Profit        06/30/2019       07/07/2020   Going            10/23/2020        1,242,320.00              10
                      University                                                             Concern
    rrrrrrrrrrrrrrrr
          04144400   Academy of        OK   Proprietary       12/31/2020       12/01/2021   Failed           12/07/2021          338,791.00              50
                      Hair Design                                                            Numeric
                      (The)                                                                  Test
    rrrrrrrrrrrrrrrr
          00314700   Bacone            OK   Non Profit        07/31/2020       12/15/2021   Going            01/10/2022          213,188.00              10
                      College                                                                Concern
    rrrrrrrrrrrrrrrr
          00314700   Bacone            OK   Non Profit        07/31/2020       12/20/2021   Untimely         01/18/2022           36,028.00              25
                      College                                                                Refunds
    rrrrrrrrrrrrrrrr
          03367400   Community         OK   Non Profit        06/30/2020                                     01/06/2022        1,236,640.00              10
                      Care College
    rrrrrrrrrrrrrrrr
          00970800   Elite Academy     OK   Proprietary       12/31/2018       06/20/2019   Failed Past      09/03/2019           98,729.00              10
                      of                                                                     Performanc
                      Cosmetology                                                            e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02531200   Formations        OK   Proprietary       12/31/2019       07/02/2021   New Owner        07/09/2021           43,460.00              10
                      Institute                                                              Missing 1
                                                                                             yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04224700   JB's Hair         OK   Proprietary       12/31/2019       04/01/2021   Failed           06/15/2021           29,414.00              10
                      Design and                                                             Numeric
                      Barber                                                                 Test
                      College
    rrrrrrrrrrrrrrrr
          00318000   Southwestern      OK   Non Profit        06/30/2020       11/05/2021   Going            11/22/2021          419,077.00              10
                      Christian                                                              Concern
                      University
    rrrrrrrrrrrrrrrr
          00767800   Spartan           OK   Proprietary       12/31/2020       01/04/2022   Failed           01/25/2022        1,164,434.00              15
                      College of                                                             Numeric
                      Aeronautics                                                            Test
                      and
                      Technology
    rrrrrrrrrrrrrrrr
          00961800   Tulsa Welding     OK   Proprietary       09/30/2020       12/15/2021   Failed           12/28/2021        1,096,813.00              10
                      School                                                                 Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03074500   East West         OR   Proprietary       06/30/2020       03/08/2021   Failed           07/21/2021          126,631.00              10
                      College of                                                             Numeric
                      The Healing                                                            Test
                      Arts
    rrrrrrrrrrrrrrrr
          02495500   All-State         PA   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021        1,106,125.00              15
                      Career                                                                 Numeric
                      School                                                                 Test
    rrrrrrrrrrrrrrrr
          04127500   CDE Career        PA   Proprietary       12/31/2019       03/18/2021   Failed Past      12/04/2019          401,000.00              10
                      Institute                                                              Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00966400   Empire Beauty     PA   Proprietary       06/30/2021       09/09/2021   Other            10/13/2021          211,716.00              10
                      School
    rrrrrrrrrrrrrrrr
          03011600   Fortis            PA   Proprietary       06/30/2020       06/01/2021   Failed           06/23/2021          505,172.00              15
                      Institute                                                              Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00328000   Keystone          PA   Non Profit        05/31/2019       06/26/2020   Failed           07/31/2021        1,395,000.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00777900   Lansdale          PA   Proprietary       08/31/2020       07/16/2021   Going            01/18/2022          492,113.00              50
                      School of                                                              Concern
                      Business
    rrrrrrrrrrrrrrrr
          04288000   Rapha School      PA   Proprietary       12/31/2019       02/24/2021   Failed           04/08/2021          158,450.00             100
                      (The)                                                                  Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00657800   Sharon            PA   Proprietary       12/31/2019       05/03/2021   Failed           05/18/2021          243,000.00              10
                      Regional                                                               Numeric
                      School of                                                              Test
                      Nursing
    rrrrrrrrrrrrrrrr
          02192800   Walnut Hill       PA   Proprietary       12/31/2019       08/21/2020   Failed           10/13/2020          372,443.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03469300   Ivaem College     PR   Proprietary                        01/20/2022   New Owner        03/15/2022           31,371.00              25
                                                                                             Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04240900   PPG Technical     PR   Proprietary                        11/04/2021   New Owner        06/08/2021          228,517.00              25
                      College                                                                Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          03638300   Rosslyn           PR   Proprietary       12/31/2019       04/22/2021   Going            06/15/2021           39,090.00              50
                      Training                                                               Concern
                      Academy of
                      Cosmetology
    rrrrrrrrrrrrrrrr
          02588600   Seminario         PR   Non Profit        12/31/2019       08/04/2021   Failed Past      09/29/2021           29,957.00              10
                      Evangelico                                                             Performanc
                      de Puerto                                                              e
                      Rico                                                                   Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03531300   Universidad       PR   Non Profit        06/30/2020       01/24/2022   Failed           03/14/2022          310,069.00              50
                      Pentecostal                                                            Numeric
                      Mizpa                                                                  Test
    rrrrrrrrrrrrrrrr
          04239000   B-Unique           SC  Proprietary       12/31/2018       09/26/2019   Failed Past      06/04/2019           22,936.00              10
                      Beauty and                                                             Performanc
                      Barber                                                                 e
                      Academy                                                                Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          00405700   National          SD   Proprietary       05/31/2020       06/17/2021   Failed           06/29/2021        4,755,426.00              10
                      American                                                               Numeric
                      University                                                             Test
    rrrrrrrrrrrrrrrr
          04253100   Allied Health     TN   Proprietary       12/31/2020       12/16/2021   Failed Past      02/16/2022           25,000.00              10
                      Careers                                                                Performanc
                      Institute                                                              e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02257400   Arnold's          TN   Proprietary       12/31/2020       02/05/2019   Failed Past      04/05/2019           43,902.00              10
                      Beauty                                                                 Performanc
                      School                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03008800   Brillare          TN   Non Profit        12/31/2020       09/20/2021   Untimely         03/02/2021            8,462.00              25
                      Beauty                                                                 Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          00348100   Carson--Newma     TN   Non Profit        07/31/2020       11/30/2022   Failed           12/01/2021        2,266,541.00              10
                      n University                                                           Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00348200   Christian         TN   Non Profit        05/31/2019       05/27/2020   Untimely         08/25/2020           12,660.00              25
                      Brothers                                                               Refunds
                      University
    rrrrrrrrrrrrrrrr
          02275000   Jenny Lea         TN   Proprietary       12/31/2020       09/14/2021   New Owner        12/21/2021          289,688.00              25
                      Academy of                                                             Missing 2
                      Cosmetology                                                            yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04246500   Massage           TN   Proprietary       12/31/2019       03/31/2021   Failed           07/29/2021           56,826.00              50
                      Institute of                                                           Numeric
                      Memphis                                                                Test
                      (The)
    rrrrrrrrrrrrrrrr
          04223900   Mind Body         TN   Proprietary       06/30/2020       03/05/2021   Other            08/19/2021          136,452.00              50
                      Institute
    rrrrrrrrrrrrrrrr
          04246100   Nashville         TN   Proprietary       12/31/2020       01/05/2022   Failed           03/01/2022           38,745.00              10
                      Film                                                                   Numeric
                      Institute                                                              Test
    rrrrrrrrrrrrrrrr
          02153100   Paul Mitchell     TN   Proprietary       12/31/2020                                     03/01/2022           20,796.00              25
                      the School
                      Murfreesboro
    rrrrrrrrrrrrrrrr
          03830300   SAE Institute     TN   Proprietary       06/30/2021       01/04/2022   Failed           01/25/2022        5,150,692.00              25
                      of                                                                     Numeric
                      Technology                                                             Test
    rrrrrrrrrrrrrrrr
          00352800   Union             TN   Non Profit        07/31/2020       12/15/2021   Untimely         01/12/2022            9,308.00              25
                      University                                                             Refunds
    rrrrrrrrrrrrrrrr
          01155300   William R         TN   Non Profit        08/31/2020       11/15/2021   Failed Past      02/16/2022           51,175.00              10
                      Moore                                                                  Performanc
                      College of                                                             e
                      Technology                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03513500   Williamson        TN   Non Profit        06/30/2020       08/25/2021   Failed           10/12/2021          105,241.00              50
                      Christian                                                              Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          04267200   Allgood           TX   Proprietary       12/31/2018       01/17/2020   Untimely         12/15/2020            8,851.00              25
                      Beauty                                                                 Refunds
                      Institute
    rrrrrrrrrrrrrrrr
          00660600   Baptist           TX   Proprietary       12/31/2019                                     12/21/2021        3,631,429.00              50
                      Health
                      System
                      School of
                      Health
                      Professions
    rrrrrrrrrrrrrrrr
          02058600   BK Cosmo          TX   Proprietary       12/31/2020       06/24/2021   New Owner        07/13/2021           77,424.00              25
                      College of                                                             Missing 2
                      Cosmetology                                                            yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04177900   Buckner           TX   Proprietary       12/31/2020       11/04/2021   New Owner        11/16/2021           22,736.00              25
                      Barber                                                                 Missing 2
                      School                                                                 yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04169100   Diamonds          TX   Proprietary       06/30/2020       03/05/2021   New Owner        03/30/2021           44,233.00              10
                      Cosmetology                                                            Missing 1
                      College                                                                yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          00356400   East Texas        TX   Non Profit        05/31/2020       05/25/2021   Untimely         07/21/2021           39,404.00              25
                      Baptist                                                                Refunds
                      University
    rrrrrrrrrrrrrrrr
          04277900   Houston           TX   Proprietary       12/31/2019       09/10/2021   Failed Past      10/26/2021          137,336.00              10
                      School of                                                              Performanc
                      Carpentry                                                              e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02527500   Houston           TX   Proprietary       12/31/2020       11/17/2021   Untimely         12/07/2021           47,676.00              25
                      Training                                                               Refunds
                      Schools
    rrrrrrrrrrrrrrrr
          00357700   Huston--Tillo     TX   Non Profit        06/30/2016       06/30/2017   Failed Past      02/23/2018        1,339,569.00              10
                      tson                                                                   Performanc
                      University                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02318200   KD                TX   Proprietary       12/31/2020       12/10/2021   Failed           01/06/2022          175,608.00              10
                      Conservatory                                                           Numeric
                      College of                                                             Test
                      Film and
                      Dramatic
                      Arts
    rrrrrrrrrrrrrrrr
          04129800   MediaTech         TX   Proprietary       12/31/2019       10/14/2021   Untimely         02/22/2022           74,937.00              25
                      Institute                                                              Refunds
    rrrrrrrrrrrrrrrr
          03092600   Messenger         TX   Non Profit        06/30/2020       04/01/2021   Failed Past      06/01/2021           57,166.00              10
                      College                                                                Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03422300   Milan             TX   Proprietary       12/31/2016       04/19/2018   Untimely         05/22/2018          193,644.00              25
                      Institute                                                              Refunds
    rrrrrrrrrrrrrrrr
          04226400   MT Training       TX   Proprietary       12/31/2017       10/04/2018   Failed Past      12/20/2018          146,262.00              10
                      Center                                                                 Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          01301600   Ogle School       TX   Proprietary       12/31/2020       09/03/2021   New Owner        09/21/2021        7,261,890.00              25
                      Hair Skin                                                              Missing 2
                      Nails                                                                  yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04168700   Peloton           TX   Proprietary       12/31/2020       12/02/2021   Failed Past      12/21/2021          281,854.00              10
                      College                                                                Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02176100   Pipo Academy      TX   Proprietary       12/31/2018       05/30/2019   Failed Past      07/20/2019            8,307.00              10
                      of Hair                                                                Performanc
                      Design                                                                 e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03400300   Quest College     TX   Proprietary                        10/13/2021   New Owner        02/08/2022        1,027,012.00              25
                                                                                             Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          03026500   Remington         TX   Non Profit                         10/29/2021   Failed           02/17/2022          477,635.00               1
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03026500   Remington         TX   Non Profit                         10/29/2021   Failed           02/17/2022        6,710,709.00               9
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          03032300   School of         TX   Proprietary       12/31/2019       04/07/2021   Failed           06/01/2021          149,177.00              10
                      Automotive                                                             Numeric
                      Machinists &                                                           Test
                      Technology
    rrrrrrrrrrrrrrrr
          04213300   Southern          TX   Proprietary       12/31/2020       12/15/2021   Failed           12/28/2021          135,670.00              50
                      Texas                                                                  Numeric
                      Careers                                                                Test
                      Academy
    rrrrrrrrrrrrrrrr
          00361800   Southwestern      TX   Non Profit        06/30/2018       06/14/2019   Failed Past      10/31/2019          104,123.00              10
                      Christian                                                              Performanc
                      College                                                                e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03035200   Tint School       TX   Proprietary       12/31/2020       07/19/2021   Failed Past      08/18/2021          227,394.00              10
                      of Makeup &                                                            Performanc
                      Cosmetology                                                            e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          03714300   Trend Barber      TX   Proprietary       12/31/2019       05/18/2021   Failed           07/01/2021          153,193.00              10
                      College                                                                Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          01202000   Victoria          TX   Proprietary       12/31/2020       08/25/2021   Failed           09/14/2021          117,019.00              10
                      Beauty and                                                             Numeric
                      Barber                                                                 Test
                      College
    rrrrrrrrrrrrrrrr
          00366900   Wiley College     TX   Non Profit        06/30/2020       10/29/2021   Going            11/18/2019        1,352,151.00              12
                                                                                             Concern
    rrrrrrrrrrrrrrrr
          02178500   Eagle Gate        UT   Proprietary       12/31/2020                                     09/21/2021        1,479,136.00              25
                      College
    rrrrrrrrrrrrrrrr
          02556800   Paul Mitchell     UT   Proprietary       12/31/2019       01/14/2021   Untimely         03/09/2021           35,203.00              25
                      the School                                                             Refunds
                      Salt Lake
                      City
    rrrrrrrrrrrrrrrr
          03110400   Paul Mitchell     UT   Proprietary       12/31/2018       09/05/2019   Failed Past      11/18/2019           11,215.00              10
                      The School                                                             Performanc
                      St. George                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          02360800   Provo College     UT   Proprietary       12/31/2020                                     09/21/2021        1,642,182.00              25
    rrrrrrrrrrrrrrrr
          00368100   Westminster       UT   Non Profit        06/30/2019       10/26/2020   Untimely         11/17/2020           21,550.00              25
                      College                                                                Refunds
    rrrrrrrrrrrrrrrr
          04180600   Appalachian       VA   Non Profit                         03/25/2021   Other            05/12/2021        1,525,164.00              15
                      College of
                      Pharmacy
    rrrrrrrrrrrrrrrr
          00370300   Bluefield         VA   Non Profit                         03/16/2021   Other            04/13/2021        2,046,836.00              15
                      College
    rrrrrrrrrrrrrrrr
          04269400   Crown Cutz        VA   Proprietary                        12/08/2020   New Owner        02/02/2021           43,172.00              25
                      Academy                                                                Missing 2
                      Bristol                                                                yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04219000   IGlobal           VA   Proprietary                        05/27/2021   Failed           06/14/2021            5,738.00              10
                      University                                                             Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          04219000   IGlobal           VA   Proprietary       12/31/2020       02/23/2022   New Owner        02/28/2022           13,602.00              25
                      University                                                             Missing 2
                                                                                             yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          01274400   Southside         VA   Proprietary       12/31/2019       02/12/2021   Failed           03/23/2021          349,176.00              35
                      College of                                                             Numeric
                      Health                                                                 Test
                      Sciences
    rrrrrrrrrrrrrrrr
          00865800   O'Briens          VT   Proprietary       04/26/2020       01/14/2021   Failed           03/04/2021          250,938.00              50
                      Aveda                                                                  Numeric
                      Institute                                                              Test
    rrrrrrrrrrrrrrrr
          02541900   BJ's Beauty &     WA   Proprietary       12/31/2020       07/16/2021   Failed           07/16/2021          128,555.00              25
                      Barber                                                                 Numeric
                      College                                                                Test
    rrrrrrrrrrrrrrrr
          03689400   Faith             WA   Non Profit        06/30/2020       04/30/2022   Failed           06/01/2021          687,495.00              30
                      Internationa                                                           Numeric
                      l University                                                           Test
    rrrrrrrrrrrrrrrr
          04149400   Gary Manuel       WA   Proprietary       12/31/2019       03/23/2021   Failed           12/17/2019           85,421.00              10
                      Aveda                                                                  Numeric
                      Institute                                                              Test
    rrrrrrrrrrrrrrrr
          02203300   Gene Juarez       WA   Proprietary       12/31/2020       12/21/2021   New Owner        02/22/2022          210,434.00              10
                      Beauty                                                                 Missing 1
                      Schools                                                                yr of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04191900   Paul Mitchell     WA   Proprietary                        11/08/2021   New Owner        11/16/2021          250,000.00              25
                      The School                                                             Missing 2
                      Spokane                                                                yrs of
                                                                                             Audited
                                                                                             Financial
                                                                                             Statement
    rrrrrrrrrrrrrrrr
          04182100   First Class       WI   Proprietary       12/31/2018       01/08/2020   Untimely         02/04/2020            8,127.00              25
                      Cosmetology                                                            Refunds
                      School
    rrrrrrrrrrrrrrrr
          00387400   Nashotah          WI   Non Profit        06/30/2019       09/02/2020   Failed           12/12/2018           22,808.00              10
                      House                                                                  Numeric
                                                                                             Test
    rrrrrrrrrrrrrrrr
          00380600   Alderson          WV   Non Profit        06/30/2020       07/26/2021   Failed           09/28/2021        2,348,198.00              15
                      Broaddus                                                               Numeric
                      University                                                             Test
    rrrrrrrrrrrrrrrr
          00380800   Bethany           WV   Non Profit        06/30/2018       11/25/2019   Failed Past      07/20/2019          766,000.00              10
                      College                                                                Performanc
                                                                                             e
                                                                                             Requiremen
                                                                                             ts
    rrrrrrrrrrrrrrrr
          04028300   Mountain          WV   Proprietary       12/31/2019       05/27/2021   Failed           07/13/2021          148,000.00              50
                      State School                                                           Numeric
                      of Massage                                                             Test
    rrrrrrrrrrrrrrrr
          00915700   WyoTech           WY   Proprietary       12/31/2020                                     07/13/2021          495,000.00              25
    --------------------------------------------------------------------------------------------------------------------------------------------------------

    Notes Regarding the Report:
      --The report identifies Letters of Credit held as of March 31, 2022.
      --An institution may have posted multiple Letters of Credit to
            satisfy the Department's financial surety requirement.
      --Cash deposits held as an alternative to a Letter of Credit are
            reported.
      --LOC Percent Requested data are recorded in whole numbers.
      --In some cases, a school provided an updated LOC before ED formally
            requested the LOC renewal.

                      Definitions of Letter of Credit Terms
    ------------------------------------------------------------------------
                Term                              Definition
    ------------------------------------------------------------------------
    OPE ID                       An OPE ID is a unique eight digit code
                                  utilized by the Department to identify an
                                  institution in its systems.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Institution Name             The institution name is the legal name of
                                  the institution.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    State/Country                State or country where the main institution
                                  is physically located.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Institution Type             Describes the institution as an nonprofit,
                                  public, or proprietary institution
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Institution Fiscal Year End  For the purposes of the LOC disclosure,
     Date                         this refers to the fiscal year end date of
                                  the institution. The compliance or
                                  financial statement audits, which served
                                  as the basis for most LOC requests, are
                                  due to the Department no later than six
                                  months (proprietary) or nine months (non-
                                  profits) after the end of the
                                  institution's fiscal year.
                                 NOTE: If this field is left blank, it is
                                  because the LOC was not predicated on the
                                  receipt of an annual financial statement.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    LOC Request Date             This serves as the date the Department
                                  formally requested a LOC from the
                                  institution.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Reason LOC Requested         Describes the reason the Department
                                  requested the LOC. See detailed
                                  descriptions for reasons below.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    LOC Received Date            This serves as the date the Department
                                  formally received the irrevocable LOC from
                                  the financial institution posting on
                                  behalf of the requisite institution. In
                                  most cases, the LOC must be received by
                                  the Department within 75 days of the date
                                  of the Department's correspondence
                                  requesting remittance of a LOC.
                                 NOTE: In some instances, the LOC Received
                                  Date precedes the LOC Request Date because
                                  an existing LOC on file was renewed or
                                  extended. In those cases, the subsequent
                                  Award Year LOC Received Date is noted.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    LOC Amount                   This serves as the total LOC dollar amount
                                  the Department received and accepted from
                                  the institution. The vast majority of
                                  designated amounts are based on a
                                  percentage applied against Title IV funds
                                  received by the institution during its
                                  most recently completed fiscal year or
                                  refunds not returned during that year.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    LOC Percent Requested        This represents the percentage applied
                                  against the Title IV funds received or
                                  unreturned by the institution and serves
                                  as the basis for the LOC requested amount.
                                  The regulations in 34 CFR Part 668 Subpart
                                  L set minimum and/or designated
                                  percentages for LOCs due to non-compliance
                                  of the financial responsibility standards.
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
        Reason LOC Requested                     Description
    ------------------------------------------------------------------------
    Disclaimer                   An institution is not considered
                                  financially responsible if, in the
                                  institution's audited financial
                                  statements, the opinion expressed by the
                                  auditor was an adverse, qualified or
                                  disclaimed opinion, unless the Secretary
                                  determines that a qualified or disclaimed
                                  opinion does not have a significant
                                  bearing on the institution's financial
                                  condition.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Failed Numeric Test          The most common reason why an institution
                                  is required to remit a letter of credit
                                  (LOC) to the Department is because they
                                  have a failing financial responsibility
                                  composite score (generally a score of 1.4
                                  or less on a scale of -1.0 to +3.0) and
                                  are not deemed financially responsible. In
                                  accordance with 34 CFR 668.175, an
                                  institution with a composite score of 1.4
                                  or less may continue to participate in the
                                  Title IV programs under the Provisional
                                  certification alternative. Institutions
                                  participating under provisional
                                  certification are subject to heightened
                                  cash monitoring, and may be required to
                                  submit an irrevocable LOC of not less than
                                  10 percent of the Title IV aid the
                                  institution received during its most
                                  recently completed fiscal year.
                                  Institutions that passed the score in the
                                  previous year may score from 1.0 to 1.4
                                  for up to three consecutive years without
                                  providing a LOC, provided other reporting
                                  conditions are met. Institutions that
                                  score below a 1.0 are required to submit a
                                  LOC of not less than 10 percent of the
                                  Title IV aid the institution received
                                  during its most recently completed fiscal
                                  year.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Failed Past Performance      Institutions are required to submit
     Requirements                 acceptable annual compliance and financial
                                  statement audits no later than six months
                                  (proprietary) or nine months (non-profits)
                                  after the end of the institution's fiscal
                                  year. Institutions cited for such past
                                  performance violations under 34 CFR
                                  668.174 are provisionally certified and
                                  must submit a LOC for a period of five
                                  years in an amount equal to no less than
                                  10 percent of the Title IV aid the
                                  institution received during its most
                                  recently completed fiscal year.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Going Concern                A LOC is generally requested when an
                                  auditor expresses a ``going concern'' in
                                  an audited financial statement which could
                                  result in risk to the Department and
                                  taxpayers.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    New Owner Missing 1 Yr. of   Prospective new owners of a participating
     Audited Financial            institution are required to provide two
     Statements                   years of audited financial statements to
                                  determine financial solvency. If a new
                                  owner can only provide one year of
                                  financial statements, they are required to
                                  remit a LOC of at least 10% of the amount
                                  of Title IV aid the Department determines
                                  the institution would receive in its first
                                  year of operations.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    New Owner Missing 2 Yrs. of  Prospective new owners of a participating
     Audited Financial            institution are required to provide two
     Statements                   years of audited financial statements to
                                  determine financial solvency. If a new
                                  owner can not provide the required
                                  financial statements, they are required to
                                  remit a LOC of at least 25% of the amount
                                  of Title IV aid the Department determines
                                  the institution would receive in its first
                                  year of operations.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Other or ``Blank''           A LOC may be requested for less common
                                  reasons such as institutional ownership
                                  having a monetary liability owed to the
                                  Department or an institution's failure to
                                  meet debt obligations or not being in
                                  compliance with a financial lender's loan
                                  covenants. The insitution may have
                                  submitted the LOC without it being
                                  requested by the Department to resolve a
                                  financial responsibility issue.
    rrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Untimely Refunds             Institutions are required to maintain
                                  sufficient cash reserves to return Title
                                  IV funds to the Department for students
                                  that withdrew from the institution in a
                                  timely fashion. As noted in 34 CFR
                                  668.173, an institution found in violation
                                  of the reserve standard is required to
                                  submit a LOC equal to 25% of the total
                                  amount of unearned Title IV funds the
                                  institution was required to return or
                                  should have returned for its most recently
                                  completed fiscal year.
    ------------------------------------------------------------------------

        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, whose collapse left 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. Since Jan. 1, 2012, the Department has received 76
    applications for a for-profit to nonprofit conversion. Six applications
    reported on our prior report have been removed because they were
    submitted prior to Jan. 1, 2012. Since our last report five more
    applications were received: one Change in Ownership (CIO) transaction
    occurred with the for-profit institution requesting recognition as a
    nonprofit institution status; two other CIO transactions occurred with
    the for-profit institutions requesting recognition as public
    institutions; one pre-acquisition review is in process for prospective
    CIO transaction where the for-profit institution will intend to request
    recognition as a nonprofit institution, and one pre-acquisition review
    was completed but the actual transaction was withdrawn. Additionally,
    we de-duplicated a record for one school that submitted a pre-
    acquisition review application but where the school closed a materially
    different transaction.
        Of those 76 applications received since Jan. 1, 2012, the
    Department has made final decisions on 38 conversion requests as of
    July 18, 2022. Of those 38 decisions, 35 conversion requests were
    approved.\*\ The Department denied Argosy University's request for
    nonprofit recognition and denied Argosy's continued participation in
    the Title IV, HEA programs. 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, which allowed those institutions to continue to
    participate in the Title IV, HEA programs as proprietary institutions.
    ---------------------------------------------------------------------------
        \*\ 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 CIO transaction involving Kaplan University and Purdue
    University resulted in Kaplan University's conversion to a public
    institution status rather than to a nonprofit institution status.
    ---------------------------------------------------------------------------
        Regarding the remaining 38 applications that do not have an issued
    agency decision, 20 applications (including pre-acquisition review
    applications) did not require a final agency decision because the
    applicant institutions either closed or voluntarily withdrew their
    applications while the applications were under review. Consequently,
    there are 18 conversion applications pending a decision by the
    Department, including 17 applications for CIO transactions which have
    occurred, and one pre-acquisition review application for a future
    anticipated conversion transaction.

    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                      Ownership as     TIN (For     Ownership as     TIN (Non                    Application
       OPE ID    Institution Name   Accreditation      For Profit      Profit)       Non Profit      Profit)     Current Status      Date      TPPPA Date   PPPA Date        Status      Closed Date
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
       00162800  American Academy  North Central    American           363778690  Council on         463291995  Change in          12/9/2014                  1/7/2021  CIO Approved--
                  of Art.           Association of   Academy of                    Postsecondary                 Ownership                                               conversion to
                                    Colleges and     Art, Inc.--                   Education,                    occured and                                             non-profit
                                    Schools          Richard Otto--                Inc. (changed                 PPPA issued on                                          denied.
                                    (Higher          100% owner.                   name to                       1/5/2021 which
                                    Learning                                       American                      allows the
                                    Commission).                                   Academy of                    school to
                                                                                   Art).                         participate in
                                                                                                                 Title IV, HEA
                                                                                                                 programs under
                                                                                                                 its new
                                                                                                                 ownership.
                                                                                                                 However, the
                                                                                                                 institution's
                                                                                                                 request for
                                                                                                                 recognition as
                                                                                                                 a nonprofit
                                                                                                                 institution
                                                                                                                 was denied on
                                                                                                                 1/5/2021. The
                                                                                                                 IHE
                                                                                                                 subsequently
                                                                                                                 submitted a
                                                                                                                 request for
                                                                                                                 reconsideratio
                                                                                                                 n for the
                                                                                                                 Department's
                                                                                                                 review on 3/26/
                                                                                                                 2021. The
                                                                                                                 Department is
                                                                                                                 evaluating the
                                                                                                                 submission and
                                                                                                                 request for
                                                                                                                 reconsideratio
                                                                                                                 n on nonprofit
                                                                                                                 status..
    rrrrrrrrrrrr
       02266200  Helms Career      Council on       American           582641179  Goodwill           581249683  Change in           8/9/2013                  2/3/2014  Approved--Inst    12/31/2015
                  Institute.        Occupational     Professional                  Industries of                 Ownership and                                           Closed.
                                    Education        Institute.                    Middle                        conversion--Ap
                                    (COE).                                         Georgia, Inc..                proved PPPA
                                                                                                                 issued 2/3/14;
                                                                                                                 Institution
                                                                                                                 closed 12/31/
                                                                                                                 15.
    rrrrrrrrrrrr
       03416500  Dallas Nursing    Accrediting      ATI, Inc.......    752060087  TCS Education--    364769956  Change in         10/18/2013                12/29/2014  Approved.......
                  Institute.        Bureau of                                      Texas, Inc..                  Ownership and
                                    Health                                                                       conversion--Ap
                                    Education                                                                    proved PPPA
                                    Schools                                                                      issued 12/29/
                                    (ABHES).                                                                     14.
    rrrrrrrrrrrr
       03612300  Birthwise         Midwifery        Birthwise          200551503  Birthwise          200551503  Application         3/4/2021    4/21/2021               Pending........
                  Midwifery         Education        Midwifery                     Midwifery                     submitted 3/4/
                  School.           Accreditation    School.                       School                        2021; TPPPA
                                    Council.                                       (corporation                  issued 4/21/
                                                                                   converted to                  2021;
                                                                                   Maine                         application
                                                                                   nonprofit and                 under review.
                                                                                   received
                                                                                   501(c)(3)
                                                                                   designation).
    rrrrrrrrrrrr
       00342100  Bob Jones         Transnational    Bob Jones          570360095  BJU, Inc.......    571088101  Change in          3/10/2017    8/31/2020               Pending........
                  University.       Association of   University,                                                 Ownership has
                                    Christian        Inc..                                                       occurred--Chan
                                    Colleges and                                                                 ge in
                                    Schools                                                                      Ownership and
                                    (TRACCS).                                                                    conversion
                                                                                                                 pending final
                                                                                                                 review and
                                                                                                                 determination
                                                                                                                 by the
                                                                                                                 Department.
    rrrrrrrrrrrr
       00751800  Apex Technical    Accrediting      Breton             131949995  Fedcap Group,      830765672  Application        1/23/2020    9/28/2020               Pending........
                  School.           Commission of    International                 Inc..                         submitted 1/23/
                                    Career Schools   Inc..                                                       2020;
                                    and Colleges                                                                 abbreviated
                                    (ACCSC).                                                                     pre-
                                                                                                                 acquisition
                                                                                                                 review letter
                                                                                                                 issued 9/3/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed 9/18/
                                                                                                                 2020; TPPPA
                                                                                                                 issued 9/28/
                                                                                                                 2020;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       00188100  Ashford           WASC Senior      Bridgepoint        593551629  University of      866050388  Application        10/2/2020    1/11/2021               Pending........
                  University.       College and      Education, Inc.               Arizona                       submitted 10/2/
                                    University                                     Foundation.                   2020;
                                    Commission                                                                   application
                                    (WASC).                                                                      under review.
    rrrrrrrrrrrr
       00188100  Ashford           WASC Senior      Bridgepoint        593551629  AU NFP.........    830529332  Change of          11/1/2018                            Withdrawn......
                  University.       College and      Education, Inc.                                             ownership and
                                    University                                                                   conversion
                                    Commission                                                                   application
                                    (WASC).                                                                      originally
                                                                                                                 submitted 11/1/
                                                                                                                 2018; revised
                                                                                                                 transaction
                                                                                                                 information
                                                                                                                 submitted on 2/
                                                                                                                 12/2020. In
                                                                                                                 July 2019, ED
                                                                                                                 issued
                                                                                                                 preacquistion
                                                                                                                 review letter
                                                                                                                 identifying a
                                                                                                                 $103 million
                                                                                                                 LOC
                                                                                                                 requirement
                                                                                                                 for the 2018
                                                                                                                 proprosed
                                                                                                                 transaction.
                                                                                                                 The
                                                                                                                 institution
                                                                                                                 submitted an
                                                                                                                 update to the
                                                                                                                 proposed
                                                                                                                 transaction
                                                                                                                 which resulted
                                                                                                                 in ED omitting
                                                                                                                 the LOC
                                                                                                                 requirement in
                                                                                                                 July 2020.
                                                                                                                 However, the
                                                                                                                 institution
                                                                                                                 proceeded with
                                                                                                                 a third type
                                                                                                                 of
                                                                                                                 transaction,
                                                                                                                 involving U.
                                                                                                                 of Arizona
                                                                                                                 Foundation,
                                                                                                                 discussed in
                                                                                                                 the preceding
                                                                                                                 row..
    rrrrrrrrrrrr
       00267800  Bryant &          Middle States    Bryant &           160364420  Prentice Family    202557712  Application        2/26/2020   12/10/2020               Pending........
                  Stratton          Commission on    Stratton                      Foundation,                   submitted 2/26/
                  College.          Higher           College, Inc..                Inc..                         2020;
                                    Education.                                                                   application
                                                                                                                 under review.
    rrrrrrrrrrrr
       02110800  California        Accrediting      California         562364005  Center for         208091013  Change in          11/7/2012                12/19/2018  Approved--Inst
                  College San       Commission of    College San                   Excellence in                 Ownership                                               Closed.
                  Diego.            Career Schools   Diego, Inc..                  Higher                        Approved and
                                    and Colleges                                   Education.                    PPPA issued on
                                    (ACCSC).                                                                     8/31/16.
                                                                                                                 Conversion
                                                                                                                 application
                                                                                                                 denied on 8/11/
                                                                                                                 16.
                                                                                                                 Institution
                                                                                                                 submitted
                                                                                                                 additional
                                                                                                                 information
                                                                                                                 and filed
                                                                                                                 lawsuit which
                                                                                                                 was eventually
                                                                                                                 settled.
                                                                                                                 Conversion
                                                                                                                 approved on
                                                                                                                 the basis of
                                                                                                                 updated
                                                                                                                 information
                                                                                                                 regarding the
                                                                                                                 transaction,
                                                                                                                 and PPPAs
                                                                                                                 issued 12/19/
                                                                                                                 18..
    rrrrrrrrrrrr
       00489000  Central Penn      Middle States    Central            231857027  Central Penn       852896768  Abbreviated pre-   3/26/2021                            Pending--Pre-
                  College.          Commission on    Pennsylvania      232527882   1801.                         acquisition                                             acq.
                                    Higher           Business                                                    review
                                    Education.       School, Inc./                                               determination
                                                     Central Penn,                                               letter issued
                                                     Inc. Employee                                               6/11/2021;
                                                     Stock                                                       transaction
                                                     Ownership Plan                                              closing
                                                     Trust.                                                      scheduled for
                                                                                                                 8/22/2021.
    rrrrrrrrrrrr
       00489000  Central Penn      Middle States    Central            231857027  Central            821929393  Application       12/14/2018                            Withdrawn......
                  College.          Commission on    Pennsylvania      232527882   Pennsylvania                  submitted 12/
                                    Higher           Business                      Educational                   14/2018;
                                    Education.       School, Inc./                 Institution.                  Institution
                                                     Central Penn,                                               requested
                                                     Inc. Employee                                               application be
                                                     Stock                                                       purged 9/6/19.
                                                     Ownership Plan
                                                     Trust.
    rrrrrrrrrrrr
       03120300  CollegeAmerica    Accrediting      CollegeAmerica     841611427  Center for         208091013  Change in          11/7/2012                12/19/2018  Approved--Inst
                  Arizona.          Commission of    Arizona, Inc..                Excellence in                 Ownership                                               Closed.
                                    Career Schools                                 Higher                        Approved and
                                    and Colleges                                   Education.                    PPPA issued on
                                    (ACCSC).                                                                     8/31/16.
                                                                                                                 Conversion
                                                                                                                 application
                                                                                                                 denied on 8/11/
                                                                                                                 16.
                                                                                                                 Institution
                                                                                                                 submitted
                                                                                                                 additional
                                                                                                                 information
                                                                                                                 and filed
                                                                                                                 lawsuit which
                                                                                                                 was eventually
                                                                                                                 settled.
                                                                                                                 Conversion
                                                                                                                 approved on
                                                                                                                 the basis of
                                                                                                                 updated
                                                                                                                 information
                                                                                                                 regarding the
                                                                                                                 transaction,
                                                                                                                 and PPPAs
                                                                                                                 issued 12/19/
                                                                                                                 18..
    rrrrrrrrrrrr
       02594300  CollegeAmerica    Accrediting      CollegeAmerica     841225827  Center for         208091013  Change in          11/7/2012                12/19/2018  Approved--Inst
                  Denver.           Commission of    Denver, Inc..                 Excellence in                 Ownership                                               Closed.
                                    Career Schools                                 Higher                        Approved and
                                    and Colleges                                   Education.                    PPPA issued on
                                    (ACCSC).                                                                     8/31/16.
                                                                                                                 Conversion
                                                                                                                 application
                                                                                                                 denied on 8/11/
                                                                                                                 16.
                                                                                                                 Institution
                                                                                                                 submitted
                                                                                                                 additional
                                                                                                                 information
                                                                                                                 and filed
                                                                                                                 lawsuit which
                                                                                                                 was eventually
                                                                                                                 settled.
                                                                                                                 Conversion
                                                                                                                 approved on
                                                                                                                 the basis of
                                                                                                                 updated
                                                                                                                 information
                                                                                                                 regarding the
                                                                                                                 transaction,
                                                                                                                 and PPPAs
                                                                                                                 issued 12/19/
                                                                                                                 18..
    rrrrrrrrrrrr
       01274400  Southside         Accrediting      Community          133893191  Bon Secours        521301088  Application        1/14/2020    3/26/2020               Pending........
                  College of        Bureau of        Health                        Mercy Health,                 submitted 1/14/
                  Health Sciences.  Health           Systems, Inc.                 Inc..                         2020;
                                    Education                                                                    transaction
                                    Schools                                                                      closed 1/1/
                                    (ABHES).                                                                     2020; TPPPA
                                                                                                                 issued 3/26/
                                                                                                                 2020;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       00149900  Everest           Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved.......
                  University--Orl   Council for      Colleges, Inc..               Education                     Ownership and
                  ando, FL.         Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/15.
                                    (ACICS).
    rrrrrrrrrrrr
       00450700  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     6/30/2019
                  Thornton, CO.     Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 6/30/19.
    rrrrrrrrrrrr
       02237500  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved.......
                  Henderson, NV.    Council for      Colleges, Inc..               Education                     Ownership and
                                    Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15. Sold by
                                                                                                                 Zenith to for-
                                                                                                                 profit owner,
                                                                                                                 Nevada Career
                                                                                                                 Education,
                                                                                                                 Inc. on 11/9/
                                                                                                                 18..
    rrrrrrrrrrrr
       00915700  WyoTech--Laramie  Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved.......
                  , WY.             Commission of    Colleges, Inc..               Education                     Ownership and
                                    Career Schools                                 Group, Inc..                  conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 7/24/
                                                                                                                 15; Sold by
                                                                                                                 Zenith to for-
                                                                                                                 profit owner,
                                                                                                                 DBJJDM
                                                                                                                 Enterprises
                                                                                                                 LLC on 7/1/18.
    rrrrrrrrrrrr
       00450300  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     9/30/2018
                  Colorado          Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                  Springs, CO.      Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 9/30/18.
    rrrrrrrrrrrr
       00709100  Everest           Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     2/17/2016
                  Institute--Pitt   Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                  sburgh, PA.       Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 2/17/16.
    rrrrrrrrrrrr
       00907900  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     8/22/2016
                  Portland, OR.     Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 8/22/16.
    rrrrrrrrrrrr
       00926700  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     9/30/2018
                  Newport News,     Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                  VA.               Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 9/30/18.
    rrrrrrrrrrrr
       00982800  Everest           Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     9/30/2018
                  Institute--Sout   Commission of    Colleges, Inc..               Education                     Ownership and                                           Closed.
                  hfield, MI.       Career Schools                                 Group, Inc..                  conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 7/24/
                                                                                                                 15;
                                                                                                                 Institution
                                                                                                                 closed 9/30/18.
    rrrrrrrrrrrr
       01185800  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     8/25/2015
                  Skokie, IL.       Commission of    Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Career Schools                                 Group, Inc..                  conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 7/24/
                                                                                                                 15;
                                                                                                                 Institution
                                                                                                                 closed 8/25/15.
    rrrrrrrrrrrr
       02250600  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     6/20/2017
                  Springfield, MO.  Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 6/20/17.
    rrrrrrrrrrrr
       02261300  Everest           Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     9/30/2018
                  Institute--San    Commission of    Colleges, Inc..               Education                     Ownership and                                           Closed.
                  Antonio, TX.      Career Schools                                 Group, Inc..                  conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 7/24/
                                                                                                                 15;
                                                                                                                 Institution
                                                                                                                 closed 9/30/18.
    rrrrrrrrrrrr
       02300100  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     9/30/2018
                  Bremerton, WA.    Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 9/30/18.
    rrrrrrrrrrrr
       02346200  WyoTech--Ormand   Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     6/28/2018
                  Beach, FL.        Commission of    Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Career Schools                                 Group, Inc..                  conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 7/24/
                                                                                                                 15;
                                                                                                                 Institution
                                                                                                                 closed 6/28/18.
    rrrrrrrrrrrr
       02606200  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     7/25/2016
                  Renton, WA.       Commission of    Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Career Schools                                 Group, Inc..                  conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 7/24/
                                                                                                                 15;
                                                                                                                 Institution
                                                                                                                 closed 7/25/16.
    rrrrrrrrrrrr
       02617500  Everest College-- Accrediting      Corinthian         330717312  Zenith             472237488  Change in          4/10/2014                 7/24/2015  Approved--Inst     9/30/2018
                  Seattle, WA.      Council for      Colleges, Inc..               Education                     Ownership and                                           Closed.
                                    Independent                                    Group, Inc..                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/24/
                                    (ACICS).                                                                     15;
                                                                                                                 Institution
                                                                                                                 closed 9/30/18.
    rrrrrrrrrrrr
       03367400  Community Care    Accrediting      Dental             731480285  Community          472654761  Change in          4/30/2015    7/28/2015               Pending........
                  College.          Commission of    Directions,                   HigherEd                      Ownership has
                                    Career Schools   Inc.--Teresa                  Institute.                    occurred on 6/
                                    and Colleges     Knox--100%                                                  30/2015--
                                    (ACCSC).         owner.                                                      Change in
                                                                                                                 Ownership and
                                                                                                                 conversion
                                                                                                                 pending final
                                                                                                                 review and
                                                                                                                 determination
                                                                                                                 by the
                                                                                                                 Department.
    rrrrrrrrrrrr
       00758600  Remington         Accrediting      Education          710641858  Remington          273339369  Change in         11/16/2010                12/15/2011  Approved.......
                  College--Tampa,   Commission of    America, Inc..                College.                      Ownership and
                  FL.               Career Schools                                                               conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 12/15/
                                                                                                                 11. Merged
                                                                                                                 into Remington
                                                                                                                 Houston, TX
                                                                                                                 campus on 7/3/
                                                                                                                 13, now an
                                                                                                                 additional
                                                                                                                 location, no
                                                                                                                 longer
                                                                                                                 separately
                                                                                                                 eligible..
    rrrrrrrrrrrr
       00777700  Remington         Accrediting      Education          710641858  Remington          273339369  Change in         11/16/2010                12/15/2011  Approved.......
                  College--Clevel   Commission of    America, Inc..                College.                      Ownership and
                  and, OH.          Career Schools                                                               conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 12/15/
                                                                                                                 11. Merged
                                                                                                                 into Remington
                                                                                                                 Houston, TX
                                                                                                                 campus on 7/3/
                                                                                                                 13, now an
                                                                                                                 additional
                                                                                                                 location, no
                                                                                                                 longer
                                                                                                                 separately
                                                                                                                 eligible..
    rrrrrrrrrrrr
       02605500  Remington         Accrediting      Education          710641858  Remington          273339369  Change in         11/16/2010                12/15/2011  Approved.......
                  College--Mobile   Commission of    America, Inc..                College.                      Ownership and
                  , AL.             Career Schools                                                               conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 12/15/
                                                                                                                 11. Merged
                                                                                                                 into Remington
                                                                                                                 Houston, TX
                                                                                                                 campus on 7/3/
                                                                                                                 13, now an
                                                                                                                 additional
                                                                                                                 location, no
                                                                                                                 longer
                                                                                                                 separately
                                                                                                                 eligible..
    rrrrrrrrrrrr
       03026500  Remington         Accrediting      Education          710641858  Remington          273339369  Change in         11/16/2010                12/15/2011  Approved.......
                  College--Housto   Commission of    America, Inc..                College.                      Ownership and
                  n, TX.            Career Schools                                                               conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 12/15/
                                                                                                                 11.
    rrrrrrrrrrrr
       03012100  Remington         Accrediting      Education          710641858  Remington          273339369  Change in         11/16/2010                12/15/2011  Approved--Inst     5/20/2014
                  College--Colora   Council for      America, Inc..                College.                      Ownership and                                           Closed.
                  do Springs, CO.   Independent                                                                  conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 12/15/
                                    (ACICS).                                                                     11. Withdrew
                                                                                                                 from Title IV
                                                                                                                 5/20/14.
    rrrrrrrrrrrr
       02179900  Argosy            WASC Senior      Education          251119571  The Dream          412269686  Preacquisition     5/11/2016   11/30/2017               Denied--(see        3/8/2019
                  University.       College and      Management                    Center                        review                                                  current
                                    University       Corporation.                  Foundation.                   completed in                                            status).
                                    Commission                                                                   September
                                    (WASC).                                                                      2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 The
                                                                                                                 institution
                                                                                                                 was included
                                                                                                                 in the DCEH
                                                                                                                 receivership
                                                                                                                 filed in
                                                                                                                 January 2019.
                                                                                                                 The Department
                                                                                                                 denied
                                                                                                                 Argosy's
                                                                                                                 request for
                                                                                                                 change of
                                                                                                                 ownership and
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status on
                                                                                                                 February 27,
                                                                                                                 2019, thereby
                                                                                                                 terminating
                                                                                                                 its
                                                                                                                 eligibility.
                                                                                                                 In March 2019
                                                                                                                 the receiver
                                                                                                                 closed all
                                                                                                                 Argosy
                                                                                                                 campuses,
                                                                                                                 other than its
                                                                                                                 law school
                                                                                                                 (Western State
                                                                                                                 College of
                                                                                                                 Law). The law
                                                                                                                 school is in
                                                                                                                 the process of
                                                                                                                 becoming an
                                                                                                                 additional
                                                                                                                 location of
                                                                                                                 Westcliff
                                                                                                                 University. No
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       04051300  The Art           Accrediting      Education          251119571  The Dream          412269686  Preacquisition     5/11/2016   11/30/2017               Institution       12/13/2019
                  Institute of      Council for      Management                    Center                        review                                                  Closed.
                  Las Vegas         Independent      Corporation.                  Foundation.                   completed in
                  (closed 12/13/    Colleges and                                                                 September
                  19).              Schools                                                                      2017, and the
                                    (ACICS).                                                                     institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 The
                                                                                                                 institution
                                                                                                                 was included
                                                                                                                 in the DCEH
                                                                                                                 receivership
                                                                                                                 filed in
                                                                                                                 January 2019.
                                                                                                                 The
                                                                                                                 institution
                                                                                                                 closed due to
                                                                                                                 loss of
                                                                                                                 accreditation
                                                                                                                 on 12/13/19.
                                                                                                                 No further
                                                                                                                 action will be
                                                                                                                 taken on the
                                                                                                                 change of
                                                                                                                 ownership or
                                                                                                                 requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       01019500  The Art           Accrediting      Education          251119571  The Dream          412269686  Preacquisition     8/30/2016   11/30/2017               Institution       12/14/2018
                  Institute of      Council for      Management                    Center                        review                                                  Closed.
                  Fort Lauderdale   Independent      Corporation.                  Foundation.                   completed in
                  (closed 12/14/    Colleges and                                                                 September
                  18).              Schools                                                                      2017, and the
                                    (ACICS).                                                                     institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 DCEH closed
                                                                                                                 the
                                                                                                                 institution on
                                                                                                                 12/14/18 as
                                                                                                                 part of a
                                                                                                                 planned
                                                                                                                 closure.
                                                                                                                 Subsequently,
                                                                                                                 DCEH and its
                                                                                                                 subsidiaries
                                                                                                                 were subject
                                                                                                                 to a
                                                                                                                 receivership
                                                                                                                 order entered
                                                                                                                 by a federal
                                                                                                                 court in
                                                                                                                 January 2019.
                                                                                                                 As a result of
                                                                                                                 the
                                                                                                                 receivership
                                                                                                                 and closure of
                                                                                                                 the school, no
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       02078900  The Art           Higher Learning  Education          251119571  The Dream          412269686  Preacquisition     8/30/2016    2/20/2018               Institution       12/14/2018
                  Institute of      Commission       Management                    Center                        review                                                  Closed.
                  Colorado          (HLC).           Corporation.                  Foundation.                   completed in
                  (closed 12/14/                                                                                 September
                  18).                                                                                           2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 DCEH closed
                                                                                                                 the
                                                                                                                 institution on
                                                                                                                 12/14/18 as
                                                                                                                 part of a
                                                                                                                 planned
                                                                                                                 closure.
                                                                                                                 Subsequently,
                                                                                                                 DCEH and its
                                                                                                                 subsidiaries
                                                                                                                 were subject
                                                                                                                 to a
                                                                                                                 receivership
                                                                                                                 order entered
                                                                                                                 by a federal
                                                                                                                 court in
                                                                                                                 January 2019.
                                                                                                                 As a result of
                                                                                                                 the
                                                                                                                 receivership
                                                                                                                 and closure of
                                                                                                                 the school, no
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       00747000  The Art           Middle States    Education          251119571  The Dream          412269686  Preacquisition     8/30/2016    2/20/2018               Institution         3/8/2019
                  Institute of      Commission on    Management                    Center                        review                                                  Closed.
                  Pittsburgh.       Higher           Corporation.                  Foundation.                   completed in
                                    Education.                                                                   September
                                                                                                                 2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 DCEH closed
                                                                                                                 the
                                                                                                                 institution on
                                                                                                                 12/14/18 as
                                                                                                                 part of a
                                                                                                                 planned
                                                                                                                 closure.
                                                                                                                 Subsequently,
                                                                                                                 DCEH and its
                                                                                                                 subsidiaries
                                                                                                                 were subject
                                                                                                                 to a
                                                                                                                 receivership
                                                                                                                 order entered
                                                                                                                 by a federal
                                                                                                                 court in
                                                                                                                 January 2019.
                                                                                                                 As a result of
                                                                                                                 the
                                                                                                                 receivership
                                                                                                                 and closure of
                                                                                                                 the school, no
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       00781900  The Art           Northwest        Education          251119571  The Dream          412269686  Preacquisition     8/31/2016   11/30/2017               Institution       12/14/2018
                  Institute of      Commission on    Management                    Center                        review                                                  Closed.
                  Portland          Colleges and     Corporation.                  Foundation.                   completed in
                  (closed 12/14/    Universities.                                                                September
                  18).                                                                                           2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 DCEH closed
                                                                                                                 the
                                                                                                                 institution on
                                                                                                                 12/14/18 as
                                                                                                                 part of a
                                                                                                                 planned
                                                                                                                 closure.
                                                                                                                 Subsequently,
                                                                                                                 DCEH and its
                                                                                                                 subsidiaries
                                                                                                                 were subject
                                                                                                                 to a
                                                                                                                 receivership
                                                                                                                 order entered
                                                                                                                 by a federal
                                                                                                                 court in
                                                                                                                 January 2019.
                                                                                                                 As a result of
                                                                                                                 the
                                                                                                                 receivership
                                                                                                                 and closure of
                                                                                                                 the school, no
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       00835000  The Art           Middle States    Education          251119571  The Dream          412269686  Preacquisition     8/31/2016    2/20/2018               Institution       12/14/2018
                  Institute of      Commission on    Management                    Center                        review                                                  Closed.
                  Philadelphia      Higher           Corporation.                  Foundation.                   completed in
                  (closed 12/14/    Education.                                                                   September
                  18).                                                                                           2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 DCEH closed
                                                                                                                 the
                                                                                                                 institution on
                                                                                                                 12/14/18 as
                                                                                                                 part of a
                                                                                                                 planned
                                                                                                                 closure.
                                                                                                                 Subsequently,
                                                                                                                 DCEH and its
                                                                                                                 subsidiaries
                                                                                                                 were subject
                                                                                                                 to a
                                                                                                                 receivership
                                                                                                                 order entered
                                                                                                                 by a federal
                                                                                                                 court in
                                                                                                                 January 2019.
                                                                                                                 As a result of
                                                                                                                 the
                                                                                                                 receivership
                                                                                                                 and closure of
                                                                                                                 the school, no
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       02291300  The Art           Northwest        Education          251119571  The Dream          412269686  Preacquisition     8/31/2016   10/17/2017               Institution
                  Institute of      Commission on    Management                    Center                        review                                                  Closed.
                  Seattle.          Colleges and     Corporation.                  Foundation.                   completed in
                                    Universities.                                                                September
                                                                                                                 2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 The
                                                                                                                 institution
                                                                                                                 was included
                                                                                                                 in the DCEH
                                                                                                                 receivership
                                                                                                                 filed in
                                                                                                                 January 2019.
                                                                                                                 The receiver
                                                                                                                 closed the
                                                                                                                 institution on
                                                                                                                 3/8/19. No
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       01258400  The Illinois      Higher Learning  Education          251119571  The Dream          412269686  Preacquisition      9/1/2016    2/20/2018               Institution       12/14/2018
                  Institute of      Commission       Management                    Center                        review                                                  Closed.
                  Art (closed 12/   (HLC).           Corporation.                  Foundation.                   completed in
                  14/18).                                                                                        September
                                                                                                                 2017, and the
                                                                                                                 institution
                                                                                                                 was thereafter
                                                                                                                 acquired by
                                                                                                                 the Dream
                                                                                                                 Center
                                                                                                                 Educational
                                                                                                                 Holdings
                                                                                                                 school group.
                                                                                                                 The
                                                                                                                 institution
                                                                                                                 was included
                                                                                                                 in the DCEH
                                                                                                                 receivership
                                                                                                                 filed in
                                                                                                                 January 2019.
                                                                                                                 The receiver
                                                                                                                 closed the
                                                                                                                 institution on
                                                                                                                 3/8/19. No
                                                                                                                 further action
                                                                                                                 will be taken
                                                                                                                 on the change
                                                                                                                 of ownership
                                                                                                                 or requested
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status under
                                                                                                                 Dream Center
                                                                                                                 ownership..
    rrrrrrrrrrrr
       00887800  Miami             Southern         Education          251119571  Educational        464265864  Prior to the       9/25/2017    2/28/2019               Pending........
                  International     Association of   Management                    Principles                    institution's
                  University of     Colleges and     Corporation.                  Foundation.                   acquisition by
                  Art & Design.     Schools                                                                      EPF, the
                                    Commission                                                                   institution
                                    (SACS).                                                                      was owned by
                                                                                                                 Dream Center
                                                                                                                 Foundation,
                                                                                                                 another
                                                                                                                 nonprofit. The
                                                                                                                 change of
                                                                                                                 ownership to
                                                                                                                 EPF and
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status is
                                                                                                                 currently
                                                                                                                 under review..
    rrrrrrrrrrrr
       01303900  South University  Southern         Education          251119571  Educational        464265864  Prior to the       1/18/2019    2/28/2019               Pending........
                                    Association of   Management                    Principles                    institution's
                                    Colleges and     Corporation.                  Foundation.                   acquisition by
                                    Schools                                                                      EPF, the
                                    Commission                                                                   institution
                                    (SACS).                                                                      was owned by
                                                                                                                 Dream Center
                                                                                                                 Foundation,
                                                                                                                 another
                                                                                                                 nonprofit. The
                                                                                                                 change of
                                                                                                                 ownership to
                                                                                                                 EPF and
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status is
                                                                                                                 currently
                                                                                                                 under review..
    rrrrrrrrrrrr
       00927000  The Art           Southern         Education          251119571  Educational        464265864  Prior to the       1/18/2019    2/28/2019               Pending........
                  Institute of      Association of   Management                    Principles                    institution's
                  Atlanta.          Colleges and     Corporation.                  Foundation.                   acquisition by
                                    Schools                                                                      EPF, the
                                    Commission                                                                   institution
                                    (SACS).                                                                      was owned by
                                                                                                                 Dream Center
                                                                                                                 Foundation,
                                                                                                                 another
                                                                                                                 nonprofit. The
                                                                                                                 change of
                                                                                                                 ownership to
                                                                                                                 EPF and
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status is
                                                                                                                 currently
                                                                                                                 under review..
    rrrrrrrrrrrr
       02117100  The Art           Southern         Education          251119571  Educational        464265864  Prior to the       1/18/2019    2/28/2019               Pending........
                  Institute of      Association of   Management                    Principles                    institution's
                  Houston.          Colleges and     Corporation.                  Foundation.                   acquisition by
                                    Schools                                                                      EPF, the
                                    Commission                                                                   institution
                                    (SACS).                                                                      was owned by
                                                                                                                 Dream Center
                                                                                                                 Foundation,
                                                                                                                 another
                                                                                                                 nonprofit. The
                                                                                                                 change of
                                                                                                                 ownership to
                                                                                                                 EPF and
                                                                                                                 conversion to
                                                                                                                 nonprofit
                                                                                                                 status is
                                                                                                                 currently
                                                                                                                 under review..
    rrrrrrrrrrrr
       02547600  Florida National  Southern         Florida            650021295    .............               Application       10/17/2018                            Withdrawn......
                  University.       Association of   National                                                    Purged 12/20/
                                    Colleges and     University,                                                 2018.
                                    Schools          Inc..
                                    Commission
                                    (SACS).
    rrrrrrrrrrrr
       04150100  Golden State      Accrediting      Golden State       593770508  Goodwill                      Institution                                             Withdrawn......
                  College of        Council for      College of                    Industries of                 closed on
                  Court Reporting   Independent      Court                         the Greater                   March 9, 2018.
                  & Captioning.     Colleges and     Reporting &                   East Bay, Inc..
                                    Schools          Captioning.
                                    (ACICS).
    rrrrrrrrrrrr
       00458600  Kaplan            North Central    Graham Holdings    530182885  Purdue             356002041  Change in          6/19/2017                 8/24/2018  Approved.......
                  University.       Association of   Company.                      University.                   ownership to
                                    Colleges and                                                                 become
                                    Schools                                                                      affiliate of a
                                    (Higher                                                                      public
                                    Learning                                                                     institution
                                    Commission).                                                                 approved. PPPA
                                                                                                                 issued on 8/24/
                                                                                                                 18Purdue
                                                                                                                 University
                                                                                                                 Global is new
                                                                                                                 name of
                                                                                                                 institution.
    rrrrrrrrrrrr
       00107400  Grand Canyon      Higher Learning  Grand Canyon       203356009  Gazelle            472507725  Grand Canyon       1/18/2018                11/14/2019  CIO approved--
                  University.       Commission       Education,                    University                    announced the                                           conversion to
                                    (HLC).           Inc..                         (changed name                 closing of its                                          non-profit
                                                                                   to Grand                      sale to a                                               denied.
                                                                                   Canyon                        nonprofit
                                                                                   University).                  entity in July
                                                                                                                 2018 without
                                                                                                                 the
                                                                                                                 Department's
                                                                                                                 completion of
                                                                                                                 the requested
                                                                                                                 pre-
                                                                                                                 acquisition
                                                                                                                 review. On 11/
                                                                                                                 6/2019 the
                                                                                                                 Department
                                                                                                                 approved GCU's
                                                                                                                 change of
                                                                                                                 ownership and
                                                                                                                 denied its
                                                                                                                 request for
                                                                                                                 nonprofit
                                                                                                                 status. GCU
                                                                                                                 subsequently
                                                                                                                 submitted
                                                                                                                 additional
                                                                                                                 information
                                                                                                                 for the
                                                                                                                 Department's
                                                                                                                 review and
                                                                                                                 requested
                                                                                                                 reconsideratio
                                                                                                                 n on 1/8/2020
                                                                                                                 with
                                                                                                                 additional
                                                                                                                 submissions on
                                                                                                                 5/6/2020 and 5/
                                                                                                                 12/2020. The
                                                                                                                 Department
                                                                                                                 conducted a
                                                                                                                 supplemental
                                                                                                                 review after
                                                                                                                 additional
                                                                                                                 requested
                                                                                                                 information
                                                                                                                 was submitted.
                                                                                                                 Reconsideratio
                                                                                                                 n decision
                                                                                                                 letter denied
                                                                                                                 nonprofit
                                                                                                                 conversion
                                                                                                                 request on 1/
                                                                                                                 12/2021. Grand
                                                                                                                 Canyon files
                                                                                                                 lawsuit
                                                                                                                 against ED due
                                                                                                                 to denial of
                                                                                                                 nonprofit
                                                                                                                 conversion on
                                                                                                                 2/2/2021 in US
                                                                                                                 District Court
                                                                                                                 in Arizona..
    rrrrrrrrrrrr
       01050900  Hallmark          Accrediting      Hallmark Aero-     741684588  Hallmark            45462000  Change in         11/15/2012                 6/12/2014  Approved.......
                  University.       Commission of    Tech, LP.                     University,                   Ownership and
                                    Career Schools                                 Inc..                         conversion--Ap
                                    and Colleges                                                                 proved PPPA
                                    (ACCSC).                                                                     issued 6/12/14.
    rrrrrrrrrrrr
       00962100  Herzing           North Central    Herzing Inc....    391040865  Herzing            271503981  Change in          6/27/2014                 2/13/2018  Approved.......
                  University.       Association of                                 Educational                   Ownership and
                                    Colleges and                                   Foundation.                   conversion--Ap
                                    Schools                                                                      provedPPPA
                                    (Higher                                                                      issued on 2/13/
                                    Learning                                                                     18.
                                    Commission).
    rrrrrrrrrrrr
       03374300  Florida Coastal   American Bar     Infilaw            113790327  PhoenixLaw                    The school         5/24/2019                            Withdrawn......
                  School of Law.    Association      Holding, LLC.                 Foundation.                   intended to
                                    (ABA).                                                                       contribute all
                                                                                                                 of its assets
                                                                                                                 and
                                                                                                                 liabilities to
                                                                                                                 a non-profit
                                                                                                                 foundation,
                                                                                                                 the PhoenixLaw
                                                                                                                 Foundation, an
                                                                                                                 Arizona
                                                                                                                 nonprofit;
                                                                                                                 abbreviated
                                                                                                                 preacquisition
                                                                                                                 offer issued--
                                                                                                                 school
                                                                                                                 withdrew this
                                                                                                                 application
                                                                                                                 because ABA
                                                                                                                 would not
                                                                                                                 approve the
                                                                                                                 transaction--p
                                                                                                                 roposed
                                                                                                                 transaction
                                                                                                                 with
                                                                                                                 Campbellsville
                                                                                                                 University
                                                                                                                 (KY) has been
                                                                                                                 described but
                                                                                                                 not formally
                                                                                                                 applied.
    rrrrrrrrrrrr
       03173300  Atlanta's John    American Bar     John Marshall      200209197  John Marshall      811827820  Application        2/13/2020    3/31/2021               Pending........
                  Marshall Law      Association.     Law School,                   Law School,                   submitted 2/13/
                  School.                            LLC.                          Inc..                         2020;
                                                                                                                 comprehensive
                                                                                                                 pre-
                                                                                                                 acquisition
                                                                                                                 review letter
                                                                                                                 issued 11/16/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed 12/31/
                                                                                                                 2020; TPPPA
                                                                                                                 issued 3/31/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       03001200  McNally Smith     National         McNally Smith,     411540201  MSP College of   ...........  The               12/19/2016                            Institution       12/15/2017
                  College of        Association of   Inc..                         Music.                        Preacquisition                                          Closed.
                  Music.            Schools of                                                                   review was
                                    Music.                                                                       completed, but
                                                                                                                 the
                                                                                                                 institution
                                                                                                                 closed on
                                                                                                                 December 15,
                                                                                                                 2017.
    rrrrrrrrrrrr
       03813300  Northcentral      WASC Senior      NCU Holdings,      860930587  WestMed            900171867  Change in           9/6/2018   10/17/2019               Pending........
                  University.       College and      LLC/Innova                    (changed name                 Ownership has
                                    University       Management                    to                            occurred--Chan
                                    Commission       Group, Inc./                  Northcentral                  ge in
                                    (WASC).          Northcentral                  University)                   Ownership and
                                                     University,                   (affiliated                   conversion
                                                     Inc.                          with National                 pending final
                                                                                   University                    review and
                                                                                   System).                      determination
                                                                                                                 by the
                                                                                                                 Department.
    rrrrrrrrrrrr
       00743700  Pittsburgh        Middle States    Pittsburgh         270093054  Center for         810903939  Change in          5/26/2016                 9/27/2017  Approved.......
                  Technical         Commission on    Technical                     Excellence in                 Ownership and
                  Institute.        Higher           Institute                     Education,                    conversion--Ap
                                    Education.       Employee Stock                Inc..                         proved PPPA
                                                     Ownership Plan.                                             issued on 9/27/
                                                                                                                 17.
    rrrrrrrrrrrr
       02533600  Ross Medical      Accrediting      Ross Education     202222476  Ross Education     202222476  Application        2/18/2019    3/31/2021               Pending........
                  Education         Bureau of        Holdings, LLC.                Holdings, LLC.                submitted on 2/
                  Center.           Health                                                                       18/2019;
                                    Education                                                                    abbreviated
                                    Schools                                                                      pre-
                                    (ABHES).                                                                     acquisition
                                                                                                                 review letter
                                                                                                                 issued on 12/8/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed on 2/1/
                                                                                                                 2021; TPPPA
                                                                                                                 issued on 3/31/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       02099700  Ross Medical      Accrediting      Ross Education     202222476  Ross Education     202222476  Application        2/18/2019    3/31/2021               Pending........
                  Education         Bureau of        Holdings, LLC.                Holdings, LLC.                submitted on 2/
                  Center.           Health                                                                       18/2019;
                                    Education                                                                    abbreviated
                                    Schools                                                                      pre-
                                    (ABHES).                                                                     acquisition
                                                                                                                 review letter
                                                                                                                 issued on 12/8/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed on 2/1/
                                                                                                                 2021; TPPPA
                                                                                                                 issued on 3/31/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       02246300  Ross Medical      Accrediting      Ross Education     202222476  Ross Education     202222476  Application        2/18/2019    3/31/2021               Pending........
                  Education         Bureau of        Holdings, LLC.                Holdings, LLC.                submitted on 2/
                  Center.           Health                                                                       18/2019;
                                    Education                                                                    abbreviated
                                    Schools                                                                      pre-
                                    (ABHES).                                                                     acquisition
                                                                                                                 review letter
                                                                                                                 issued on 12/8/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed on 2/1/
                                                                                                                 2021; TPPPA
                                                                                                                 issued on 3/31/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       02339700  Ross Medical      Accrediting      Ross Education     202222476  Ross Education     202222476  Application        2/18/2019    3/31/2021               Pending........
                  Education         Bureau of        Holdings, LLC.                Holdings, LLC.                submitted on 2/
                  Center.           Health                                                                       18/2019;
                                    Education                                                                    abbreviated
                                    Schools                                                                      pre-
                                    (ABHES).                                                                     acquisition
                                                                                                                 review letter
                                                                                                                 issued on 12/8/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed on 2/1/
                                                                                                                 2021; TPPPA
                                                                                                                 issued on 3/31/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       02180100  Ross Medical      Accrediting      Ross Education     202222476  Ross Education     202222476  Application        2/18/2019    3/31/2021               Pending........
                  Education         Bureau of        Holdings, LLC.                Holdings, LLC.                submitted on 2/
                  Center.           Health                                                                       18/2019;
                                    Education                                                                    abbreviated
                                    Schools                                                                      pre-
                                    (ABHES).                                                                     acquisition
                                                                                                                 review letter
                                                                                                                 issued on 12/8/
                                                                                                                 2020;
                                                                                                                 transaction
                                                                                                                 closed on 2/1/
                                                                                                                 2021; TPPPA
                                                                                                                 issued on 3/31/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       00746800  School of Visual  Middle States    School of          135568364  SVA Alumni                    Application        5/31/2016                            Withdrawn......
                  Arts.             Commission on    Visual Arts,                  Association,                  submitted 9/12/
                                    Higher           Inc..                         Inc..                         2019;
                                    Education.                                                                   application
                                                                                                                 withdrawn 8/21/
                                                                                                                 2020--plan to
                                                                                                                 finalize the
                                                                                                                 transaction
                                                                                                                 later for a 9/
                                                                                                                 1/2021 close.
    rrrrrrrrrrrr
       00746800  School of Visual  Middle States    School of          135568364  SVA Alumni         237193748  Preacquistion      9/12/2019                            Withdrawn......
                  Arts.             Commission on    Visual Arts,                  Society, Inc.                 Review
                                    Higher           Inc..                         [501 (c)(3)].                 completed.
                                    Education.                                                                   Application
                                                                                                                 purged on 6/22/
                                                                                                                 18.
    rrrrrrrrrrrr
       03280300  Seattle           Accreditation    Seattle Inst.      911637769  Center for         271791496  Application        4/15/2019     3/2/2021               Pending........
                  Institute of      Commission for   of Oriental                   Integrated                    submitted 4/15/
                  East Asian        Acupuncture      Medicine.                     Care.                         2019;
                  Medicine.         and Oriental                                                                 transaction
                                    Medicine                                                                     closed 9/1/
                                    (ACAOM).                                                                     2019; TPPPA
                                                                                                                 issued 3/2/
                                                                                                                 2021;
                                                                                                                 application
                                                                                                                 under review.
    rrrrrrrrrrrr
       04195600  Tribeca           Accrediting      Sterling           263922906  Columbia           952077629  Acquisition of      1/3/2017                 6/11/2018  Approved.......
                  Flashpoint        Council for      Partners--Smal                College                       Tribeca as an
                  College.          Independent      l Market                      Hollywood.                    additional
                                    Colleges and     Growth 2009,                                                location of
                                    Schools          L.P..                                                       Columbia
                                    (ACICS).                                                                     closed on 3/20/
                                                                                                                 18. Merger
                                                                                                                 approved, full
                                                                                                                 PPAs
                                                                                                                 reflecting
                                                                                                                 merger issued
                                                                                                                 6/11/18. No
                                                                                                                 longer
                                                                                                                 separately
                                                                                                                 eligible.
    rrrrrrrrrrrr
       00367400  Stevens Henager   Accrediting      Stevens Henager     87050023  Center for         208091013  Change in          11/7/2012                12/19/2018  Approved--Inst      8/1/2021
                  College.          Commission of    College, Inc..                Excellence in                 Ownership                                               Closed.
                                    Career Schools                                 Higher                        Approved and
                                    and Colleges                                   Education.                    PPPA issued on
                                    (ACCSC).                                                                     8/31/16.
                                                                                                                 Conversion
                                                                                                                 application
                                                                                                                 denied on 8/11/
                                                                                                                 16.
                                                                                                                 Institution
                                                                                                                 submitted
                                                                                                                 additional
                                                                                                                 information
                                                                                                                 and filed
                                                                                                                 lawsuit which
                                                                                                                 was eventually
                                                                                                                 settled.
                                                                                                                 Conversion
                                                                                                                 approved on
                                                                                                                 the basis of
                                                                                                                 updated
                                                                                                                 information
                                                                                                                 regarding the
                                                                                                                 transaction,
                                                                                                                 and PPPAs
                                                                                                                 issued 12/19/
                                                                                                                 18..
    rrrrrrrrrrrr
       02326900  Sunstate          Accrediting      Sunstate           592390702  Compass Rose       590972013  Change in          9/11/2015                10/18/2017  Approved.......
                  Academy--Ft.      Commission of    College, Inc..                Foundation,                   Ownership and
                  Myers.            Career Schools                                 Inc..                         conversion--Ap
                                    and Colleges                                                                 proved PPPAs
                                    (ACCSC).                                                                     issued on 10/
                                                                                                                 18/17.
    rrrrrrrrrrrr
       02524000  Sunstate          Accrediting      Sunstate           592390702  Compass Rose       590972013  Change in          9/11/2015                10/18/2017  Approved.......
                  Academy--Clearw   Commission of    College, Inc..                Foundation,                   Ownership and
                  ater.             Career Schools                                 Inc..                         conversion--Ap
                                    and Colleges                                                                 provedPPPAs
                                    (ACCSC).                                                                     issued on 10/
                                                                                                                 18/17.
    rrrrrrrrrrrr
       02491500  Southwest         Higher Learning  The Art Center     860567728  The Art Center.    860567728  SUVA has            1/3/2019     4/1/2019               Institution       11/30/2020
                  University of     Commission       (a Subchapter                                               changed its                                             Closed.
                  Visual Arts.      (HLC).           S Corporation).                                             tax status
                                                                                                                 under an
                                                                                                                 Arizona law
                                                                                                                 that allows an
                                                                                                                 existing
                                                                                                                 corporation to
                                                                                                                 transition to
                                                                                                                 nonprofit.
                                                                                                                 That
                                                                                                                 transaction
                                                                                                                 has occurred
                                                                                                                 and a TPPPA
                                                                                                                 has been
                                                                                                                 issued. While
                                                                                                                 the conversion
                                                                                                                 to nonprofit
                                                                                                                 status was
                                                                                                                 under review
                                                                                                                 by the
                                                                                                                 Department,
                                                                                                                 the
                                                                                                                 institution
                                                                                                                 entered
                                                                                                                 bankruptcy and
                                                                                                                 closed 11/30/
                                                                                                                 2020..
    rrrrrrrrrrrr
       02151900  Keiser            Southern         The Keiser         591829662  Everglades         650216638  Change in         11/11/2010                 8/10/2011  Approved.......
                  University.       Association of   School, Inc..                 College.                      Ownership and
                                    Colleges and                                                                 conversion--Ap
                                    Schools                                                                      proved PPPA
                                    Commission                                                                   issued 8/10/11.
                                    (SACS).
    rrrrrrrrrrrr
       03549300  Ultimate Medical  Accrediting      Ultimate           202000570  UMA Education,     472578950  Change in           4/1/2015                  7/9/2015  Approved.......
                  Academy.          Council for      Medical                       Inc..                         Ownership and
                                    Independent      Academy, LLC.                                               conversion--Ap
                                    Colleges and                                                                 proved PPPA
                                    Schools                                                                      issued 7/9/15.
                                    (ACICS).
    rrrrrrrrrrrr
       00170300  Kendall College.  North Central    Wengen Alberta,    208658661  National Louis     362167804  Acquisition of     1/17/2018                 9/20/2018  Approved.......
                                    Association of   Limited                       University.                   Kendall as an
                                    Colleges and     Partnership                                                 additional
                                    Schools          (Laureate                                                   location of
                                    (Higher          Education).                                                 National
                                    Learning                                                                     Louis. Merger
                                    Commission).                                                                 approved, full
                                                                                                                 PPAs
                                                                                                                 reflecting
                                                                                                                 merger issued
                                                                                                                 9/20/18. No
                                                                                                                 longer
                                                                                                                 separately
                                                                                                                 eligible.
    rrrrrrrrrrrr
       03874300  Cambridge Junior  Accrediting      Workforce          680466305  ASPIRA Inc. of                Application         6/5/2015                            Withdrawn......
                  College.          Council for      Training                      Pennsylvania.                 voluntarily
                                    Independent      Solutions.                                                  withdrawn by
                                    Colleges and     Inc..                                                       ownership
                                    Schools                                                                      (purged 10/11/
                                    (ACICS).                                                                     2016).
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        Question. Former Secretary DeVos allowed borrower defense claims to
    balloon at the Department without processing any claim for more than a
    year. At one point, the backlog grew to several hundred thousand
    claims. As pressure mounted to clear the backlog she created, former
    Secretary DeVos issued blanket and cursory denials of tens of thousands
    of claims. Many of these are potentially meritorious claims that were
    cast aside by the previous Administration, which viewed borrower
    defense as a problem to ignore rather than a mechanism for justice and
    fairness. You previously responded that Federal Student Aid would be
    conducting outreach to state Attorneys Generals, other government
    agencies, and other parties that might be in possession of evidence
    showing institutional misconduct. Based on your outreach and your
    intent to reopen borrower defense denials when evidence indicates
    misconduct or other concerns that were not considered during the
    initial adjudication:
        How many denied applications has the Department reopened?
        Answer. Under the proposed Sweet v. Cardona (Sweet) settlement, the
    Department would void all denials issued in December 2019 or later and
    re-adjudicate the applications under the terms of the settlement.
        Question. How many of those applications has the Department
    approved?
        Answer. As stated above, under the proposed Sweet settlement, the
    Department would void all denials issued in December 2019 or later and
    re-adjudicate the applications under the terms of the settlement. That
    process has not happened yet because the Court has not approved the
    settlement.
        Question. What steps will you take to further review the DeVos
    Department's borrower defense denials?
        Answer. The Department believes that the Sweet settlement, if
    approved, will address the DeVos Department's borrower defense denials.
        Question. In the fall of 2021 and the winter of 2022, the
    Department conducted negotiated rulemaking to make regulatory changes
    for programs authorized by Title IV of the Higher Education Act. Topics
    included gainful employment, for-profit conversions, borrower defense,
    the 90/10 rule, financial responsibility, and administrative
    capability. While I'm glad the Department is undertaking this process,
    it is lengthy and the Department's rules are subject to litigation;
    however, students and borrowers need protection now.
        When does the Department plan to send the draft of the gainful
    employment rule to the Office of Information and Regulatory Affairs for
    review?
        When does the Department plan to release the Notice of Proposed
    Rulemaking?
        Does the Department plan to release all the topics at once?
        Does the Department plan to have the final rule published by
    November 1, 2022, so that important rules on institutional
    accountability go into effect by July 1, 2023?
        Answer. Response to all questions:
        We are working to publish a proposed rule in a timely manner, given
    the critical importance of the issue. On July 26, 2022 we announced
    regulations to address the loophole in the 90/10 rule and to strengthen
    rules related to changes in ownership. On the Spring 2022 unified
    agenda, the Department noted that we hope to publish proposed rules for
    gainful employment, certification procedures, financial responsibility,
    administrative capability, and ability to benefit--the remainder of the
    issues negotiated by the Institutional and Programmatic Eligibility
    Committee--in Spring 2023. Pursuant to master calendar requirements in
    the Higher Education Act, the soonest those rules could take effect if
    published by November 1, 2023, is July 1, 2024.
        Question. During the Obama Administration, former Secretary Arne
    Duncan created a Federal interagency task force to coordinate oversight
    and enforcement efforts related to for-profit colleges. The task force
    was based on a bill that I introduced 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. The Department has expressed its deep
    interest in strengthening oversight and accountability for higher
    education institutions, including for-profit colleges.
        Would the Department consider recreating an interagency task force?
        Answer. The Department believes our work is stronger when we are
    able to collaborate with other key parties that investigate
    institutions. During the first year-plus of the administration we have
    worked hard to strengthen relationships both with other Federal
    agencies as well as with State Attorneys General. This has included
    reinvigorating the Principles of Excellence work in which the
    Departments of Education, Defense, and Veterans Affairs, and the
    Consumer Financial Protection Bureau collaborate on issues affecting
    veteran and military students. Many of these issues relate to the
    concerns you have raised. We are continuing to identify opportunities
    to make the Federal Government more effectively collaborate on
    important issues and will keep this idea in mind as we explore options.
        Question. What steps has the Department taken to reestablish
    relationships with other Federal agencies and state Attorneys General?
        Answer. The Department views State Attorneys General as critical
    partners in our oversight and enforcement work. Since the early days of
    the Administration, we have been conducting additional outreach to
    strengthen relationships. For instance, we have been reaching out to
    Attorneys General to obtain additional information that can assist us
    in the review of borrower defense applications. This information was
    critical to the approval of findings against ITT Technical Institute,
    Westwood College, Minnesota School of Business/Globe University, and
    the Court Reporting Institute. Federal Student Aid also has regular
    calls with the Attorneys General to discuss ongoing issues. We believe
    that collaboration will continue to be useful for ongoing reviews of
    borrower defense claims and investigations and reviews of institutions.
        Question. What further steps does the Department plan to take to
    strengthen these relationships?
        Answer. In addition to the continued collaboration discussed above,
    the Department proposed in its draft regulations for borrower defense
    to repayment to create a formal process for a State representative,
    including attorneys general, to submit requests for consideration of
    group claims. We also anticipate that the newly reconstituted Office of
    Enforcement within Federal Student Aid to collaborate with relevant
    Federal and State actors as their investigations continue.
        Question. Over the last five fiscal years, this Subcommittee--with
    the support of Chair Murray and Ranking Member Blunt--has provided $35
    million for an Open Textbooks Pilot to expand the use of open textbooks
    on college campuses and 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 do not purchase required
    course materials because they are too costly, which affects student
    outcomes. The College Board estimates that the average student budget
    at a four-year public institution of higher education for books and
    supplies was $1,240 during the 2021-22 academic year. These costs
    disproportionately affect low-income, first-generation, and students of
    color. In June 2020, the Department made nine new awards with its
    fiscal year (FY) 2021 appropriation. Using fiscal year 2022 funds, the
    Department fully funded the nine additional fiscal year 2021 awardees.
    Research shows that projects supported by the grant program are
    estimated to save students $220 million.
        Given the initial success of the pilot program, will the Department
    request funding for the Open Textbooks Pilot in the fiscal year 2024
    President's Budget Request?
        Answer. Thank you for your question regarding the Open Textbook
    Pilot. The Department has not yet finalized plans for the fiscal year
    2024 President's Budget Request.
        Question. The Public Service Loan Forgiveness Program offers loan
    forgiveness for public servants after 120 qualifying student loan
    payments. This well-intentioned program is meant to encourage
    individuals to enter into public service careers without having to
    worry about looming student loan debt. However, due to the Department
    and loan servicers' failures in running the program, 99 percent of
    those who applied were denied before President Biden implemented the
    PSLF waiver. The waiver, which qualifies almost all types of Federal
    loans, all repayment plans, and some kinds of forbearance and deferment
    for PSFL forgiveness, has provided more than 100,000 borrowers with
    forgiveness. I applaud the Administration's efforts to make up for the
    previous mistakes in the program's implementation. Although forgiveness
    through PSFL has risen, according the Education Data Initiative, the
    total dollar amount forgiven was less than 1 percent of national
    outstanding student loan debt balance in 2021. 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 and simplify the problems with PSLF?
        Answer. Since Day One, the Biden Administration has worked to
    ensure that students and student loan borrowers can depend on the
    Department for support in repaying their loans and have access to
    quality student loan servicing. To that end, ED has taken decisive
    action to increase oversight over the student loan program and clean up
    past wrongs.
        In fall 2021, ED announced a change to the PSLF program rules for a
    limited time as a result of the COVID-19 emergency. Now, for a limited
    time, borrowers may receive credit for past periods of repayment that
    would otherwise not qualify for PSLF. Since implementing the waiver,
    this Administration has helped approximately 150,000 borrowers earn
    PSLF forgiveness, increasing beneficiaries by more than 2,000 percent.
    We are launching a four-month sprint to increase usage of the waiver.
        Long-term, The Department is working to ensure more borrowers have
    access to the PSLF program and can consider careers in public service
    by automating PSLF eligibility through data matches with qualifying
    employers so borrowers can focus on giving back. For example, Federal
    Student Aid (FSA) is currently building data exchanges with other
    Federal agencies, and we are also actively recruiting state and local
    agencies to participate.
        We also look forward to creating new regulations that intend to end
    bureaucratic barriers that prevented millions of borrowers from earning
    monthly PSLF credit for paying too much, too little, or on the wrong
    day, or by resetting their progress toward forgiveness just for
    consolidating their loans.
        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 more
    than half of Pell-eligible applicants were selected for verification in
    the 2015-2016 Award Year. It is estimated that more than one in five
    low-income students selected for verification never complete the
    process, and thus never receive 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 aid. It is possible that
    the verification process is disproportionately harming the educational
    success of low-income students, which runs counter to the intention of
    the Pell Grant program. The Department recognized the need to be
    flexible for the 2021-2022 Award Year due to the COVID-19 pandemic and
    verified students' FAFSA applications based on identity, high school
    completion, and their Statement of Educational Purpose instead of
    family financial information. I applaud this move, and with the
    implementation of the FAFSA Simplification Act, I urge continued ease
    for low-income students during the verification process.
        Please provide the percentage of students who were chosen for
    verification out of the total number of students who applied for
    Federal financial aid during the most recent award year.
        Answer. The verification selection rate for all FAFSA applications
    for the 2021-22 cycle was 20.27 percent (note that 3.98 percent of that
    total was verification for identity theft and fraud). The data is
    accurate as of the last transaction on file through July 8, 2022. The
    verification selection rate for the 2022-23 cycle through the
    transaction on file as of June 30, 2022 is 9.53 percent. In both of
    these years, we expect that the actual verification rate for FAFSA
    filers was lower than the numbers above due to waivers issued for
    income verification by the Department for both cycles. The waivers of
    income verification for 2021-2022 would have enabled schools to verify
    as little as 3.98 percent, but schools had the final say in whether to
    conduct income verification or not.
        Question. What percentage of students chosen for verification did
    not complete and failed their verification during the most recent award
    year?
        Answer. FSA uses the receipt of either a Pell Grant or Direct Loan
    as a measure of whether an applicant successfully completes
    verification once selected. Of those selected for verification during
    the 2021-22 FAFSA cycle, 63.7 percent received either a Pell Grant or a
    Direct Loan, leaving 36.3 percent who did not receive a Pell Grant or
    Direct Loan. Please note this data is as of July 13, 2022 and may
    change slightly as Award Year 2022 aid is finalized.
        Question. Please provide the metrics by which the Department will
    select which applications are to be verified after implementation of
    the FAFSA Simplification Act.
        Answer. The metrics that will be used are the probability of aid,
    the estimated under-award, and the estimated over-award amounts
    associated with a FAFSA. We do know that more FAFSA filers will have
    data pulled directly from the IRS following implementation of the FAFSA
    Simplification Act, so we expect future verification rates to be lower
    than current rates.
        Question. On March 31, 2022, I wrote to you and urged you to update
    the Department's 2015 guidance on undue hardship adversary proceedings
    to make it simpler and fairer for borrowers who have demonstrated
    legitimate hardships to receive a bankruptcy discharge for student
    loans. On June 3, Under Secretary Kvaal responded and said: ``the
    Department of Education will update relevant guidance documents as
    necessary, including the 2015 Dear Colleague Letter (DCL GEN-15-13) you
    referred to in your letter. We have been pursuing this work diligently
    and hope to be able to provide your office an update on our progress in
    the near future.'' I appreciate this response, but want to stress the
    urgent need for this updated guidance to be issued without delay.
        When will the updated guidance be issued?
        Answer. Federal law requires borrowers to prove that they face an
    undue hardship to discharge their loans in bankruptcy. The Department
    of Education cannot change the law, but we want to ensure that the law
    is implemented fairly and broadly. The Secretary of Education is not
    solely in charge of this issue, so we are working with the Department
    of Justice to get there. We want to make sure that borrowers are not
    harmed while this process is ongoing. That's why we have worked with
    DOJ to assent to stays in any active student loan bankruptcy
    proceeding, so those borrowers can get the benefit of our new policy
    when it is finalized.
        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 an individual two times less likely to graduate high
    school, and make an individual 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. An entire generation of kids is being traumatized by
    gun violence. The pandemic has magnified this problem, with the CDC
    recently reporting that guns have surpassed auto accidents as the
    leading cause of death for children and teenagers in America. 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 Health and Human Services (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 was funded at $7 million in fiscal year 2022. 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. The Biden Administration has proposed $1 billion to
    support more counselors in schools, and I also signed onto the fiscal
    year 2023 Dear Colleague letter to support funding at the same level.
        Do you support appropriations for Section 7134 of the SUPPORT Act,
    which is already an authorized program, to address the breadth of
    trauma needs in schools, including setting up comprehensive plans,
    trainings, and partnerships?
        Answer. The Administration is committed to improving access to
    school-based mental services, and we will consider funding for the
    Grants to Improve Trauma Support Services and Mental Health Care for
    Children and Youth in Educational Settings program, which is authorized
    by section 7134 of the SUPPORT Act, as we develop the President's
    budget request for fiscal year 2024.
        Question. What more does the Department plan to do to address
    childhood trauma and the mental health toll facing children across
    America?
        Answer. The Department of Education (Department) and its Office of
    Safe and Supportive Schools (OSSS), has long supported increasing
    access to mental health services to make it easier for individuals
    struggling with these issues to get the help they need, supporting
    school's efforts to recognize psychological distress and helping
    States, school districts, and schools ensure access to the care and
    services needed to diagnose and treat mental health needs in students.
    The Department continues to actively work to identify ways to support
    social, emotional, and mental health services for students, including
    administering grant programs that will allow school districts to
    increase the number of trained mental health service providers in
    schools and providing information and resources for stakeholders
    directly through the Department and through our numerous technical
    assistance centers. This work has been enhanced in recent years with
    several appropriations and legislation in support of student mental
    health, most recently in the Bipartisan Safer Communities Act which
    provided unprecedented funding for this work through the Department of
    Education and other Federal agencies. For the Department, this
    legislation provides funding to two extant mental health programs--the
    Mental Health Service Professionals grant and the School-Based Mental
    Health Services grant.
        Generally, Title IV, Part A Student Support and Academic Enrichment
    (SSAE) program funds may be used under section 4108 for any program or
    activity that fosters safe, healthy, supportive, and drug-free school
    environments, which may include school-based health and mental health
    services, trauma-informed classroom management, mentoring and school
    counseling, schoolwide positive behavioral interventions, etc.
    Additionally, the T4PA Center has provided State educational agencies
    (SEA) and the SSAE State Coordinators with numerous mental health
    resources and trainings so that the SEA can help LEAs use funds more
    creatively.
        The Department of Education's Office of Safe and Supportive Schools
    (OSSS), the White House's Office of National Drug Control Policy
    (ONDCP), and OSSS' TA center the National Center on Safe Supportive
    Learning Environments (NCSSLE) will be hosting a 3-part webinar series
    in August-September 2022 that will highlight mental health and
    substance use disorder data trends; best practices from the field; and
    Federal funding to support mental health and drug prevention activities
    in schools. HHS and its many subagencies (e.g., SAMHSA, CDC, HRSA, NIH,
    ACF) have been invited as guest presenters.
        OSSS continues to support other grant programs that recognize
    related areas of the mental health crises facing children including
    the:
      --Project Prevent Grant Program, which enhances schools' and school
            districts' ability to identify, assess, and serve students
            exposed to pervasive violence;
      --School Climate Transformation Grant Program -Local Educational
            Agency (LEA), which helps schools and school districts develop,
            enhance, or expand their systems of support related school
            climate programs; and
      --School Climate Transformation Grant Program -State Educational
            Agency (SEA), which provides to develop, enhance, or expand
            systems of support for, and technical assistance to, local
            educational agencies (LEAs) and schools implementing an
            evidence-based, multi-tiered behavioral framework for improving
            behavioral outcomes and learning conditions for all students.
        Question. How does the Department plan to coordinate with HHS on
    these efforts?
        Answer. Public Law 115-271; Subtitle N--Trauma-Informed Care SEC.
    7132. TASK FORCE TO DEVELOP BEST PRACTICES FOR TRAUMAINFORMED
    IDENTIFICATION, REFERRAL, AND SUPPORT. The Interagency Task Force on
    Trauma-Informed Care, led by HHS' SAMSHSA, was created to identify,
    evaluate, and make recommendations regarding ways in which Federal
    agencies can better coordinate to improve the Federal response to
    families impacted by substance use disorders and other forms of trauma.
    The duty of the Task Force is to create a national strategy on how the
    task force and member agencies will collaborate, prioritize options
    for, and implement a coordinated approach. This strategy now has an
    operating plan that provides an explanation of Federal agency
    involvement and coordination needed to carry out such activities,
    including any statutory or regulatory barriers to such coordination.
    The Department of Education has representation on the Task Force from
    several offices, including the Office of Elementary and Secondary
    Education's Office of Safe and Supportive Schools. The Task Force has
    four pillars that work to achieve the purpose of the Task Force: (1)
    Best Practices; (2) Research; (3) Data; and (4) Federal Coordination.
    The Task Force has divided up into subgroups to focus on coordination
    for each of the pillars.
        First, OSSS and NCSSLE have sent initial invitations to guest
    speakers from HSS subagencies to participate in our 3-part webinar
    series in August-September 2022. OSSS, ONDCP, and NCSSLE will organize
    planning calls with confirmed speakers to finalize presentation content
    and identify practitioners from the field to participation in the
    upcoming webinars.
        Additionally, the Departments of Health and Human Services and
    Education continue to collaborate on strategies to increase access to
    mental health services elementary and secondary education students. In
    addition to providing additional funding for key programs, the
    Bipartisan Safer Communities Act also directs HHS to collaborate with
    Education to develop guidance on how local educational agencies can
    partner with their state's Medicaid program to increase the
    availability of health services, including mental health services in
    schools. In addition, the law establishes a national technical
    assistance center to assist with this process and provides $50 million
    to states to address this work. We anticipate strong collaboration
    between ED and HHS that will increase access to mental health and other
    services in schools.
                                     ______

                  Questions Submitted by Senator Jeff Merkley
        Question. Secretary Cardona, thank you for the work that you and
    the Administration have done so far to help student loan borrowers.
    However, I remain concerned about increasing access to income-driven
    repayment (IDR) plans. Right now, the system remains complicated for
    borrowers across the country, with four different IDR plans from which
    students can choose.
        Can you explain the Department's priorities as they relate to IDR,
    and where the committee can provide additional support to the
    Department to help in streamlining the number of IDR plans to simplify
    the system for borrowers?
        Answer. The Department thinks that income-driven repayment can be a
    crucial way to help borrowers keep their payments manageable. In
    considering improvements to income-driven repayment we are looking at
    concerns raised by stakeholders to identify problems that might need
    addressing. This includes both the design of the plan as well as
    operational items, such as what it takes to enroll. We ultimately want
    to make sure that it is easier for borrowers to choose the best
    repayment plan for them, that it gives them affordable payments, and
    that we do more to reach the borrowers who would likely benefit from
    IDR as a way to avoid delinquency and default but unfortunately do not
    make use of these options in sufficiently large numbers today.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. School safety has become a major topic recently,
    especially following the tragic school shooting in Uvalde. In March
    2018, President Trump appointed then Secretary DeVos to lead a Federal
    Commission on School Safety. The Commission found that while there is
    no universal school safety plan that will work for every school across
    the country, the Federal Government can play a role in enhancing school
    safety. The Department's budget asks for $129 million to address School
    Safety National Activities, a $23 million increase. This includes $24.7
    million for new grants under Project Prevent, and just $2 million for a
    proposed National Clearinghouse on School Infrastructure and
    Sustainability to help with technical assistance on school facility
    construction and improvement. Issues, such as self-locking doors, armed
    security guards, active shooter training for teachers and students,
    bullet proof windows, and other training, have all been discussed as
    ways to help improve student safety.
        One of the findings of the 2018 School Safety Report was on Active
    Shooter Preparedness and Mitigation. The Department has undertaken a
    review of that Report.
        What is the status of that review?
        Answer. The report remains under review by the White House and all
    agencies that contributed to the report.
        Question. What, if anything, has the Department done to implement
    the recommendations contained in the Report?
        Answer. As the report is still under review, ED is unable to report
    on implementation of the recommendations therein.
        Question. What incentives are currently in place to encourage
    schools and school districts to implement safety procedures?
        Answer. The Department has many technical assistance centers and
    resources available to encourage safe, thoughtful, and age-appropriate
    implementation of safety procedures. The primary source of support for
    k-12 schools is the Office of Elementary and Secondary Education's
    Readiness and Emergency Management for Schools (REMS) Technical
    Assistance Center, which helps educational agencies and their community
    partners develop, for free, their readiness and capacity to manage
    emergencies, including prevention, protection, mitigation, response,
    and recovery efforts.
        Question. How many school districts are utilizing these grants to
    improve training and physical safety of their schools?
        Answer. Approximately 108 of the current grant recipients, both
    State educational agencies and local educational agencies, may use
    grant funds to assist multiple schools to establish school safety
    plans. According to the National Center for Education Statistics, as of
    school year 2019--2020, 96.2 percent of public schools reported having
    written plans to address a shooting on campus and 93.3 percent reported
    having written plans to address bomb threat incidents.
        Question. Last month, the Administration released its National Drug
    Control Strategy. This strategy lays out the steps the Administration,
    in coordination with Federal agency staff across the government, will
    take to address the drug epidemic, which continues to grow in West
    Virginia and across the nation. Prevention and early intervention are
    listed in the National Drug Control Strategy as priorities. In 2020,
    the Substance Abuse and Mental Health Services Administration issued
    its annual report on substance use. The report found that 158,000
    people ages 12 to 17 started using prescription pain relievers for the
    first time in 2020. While this a decline from previous years, youth
    substance use needs our full attention before we lose the next
    generation of leaders to the drug epidemic. Senator Manchin's bill, the
    Saving America's Future by Educating (SAFE) Kids Act, directs the
    Department of Education and several other agencies to develop evidence-
    based, age appropriate curriculum on the negative impacts of substance
    use--including but not limited to opioids, tobacco and vaping. The bill
    also establishes a competitive grant program for states to implement
    the curriculum in school if they choose to do so.
        What efforts are underway at the Department to address substance
    use by the youngest and most vulnerable populations?
        Answer. The Department is considering options for supporting the
    National Drug Control Strategy, including possible efforts to prevent
    substance abuse by children and youth, during development of the
    President's fiscal year 2024 budget request.
        When parents send their children to school, they expect them to be
    safe. However, this is not always the case. In 1997, a young student
    from Fayette County was killed by his teacher. That same teacher had
    previously taught at a school in Pennsylvania, but was dismissed
    following a string of allegations involving sexual misconduct with
    students. The teacher somehow received a positive recommendation and
    was able to transfer schools without consequences. Senators Manchin and
    Toomey (R-PA) introduced a bill to ensure that what happened in West
    Virginia could never happen again. The bill, which was signed into law
    as part of a larger education reform package, requires states, state
    educational agencies and local educational agencies to institute
    policies, laws or regulations to prohibit the practice of allowing
    teachers with a history of abusing students to transfer schools without
    facing any consequences. However, almost 8 years later, many states are
    out of compliance with the law. The vast majority of teachers are doing
    important work to educate our next generation, however, so far this
    year, more than 130 teachers and teachers' aides have reportedly been
    arrested on sex-related crimes. While that is 130 too many, it is
    important to acknowledge that it represents a small portion of teachers
    and teachers aides nationwide. In February, Senators Manchin and Toomey
    wrote Secretary Cardona to express concerns regarding the lack of state
    compliance with the law, as well as the Department's lack of
    enforcement of the law. In the Department's response, the Department
    wrote that each state has provided the Department with assurances that
    they will comply with ``all applicable statutory provisions,'' and that
    the Department will develop a further plan to monitor those assurances
    in ``future monitoring.''
        Question. Why are states that are not complying with this law still
    receiving funding from the Department of Education?
        Answer. When needed, the Department's typical process is to
    consider enforcement actions on a case-by-case basis, depending on the
    nature of the non-compliance or violation. These actions may include 1)
    requiring a corrective action plan and closely monitoring
    implementation of that plan to ensure resolution of the instance of
    non-compliance, 2) attaching a specific condition to a grant award, or
    3) designating a grantee as a ``high-risk grantee.'' Withholding is
    also an available enforcement action under the General Education
    Provisions Act, after notice and an opportunity for a hearing.
        Question. How does the Department plan to monitor these assurances
    from states, and whether states are doing what they said they would?
        Answer. Consistent with our ongoing monitoring, technical
    assistance, and oversight processes, the Department is committed to
    helping States better understand their responsibilities under Section
    8546. In the coming months, we will provide further outreach and
    technical assistance so that States may take steps to ensure that they
    are in compliance in as timely a manner as possible given the specific
    processes necessary in that State to implement new, laws, regulations,
    rules, or policies.
        Question. How will the Department ensure that states are brought
    into compliance with this statutory requirement?
        Answer. As noted above, we will work with States to ensure that
    they are brought into compliance with section 8546.
        Question. The Upward Bound Program is one of eight Federal TRIO
    Programs managed by the Department of Education. Upward Bound programs
    in West Virginia provide both educational and living options for
    students during the summer, which are invaluable experiences for
    students who are interested in pursuing undergraduate or graduate
    degrees, especially because Federal TRIO Programs are designed to
    support students who are low-income or come from disadvantaged
    backgrounds. Last month, more than 30 students from West Virginia wrote
    to Senator Manchin to describe how much these programs mean to them,
    including James from Webster County. James told Senator Manchin that
    within a short span of time, TRIO has offered him access to ``college
    prep, tutoring, financial knowledge,'' as well as friends and family
    and so much more. He wrote that these programs would impact him for the
    rest of his life. Despite its important, the Upward Bound grant awards
    were released just one week before previous funding was set to expire.
    This caused great uncertainty for not only the programs, but also the
    students who attend them. It is unacceptable that these programs and
    students were caused uncertainty that they would be funded. At a time
    when youth mental health is at an all-time low, students and families
    do not need more stress and anxiety.
        Why did the Department wait until there was only one week of
    funding left to make the highly anticipated announcement about the
    Upward Bound slate?
        Answer. We agree that it is important to ensure that grantees know
    their funding status as soon as possible, and we make every effort to
    complete the large and complex Upward Bound competition in a timely
    manner. While our fiscal year 2022 award announcements were made in
    late May, close to the end of the 2021-2022 academic year, these
    announcements arrived well in advance of the 2022-2023 program year
    funded by the first year of the new grants.
        Question. Is there a way Congress can provide the Department with
    additional support to streamline the application review and
    determination process?
        Answer. As one of the largest discretionary grant programs in the
    Department. the Upward Bound competitions are administratively complex
    and require considerable Department resources to implement. The
    Department administered the fiscal year 2022 Upward Bound peer review
    remotely with approximately 441 peer reviewers across 147 panels. For
    future grant competitions the Department is considering returning to a
    hybrid peer review process where reviewers would remotely participate
    in the peer review during the first week and then travel to Washington
    DC for a one week in-person peer review.
        The Department believes that, specific to the Upward Bound program,
    the hybrid peer review process will allow for a shorter peer review
    with increased peer review engagement and accountability. An in-person
    peer review for a program as large as Upward Bound would have
    significant travel, hotel, and logistical costs and also require
    additional Department staff for effective oversight of the review.
        Question. The Department of Education manages the Gaining Early
    Awareness and Readiness for Undergraduate Programs, or GEAR UP. This
    program provides competitive grants to states to help prepare low-
    income and first-generation students for post-secondary education
    starting as early as seventh grade. Grant funds may be used to offer
    services to students at high-poverty middle and high schools, such as
    professional development for counselors and instructors, college and
    career planning, counseling and tutoring services to support college
    enrollment. The President's Budget requests $408 million for GEAR UP in
    fiscal year 2023, a significant increase over the past fiscal year.
    GEAR UP has been incredibly successful in helping students achieve
    their dreams to attend college, no matter their background. According
    to the Department of Education, 77 percent of GEAR UP students enroll
    in post-secondary education immediately after graduating from high
    school, as opposed to 45.5 percent of low-income students that do not
    participate in the program.
        Can the successes of this program be applied to other grant
    programs offered by the Department to ensure every program is as
    successful as this one?
        Answer. GEAR UP benefits in this case from a very clear primary
    program purpose and easily measured performance goal related to that
    purpose. Performance measurement for other programs is not always so
    straightforward, but the Department is committed to working with all
    grantees to promote successful outcomes in each program administered by
    the agency. The Department develops and publicly reports measurable and
    relevant program performance measures to provide an accountability
    framework for meeting long-term program goals. Furthermore, the
    Department supports its grantees with Technical Assistance, including
    webinars, workshops and regular communications, and performance
    monitoring, such as annual substantial progress reviews, to assist each
    grantee in meeting its project goals.
        Question. How will the Department coordinate with states and other
    organizations to ensure that students who receive aid from a state or
    local entity are not disqualified for GEAR UP scholarships?
        Answer. The Department is committed to ensuring that all students
    who are eligible to receive a GEAR UP scholarship are provided one.
    State applicants are required to have a scholarship component unless
    granted a waiver; however, Partnership applicants are not required to
    have a scholarship component as part of their project.
        GEAR UP students are eligible to receive scholarships if they:
      --have participated in a GEAR UP project;
      --are under 22 years of age;
      --possess a high school diploma or equivalent; and
      --are enrolled or accepted for enrollment at a program of
            undergraduate instruction at an IHE that is located in the
            State's boundaries, except that, at the grantee's option, a
            State or Partnership may offer scholarships to students who
            attend institutions of higher education outside the State. (See
            20 USC Sec. 1070a-25(g)(3); 34 CFR Sec. 694.14.)
        The Department does not allow State applicants to add other
    criteria or requirements for students to receive GEAR UP scholarships.
    Assuming that a GEAR UP student meets all of the above criteria, they
    would not be disqualified from receiving a scholarship. A student may
    also receive a scholarship if the student transfers from the
    originating school and graduates from a high school that does not serve
    a ``substantial majority'' of GEAR UP students. In addition, projects
    have the option of providing scholarships to students that attend IHEs
    that are outside of their State; however, this is done at the State
    grantee's discretion.
        The minimum amount a project must award to a student is the minimum
    Pell grant amount for the year the student will be utilizing the GEAR
    UP scholarship. In order to ensure scholarship funds are available for
    all eligible students, scholarship funds must be held in reserve with
    at least an amount equal to the minimum scholarship amount multiplied
    by the estimated number of eligible students. However, State projects
    using a priority model may award scholarships directly rather than
    holding funds in reserve, as applicable.
        Although GEAR UP State applicants may request a waiver to the GEAR
    UP scholarship requirement in their application (See 20 USC
    Sec. 1070a--25(b)(2)), this does not preclude the State from
    guaranteeing a scholarship to all eligible GEAR UP participants; rather
    it allows the State to use other State or local resources to provide
    these scholarships.
        In order to receive a waiver, the State applicant must demonstrate
    and describe in its scholarship waiver request the following
    information:
      --Sec. 404E(b)(2) of the HEA- (1) Did the eligible entity demonstrate
            (show either historical or current available data on stated
            financial assistance to students in the state) that the
            eligible entity has another means of providing the students
            with the financial assistance described in this section and (2)
            Did the eligible entity describe (how much funding, what is the
            source of funding (private, state, other) and is there any
            criteria attached to cited financial assistance (income based,
            GPA, etc.) that could potential disqualify a GEAR UP
            participant from receiving such assistance.
      --34 CFR 694.14(c)(3)- Assurance of one-time minimum Pell to a GEAR
            UP participant that does not meet the requirements of any of
            the resources identified as other means for providing the
            student with the financial assistance described in Sec.
            402E(b)(2) of the HEA.
        In short, the Department requires each State to give assurances
    that they have another source of funds to provide all eligible GEAR UP
    students with the required scholarships, and that the State grantee
    will provide the required scholarship to any eligible GEAR UP student
    who does not meet eligibility requirements of the other proposed
    sources of scholarship funding.
        Question. The McKinney-Vento Education for Homeless Children and
    Youth program provides critical assistance for community organizations,
    schools, and state agencies to help address the needs of homeless
    children and youth. The President's Budget requests $110 million for
    Education for Homeless Children and Youths. It is critical that this
    funding gets to states and local entities that can target funding to
    help the students that need it most. The West Virginia Department of
    Education has identified more than 9,500 students who experienced
    homelessness during the 2021 school year, and after hearing from
    individuals on the front lines who are providing needed services to
    these individuals, it is likely these numbers will increase further
    during the 2022-2023 school year.
        How would the Department use increased funding to ensure that all
    children can have the education they deserve, especially our most
    vulnerable?
        Answer. Increased funding under the McKinney-Vento Education for
    Homeless Children and Youth program will provide additional resources
    to States and local educational services to identify and serve eligible
    students and provide them with the access and support services they
    need to participate in academic and extracurricular activities as other
    children and youths.
                                     ______

                    Questions Submitted by Senator Roy Blunt
    Student Loan Forgiveness
        Question. Mr. Secretary, as I highlighted in my opening statement,
    I'm alarmed by the potential of widespread loan forgiveness currently
    under discussion by the administration. It's an illegal, regressive,
    unfair, and expensive proposal that does nothing to address the real
    issues with college costs and is likely to exacerbate them further. Why
    should American taxpayers who never went to college, those who worked
    through college to keep their debt low, or those that worked hard to
    repay their loans have to pay this for this political giveaway?
        Answer. As you note there has been no decision made with regard to
    broad-based student loan forgiveness and discussions are ongoing.
    Overall, student loans should help finance a ticket to opportunity, not
    become a lifelong burden for borrowers. And there is evidence that
    while many students can successfully repay debt, many cannot. Over the
    past 2 years, the Department has engaged in a multi-pronged effort to
    remedy the financial harms to borrowers related to the COVID-19
    pandemic. We have also worked hard to ensure that the different
    programs authorized to discharge borrowers' loans are living up to the
    promises and intents of Congress. We believe these efforts are about
    ensuring borrowers receive the benefits to which they are legally
    entitled.
        Question. Furthermore, widespread loan forgiveness would
    disproportionately benefit high income households as the top 40 percent
    of household hold nearly 60 percent of education debt. Why do you think
    high income borrowers shouldn't have to pay back their loans?
        Answer. The Department maintains that it expects student loan
    borrowers to repay their loans under the terms of the various loan
    repayment plans and other benefits available to them. We note that
    while there are high-income individuals who have student loans, there
    are also significant numbers of borrowers who are not. We are
    particularly concerned about taking steps to address the fact that
    prior to the COVID-19 national emergency there were more than 1 million
    borrowers defaulting on their loans each year, most of whom never
    finished their program, and many of whom were low-income.
        Question. And for low-income borrowers, we have several income-
    driven repayment plans that allow them to pay as little as $0 per month
    and eventually do result in forgiveness if their income remains low.
    Why is this not sufficient?
        Answer. The Department believes that income-driven repayment plans
    are an important tool for helping borrowers to repay their loans. But
    as we have discussed during our ongoing regulatory process considering
    new rules in this area, we are concerned that far too many borrowers
    who might be eligible for income-driven repayment are not making use of
    these plans. And that even with the presence of these plans we have
    seen more than 1 million borrowers defaulting on their loans each year
    prior to the national pause on student loan repayment.
        Question. I'm also concerned about the moral hazard this would
    create with colleges raising prices and future students taking on more
    debt than necessary because both expect another round of forgiveness.
    How would forgiveness not lead to these outcomes?
        Answer. We believe that borrowers intend to repay their loans when
    they take them out. We do, however, share your concerns that more must
    be done to make college more affordable and ensure that borrowers
    receive sufficient value for their investments. The administration has
    unveiled a number of proposals, such as putting Pell Grants on a path
    to doubling by 2029, that we believe would be critical for addressing
    affordability upfront and we would be interested in collaborating on
    further steps to improve postsecondary accountability.
        Question. Do you expect this forgiveness to be one time only or are
    future borrowers right to expect future rounds of forgiveness?
        Answer. We believe it is critical to build a durable and successful
    student loan program for the long-term. For instance, the proposed
    durable improvements to the discharge programs authorized by Congress
    that we unveiled on July 13, 2022 will make much-needed fixes that will
    ensure these options for borrowers live up to their promises. We are
    also working to make significant improvements to FSA operational
    systems and to stand up a new vision for student loan servicing that we
    believe will deliver higher-quality service to borrowers and assist
    with repayment.
        Question. Given all the comments from the Administration on the
    student loan system being broken, I would have expected to see some
    sort of student loan proposals in your budget, yet there are none. Why
    is that? Do you think we should continue to have a Federal student loan
    program?
        If so, then why wouldn't you propose reforms to simplify and
    improve the repayment process?
        Answer. We believe that a significant area of work is for the
    Department to ensure that the programs Congress has authorized for us
    to administer are working effectively. Since the beginning of the
    administration, we have been taking a close look at the various
    authorized discharge programs that far too often failed to deliver on
    their promises. We have been working through executive action and
    regulatory proposals to make those programs more effective and
    efficient, so they better reflect the goals laid out by Congress. We
    believe the changes in the proposed regulations that are currently out
    for public comment will make significant strides to improve the
    repayment experience for borrowers.
    Charter Schools
        Question. The Department of Education proposed an unprecedented
    number of new regulations for the Charter School Program (CSP) for this
    fiscal year, which ends on September 30th, with no prior stakeholder
    engagement. These regulations were posted on March 11th and comments
    were due on April 18th. The Department has received almost 30,000
    comments that it must respond to in addition to finalizing the
    applications and priorities for several separate CSP programs.
        It is essential that eligible applicants have ample time to address
    any new application requirements, and the funds for all but one of the
    programs must be awarded by September 30th. This is a narrow window for
    so many complex tasks and provides no time for the Department to
    authentically respond to real implementation issues with the proposed
    rule. You are already way behind schedule for conducting the State
    Entities and Developers competitions. Are you certain that you have
    enough time to make those grants, along with the Credit Enhancement
    awards which are also planned for this fiscal year?
        Isn't this another reason to run the fiscal year 2022 competitions
    under the existing rules?
        Answer. The Department issued the final rules and Notices Inviting
    Applications for the State Entities and Developer competitions on July
    1st. The Department is fully committed to providing the technical
    assistance needed to support high-quality applications and a diversity
    of applicants. To support these efforts, the Department:
      --Released a Fact Sheet and Blog summarizing the key changes,
            timelines, and funding available.
      --Hosted four webinars to support applicants, one for State Entity
            applicants and one for Developer applicants on Monday, July
            11th and two follow-up webinars, one for each program on
            Monday, July 18th to answer any additional questions applicants
            might have after participating in this week's webinars.
      --Provided an email address to submit questions related to the
            application process.
        The Department also made changes in the final notice to address
    concerns raised during public comment and in recognition of the 30-day
    application window. These include:
      --Encouraging--but not requiring--collaboration between charter
            schools and traditional school systems. We are also providing
            more flexibility regarding the types of collaborations that can
            meet the priority, including being clear that existing
            collaborations may qualify for the priority, as well as
            allowing more flexibility for how a charter might demonstrate
            evidence of the collaboration. For example, in the fiscal year
            2022 competition, the Department encouraged these
            collaborations through an invitational priority in the
            Developer competition and has indicated that the Department
            will not use this as an absolute priority in future
            competitions during this Administration.
      --Clarifying that applicants can provide a range of information and
            evidence to meet the needs analysis requirements. Further, the
            Department is not applying the needs analysis requirement to
            the Developer competition this year, recognizing the capacity
            constraints for independent charter school operators during a
            30-day application window.
      --Streamlining application requirements. The final rules reflect
            efforts to streamline requirements and reduce burden, for
            example by allowing applicants to submit information that they
            have already submitted to their authorizer to meet the needs
            analysis requirement.
        Question. The proposed regulations state that CSP applicants must
    provide information on ``how the applicant plans to establish and
    maintain racially and socio-economically diverse student and staff
    populations.'' Charter advocates oppose this proposed requirement
    because it appears to make ineligible for funding schools supporting
    students that live in racially isolated communities, as well as those
    that are designed to meet the cultural and language needs of tribes and
    native populations.
        Given this requirement and selection criteria that you are
    proposing, do you agree that all other things being equal, this notice,
    for example, would prioritize funds for a school with more affluent
    white students that is more ``diverse'' over a tribal application that
    proposes to meet the cultural and unique educational needs of their
    students in a school district?
        Answer. The Administration is committed to supporting state and
    local efforts to increase school diversity and reduce racial and socio-
    economic isolation in schools, both to ensure that all families can see
    a place for their child in their local public school, whether
    traditional or charter, and in recognition of the significant benefits
    that diverse schools confer--including higher graduation rates,
    improved academic outcomes, and increased levels of college enrollment
    for students of all races.
        Accordingly, the final rule requires CSP applicants to perform
    analyses of a proposed charter school's projected student demographics,
    and share information on the demographics of the local community in
    which the charter school will be located or from which it would draw
    students; to outline plans to establish and maintain a racially and
    socio-economically diverse student body or describe how its student
    body promotes the CSP's mission to provide high-quality educational
    opportunities to underserved students; and to assure that a proposed
    charter school will not negatively affect any desegregation efforts in
    the local community in which the charter school would be located.
        The final rule acknowledges the complexities of recruiting and
    enrolling a diverse student body in certain isolated or racially
    homogeneous communities or where the charter school has a unique
    educational mission, such as primarily serving underserved students,
    and provides such charter schools with a framework for demonstrating
    compliance with CSP requirements. An applicant that proposes to create,
    replicate, or expand a charter school in a racially or socio-
    economically segregated or isolated community or a charter school with
    a unique educational mission would not be ineligible or at a
    competitive disadvantage for funding.
        Question. Does the Department consider a school on an Indian
    reservation or a school serving a heavily minority urban community an
    effort to resegregate schools?
        Answer. As previously stated, the final rule acknowledges the
    complexities of recruiting and enrolling a diverse student body in
    certain isolated or racially homogeneous communities or where the
    charter school has a unique educational mission, such as primarily
    serving underserved students, and provides such charter schools with a
    framework for demonstrating compliance with CSP requirements. An
    applicant that proposes to create, replicate, or expand a charter
    school in a racially or socio-economically segregated or isolated
    community or a charter school with a unique educational mission would
    not be ineligible or at a competitive disadvantage for funding.
        Question. In addition to the proposed regulations, you have also
    included new language in your fiscal year 2023 budget request related
    to whether Charter Schools Program grantees can contract with for-
    profit management companies. The Department's justification is that the
    language would merely clarify Congressional ``intent'' about these
    types of arrangements, yet Congress rejected the inclusion of similar
    language in the final fiscal year 2022 Omnibus appropriations bill.
    Moreover, the two proposals (the regulations and the proposed
    appropriations language) use inconsistent language. For example, the
    proposed regulations address charter schools based on whether the for-
    profit entity has full or ``substantial'' control, but the proposed
    fiscal year 2023 language does not use those terms.
        Agencies typically ask the appropriators for legislative fixes when
    they cannot achieve their policy objectives through regulations or
    other administrative means. Should the Committee consider the
    Department's request as an admission that you don't have the authority
    to address for-profit charter school issues through regulation? If not,
    why did you make two overlapping and inconsistent proposals?
        Answer. Given the significant risks to public funds that fall under
    the purview of for-profit charter school operators, the Department's
    rulemaking is in alignment with Federal statute that expressly
    prohibits for-profit organizations from applying for grants or
    subgrants under the CSP. To ensure additional safeguards, the
    Department's rulemaking requires CSP applicants to: (1) Provide
    detailed information on proposed school governance and ensure
    meaningful, ongoing opportunities for family, educator, and community
    input into school decisionmaking; (2) State whether they have entered,
    or plan to enter into, a contract with a for-profit management
    organization and if so, provide detailed information regarding such
    contract; (3) Report on individuals who have a financial interest in
    the for-profit management organization, including any affiliations or
    conflicts of interest involving charter school staff or board members;
    (4) Detail descriptions of any actual or perceived conflicts of
    interest and the steps the applicant took, or will take, to avoid
    conflicts of interest; and (5) Assure that any for-profit management
    contract is subject to important controls.
        While the fiscal year 2022 rulemaking serves to shine an important
    light on CSP-funded schools that contract with for-profit management
    organizations, it does not and cannot prohibit such relationships. The
    Administration strongly believes, however, that CSP funds should not
    support schools that are managed by organizations with a profit motive.
    Accordingly, the requested legislative language would ensure that CSP-
    funded schools are operated only by nonprofit entities, beginning with
    new awards made with fiscal year 2023 funds.
        Question. In the fiscal year 2022 Senate report, the Committee
    expressed concern about adequate staffing in the Charter Schools
    Program office. Nearly every CSP grantee has had numerous Department of
    Education program officers--some as many as 7 over 2 years. The office
    has been reorganized and in flux since the changes made by The Every
    Student Succeeds Act (ESSA) reauthorization were implemented, and the
    2014 CSP guidance has not been updated to incorporate the ESSA changes.
    Given the lack of technical assistance and support at the Federal level
    that has existed for years now, why is the Department prioritizing
    placing even more requirements on grantees without first addressing
    these other issues? Will the program office be able to respond quickly
    and effectively to the many questions that the new regulations will
    generate? Can you ensure the applicants will have at least 60 days to
    respond to the application process?
        Answer. The Department believes the final priorities and
    requirements are critical to ensuring that schools that receive Charter
    Schools Program funds are subject to strong accountability,
    transparency, and oversight, show demonstrated family and community
    support, provide access for students with disabilities and English
    learners, and serve students from diverse racial and socioeconomic
    backgrounds. We will continue to support applicants and grantees in
    advancing these goals, both directly and through expanded technical
    assistance offerings of the CSP-funded National Charter School Resource
    Center.
        To ensure we can make awards before the end of the fiscal year, the
    Department has allowed applicants for State Entity and Developer grants
    30 days to submit applications after the notices inviting applications
    were issued. We recognize that this might be not ideal; however, we
    anticipate that many prospective applicants will have begun preparing
    to submit applications during the rulemaking process and will be able
    to submit high-quality applications by the established deadline.
    Student Loan Pause
        Question. Mr. Secretary, I am concerned that there is no plan in
    place to transition borrowers back into student loan repayment. At the
    height of the pandemic, it made sense to give borrowers limited relief
    from repaying student loans, and Congress provided that relief through
    the CARES Act. However, the pause has been extended six times via
    executive action, including four times under the current
    administration. The unemployment rate is now back to pre-pandemic rates
    and individuals have largely returned to their normal lives. Is the
    pause going to end on August 31st?
        Answer. Over the past 2 years, the Department has engaged in a
    multi-pronged effort to remedy the financial harms to borrowers related
    to the COVID-19 pandemic. Among other measures, the Department has
    continued the pause in interest and payments on student loans started
    by the prior Administration. As the Department plans for the resumption
    of payments, it will consider additional measures to reduce delinquency
    and defaults.
        Question. And if you can't commit to restarting repayment in
    September, what metrics are you using to determine when repayment
    should restart?
        Answer. The Department's actions to provide relief to struggling
    borrowers considers the continuing COVID-19 national emergency and the
    resulting financial impacts on student loan borrowers.
    Student Loan Servicing
        Question. I am concerned that the Department just released a
    solicitation for student loan servicing last month. Using the extension
    we provided you in the fiscal year 2021 Labor/HHS bill, legacy loan
    servicing contracts are now set to expire in December 2023. While that
    may feel far away, you and I both know that it is a very short time to
    complete the procurement process, particularly for something that has
    been so fraught with challenges like student loan servicing. When do
    you expect to make awards for new student loan contracts and have you
    accounted for the very likely possibility of bid protests in that
    timeline?
        Do you think it will be possible to fully transition the 35 million
    borrowers with federally managed student loans over to servicers
    awarded contracts under the Unified Servicing and Data Solution before
    the legacy contracts expire, given that a solicitation was just
    recently released?
        Answer. The Department anticipates making new contract awards under
    the Unified Servicing and Data Solution (USDS) procurement this coming
    winter. While acquisitions schedules can be challenging to manage, we
    have actively worked to reduce procurement and development timelines,
    mitigate risks, and develop contingencies where possible in order to go
    live with the new USDS contracts by the time the legacy contracts
    expire in December 2023. This plan includes transitioning borrowers
    away from incumbent servicers who do not receive a USDS award to
    incumbents who are awarded a USDS contract before December 2023, then
    allocating accounts to new USDS servicers after go-live, if necessary.
    To the greatest extent possible, the Department is dedicated to
    ensuring borrowers do not experience more than one transfer during the
    transition period.
        Question. Over the last year, several Federal student loan
    servicers have quit the program, representing nearly 20 million
    borrower accounts, and it is possible that additional vendors may leave
    in the future. These departures seem driven by the fact that the
    economics of their contracts are upside down, and even nonprofit
    organizations are losing millions of dollars each year servicing Direct
    Loans. What is your plan under the Unified Servicing and Data Solution
    to ensure that the Office of Federal Student Aid (FSA) does not
    continue to lose qualified loan servicers? Will you commit to
    compensating the Department's servicers fairly for the additional work
    they currently are doing and will do to prepare millions of student and
    parent borrowers for repayment later this year?
        Answer. USDS was strategically developed to address the pain points
    that borrowers, servicers, and FSA experience in the current servicing
    environment. USDS includes a pricing structure that we feel better
    accounts for the costs borne by servicers across several areas of
    operations, including processing systems, contact centers, fulfillment,
    web functionality, and cybersecurity. Through this new pricing
    structure, we believe we will be able to better compensate servicers
    for the true cost of servicing loans, work to realize efficiencies that
    come with greater self-service functionality and economies of scale,
    and manage a complex oversight environment. We will leverage this
    pricing information to construct our budget requests for fiscal year
    2023 and beyond and look forward to collaboration with Congress to
    appropriately fund the student loan servicing environment.
        Question. Mr. Secretary, your budget requests $2.7 billion to
    administer student aid programs, which is an increase of $620 million
    from the fiscal year 2022 level. Every year, we provide this account
    with significant increases and we've yet to see a new student loan
    servicing solution come to fruition. FSA's management plans for the
    Federal student loan program seem to change every few months, and the
    true costs for current and future loan servicing contracts are unknown.
    Will you commit that FSA will provide increased transparency on current
    and future loan servicing contract plans, and that you will brief this
    subcommittee on the proposed structure and associated costs for future
    loan servicing contracts in advance of any public announcements?
        Answer. The fiscal year 2023 President's Budget Request includes
    funding for loan servicing operations and maintenance, as well as
    funding to implement reforms that improve FSA's ability to serve
    students and borrowers, including fully implementing the FAFSA
    Simplification Act and FUTURE Act, improving access to Public Service
    Loan Forgiveness (PSLF), expanding enforcement efforts to ensure
    program compliance, and ultimately holding vendors more accountable for
    providing high quality loan servicing to more than 42 million student
    loan borrowers. A major portion of this increased budget request is
    attributed to the Unified Servicing and Data Solution (USDS), FSA's
    recompete of loan servicing.
        The Committee is aware that the Federal procurement process is
    highly confidential and that, in order to protect the integrity of the
    process for all offerors, FSA cannot share procurement-sensitive
    information before it is made public. However, throughout the USDS
    procurement, FSA has been committed to transparency in the earliest
    possible stages of the process, publishing a Request for Information
    prior to briefing Congress in February 2022 and providing staff with
    several individual and group briefings since that time, including after
    the procurement was published. In addition, the Department holds a bi-
    weekly call with both Appropriations and Authorizing Committee staff;
    previous calls have included discussions of FSA's current and future
    servicing contract plans as well as updates on servicing cost
    estimates. We are committed to continuing this level of communication,
    providing information, and requesting feedback, provided the
    information shared does not violate Federal procurement laws or
    regulations.
    Proprietary Colleges
        Question. Mr. Secretary, I am concerned about this administration's
    treatment of proprietary colleges. There are many high-performing
    proprietary schools in my state and across the country that are
    providing an invaluable service by generating high-skilled graduates
    for vital economic industries that have tight labor markets. How is the
    Administration ensuring that proprietary colleges are being evaluated
    based on their merit and not merely their tax status? Do you believe
    that all programs of higher education, and not just those at
    proprietary colleges, should be held to the same accountability
    standards?
        Answer. The Department agrees that there are high-quality--and low-
    quality--programs in every sector; and we are concerned about programs
    where graduates see earnings that are too low, or debts that are too
    high, across the board. That is why the Department proposed during
    negotiations with the field to require disclosures to students at all
    institutions of key data points about their programs, which may include
    typical debt levels and typical earnings. However, we are also seeking
    to clarify long-standing eligibility requirements in the Higher
    Education Act that are specific to gainful employment programs, defined
    as for-profit and certificate programs. We also see a particular need
    for this clarity in the proprietary sector, given a concentration of
    programs that leave graduates in very low-wage jobs or with debts they
    cannot afford.
                                     ______

                 Questions Submitted by Senator Lindsey Graham
        Question. Secretary Cardona, it has been reported that you were,
    ``Excited about short-term Pell'' when asked if you were supportive of
    a provision in the COMPETES Act modeled off of the JOBS Act. As you
    know, the JOBS Act legislation aims to expand Pell grant program
    eligibility for shorter-term career education programs. However, as
    currently proposed in the House's COMPETES legislation this much-needed
    expansion would prohibit postsecondary programs from being delivered in
    virtual settings and would place a number of overly restrictive
    requirements on these efforts. This would have the practical effect of
    preventing students from using short-term Pell grants to pursue in-
    demand credentials in the rapidly growing field of Information
    Technology, where the workplace is entirely virtual. Many other sectors
    of our economy are also moving in this direction.
        Would a better way to expand access for adult learners to life-
    changing technical training be to set guardrails for outcomes in terms
    of graduation, job placement, and salary attainment, and then to allow
    all providers -whether in-person or virtual--to compete to create the
    best offering?
        Answer. Many short-term programs deliver great value to students.
    They deserve equal respect to academic programs and four-year degrees,
    and they are worthy of Federal investment. Additionally, many workers
    need to reskill or upskill quickly and often pursue?short-
    term?credentials to do so. I want to make sure those credentials are
    high-quality and provide students with real economic opportunity. I do
    support the idea of investing in high-quality short-term training
    programs. While the Administration hasn't yet taken a position on
    particular legislation, the President has proposed significant
    workforce development programs, and we look forward to working with
    Congress to ensure that workers have access to high-quality credentials
    through those investments.?
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. As you know, Medicaid reimbursement for school-based
    health services to eligible students is a significant source of revenue
    for school districts. I've heard from educators in my community about
    the immense administrative burden experienced by school-based providers
    who utilize IDEA funding and bill Medicaid, which often duplicates
    needless paperwork and hinders their ability to deliver the appropriate
    individualization, frequency, and intensity of services that children
    with disabilities are entitled to under law. For example, the American
    Speech-Language-Hearing Association's 2020 Schools Survey found that
    school-based SLP and educational audiologists identified excessive
    paperwork, high workload/caseload, and Medicaid reimbursement as
    critical challenges in their workplace.
        Can the Department of Education increase its support for addressing
    these challenges, such as through the establishment of dedicated
    technical assistances centers to address Medicaid Services and
    Reimbursement; Workload Mitigation; and Telepractice Services?
        Answer. Thank you for raising these important issues. Every day,
    talented related services providers, like speech language pathologists,
    occupational therapists, and audiologists, provide our nation's
    students with a wide range of valuable and necessary supports, and I
    believe it is critical that we work to ensure that they, and all school
    staff, have the resources they need to be successful. The Department
    carefully considers its technical assistance investments to ensure that
    they meet the needs of the field, and we will take your suggestions
    under advisement.
        In addition, I can specifically assure you that the Department will
    work with the Department of Health and Human Services to implement the
    Bipartisan Safer Communities Act requirement that the Departments
    establish a technical assistance center to support State Medicaid
    agencies, LEAs and school-based entities to expand their capacity to
    provide Medicaid-funded school-based services, and to reduce
    administrative burden
                                     ______

                   Questions Submitted by Senator Mike Braun
        Question. Section 4307 of the Elementary and Secondary Education
    Act requires the Department to consult with administrators, teachers,
    and other individuals involved in the operation of charter schools in
    the development of any regulations that impact charter schools. Leaders
    in the charter school community could not identify any members of that
    community who were consulted with in the development of the Notice of
    Proposed Priorities (NPP). Your department has proposed an
    unprecedented number of new regulations for the CSP for this fiscal
    year, with seemingly no prior stakeholder engagement.
        How did the Department comply with Section 4307 and which specific
    individuals or groups did you consult with?
        Answer. The rulemaking process included a dedicated opportunity for
    written public comment. Public comment is an important opportunity for
    the Department to hear from individuals and entities most connected to
    the work and who represent the students and families most impacted by a
    particular program. The resulting public comments--which involved more
    than 25,000 submissions that were read and given careful
    consideration--revealed ways to further strengthen our proposal for
    this grant program. We appreciate the robust stakeholder feedback. The
    final rules reflect the numerous changes in response to stakeholder
    comments to clarify intent, and to maintain our commitment to providing
    all students with a high-quality education, in particular to our most
    underserved students. The Department is grateful for the thoughtful
    input and comments received as the Department worked to finalize rules
    under the Charter School Program. We are all working toward the same
    goal of ensuring students from all ages, backgrounds, and communities
    have access to high-quality education, including through high-quality
    public schools.
        Question. Student loan debt recently reached a record $1.7
    trillion. The student loan repayment pause in the name of pandemic
    relief has already added nearly $100 billion to the national debt.
    According to the Committee for a Responsible Federal Budget, student
    loan forgiveness would increase inflation rate forecasts between 4
    percent and 20 percent, forcing millions of families that hold no
    student loan debt to suffer higher inflation. It would also worsen
    inequality since nearly one-third of all student debt is owed by the
    wealthiest 20 percent and only 8 percent is owed by the bottom 20
    percent, according to a Brookings Institution study. The Biden
    Administration continues to float the idea of student loan forgiveness
    to appease far-left activists even though it is unlikely that your
    Department has the legal authority to do so.
        Do you believe that even though most Americans do not have college
    degrees that they should be forced to pick up the cost of student debt
    forgiveness?
        Answer. At this time, the Department of Education's work with the
    White House and Department of Justice on the question of the
    Administration's authority to cancel student debt is ongoing. The
    Department believes it is crucial congressional action address
    affordability going forward to ensure debt is more manageable in the
    first place and more Americans have access to an affordable education.
        Question. Can you detail the legal authority that the Executive
    Branch has to unilaterally engage in mass student debt cancellation?
        Answer. The Department of Education's work with the White House and
    Department of Justice on the question of the Administration's authority
    to cancel student debt is ongoing. As a result, we are unable to share
    any legal analyses at this time.

                              SUBCOMMITTEE RECESS

        Senator Murray. The committee will next meet in Dirksen
    138, Wednesday, June 15, at 9:30 a.m. for a hearing on the
    Biden Administration's budget request for the Department of
    Labor. The hearing is closed.
        [Whereupon, at 11:55 a.m., Tuesday, June 7, the
    subcommittee was recessed, to reconvene at 9:30 a.m.,
    Wednesday, June 15.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2023

                                  ----------

                            WEDNESDAY, JUNE 15, 2022

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:32 a.m. in room SD-138, Dirksen
    Senate Office Building, Hon. Patty Murray (chairwoman)
    presiding.
        Present: Senators Murray, Schatz, Baldwin, Blunt, Capito,
    Hyde-Smith, and Braun.

                              DEPARTMENT OF LABOR

    STATEMENT OF HON. MARTIN J. WALSH, 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 2023 budget request for the
    Department of Labor.
        Senator Blunt and I will each have an opening statement.
    Then I will introduce our witness. And after his testimony
    Senators will each have 5 minutes for a round of questions.
        We are not able to have this hearing fully open to the
    public yet, or for media and for in-person attendance, but live
    video is available on our committee website. If you are in need
    of accommodations, including closed captioning, please reach
    out to the Committee, or the Office of Congressional
    Accessibility Services.
        Well, this is the last hearings we have scheduled for this
    subcommittee to discuss the President's budget for fiscal year
    2023; and of course the last hearing with Senator Blunt on the
    other side of the dais.
        And after all of the issues that we have worked through
    together, I can't think of a more fitting tribute to that
    partnership than a bill that continues that legacy of making
    meaningful bipartisan investments to help families in my Home
    State of Washington, in Missouri, and across the country.
        So I just want to say that my hope is, after today, we will
    be able to come together quickly in a bipartisan way, as we
    have so many times in the past, to turn to the hard work of
    writing our fiscal year 2023 appropriations bills, and getting
    in a good position to pass everything before the end of the
    year. Families are counting on us to get that done.
        I hope we can all agree it is critical to continue
    strengthening our economy, building off the progress we made
    thanks to the American Rescue Plan, and last year's
    appropriations bills.
        Under President Biden we have added around 8.7 million
    jobs. That is an all-time high. And unemployment is near all-
    time lows at 3.6 percent. Meanwhile, the Pension Relief we
    passed has already given a lifeline to struggling businesses,
    and saved the pensions of tens of thousands of workers and
    retirees who were at risk of having their financial situation
    turned upside down.
        Now, that progress is good, but we still have a lot of work
    ahead to build a stronger, fairer economy that truly works for
    workers not just those at the very top and giant corporations.
        And right now inflation is a serious challenge that we need
    to get our arms around, so we need to bring down everyday costs
    for the basics, like groceries, and gas, and more, that so many
    families are struggling with today. That is why Democrats are
    working to lower the cost of prescription drugs and health
    coverage, and why I believe we need to lower the child care
    costs for families, and fix our broken child care system that
    is on the verge of collapse.
        We have to get it done through reconciliation before it is
    too late, because it is plain as day, the child care crisis is
    holding our economy back. It is keeping so many parents,
    especially moms, out of the workforce, and making it so much
    harder for businesses to find the workers that they need.
        I have put forward a plan that will lower child care costs
    for families across the country by thousands of a year, reach
    more than a million new children and their families, raise
    wages for child care workers and stabilize the sector, keeping
    providers' doors open, and making more options available to
    families, and ultimately to strengthen our entire economy. I am
    going to keep pushing with everything I have to get that done.
        Now, Secretary Walsh, I am glad you were able to hear
    directly from workers in my Home State of Washington about the
    challenges that they are facing when you visited a few months
    ago. And I am especially glad to see that President Biden's
    budget takes to heart so much of what the people in my State
    had to share with you.
        We have important work ahead to protect workers' rights, to
    raise wages, to make sure we have decent, safe, fair working
    conditions, and deliver high quality workforce development
    opportunities. And the increased funding for the Labor
    Department in this budget will help us get it done with many
    much needed investments.
        First, it would provide resources to help fix and
    strengthen our unemployment insurance systems, which so many
    people rely on when they hit hard times and are looking for
    their next job, and which this pandemic has shown, is broken in
    far too many ways. This should be a reliable lifeline for
    people so they can get back on their feet. But back in my State
    and in several others, our unemployment programs have been
    undermined by fraud, outdated technology, and massive data
    hacks.
        We have to do better for families, and that starts with
    providing the resources we need to actually update IT programs,
    and fix the system.
        This budget will also help people who are working to find
    good, high-paying jobs by increasing support for registered
    apprenticeships, and other high-quality workforce development
    programs so they can provide quality opportunities in even more
    industries and occupations. And reach more women, people of
    color, formerly incarcerated individuals, people with
    disabilities, and others who are too often left out, because
    you shouldn't have to have a college degree to make a decent
    living in this country.
        Of course, the Department must do more than provide workers
    new opportunities; we need to be bold in protecting their
    rights as well. That is why it is so important this budget
    invest in the worker protection agencies charged with ensuring
    employers respect workers' rights and follow Federal laws.
        Better enforcing these laws will help make sure workers are
    paid the wages they have earned, not shortchanged on overtime,
    or denied minimum wage, get the family and medical leave they
    are eligible for, and go to work in a safe and healthy
    workplace.
        For too long the number of investigators in the Wage and
    Hour Division has been declining. We actually just hit a 50-
    year low. Too often, the division simply cannot investigate
    wage theft at huge, very well resourced corporations. So I
    think we need to level the playing field for workers to make
    sure they are getting a fair shake. And these resources will
    allow us to crack down on employers who don't pay employees the
    overtime pay they are owed, pay workers less than prevailing
    wages required under law and, otherwise, cheat employees out of
    the pay they earned.
        These investments will not just provide accountability to
    businesses; they will put money directly back in workers'
    pockets where it belongs.
        Meanwhile, increased resources for the International Labor
    Affairs Bureau will protect workers here at home from unfair
    competition when foreign companies do not play by the rules,
    ensuring our trading partners follow through on their
    commitment to workers' rights and keep our Nation competitive
    on the world stage.
        And increased investments in the Office of Federal Contract
    Compliance, will help ensure employers working for the
    government follow the law, including protecting against
    workplace discrimination and harassment. And when it comes to
    enforcing labor laws, this pandemic has put a harsh spotlight
    on how critical workplace health and safety laws are. We need
    the occupational Safety and Health Administration to do more to
    live up to its responsibility here.

                                WORKPLACE SAFETY

        In 2020, our country lost an average of 15 people to
    workplace injuries every day. Everyday 15 loved ones never made
    it home. And workplace deaths like these are disproportionately
    workers of color. That is heartbreaking, we have to do better,
    which is why it is critical this budget bolsters support for
    OSHA's (Occupational Safety and Health Administration) mission
    to keep workers safe on the job, and protected from retaliation
    for calling out safety and health issues in the workplace.

                        PERMANENT COVID SAFETY STANDARD

        It is also why I am continuing to push OSHA to move quickly
    to finally issue a permanent COVID-19 standard for healthcare
    workers, and work on a permanent infectious disease standard as
    well. Healthcare workers have been on the frontline of this
    pandemic. They have worked tirelessly to save the lives of
    countless patients, but they have faced grave danger during
    this pandemic just trying to do their jobs.
        COVID-19 has killed over 5,000 nurses and healthcare
    professionals. We owe it to each, and every one of our
    healthcare heroes to keep them safe.
        So Mr. Secretary, I expect to see the Permanent COVID
    Safety Standard from the Department soon. We should have had
    one already. Workers cannot keep waiting. It is clear to me,
    and I think it is clear to everyone listening, that we have
    more work to do to support our workers and their families. So I
    am going to keep pushing to make sure families have a little
    less stress on their shoulders; and a little more money in
    their pockets.
        That means bringing down costs across the board on things
    like groceries, and gas, and healthcare, and child care, and
    everyday essentials. It means ensuring workers get paid a fair
    living wage, and are not cheated out of it, and go to work
    confident they will be coming home safely. It means making sure
    they can choose to care for themselves and their loved ones
    without losing the paycheck they need, and can learn new skills
    if they want to pursue a new career in a higher paying field.
        And it absolutely means ensuring we protect workers'
    rights, especially the right to join, or form, aunion, to
    collectively bargain for better benefits, better healthcare,
    better retirement plans, and higher wages.

                      BUDGET PRIORITIES IMPACTING WORKERS

        I am glad to say this budget makes clear the Biden
    administration is also committed to these goals, and President
    Biden understands, as well as anyone, that working families are
    the heart of our country and the backbone of our economy.
        Democrats are focused on the economy, Mr. Secretary. We are
    focused on tackling inflation, lowering costs, and making sure
    working people get a fair shake and their fair share. So I look
    forward to working with you and the President to keep building
    an economy that puts those working people first.
        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. And good
    morning to everybody participating in the hearing; and welcome
    Secretary Walsh. I look forward to your testimony on the
    Department of Labor's fiscal year 2023 budget request.
        Last year when you testified before the subcommittee a
    principal topic, and certainly a topic I raised, was how the
    COVID-19 pandemic had put an unprecedented strain on our
    economy and on our workforce. At the time, I had serious
    concerns that our country would not return to our pre-pandemic
    unemployment levels, which had been the lowest since the late
    1960s.
        And while I am pleased that we are making real progress in
    lowering the unemployment rate, I am concerned about the very
    real economic and labor shifts that have occurred since the
    last time we had a hearing, and you were before this committee.
    I am talking of course about the economic impact of inflation,
    an invisible tax that takes its toll on every American, but it
    is particularly burdensome for those who can least afford it.
        Many of the increases in paychecks have been more than
    offset by increases in what you have to pay for, and it only
    takes a trip to the gas station or the grocery store to know,
    for most families, exactly what that means. In recent months
    that inflation number has been above 8 percent, the highest
    rate in over 40 years, and the Treasury Secretary recently
    testified before the Senate Finance Committee that inflation
    was here to stay for any foreseeable future.
        This administration's inflation forecast has already showed
    prices rising this year at nearly twice the pre-pandemic rate.
    And while we might disagree on the root causes of this historic
    inflation, that is really reversing those economic gains made
    in the past, I do believe we can agree that every American is
    feeling the impact.
        History has told us that we can't spend our way out of
    inflation. Instead we have to exercise fiscal responsibility
    and be prudent about determining what is truly needed to right
    the ship, and begin to head things in a different direction.
    Additionally, we are seeing major labor shifts that I think
    will impact the labor market for years to come, dubbed by some
    the ``Great Resignation'', we have watched record numbers of
    employees resign following the COVID-19 pandemic, and that was
    particularly apparent and evident in the young adult
    population.
        Simultaneously help-wanted signs are still visible almost
    everywhere across the country as businesses and employers
    continue to search for workers to fill the vacancies they have.
    There is no question that this is a turbulent moment in our
    country's history, particularly our economic history. But often
    during times like this, of economic and market uncertainty, we
    have the opportunity to rethink the way we have been doing
    things, and prioritize programs that provide the most benefit--
    in the case of the Department of Labor--to workers and
    employers alike.
        This is why I was surprised to see the fiscal year 2023
    budget doubling down on new programs, and funding levels
    rejected just 3 months ago in the fiscal year 2022 bill.
        The fiscal year 2023 proposed budget for the Department of
    Labor totals $14.9 billion, an increase of almost $2 billion,
    and nearly 13 percent over the appropriations bill that we just
    passed. That is nearly triple the increase that was provided in
    that bill. I wouldn't expect to see that if I were you. And we
    want to be talking about what those priorities really are,
    funding such as $100 million for the POWER Plus initiative
    which will transition workers away from jobs in the fossil fuel
    industry, to what would be considered generally green jobs, is
    not included in the fiscal year 2022 final bill, and here it is
    that $100 million is right back in this budget request.
        Similarly, a Career Pathways for Youth Grants, a program
    that I began as Chairman in 2020, to ensure that young adults
    in this country have adequate knowledge, before they get there,
    of all the post-secondary options that they need to know about,
    to be informed about what their pathway really is.
        I agree with the Chairman's view that there are a lot of
    ways to get to a successful career, and a successful life that
    allows you to do the things that are best suited for the kind
    of life you want to lead, and we need to be sure that we are
    not just looking at one pathway. I think so much of education,
    secondary education has been focused on only one way forward
    for a long time, and that is why we try to fund, I think the
    funding was about $15 million, to look at career pathways early
    in the education process so that people in junior high school,
    middle school, and high school begin to get a sense of what
    kinds of jobs that are out there.
        I was surprised you didn't ask for the continuation of that
    program. Why is the funding for workers to transition out of
    their current stable career for jobs and industries that the
    administration prefers being prioritized, and looking at how
    the future labor force gets ready for the work that they would
    want to do, isn't?
        We need to ensure that our labor programs are nimble, and
    quite adequately and appropriately address unexpected workforce
    challenges. For example, while I supported funding for
    registered apprenticeships, the registered apprenticeship model
    is underutilized by industries that need it the most, such as
    healthcare, and IT, and cybersecurity, because it has just not
    been a very flexible model.
        And I hope we can work with you to find more flexibility in
    that whole concept of apprenticeships. I have said it before,
    and I will say it again, we need to create an environment for
    Americans to thrive, and we need to target our Federal
    resources to cultivating the workforce of the future.
        It is wrong for the Federal Government to dictate what that
    workforce should look like, and for bureaucrats in Washington
    to determine the speed in which we get there, that should be
    left up to States, and communities, and local economies. I
    believe we can work together to find consensus on the
    Department's budget.
        I look forward to working with you, Mr. Secretary, as well
    as Chair Murray, and our colleagues on the subcommittee, to
    once again, come up with a bill that prioritizes bipartisan
    initiatives, and innovation in the workforce system.
        As the Chair mentioned, this is my last likely hearing on
    the Labor Appropriations part of this budget, but we have had
    good success working together, finding ways to find a path
    forward. I certainly hope we can do that.
        I want to thank all my colleagues for their support over
    the time I have been on this committee, and particularly Chair
    Murray for the great working relationship we have had.
        Again, thank you for your time here today, Secretary Walsh.
    I look forward to working with you to strengthen our Nation's
    workforce, and create a more prosperous economy for all
    Americans.
        Thank you, Chairman.
                    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 2023 budget request.
        Last year, when you testified before this Subcommittee, I spoke a
    great deal about how the COVID-19 pandemic put an unprecedented strain
    on our economy and its workforce.
        At the time, I had serious concerns that our nation wouldn't return
    to our pre-pandemic unemployment levels, which were the lowest since
    the late 1960s. While I am pleased that we are making progress in
    lowering the unemployment rate, I am concerned about the very real
    economic and labor shifts that have occurred since the last time you
    came before this Subcommittee.
        I'm talking about inflation, of course, which is an invisible tax
    that takes its toll on every American, but is particularly burdensome
    to those who truly can't afford it.
        In recent months, consumer inflation in the United States has
    trended above 8 percent, the highest rate in over 40 years, and the
    Treasury Secretary recently testified before the Senate Finance
    Committee that inflation was here to stay.
        This Administration's inflation forecast has already showed prices
    rising this year at nearly twice the pre-pandemic rate.
        While we may disagree on the root causes of this historic inflation
    that's reversing the economic gains made under the previous
    Administration, I do think we can agree that every American is feeling
    the impact.
        And history has told us that we cannot spend our way out of
    inflation; instead, we must exercise fiscal responsibility and be
    prudent about determining what is truly needed to right the ship.
        Additionally, we are seeing major labor shifts that I think will
    impact the labor market for years to come. Dubbed the ``Great
    Resignation,'' we've watched record numbers of employees resign
    following the COVID-19 pandemic, particularly amongst the young adult
    population.
        Simultaneously, ``help wanted'' signs are still visible across the
    country, as businesses and employers continue to search for workers to
    fill the vacancies.
        There's no question that this is a turbulent moment in our Nation's
    history--but often during economic and market uncertainty, we have an
    opportunity to rethink the status quo and prioritize programs that
    provide the most benefit to workers and employers alike.
        This is why I was surprised to see the fiscal year 2023 budget
    doubling down on new activities and funding levels that were rejected
    just 3 months ago in the fiscal year 2022 bill.
        The fiscal year 2023 budget for the Department of Labor totals
    $14.9 billion, an increase of $1.7 billion and nearly 13 percent over
    fiscal year 2022, which is nearly triple the increase that was provided
    in fiscal year 2022.
        Funding, such as $100 million for the POWER+ Initiative, which will
    transition workers away from jobs in the fossil fuel industry to what
    some consider ``green jobs'' was not included in our fiscal year 2022
    final bill, and yet it appears again in your budget request.
        Simultaneously, ``Career Pathways for Youth'' grants, a program
    that I began as Chairman in fiscal year 2020 to ensure the young adults
    in this country have adequate knowledge of all post-secondary options
    to make an informed decision about their career trajectory, was
    excluded from the budget request.
        Which begs the question: why is funding for workers to transition
    out of their current, stable careers for jobs in industries this
    Administration prefers prioritized over funding for informing the
    future of our workforce about all of their options?
        We need to ensure that our labor programs are nimble and can
    adequately and appropriately address unexpected workforce challenges.
        For example, while I supported funding for registered
    apprenticeships, the registered apprenticeship model is underutilized
    by industries that need it the most, such as healthcare, IT, and
    cybersecurity, due to its lack of flexibility.
        I've said it before and I'll say it again: we need to create an
    environment for Americans to thrive, and we need to target our Federal
    resources to cultivating the workforce of the future.
        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.
        I believe we can work toward consensus on the Department's budget.
        I'm looking forward to working with you, Mr. Secretary, as well as
    Chair Murray our colleagues on the Subcommittee to once again put forth
    a bill that prioritizes bipartisan initiatives and innovation in the
    workforce system for fiscal year 2023.
        Finally, I'd like to thank all of my colleagues for their support
    over the years on this Committee, especially Chair Murray.
        This is likely my last Labor/HHS hearing, and I'd like to take the
    opportunity to say that it has been a tremendous honor to serve with
    you on this Subcommittee on behalf of the great State of Missouri.
        Again, thank you for your time here today, Mr. Secretary. 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 Blunt.
        With that, our witness today is Marty Walsh, Secretary of
    the Department of Labor. Secretary Walsh, thank you for joining
    us today. I look forward to your testimony. You may begin.

                   SUMMARY STATEMENT OF HON. MARTIN J. WALSH

        Secretary Walsh. Thank you very much, Chairwoman Murray;
    and Ranking Member Blunt, thank you as well; members of the
    committee that are here today, and that will be coming in and
    out, I want to thank you for the opportunity to testify in
    front of you today.

                      STRENGTHENING THE AMERICAN WORKFORCE

        I am certainly pleased to outline the Biden-Harris
    administration's priority for the Department of Labor's fiscal
    year 2023 budget. My mission as Secretary, quite honestly, of
    Labor, is to empower all workers morning, noon, and night.
    Frontline workers who carried us through the worst days of the
    pandemic, the marginalized workers who face barriers to
    employment opportunities, the veterans who serve our Nation,
    the rural workers who we serve through targeted workforce
    grants. The Department of Labor, quite honestly, stands with
    all workers in every community to build stronger, more
    resilient, and a more inclusive economy.
        I am certainly proud of all that the Department has
    accomplished in the past year, and the folks that work with me
    every single day. We implemented key provisions of the
    President's American Rescue Plan, supporting healthcare, and
    pensions, and unemployment insurance. We protected workers from
    COVID-19 and heat exposure. We strengthened retirement
    security, and access to mental health services. We expanded
    career-training programs to connect more Americans to
    opportunities that they, quite honestly, need.
        Ranking Member Blunt talked a little bit about, you know,
    people resigning, putting those people back into better paying
    jobs, connecting more industry as well to skilled workers. We
    implemented the President's $15 an hour minimum wage for
    Federal contracts, legislation to stop surprise billing,
    medical billing, protections for Tip workers, we advanced
    government-wide initiatives to support workers organizing
    rights, climate action, and infrastructure implementation.
        In all of our work, we are committed to equity for the most
    vulnerable workers in communities all across America. And we
    have in this moment a unique opportunity to help all workers
    thrive. The President's plan has produced historic job recovery
    and Congress has made major investments in workers through the
    Bipartisan Infrastructure Law.

                              GOOD JOBS INITIATIVE

        In the Department of Labor the Good Jobs Initiative we are
    partnering across government to make sure these investments
    create good jobs and access to all. And I am committed to
    supporting the congressional efforts to invest in the workforce
    training, child care support, education, healthcare, and work
    things that, quite honestly, families depend upon.

                       WORKFORCE DEVELOPMENT INITIATIVES

        The fiscal 2023 budget submission builds on these
    investments and renews our pledge to serve workers, job
    seekers, and retirees all across America. Workforce development
    is a vitally important area of opportunity, high quality job
    training lifts workers into the middle class, and increases
    equity in our economy, and these programs meet the talent needs
    of employers, and strengthens our supply chain. That is why the
    President's budget requests $303 million, we are looking to
    expand registered apprenticeships.
        I agree with you Senator Blunt, about creating
    opportunities into other industries, and we have been working
    on that, and that is really, what we need to do in America
    more. We have $100 million for career training and growing
    industry sectors, $100 million for community college
    partnerships with employers.
        I have visited community colleges in dozens of States
    across this country. I visited dozens of Job Corps centers
    around this country. And I see innovative programs designed in
    collaboration with employers working for students of all
    backgrounds. We need to invest in these partnerships and reach
    out to more employers, and we need to provide more workers with
    better opportunities for their future.
        This budget also increased funding for veterans through our
    Veterans Employment and Training Service Agency. It increases
    funding for our Women's Bureau to expand access for women's
    careers where they are under representative--represented,
    excuse me.

                         INVESTING IN WORKER PROTECTION

        This budget invests $2.2 billion in the Department's worker
    protection agencies. This work is more essential now than ever
    to rebuild our staffing levels, as you said Madam Chair, in
    your very first line. That includes OSHA's efforts to double
    the number of inspectors by the end of the President's first
    term. It will restore MSHA's (Mine Safety and Health
    Administration) capacity for enforcement in mine plant
    equipment reviews. It would restore staffing for unemployment
    benefit, and security administration to protect workers'
    health, retirements, and disabilities.
        It would increase funding for Wage and Hour to safeguard
    our wages for the most vulnerable workers. It would fund the
    Office of Federal Contract Compliance to ensure Federal
    contracting advances America's promise of fairness for all
    workers.
        This budget increases funding to the Office of Labor
    Solicitor to rebuild the entire Department's capacity to
    enforce the laws that are on the books; we also have requested
    the resources for the Bureau Of International Labor Affairs,
    ILAB, to ensure our training partners uphold their labor
    commitments so America's workers can compete on a level playing
    field.

                         UNEMPLOYMENT INSURANCE REFORM

        The budget fully funds and updates the State funding
    formula for unemployment insurance that will be the first
    comprehensive update in decades. It allows States to serve
    claimants more effectively. And our request includes $150
    million to strengthen the integrity of the system.
        Finally, the budget requests nearly $4 million to support
    the Good Jobs Initiative. This will enable us to advance the
    President's priorities of good jobs, and free and fair choice
    to join a union.

                       CONFRONTING INFLATIONARY PRESSURES

        And I just want to touch briefly, before I end my remarks,
    on inflation. Certainly, the President has talked to all the
    Cabinet. It is an all-of-government approach to bring down
    those pressures at the kitchen table, to bring down those
    pressures at the gas pump, to bring down those pressures at the
    grocery store.
        The President, his administration did not cause inflation,
    but we certainly are not running away from inflation because it
    impacts every single American person, and we need to do
    everything in our power to bring those pressures down. This is
    a worldwide challenge that is happening in other countries
    around the globe, but we need to focus on what we are doing
    here in America. So I look forward to talking about that a
    little later.
        I see all of what we do everywhere I travel, workers are
    showing up each and every day to move our communities and our
    Nation forward, and in return we must do everything we can to
    ensure the well-being and empower them with opportunity.
        I want to thank you, both, and all the committee members
    once again for the opportunity to testify today. I look forward
    to discussing our budget requests here with the committee and
    certainly any time that anyone needs to reach out to the
    Department of Labor, do feel free to call me. Thank you.
        [The statement follows:]
                     Prepared Statement of Martin J. Walsh
        Chair 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 and to outline the Biden
    Administration's vision and priorities for the Department of Labor in
    fiscal year (FY) 2023. I am honored and humbled to lead the Department
    in its critical work.
        My vision as the Secretary of Labor is to empower workers morning,
    noon, and night. This includes centering our work on the most
    vulnerable workers, those facing barriers to employment, misclassified
    workers, and workers in temporary jobs or other jobs that heighten
    their economic insecurity and vulnerability. The Department honors the
    nurses, doctors, first responders, farm workers, construction workers,
    communication workers, warehouse workers, grocery store workers,
    servers, teachers, childcare providers, and government workers who have
    carried us this far through the COVID-19 pandemic. The Department also
    acknowledges that many of the workers and families on the frontlines of
    the COVID-19 pandemic are among the lowest paid, and most marginalized.
    As Labor Secretary, I am focused on advancing equity, creating good
    jobs, and empowering workers to organize and successfully bargain with
    their employers. The Department stands shoulder to shoulder with all
    workers to build a better and brighter future.
                              dol accomplishments
        When I testified before this Committee last year, I was new to the
    Department of Labor. A little more than year later--I am proud of
    everything the Department has accomplished. We have issued standards
    and guidance and pursued strong enforcement strategies to keep workers
    in healthcare and other key industries safe and fight the spread of
    COVID-19. We extended and expanded unemployment relief for workers
    during the pandemic.
        During this past year, the Department has worked tirelessly to
    address acute and long-term supply chain issues, and issues affecting
    retirement, wages, tipped workers, workers' rights, and collective
    bargaining. In collaboration with the Department of Transportation, the
    Department recently announced a Trucking Action Plan to expand
    Registered Apprenticeship and to improve job quality in the industry
    overall through the ``Driving Good Jobs'' Initiative. The American
    Rescue Plan (ARP) authorized special financial assistance (SFA) through
    the Pension Benefit Guaranty Corporation (PBGC) to help save severely
    underfunded multiemployer plans and enabled over three million
    participants and beneficiaries to continue to receive their pension
    benefits now and in the future. PBGC estimates that ARP will provide an
    estimated $94 billion in assistance to eligible plans that apply for
    SFA.
        The Department continued to strengthen enforcement by using every
    tool available in order to keep workers in America safe and healthy on
    the job and ensure that they receive the wages that they have earned.
    The Department's Wage and Hour Division (WHD) has recovered over $230
    million in back wages for more than 190,000 workers, averaging $1,200
    in back wages per employee. The Department also issued final rules to
    restore protections for tipped workers, including protections that
    Chair Murray and Chair DeLauro were integral to enacting in 2018.
        The Employee Benefits Security Administration (EBSA) worked with
    the Departments of Health and Human Services and Treasury to implement
    the provisions of the No Surprises Act, preventing patients in need of
    care from being saddled with large, unexpected out-of-network medical
    bills. In 2021, EBSA recovered over $2.5 billion in retirement savings
    and healthcare benefits owed to workers. This is real money--money
    people earned and were owed--and the Department's staff returned it
    into people's pockets and retirement accounts.
        Additionally, despite unions' long history of fighting for higher
    wages and lifting up workers' voices, only 10.3 percent of the U.S.
    workforce is unionized, even as a full 52 percent of non-union workers
    say they want to join a union. The Biden-Harris Administration took
    action and established the White House Task Force on Worker Organizing
    and Empowerment. This first-of- its-kind government-wide effort is
    promoting policies, programs, and practices to help more workers
    organize and successfully bargain with their employers, and to lift up
    as models cooperative labor-management relations where unions and
    employers jointly solve problems advancing both workers and employers'
    interests, though we continue to urge Congress to pass the Protecting
    the Right to Organize (PRO) Act. The Department also continues to
    support efforts to raise the minimum wage for workers in America. One
    significant step and progress is implementing President Biden's
    Executive Order raising the minimum wage to $15 an hour for 300,000
    workers on Federal contracts.
        We will continue to take steps to unleash the full power of the
    Department to continue addressing wage theft, keeping workers safe and
    healthy, and expanding access to good jobs for all.
                              commitment to equity
        Shortly after being sworn in, President Biden issued several
    groundbreaking executive orders to dismantle entrenched disparities in
    our laws and public policies: E.O. 13985 calls for the Federal
    Government to advance racial equity and support underserved communities
    through immediate and sustained action and E.O. 14035 charges Federal
    agencies with cultivating a workforce that draws from the full
    diversity of the Nation. The Department has been hard at work
    delivering on both of these mandates. The Department continues to
    strive to be a model workplace and make the Federal government a model
    employer. Indeed, our Chief Evaluation Office is leading efforts to
    evaluate how we can improve diversity, equity, inclusion, and
    accessibility across the Federal workforce. In addition, we are focused
    on understanding how well our programs, protections, and contracting
    opportunities reach different communities and what barriers to access
    they face, as well as what data we have or need to understand how the
    Department is serving different communities. We have taken a number of
    important steps across our rulemaking, grantmaking, and enforcement
    programs to better reach the most underserved and disadvantaged
    populations.
        Both with the funding already appropriated to us, and as outlined
    in our fiscal year 2023 budget request, these questions guide our
    efforts. For example, we recently announced the availability of $260
    million in American Rescue Plan funding available to states to promote
    equitable access to unemployment compensation programs. The fiscal year
    2023 Budget also includes $15.4 million in the Office of Disability
    Employment Policy to plan and implement Equitable Transition Model
    projects to develop the strategies we need to ensure youth with
    disabilities can get good jobs. These resources will help the
    Department tackle the inequities facing youth with disabilities,
    including youth who are experiencing homelessness, leaving foster care,
    or involved in the justice system.
        We have accomplished a lot over the past year, but we have a lot
    more we need to do. We see that even as the economy recovers from the
    pandemic, most of the job gains have gone to men. In the May jobs
    report, there are still 812,000 (1.1 percent) fewer employed adult
    women than there were pre-pandemic, whereas the number of employed
    adult men, at 81.4 million, has returned to the pre-pandemic level.
    Black women's unemployment rate (5.9 percent) is the highest among
    women by race and ethnicity. The intersection of racism and sexism
    means that Black women are experiencing a different, and more
    difficult, recovery not just because of the types of jobs they are
    likely to hold, but also because they are often treated differently
    within those jobs.
        We must embed equity into how we recruit, hire, and retain all
    workers, including leave and scheduling policies that support families.
    An economy that works only for some in our country means that economy
    is fundamentally broken. I welcome all of you to join me in these
    efforts.
                     investment in workers is long overdue
        Over the past year, Congress has made historic investments in
    workers--in the Unemployment Insurance (UI) system, in resources to
    better protect workers, and in the bipartisan infrastructure
    investments. The UI system, in particular the emergency unemployment
    compensation programs extended by the American Rescue Plan, provided
    life-saving benefits to American families throughout the COVID-19
    pandemic. During the pandemic, UI benefits helped over 53 million
    workers who lost their jobs through no fault of their own and put some
    $870 billion back into the economy. These benefits helped Americans
    across the country stay in their homes and support their families and
    protected the economy from even more devastating consequences. Studies
    have shown that every $1 paid in UI benefits translates into $2 to
    boost the economy.
        However, the pandemic also highlighted that more can be done to
    ensure that workers have timely and equitable access to UI benefits and
    that fraudsters, particularly sophisticated international criminal
    rings, do not flood the UI system with false claims to wrongly acquire
    taxpayer funds while creating further delays and barriers for genuine
    claimants in need. With the $2 billion provided in the American Rescue
    Plan, the Department is making progress to modernize the UI system to
    be more timely, equitable, and safe. The Department has already
    provided significant funding to states to strengthen their UI identity
    verification systems, enhance their fraud detection and prevention
    strategies, and increase cybersecurity. We have made additional funds
    available to help workers learn about, apply for, and better navigate
    the UI system and to provide states with a comprehensive, multi-
    disciplinary assessment of their UI systems and the resources to
    implement improvements identified in the assessment.
        The American Rescue Plan also provided $200 million for the
    Department's worker protection activities. The Department continues to
    provide outreach to essential COVID-19 frontline workers most
    vulnerable to violations of worker protection laws as well as
    compliance assistance to employers delivering essential services.
        Through your coordination and cooperation, Congress delivered a $1
    trillion Bipartisan Infrastructure Law (BIL) to build a better America.
    This represents an investment in well-paid, union and middle-class jobs
    for every single community in America. Our goal is to ensure these
    Federal resources are leveraged to create economic opportunities for
    workers in the communities in which they live. In support of this goal,
    in March of this year, the Department published a proposed rule to
    update and modernize the regulations implementing the Davis-Bacon and
    Related Acts, proposing changes that will be good for workers and good
    for building high-quality infrastructure and for a strong construction
    industry.
        The Administration is committed to working with Congress to enact
    the President's plan to lower healthcare, child care, energy, and other
    costs for families; reduce the deficit; and expand our economy's
    productive capacity. If enacted, the Department will use these
    resources to get our programs where they need to be to operate
    effectively and efficiently while transforming them to address what we
    value including worker empowerment, equity, program access, and the
    other areas of emphasis set out by this Administration. I am committed
    to doing what I can to help Congress get this important legislation
    passed.
        We appreciate Congress enacting additional funding in fiscal year
    2022 for investments in job training, apprenticeship programs, and
    protecting workers through the Department's worker protection agencies.
    Through the Good Jobs Initiative, we are coordinating the Department's
    on-going efforts to advance job quality for all workers, including
    people of color, LGBTQ+ individuals, women, immigrants, veterans,
    people with disabilities, justice-involved individuals, and individuals
    in rural communities. Additionally, we are partnering across Federal
    agencies to enhance implementation of job quality and equity standards
    into Federal investments. This funding, together with the already-
    appropriated resources through the American Rescue Plan, lays the
    groundwork for ensuring that all workers can participate and thrive in
    a growing economy.
                        fiscal year 2023 budget request
        The fiscal year 2023 President's Budget builds on these investments
    and renews DOL's pledge to help all workers and job seekers in
    America--particularly those from disadvantaged communities--access
    training and find pathways to high-quality jobs that can support a
    middle- class life.
        The Budget requests $303 million 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. RA is a proven
    earn-and-learn model that raises participants' wages and is a reliable
    pathway to the middle class. This investment would provide critical
    funding to support capacity-building, including expanding and
    diversifying RA programs as well as expanding pre-apprenticeship
    programs to increase access to RA. Community colleges play a critical
    role in providing accessible, low-cost, and high-quality training. The
    Budget invests $100 million to build their capacity to work with the
    public workforce development system and employers to design and deliver
    high-quality training for in-demand jobs. The Budget also includes $100
    million for a new Sectoral Employment through Career Training for
    Occupational Readiness (SECTOR) program, which will support evidence-
    based training programs focused on growing industries, enabling
    underserved and underrepresented workers to access good jobs and
    creating the skilled workforce the economy needs to thrive.
        The Budget advances the goal of developing pathways for diverse
    workers, including those from disadvantaged groups, to access training
    and career opportunities through increased investments in programs that
    serve justice-involved individuals, at-risk youth, and American Indian,
    Alaska Native, and Native Hawaiian individuals. No economic recovery
    can be complete if some communities are left behind, and this Budget
    reflects the Department's commitment to helping all workers get back on
    their feet.
        The pandemic has been particularly damaging for women workers,
    specifically women of color and low-wage workers, many of whom have
    faced the loss of childcare while trying to protect the safety of
    themselves and their families and still put food on the table. The
    fiscal year 2023 Budget requests more than $25 million for the Women's
    Bureau, including additional funding to strengthen the Women in
    Apprenticeship and Nontraditional Occupations program and expand the
    Fostering Access, Rights, and Equity program. This grant program is
    designed to support targeted education and outreach efforts by
    ``trusted messengers'' and community intermediaries to ensure that
    marginalized workers--disproportionately women of color--avail
    themselves of critical and timely income supports and employment rights
    and benefits.
        Our nation's veterans, transitioning service members, and their
    spouses deserve every opportunity to successfully transition from
    active duty to civilian life, receive access to benefits and
    protections, and find good jobs with family-sustaining wages. The
    Budget provides funding for the Veterans' Employment and Training
    Service's core programs, which help improve skills and provide
    employment opportunities for veterans across the country. The Budget
    increases funding for VETS' Homeless Veterans' Reintegration Program to
    more than $62 million, enabling the program to serve over 1,000
    additional veterans experiencing homelessness.
        Throughout the pandemic, workers have shown up for America, helping
    to keep the economy growing, hospitals operating, food in stores, and
    construction projects booming. In appreciation of the incredible
    dedication of workers in America, DOL must ensure workers are treated
    with dignity and respect in the workplace. The fiscal year 2023 Budget
    invests $2.2 billion in the Department's worker protection agencies.
        Staff losses at the Occupational Safety and Health Administration
    (OSHA) and the Mine Safety and Health Administration (MSHA) have left
    workers less safe on the job, particularly amid the increased threats
    to workplace health and safety created by the pandemic. The fiscal year
    2023 Budget provides resources to help OSHA rebuild its rulemaking and
    enforcement capacity, expand its whistleblower protection program, and
    increase its outreach and compliance assistance. This investment will
    support OSHA's efforts to double the number of inspectors by the end of
    President Biden's first term. The request also includes resources to
    restore MSHA's capabilities in enforcement to help ensure miners'
    health and safety amid a projected increase in workload stemming from
    the BIL.
        Losses to front-line enforcement, regulatory, and compliance
    assistance staff at the Employee Benefits Security Administration have
    similarly compromised the Agency's ability to ensure the solvency of
    self-funded health plans, the security of retirement benefits, the
    integrity of plan assets, the payment of promised benefits, the
    cybersecurity of plan accounts, and the integrity of health and
    disability plans. The requested fiscal year 2023 Budget would restore
    lost staff and enable the agency to protect workers' interest in their
    health, retirement, and disability benefits. The return on the
    taxpayer's investment is significant, as reflected in the $2.5 billion
    it recovered last year. The additional funds requested would contribute
    greatly to the benefit of the more than 158 million workers, retirees,
    and their families who depend on ERISA-covered plans for their medical
    benefits and for the security of their retirement in old age.
        Currently, WHD enforcement staffing is near historic lows,
    impacting the ability of the agency to enforce fundamental labor
    protections including minimum wage, overtime, and family and medical
    leave for 148 million workers across the country. In particular,
    retaliation against workers for coming forward with a complaint about
    their pay or the misclassification of employees as independent
    contractors robs workers of their rightful wages, benefits, and
    protections. The fiscal year 2023 Budget increases funding to the WHD
    by more than $56 million over the fiscal year 2022 enacted level. This
    funding increase will enable WHD to hire, train, and equip enforcement
    staff to better protect essential workers by safeguarding their pay and
    recovering back wages, with particular emphasis on the workers most
    vulnerable to wage violations and exploitive labor conditions.
        The Budget requests to increase funding for the Office of Federal
    Contract Compliance Programs (OFCCP) by nearly $39 million above the
    fiscal year 2022 enacted level, enabling it to fully enforce employment
    antidiscrimination requirements to ensure Federal contracting
    consistent with America's promise to all workers in America. Included
    in this increase is $3.2 million to enable OFCCP to meet the increased
    need for its services as a result of the BIL. This funding will allow
    OFCCP to build its capacity to remove systemic barriers that workers in
    underrepresented communities face to accessing good jobs in
    construction and other growth industries that the BIL will bolster.
        Critical to all these investments in protecting workers' pay,
    benefits, safety and health, and rights is rebuilding the Department's
    capacity to actually enforce the law. This can only be accomplished if
    the Office of the Solicitor is fully funded. SOL, the legal enforcement
    and support arm of the Department, has been kept approximately level-
    funded since fiscal year 2013 despite increasing operational costs and
    rising demand for legal support in litigation, investigative
    assistance, advice, and regulatory work. As a result, SOL has lost over
    100 staff since 2013, resulting in a severe diminution in enforcement
    actions. The Budget recognizes that without adequate resources for SOL,
    DOL will not be able to achieve its mission in any area. To avoid this,
    the Budget increases funding to SOL by $52 million above the fiscal
    year 2022 enacted level to support a total of 740 FTE.
        The Budget also includes resources for the Department's Bureau of
    International Labor Affairs (ILAB) which safeguards dignity at work,
    both at home and abroad. ILAB ensures that our trading partners uphold
    their labor commitments so that America's workers can compete on a
    level playing field. Just this year, ILAB has been integral in
    supporting the first independent union elections at the General Motors
    plant in Silao, Mexico and the Tridonex auto parts facility in
    Matamoros, Mexico. We are proud to support these efforts to ensure that
    all workers can exercise their right to freedom of association and
    collective bargaining. Supporting workplace democracy across the world
    improves working conditions abroad, combats forced labor and child
    labor, improves livelihoods for vulnerable workers, and creates a
    fairer global economy for America's workers.
        President Biden has made the creation of good jobs with the free
    and fair choice to join a union a cornerstone of this Administration.
    Fulfilling this promise requires a comprehensive rethinking of
    everything in the Department's capacity to improve job quality
    throughout the country. The Budget requests nearly $4 million to
    support the Good Jobs Initiative, enabling the Department to provide
    additional training and technical assistance to agencies as they work
    to embed and promote good jobs principles in procurement, loans, and
    grants; engage employers on strategies and initiatives to improve job
    quality; and provide a centralized location of information and services
    on workers' rights under key workplace laws and on unions and
    collective bargaining for use by workers, unions, employers,
    researchers, other government agencies, and policymakers.
        While UI provided a lifeline for millions of families throughout
    the pandemic, the pandemic has also shined a light on the inadequacies
    in the UI system after decades of underinvestment. Overburdened and
    outdated state UI systems kept millions of workers from getting
    benefits quickly and left many unable to access the program. These
    painful delays and barriers fell disproportionately hard on workers of
    color and low-income workers. To address these shortcomings, the Budget
    makes investments to ensure states can better handle higher volumes of
    claims and be better prepared for future crises. The Budget fully funds
    and updates the formula for determining the amount states receive to
    administer UI, which will allow states to serve claimants more quickly
    and effectively. In addition, the Budget includes a $150 million
    investment to promote integrity in the UI system. This investment will
    provide funding to states for identity verification services while also
    supporting IT infrastructure updates to prevent fraud and improve the
    claimant experience.
        While these critical investments will make meaningful improvements
    to the UI system and help ensure families across the country can access
    this vital assistance when workers need it most, we must also keep in
    mind that no amount of financial investment will be able to, on its
    own, fix all of the issues in the UI system. That is why the Budget
    puts forward principles for UI reform. As the pandemic has made clear,
    regular UI benefits in most states are far too low, leaving families
    without the resources they need to make ends meet in times of economic
    crisis. Additionally, millions of workers who lost income due to the
    pandemic and recession were ineligible for UI benefits. And despite its
    important relief and stimulative effects, UI's reach across jobless
    workers remains uneven, with Black and Hispanic workers facing lower
    success rates for receiving benefits than white workers. The
    Administration and I are eager to work with Congress on broad changes
    to modernize the program as well as advance racial, geographic, and
    gender equity in the UI system.
                                   conclusion
        As Labor Secretary, I've made it my priority to travel across the
    Nation. It's a personal mission of mine to amplify the voices of
    working people and share their stories on what they need, successes
    they have had, and how the Biden-Harris administration can support
    them. I was able to see how lead pipes impact communities like Harambee
    in Wisconsin, where the health of the children and everyone else
    depends on the success of a stalled lead pipe replacement project. I
    visited a public library in Dallas, Texas, that provides broadband
    Internet for residents to help more people get access to online
    resources. And across the country I have seen first-hand how union-led
    job sites can boost local economies by hiring locally.
        Despite all that we have been through, workers across the Nation
    are still showing up each and every day to help meet this moment. All
    of us have an opportunity to create an economy where everyone is
    respected, protected, and can thrive. The Department and the Biden-
    Harris Administration recommits its efforts to build an economy and a
    labor market that is more just and equitable and create opportunity for
    all.
        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.
        Let me begin with something I referenced in my opening
    remarks, and that is that workers deserve to be safe at work. I
    am concerned because right now we still do not have a COVID-19
    workplace safety standard, and to me that is just really
    unacceptable, especially because last year, in a report by the
    Government Accountability Office on the Federal response to the
    pandemic, GAO (Government Accountability Office) made clear
    that OSHA inspectors were facing challenges with COVID-19 cases
    without a specific standard.

                    DEPARTMENT OF LABOR RULEMAKING TIMELINES

        I have two questions for you. And let me start with the
    first. When will OSHA finalize a permanent COVID-19 standard
    for healthcare workers? And can you just give me a clear
    timeline here?
        Secretary Walsh. I believe it will be done in the next 3 to
    6 months. We are going through the process now, I do believe we
    are taking public comments, and we are moving through that
    final healthcare standard.
        Senator Murray. Three to 6 months from now?
        Secretary Walsh. Yes. Because it is a rule-making process,
    as you know the rule-making process, and I mean, I would love
    to speed it up, but unfortunately we have this, it is a process
    that is in place that we have to work on now.
        Senator Murray. Well, when will OSHA take the next steps on
    a Permanent Infectious Disease Standard, a process that was
    actually initiated more than a decade ago?
        Secretary Walsh. We are working on that as well right now.
    And I think that is in the same timeline. So OSHA made some
    priorities, and obviously we worked really hard on the rule-
    making process that was struck down by the Supreme Court on
    Vax-or-Test situation. And then at the same time that set us
    back a little bit in the infectious disease, and we got back on
    track with this infectious disease now we will focus on that.
        And in my budget we are looking for a little more money on
    some of the rule-making processes, because we have lots of
    issues that we cannot get to because we can't unless we have
    the resources.
        Senator Murray. Okay. Mr. Secretary, funding in this
    budget, together with investments through the American Rescue
    Plan and the Infrastructure Investment and Jobs Act, can really
    help us have an equitable recovery from the pandemic. But
    unfortunately, jobs that pay low wages and lack benefits have
    been, and actually continue to be, disproportionately filled by
    women, people of color, people living in poverty, people with
    disabilities, and the painful reality is our workforce
    development systems have long struggled to address these
    inequities, and too often leave out those same workers. And
    when we leave some people behind it actually holds us all back.

                    ENSURING AN EQUITABLE ECONOMIC RECOVERY

        So tell me what specific steps you are taking to ensure our
    workforce development programs, including the registered
    apprenticeship program, are supporting all of our workers,
    including women, and people of color so we can build a stronger
    economy?
        Secretary Walsh. Yes. Well, thank you for that. Let me just
    first say that one of the things, when we think about the
    infrastructure investments and the Bipartisan Infrastructure
    Law, we are thinking about making sure that it is an equitable
    investment across the board. When I look at the unemployment
    numbers in America, 3.6 percent unemployment rate right now in
    America, in the White community 3.4 percent, in the Black
    community it is 6.2 percent, historically the Black
    unemployment number has always been historically double that of
    White--the White number all across the country.
        So when we think about making these investments when we
    think about these investments, and we don't have--the
    Department of Labor isn't responsible for making a lot of
    investments in the Infrastructure Bill, because most of that is
    in transportation, and in commerce, and in energy. But what we
    have done is we have created the--we haven't created--the Good
    Jobs Initiative is an umbrella of making sure that as we make
    these investments we are making these investments to
    communities who are not leaving people behind. Who are not
    leaving opportunities for women, who are not leaving
    opportunities for people of color, who are not leaving
    opportunities for Native American, Alaskan Indian, all of the
    different communities in our community quite honestly, that
    have been underrepresented for so long.
        So that is one of the--that is one of the ways that we are
    looking to the Good Jobs Initiative to make sure that this is
    an equitable investment in people's future.

                       EXPANDING APPRENTICESHIP PROGRAMS

        We also, quite honestly, in the workforce development
    programs and grants, we are looking at expanding
    apprenticeships, and registered apprenticeship programs, we are
    doing more pre-apprenticeship programs to really create a
    pathway into different industries.
        When you take the issue of nursing, we are headed towards a
    crisis in nursing in America in the next 5 to 10 years if we
    don't address it today. We have 60,000 people, young people, on
    waiting lists to get into nursing programs in the country, and
    we have a shortage coming. So when you look at that, we have
    certainly an ability to create a talent pool to go into
    nursing, what we want to do is make sure we are making the
    right investments, to make sure to see what the shortfalls are
    in those different industries.
        We did it with the trucking--the trucking challenge, we had
    an issue at the ports with a lack of truck drivers. We sat down
    at the White House, myself, Secretary Buttigieg, we created a
    program, apprenticeship program, where any company in America
    could sign up with the Department of Labor for an
    apprenticeship and within 48 hours, we would turn that around
    and get that program running.
        We had over 100 companies right now in America that are
    currently having apprenticeships in trucking in America. We are
    working on building the future. We are looking at the numbers
    and the ages of truck drivers in America. Do they need to be 21
    to 25--it is okay.
        [Interruption].
        Senator Murray. Hold on. Just a minute, we apparently have
    a----
        Mr. Secretary, I believe the outside feed has stopped. We
    will continue with our hearing.
        You were talking about specific worker training skills, and
    I will just take a few seconds and just ask, worker training is
    critically important, but I am also concerned about those
    support services that allow somebody to go to work.
        Secretary Walsh. Yes.

                         CHILD CARE INDUSTRY CHALLENGES

        Senator Murray. I am talking about child care,
    transportation, those kinds of barriers. Can you just address
    that really quickly how the Department plans----
        Secretary Walsh. Yes, real quick. I mean, I think in the
    child care space, and in the--that is one of the biggest
    challenges we have as a country. And when you think about,
    yesterday I testified in front of Ed and Labor, and child care
    was a big--great part of the conversation.
        And quite honestly, you know, I think as a country we have
    to look and see, and realign what we do with child care. The
    pandemic has been devastating to child care industries in the
    very beginning days of the pandemic, March of 2020. We saw many
    child care facilities have to shut down because the kids
    weren't going there and there was no revenue coming in.
        A lot of those agencies didn't recover. They had workers,
    particularly women of color, working in those areas that were
    making minimum wage, and very low wages, those workers left
    there and found other options for employment because they had
    to. And now as we think about the child care industry,
    rebuilding it, we have to really be really intentional about
    it.
        And I feel that when we talk about child care and, you
    know, it has to be an all-of-government approach, meaning the
    Federal, the State, the local, but also the private sector. We
    really have to think about--outside the box when it comes to
    child care. And also universal pre-kindergarten is an
    opportunity for us as well to think about any additional child
    care.
        So as we think about this, our office, the Women's Bureau
    is working very intently on this, and also through the Good
    Jobs Initiative we are looking at different ways of supporting
    communities across America.
        Senator Murray. Okay. Thank you very much. Senator Blunt.
        Senator Blunt. Thank you, Chair.

                         CAREER PATHWAYS FUNDING LEVELS

        Secretary, let us go back to my comment on Career Pathways.
    I think it is really important that people certainly, in high
    school, begin to get a sense of what jobs are out there: What
    the job satisfaction of those jobs is like, what the
    comparative salary level of those jobs is compared to other
    jobs, and let us be sure people have choices.
        In the Career Pathways account, we started that in fiscal
    year 2020. In the most recent bill, we provided $15 million,
    which was an increase of $5 million. Your Department last June
    gave the first awards under this program, were made through the
    2020 funding. As you start making--what are you going to do
    about this program? And how are you going to monitor the
    success of the awards you have already given?
        Secretary Walsh. Thank you very much. Well, first of all,
    Senator, you know, I certainly agree with you in Career
    Pathways being an important aspect to make sure we continue to
    fund in this budget, because many young people in America, as
    was said in, actually both of your opening statements, not
    everyone is on a pathway to a college, and we have to make sure
    we are creating pathways into different careers.
        This program was not dropped out of the budget, we didn't
    specifically call it out in the 2023 budget, we actually
    requested an increase of $226 million for the National
    Dislocated Reserve which funds these grants. So it is part of
    the National Dislocated funds, which funds these grants. And
    one other thing, to be more clarifying this, I will absolutely
    work with you in your office afterwards to make sure that this
    is very clear, that we understand that these pathways monies
    are still in the budget when we actually look for an increase.
        Senator Blunt. Well, let us do that, because your staff
    told us just a couple of days ago, you specifically didn't
    request money in this category. So let us talk about, not
    today, but let us follow up and talk about what we intend to do
    there, how we are going to monitor the grants that are already
    out there.

              INDUSTRY PARTICIPATION IN REGISTERED APPRENTICESHIPS

        And I think what the Chair and I have tried to focus on in
    the committee, has been being sure people have the information
    they need, and then the opportunities they need to pursue as
    quickly as they can the jobs they would like to have, rather
    than spending years after high school searching for the
    information that they could have gotten while they were in high
    school, or just after they got out of high school. And so we
    are going to continue to talk about that.
        On apprenticeships, generally, how do we ensure that all of
    the industries that want to participate in the registered
    apprenticeship program, have a chance to do that?
        Secretary Walsh. Yes. We are reaching out right now, we are
    sitting down with stakeholders, and we are talking to industry
    about creating those pathways. I honestly feel in my heart that
    we are living in a unique moment in time, we are seeing people
    quit their jobs at high rates, we are seeing companies having a
    hard time finding people to go work for them. We are seeing
    young people that just can't connect to a good-paying job.
        And I think the best way, in my opinion, is looking at
    apprenticeships in different industries, in the healthcare
    sector, in the IT sector. You see it in the building trades,
    and you see it in trucking now, how it is working. We take that
    model that is working in those industries.

                    BENEFITS OF PRE-APPRENTICESHIP PROGRAMS

        I also want to add a component of pre-apprenticeship, so
    young people will have the opportunity. I was over in Germany a
    couple weeks ago, I was at Volkswagen, and I met with the
    leadership of the Volkswagen Company, and I saw the technology
    in there. But I met with about 20 young people between the ages
    of 16 and 18 years old that were apprentices, they were in an
    apprenticeship, pre-apprenticeship at Volkswagen.
        And they were getting a stipend, but they were also
    learning on-the-job training, not necessarily how to use the
    machinery, but they were getting skills in coding, and how to
    use technology. And I asked them. You know, they go to school a
    couple days a week, and they are in the company a couple days a
    week. We need to start thinking of those models that we are
    seeing in Europe that have been so successful in
    apprenticeships, in Switzerland. So we are working on those.

                             MONITORING H-2B VISAS

        Senator Blunt. Okay. Good. On H-2B visas, the temporary
    workers, and this is a big issue in a lot of sectors of our
    economy, particularly the tourist sector. And if you don't have
    those part-time workers the full-time jobs go away. We need to
    be sure that people understand that. That there are seasonal
    jobs, where, if you don't have the seasonal workers ready to
    come in and take the seasonal jobs then the jobs for other
    people that are full-time, year-round jobs, go away because the
    whole process just doesn't work.
        That is particularly evident in tourism. In the last
    addition of workers, and I think the Department has expanded
    the program in a significant way to about 121,000 H-2B visas,
    but the last 35,000 of those were gone within five business
    days.
        How are we monitoring that? And would you help me express
    the importance of being sure those kinds of jobs are filled for
    people who work alongside part-time workers, and have full-time
    jobs they wouldn't have if those part-time workers weren't
    there?
        Secretary Walsh. Yes. Let me, first and foremost, I had a
    meeting with my office last week to talk about the H-2B
    program, about the distribution of the visas, because some of
    the Senators here at this table, and other members of the
    Congress and Senate, have called me, both Democrats and
    Republicans, about it.
        And the increase in interest in this program, in the
    thousands of companies that are now applying for these visas,
    have exceeded--that we have never seen as much business, or as
    much interest in this program.

                  INCREASED TARGETING OF THE H-2B VISA PROGRAM

        So we are having conversations. I think what we need to do
    with the H-2B visa program, and we are doing some internal
    conversations, I think we need to have a real honest
    conversation about what the future of the program should look
    like. We expanded this year, in the first round of the H-2B
    visas, I want to say, 22,000 visas. In the second round, we
    added another 35,000. That is the largest allotment,
    additionally, of H-2B visas since the program was revamped in
    2000--I think--2013.
        And the need or the desire to be getting these programs
    just getting bigger, and bigger, and bigger. And what is
    happening is, a lot of companies that are filling out
    applications for these programs they are doing it wrong because
    they have never done it before, and they get disqualified. So
    all of the people that know what they are doing are getting
    their applications in, and they get these grants. That is one
    problem.
        The second problem is, and we had this conversation, as I
    said, the other day; we talked about the different industries
    in America. You have sugar down South. You have the crabbing
    industry on the coast. You have the fishing industry in Alaska.
    We are thinking about how do we make sure when we create these
    extra allotments, is there a way for us to be able to put some
    allotments aside, because if it comes out in April then the
    farmers might get all the H-2B visas, but you need something in
    September or October for a different harvest, or something like
    that.
        So we are looking at the program right now, on how to, how
    do we make this program, I wouldn't say more efficient, more
    successful. This program is needed. I am a supporter of the
    program, quite honestly, because in a lot of areas that it is
    really difficult to get workers in a short period of time.
    These companies, we asked these companies two things. One is to
    make sure there are strong labor protections for the workers
    that come from the southern border, number one--and Haiti, and
    some other places.
        And number two, we want to make sure that they do their due
    diligence in trying to hire local American workers prior to
    them getting H-2B visas. So we are asking them those two
    things. Make sure you make an honest effort to look for
    workers, number one. And number two, we ask them as well to
    make sure they treat their workers fairly.
        Senator Blunt. Good. I would be more than happy to work
    with you and your staff on this. It is a problem. It is a
    problem we have dealt with for a long time. I think the numbers
    you have put out there this year, are as aggressive on this
    program as anybody has ever been, but the work environment is
    different than any environment we have ever been in. And that
    is why it makes some sense. But I would love to work with you
    on it.
        Thank you, Chair.
        Senator Murray. Thank you. Senator Schatz.

          RESCINDING JOB CORPS EXEMPTION FROM THE SERVICE CONTRACT ACT

        Senator Schatz. Thank you, Chair and Vice Chair.
        Secretary, nice to see you again; and really enjoyed our
    conversation the other day. I know you are a big fan of the Job
    Corps. Hawaii Job Corps is one of the best in the Nation,
    regularly at capacity, and really delivering on the mission. I
    want to talk to you about the pay. DOL (Department of Labor)
    exempts Job Corps' contracts from the Service Contract Act,
    which means the Job Corps employees don't get prevailing wages
    and benefits.
        My understanding is that is an administrative authority
    that you have. You could waive that but you don't have the
    money, and so the question is pretty simple. Would the
    Department consider rescinding the exemption if Congress
    provides the resources to do so?
        Secretary Walsh. Yes.
        Senator Schatz. Good enough for me. And if so, can you
    provide the committee with the amount of funding that would be
    required to do so?
        Secretary Walsh. I will get that number for you. But I
    appreciate you asking that question. And I don't want to take
    too much of your time, but I think Job Corps is one of the most
    underutilized programs that we have in the Federal Government,
    that we could have 57,000 people a year that go to Job Corps,
    prepared for a job. And when a young person leaves Job Corps--
    and I look forward to visiting your district and seeing the Job
    Corps there--they should be guaranteed a job when they graduate
    Job Corps.

               ONLINE PRESENCE OF DEPARTMENTAL TRAINING RESOURCES

        Senator Schatz. Thank you very much. And speaking of job
    placement, this is a sort of broader question. I want you to
    imagine, say, 10 years from now, 5 or 10 years from now, what
    does the Department of Labor's online presence, online training
    resources look like?
        You know, coming from State government, you know, more than
    a decade ago, the implementation of Federal workforce training
    programs is very siloed. We have got a Workforce Development
    Board that meets as a committee of the whole, with maybe more
    than 100 people, and they ratify their workforce development
    plan, mostly based on the fact that if they ratify it they get
    their revenue. And so there is not a lot of big-picture
    thinking.
        And I am wondering whether there is a way to turn the
    Department of Labor's website, and other online presence into a
    real resource for workers, so they can, not just find jobs
    because there are plenty of private sector platforms for that,
    but figure out what the, you know, college and career readiness
    pathways are, what kind of technical training you need.
        All of it is a labyrinth if you are new to the workforce,
    or if you are transitioning from one job to the other. And so
    this is a broader question. What does that website look like if
    you have all the resources in the world, in 10 years, so that
    it is really servicing people in a new economy?
        Secretary Walsh. Yes. That is a great question. I think
    number one it is, in 10 years from now we get to expand our
    American job centers that do that work on the ground in cities
    and towns all across America, number one.
        Number two, if there is a worker in America that is looking
    to make a change in their career, or put themselves in a better
    situation, they should be able to click a few buttons, get to a
    resource guide on the Department of Labor that directs them to
    their State or their city, that has the ability, that there is
    a partnership with the Federal Government in creating a pathway
    into a good-paying job.
        So for example, if you live in, a small town in Hawaii and
    you are looking for a job, well the Department of Labor might
    not know who the employers are there, but we work collectively
    with the local government to make sure that that resource is
    there.

                  LINKING INDIVIDUALS TO EMPLOYMENT RESOURCES

        It does two things: Number one, it would allow the person,
    the individual to be able to find the resources, but as
    important, it will allow employers to also find the people. So
    you would have to work with the employers as well, to make sure
    that they are part of the system, because the employers, if
    they feel that it is a good training opportunity, and the
    resources are being spent well in good workforce development,
    then we are helping employers grow.
        We saw this year in this country 4.7 million people go into
    entrepreneurship on their own, 20 percent increase in the past.
    Some of those folks are going to become companies, some of
    those folks are going to become big companies, some of those
    folks are going to be looking for employees. The best way to do
    that is having the resources. So I think it is about both sides
    tying the worker to the job, and the job to the worker.

                         WOMEN'S BUREAU ACCOMPLISHMENTS

        Senator Schatz. Thank you. A final question: I have
    skepticism about bureaus, and so I pushed on my staff about the
    Women's Bureau. I said, what has the Women's Bureau actually
    done for women? And they have done an extraordinary amount for
    women.
        Secretary Walsh. Yes.
        Senator Schatz. Helping with the Equal Pay Act, the FMLA
    (Family and Medical Leave Act), and they can also be credited
    for helping to ensure women were included in laws providing
    minimum wage and overtime. Do I have your commitment to
    continue to support the Women's Bureau so that it can build on
    the successes from the last century?
        Secretary Walsh. Yes. When I first became Secretary of
    Labor, the first thing I did was I asked for an increase in
    budget for the Women's Bureau. When I was Mayor of Boston we
    had a Women's Commission in Boston, and I changed it from a
    commission to an office in the Bureau. We need to give the
    Women's Bureau more power in the Department of Labor, as well
    as the Veterans' Office as well.
        Senator Schatz. Final, just a comment. I want to thank you
    for your decision to include data on American Indians, Alaska
    Natives in the last monthly report. And look forward to working
    with you in this space. Thank you.
        Secretary Walsh. Thank you, and thank you for bringing that
    up, because I think I misspoke in the very beginning in my
    comment about the numbers. So thank you.
        Senator Schatz. Thank you.
        Senator Murray. Thank you. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Madam Chairman and Ranking
    Member.
        And thank you for being here today, Mr. Secretary, and I
    certainly appreciate your help with my labor issue with the
    catfish processing plant in Mississippi. And one of the things
    I want to talk about, is this administration continues to blame
    President Putin for this inflation, and despite the price
    increases going through the roof, but the administration, in my
    opinion, got it wrong when they kept insisting that this is
    transitory.

               THE NATURE AND IMPACTS OF INFLATION ON EMPLOYMENT

        And, you know, we have--it has been proven that it is
    anything but transitory. But the Biden administration has
    expressed that the United States is prepared for this, and
    positioned to meet the challenges of this stagflation, given
    the local--the strong labor market, but employment levels are
    still way below pre-pandemic levels.
        So how can this possibly be true that we are positioned
    with the employment levels being so low, that we are positioned
    to overcome this?
        Secretary Walsh. Thank you very much, Senator. Let me just
    begin by, there is no question that inflation, we all know this
    is causing pain for families in America, rising energy costs,
    food prices, stretching budgets, all across the United States
    to very thin. But this is also an issue that Europe and U.K.
    are dealing with as well.
        So there is no question, there are two things that we
    cannot deny. Number one is, the economic challenges we have had
    over the last two-and-a-half years due to the pandemic,
    shutting America down, and tens of millions of Americans not
    going to work and, not having really a strong plan for that,
    because we weren't prepared for a pandemic. The last time there
    was a pandemic was a hundred years ago.

                       IMPACTS OF RUSSIA'S WAR ON UKRAINE

        And what Vladimir Putin is doing in Ukraine is an atrocity
    number one, and number two, absolutely is having stresses on
    the global economic crisis. I was with the President last week
    and we were talking about wheat. There is wheat in Ukraine that
    we can't get out of Ukraine, because Russia is blocking the
    exportation out of Ukraine. We have oil that we are taking from
    Russia, we have European countries that aren't taking oil. So
    we can't deny the fact that those challenges aren't adding to
    inflation.
        The President has been very clear on lowering the costs
    that families have in front of them. He is also focused on
    reducing the deficit. I am working myself, 8.7 million
    Americans have gone back to work since the end of the pandemic,
    since the beginning--not since the end of the pandemic--since
    the pandemic kind of began and is moving forward.

                         IMPROVING EMPLOYMENT PROSPECTS

        We have the lowest unemployment since 1970, and we have
    identified, and I have identified that we do have a problem in
    our country with making sure we are creating pathways for
    people to connect into jobs. And that is why I have asked for
    the increase in this budget in workforce development programs,
    in job training programs, in community college programs, and
    also in apprenticeship programs, and creating better pathways
    for people.

                        CHALLENGES FOR SMALL BUSINESSES

        Senator Hyde-Smith. How is the Labor Department adjusting
    or correcting its policies to address the issues of these small
    businesses that are having such a time trying to fill these
    positions, and related to the hardships placed on the American
    families?
        Secretary Walsh. Yes. Well, I am willing to talk to any
    businesses and communities around America, to talk about ideas.
    I spent a lot of my time--you know, as Labor Secretary I spent
    a good amount of time reaching out and talking to businesses,
    as well, in America. Probably as much--more time than I talked
    to, quite honestly, unions in America.
        Because I find it is really important to understand the
    challenges that businesses, particularly small businesses are
    having in our country. And small businesses, the biggest
    challenge is--well they have a lot of challenges right now,
    particularly with the pandemic, but their challenges now are
    trying to find workers that want to work in those different
    industries. So we absolutely will. If these industries, that
    you, or companies, you want me to talk to, I would love to.
        Senator Hyde-Smith. And I agree obviously, that the Russian
    invasion has had a lot to do with this, but I also
    wholeheartedly believe that shutting down the Keystone Pipeline
    is what started it before the invasion. And employer retention,
    particularly in the manufacturing and the warehousing sectors,
    is a highly significant issue and quite a problem in the
    workforce today, obviously.

           CREATING JOBS THROUGH MODERNIZING HIGH TURNOVER INDUSTRIES

        But more and more companies find it hard to hire and retain
    workers for roles that normally have high turnovers, that are
    repetitive task jobs, and it seems that the opportunity to
    utilize technology could be a solution to fill these positions,
    while also creating a higher skilled position for the
    programming and operations of such things as collaborative
    robots.
        And I believe this concept could be a game changer to
    reduce turnover while increasing higher wages and the workers
    for these positions, that so many people have difficulty
    dealing with. But it is just, you know, with the manufacturing
    that they are in, does the Department share this view? And will
    you provide any insight into the Department's focus in this
    area?
        Secretary Walsh. Yes. Certainly the President is very
    supportive of creating more, and it is expanding manufacturing
    in America. And I know I can't lobby for legislation, but I
    would hope that we can get the Bipartisan Innovation Act
    through Congress, so that we can continue to make investments
    in American workers, in manufacturing. Some of that will be
    industrial manufacturing, and some of that will be technology
    in manufacturing.
        And I think that we have such a great opportunity in front
    of us. I don't want to say. I said this yesterday and I
    probably shouldn't say it today, but I think that this
    Bipartisan Innovation Act is actually one of the biggest pieces
    of legislation for the future of our economy, and for the
    future of our workforce moving forward.
        Senator Hyde-Smith. Thank you. And my time is up.
        Senator Murray. Thank you. Senator Baldwin.
        Senator Baldwin. Thank you, Madam Chair.
        Welcome, Secretary Walsh. I know our Chair asked you
    earlier about the importance of child care in terms of getting
    people back to work, but I have a more specific question to ask
    you about.

           INVESTING IN EDUCATIONAL AND CHILD CARE TRAINING PROGRAMS

        Wisconsin is using a Department of Labor grant to test out
    an apprenticeship program that would train workers who enter
    the early childhood education and child care workforce.
        Expanding this type of apprenticeship in my mind could have
    a real multiplier effect. So not only would it address severe
    shortages in the child care workforce and industry, but by
    increasing the supply of available providers, it would free up
    more parents to be able to look at full-time work. And by
    filling open positions we might even reduce inflation by
    helping businesses increase their production.
        So how can the Department encourage investment in child
    care apprenticeship programs to reduce the workforce shortages,
    and increase the output of our economy?
        Secretary Walsh. First of all, thank you for the question.
    And I am encouraged to see what is happening in Wisconsin, to
    see how that works. And I think that having programs like that
    around the country, to check is really important. This budget
    request that we are asking for is $303 million for
    apprenticeships to further expand and modernize diversified,
    registered apprenticeships, by investing in high-quality youth
    and pre-apprenticeship models.
        So you are doing it in Wisconsin, we are doing it here with
    the trucking challenge here in Washington, and around the
    country, quite honestly. We are looking at other areas, we are
    looking at healthcare, we are looking at IT. There is no
    question. When you think about the child care industry, number
    one, the challenges they have.
        Number one, they have a challenge with funding, and the
    funding is not consistent in every State, sometimes the States
    fund it, sometimes the cities fund it, the Federal Government
    is funding it to some degree. That is one challenge.
        The second challenge is recruiting and retaining talent,
    and having that pipeline, that young-person pipeline, or that
    pipeline into that industry where people can get paid while
    they are learning, on-the-job training, is going to be really
    important, number two.
        Number three, the President filed the bill that really
    deals with the cost of child care. I think that the latest
    bill, if I am not mistaken, is a family earns $150,000
    collectively; they pay no more than 7 percent of their salary
    for child care. That is another important aspect of it, making
    it affordable for families at the kitchen table.
        And the last thing, which is the first thing that you
    talked about, it really is not just about training people into
    this industry, but making sure we are paying them, and treating
    them fairly, because the long-term sustainability of the child
    care industry is key, the long-term sustainability of our
    economy is key, and they go hand in hand.

                       STATUS OF WORKPLACE VIOLENCE RULE

        Senator Baldwin. Thank you. Last month I introduced the
    Workplace Violence for Healthcare and Social Service Workers
    Act. It would require OSHA to set an enforceable standard to
    require healthcare employers to establish plans to prevent
    workplace violence.
        Incidents of workplace violence have increased
    significantly during the pandemic, but were high for healthcare
    workers and social workers prior to the beginning of the
    pandemic. And frankly, our healthcare heroes have been put
    through hell, and certainly deserve better from all of us.
        The need for action was made even more tragically clear by
    a deadly shooting at a hospital in Tulsa, Oklahoma, just a few
    weeks ago. So I know this item has been on OSHA's regulatory
    agenda. I wonder if you can update me and the committee on the
    status of the Workplace Violence Rule.
        Secretary Walsh. Yes. Thank you. First of all, no one, as
    you know, should lose their life on the job for whatever
    reason, or even be concerned about losing their life on the
    job. And I know the administration strongly supports the
    passage of your bill, which is really important. In the
    meantime, OSHA has also worked extremely hard and has
    successfully prosecuted several important workplace violence
    cases under the Occupational Health and Safety Act. So we have
    done that. OSHA continues to issue citations in this space. So
    thank you for that.
        And the last thing is, and I said earlier to the
    Chairwoman, I believe that we are on pace, hopefully, to get
    some final rule in the next 3 to 6 months.

               RACIAL DISPARITIES IN STATE UNEMPLOYMENT PROGRAMS

        Senator Baldwin. Okay. Final question; this week a GAO
    report examining State's execution of the Pandemic Unemployment
    Assistance Program found significant racial disparities in the
    rate of approval. The report recommended that as a part of
    efforts to modernize the unemployment system that Department of
    Labor examine the potential causes of racial and ethnic
    disparities.
        Will you commit to making that examination as recommended
    by GAO? And do you have any insights at this point?
        Secretary Walsh. Yes, no. Absolutely, you know, the
    Department is focused right now on both fixing, and the short-
    and long-term issues with the unemployment system. You know, we
    have announced the availability of more than $750 million in
    grants, funding for States. We have Tiger Teams that are out
    working--we are working on improving identity--improvement to
    the identity verification tools within the UI (Unemployment
    Insurance) program, we are working on equity grants, we are
    piloting programs.
        I actually feel, I feel really good where we are right now
    in this process, because we have both States, Democrat and
    Republican Governor States that are very active with us in the
    UI reform. So I feel good where it is at. Eventually--I mean I
    asked for an increase in funding this year, but eventually
    States are going to have to really step up if they really want
    to make their systems equitable across the board. When I say
    ``step up'', I mean making investments by stepping up.
        Senator Baldwin. Thank you.
        Senator Murray. Thank you. I see Senator Braun has joined
    us. Are you ready to go? Or do you want 5 minutes? Senator
    Braun, if you want to go ahead.
        Senator Braun. Thank you, Madam Chair. Good to be talking
    to you again.

                MAINSTREET AND GIG ECONOMY WORKFORCE CHALLENGES

        I just attended, earlier today, the National Federation of
    Independent Business Owners, and I and another Congresswoman,
    we were answering questions that they have. And many there are
    concerned, in general, about Main Street businesses. My wife
    has had one since 1978 and they are downtown. Some of the stuff
    that happened through COVID, a lot of those businesses got shut
    down, and many of them are grappling with all the issues we
    hear every day, a lot of pre-COVID, workforce, workforce,
    workforce.
        There is a particular part of the economy though, the gig
    economy. And independent contractors, Main Street business
    owners that so many of them, to me, are so analogous to blue-
    collar workers, because they actually live out of these
    businesses, and I have always been a proponent in running my
    own business for 37 years: high wages, great benefits, safe
    workplace, no turnover. And I think that, generally, Main
    Street America, smaller businesses do all of that.
        Let us focus on the gig economy, particularly independent
    contractors. It seems like, and they think that the current
    administration is trying to, you know, take their way of life
    away. You know, they looked at the PRO Act, they look at some
    of the things that are being done.
        I would like your general comment on: Why we would look at
    them any differently from the good, blue-collar worker that
    most of us employ for those same reasons? Why would we want to
    do anything that would diminish their way of living because to
    me, they are that?

                        DEFINING INDEPENDENT CONTRACTORS

        Secretary Walsh. No. Thank you, Senator. And you know, in a
    lot of cases independent contractors, people who are
    independently employed do great work, and they are part of our
    economy, and they are part of our--in some cases part of our
    main streets. We see it in trucking, and we see it in different
    industries.
        The concern that I have always had when it comes to
    independent contracting, is folks that are under the
    understanding that they are hired as employees, and then they
    are paid with a 1099, and they are not--they are not
    technically--they are actually an employee of a company.
        And I think that there are many different definitions of
    the concerns that people have in that, and that is kind of
    where, when I say this, I will speak for myself personally,
    that I have always gotten concerned. An example of that is a
    restaurant where somebody gets hired as a dishwasher, and then
    all of a sudden they are being paid with a 1099, and they have
    no repercussion at all.
        They are really not an independent contractor, they are a
    dishwasher who works for a company. And we have been able--the
    Department of Labor, over the years, has gone back and claimed
    lost wages for people that have been characterized, or
    described in those different areas.
        But when you talk about Main Street, I hear what you are
    saying. I mean, my formal role, obviously, you know, we had a
    lot of businesses, that people might have had a flower shop, or
    they had something that they were in themselves, their own
    worker, they were independent, they kind of did their own
    thing, or they were a planner, or things like that. I
    understand that.

                     BUSINESS OWNERS WITHIN THE GIG ECONOMY

        Senator Braun. So let us focus more closely on gig economy
    then, because I don't think you should game the system by
    issuing 1099s when, technically, that individual is an
    employee. That to me is maybe skirting the rules.
        But let us focus on gig economy. These are individual
    business owners. And they are worried too that they are going
    to be drawn into that independent contractor issue, and then
    lose their independence, their livelihood, because they would
    not be of that same category you are talking to. They are
    running their own businesses, and generally a business of one.
        Secretary Walsh. Yes. In the gig economy, I mean, I have
    spent a lot--I don't want to say a lot of time--I have spent a
    fair amount of time in talking to the gig economy companies
    here in America, both the leadership of the companies, the
    advocacy groups that are pro-gig economy companies. And some of
    the other side that that isn't a pro-gig economy.
        And I know that in a lot of States, California passed the
    Ballot Initiative, Washington State passed a law, and in
    Massachusetts, yesterday the Massachusetts Supreme Court just
    threw the ballot question for the gig economy for the Uber and
    Lyfts off the ballot. So basically saying, you have to come up
    with legislation.
        So I know a lot of these conversations are happening in
    other places. I actually had a conversation last week--I will
    be real quick on this and actually provide another question--
    with Germany, talking about what they did with the gig economy
    in Germany. So just asking, what was the path forward there? So
    we have not taken any action as a Department, but I am still
    talking to all these groups.
        Senator Braun. Well, very good, because I think that in our
    unique economy, you have got anywhere from huge corporations
    that, to me, shoulder the biggest responsibility, and where
    unions definitely come into play, because of the counterweight
    against that much financial power, make sure that we don't take
    Main Street America in all of its individualism, you know, kind
    of swept into a category that they are not part of.
        Because you never know when that individual, that gig
    business, that small business on Main Street becomes a larger
    business. And to realize most of them make their living out of
    that. They are not growing it with return on equity in mind.
        Secretary Walsh. And if you want to let the independent
    group that you spoke to today, they are more than welcome, I
    would love to sit and talk to them.
        Senator Braun. Thank you.
        Senator Murray. Thank you. Senator Capito.
        Senator Capito. Thank you, Madam Chairman.
        Thank you, Mr. Secretary, for being with us here today, and
    thank you also for the visit that we had in March. I enjoyed
    our conversation. And we talked about apprenticeships there. So
    I would like to ask a question.

                 DIVERSITY OF SUPPORTED APPRENTICESHIP PROGRAMS

        We have some excellent apprenticeship programs in our
    State. And I recently visited one at Marshall University's, at
    the Manufacturing Tech Accelerator at the Robert C. Byrd
    Institute at Marshall. And it is providing participants with
    the skills they need to succeed in entry-level positions in
    manufacturing, you complete 2,000 hours of paid, on-the-job
    training from a participating employer, and the apprentices
    will qualify for a certificate to be a manufacturing
    technician.
        I met a veteran there who had obtained this certification
    after retiring fully from his career in the military, and he is
    also now, excitingly, in the process of attaining a patent for
    an efficient manufacturing process that he created just months
    ago; a very impressive story.
        So after visiting RCBI (Robert C. Byrd Institute), and
    after our conversation, I am wondering about your approach at
    Labor on apprenticeships, whether it is organized labors, or
    some such as the apprenticeships that are being offered through
    this program. And you know, would you say you support a wide
    range of these? And how are you approaching this at the
    Department?
        Secretary Walsh. Yes. I absolutely--thank you first and
    foremost for having me in your district. I support a wide range
    of apprenticeships in different industries. I think the model
    of the building trades is the gold standard, $2 billion a year
    investment, all by companies, and there is no Federal
    investment, or State investment. There are small grants around
    for different programs, but the majority of those programs get
    funded.
        And you are talking about high quality training going on
    there. That is one model we could use. I think that there is an
    opportunity for us in this country to really have the ability
    to partner with community colleges, workforce development
    programs. I had the urban league in my office yesterday, we
    talked a little bit about diversity, and inclusion.
        So you know, I have answered this question a couple times
    today about apprenticeships, but I hope by this--next year's
    hearing when I am here, we are able to point to several dozen
    apprenticeship programs that we are kicking off in the country,
    whether it is in healthcare, IT, early child's care, different
    industries that we can actually make a difference in.
        Senator Capito. Great. We all look forward to that
    announcement. And certainly, as we see workforce shortages in
    just about everything; this is, I think, going to be extremely
    important because, not just the skill sets developed, but the
    time that it takes in certain instances, I think we can maybe
    short-cut some of the time to get a trained individual on the
    job.

                IMPROVING SAFETY IN THE AMERICAN MINING INDUSTRY

        I am very proud that I supported the nomination of
    Christopher Williamson to be the Assistant Secretary for the
    Mine Safety and Health Administration, or MSHA, as we call it
    at home. He is a proud son of Williamson, West Virginia, and we
    are happy that he is there. I don't know what initiatives he or
    you plan to take in the mine safety obviously.
        Secretary Walsh. Yes.
        Senator Capito. It is extremely important. I will tell you
    that our mines are operating at much higher capacity than they
    have in the past year or so, because of the increased demand,
    because of the geopolitical situation we see around the world,
    we are happy about that. We are not happy about the
    geopolitical situation, we are happy we got more miners to
    work.
        So in the MSHA area, what are you guys looking at and how
    can we be helpful?
        Secretary Walsh. Well, one thing we are looking at is we
    have seen an increase in fatalities this year, in mining. And a
    couple months ago we had the major miners on a call, we did a
    call with them, to talk about sharing best practices on safety,
    something I did when I was the Mayor of Boston whenever we had
    high shootings in Boston, we brought all the stakeholders to
    the table. We did the same thing with the mining industry.
        We are asking for an increase in mine safety work in this
    budget. Chris is doing a great job, you know, his feet are wet.
    He didn't have--there wasn't much of a learning curve there, he
    knew the issue. And certainly they are working hard, and we do
    need to--we get some money from the American Rescue Plan, and
    we need some additional funding on the mine safety.
        We are actually seeing an increase in mining, maybe not
    coal mining but we are seeing an increase in mining in America
    as well, metal mines, and things like that. So we need to make
    sure we stay on top of it.
        Senator Capito. Right.
        Secretary Walsh. And any time we acknowledge that these are
    tragedies happening, we are on top of it.
        Senator Capito. Good. And I know a lot of those can occur
    in a lot of different--they may not be at the face of the mine,
    in the instance of the coal mining, a lot of them are vehicular
    accidents; and things like that, on the work site. So anything
    we can do to make them safer, and keep them healthy is
    important.

                     YOUTHBUILD GRANT PROGRAM DEPENDABILITY

        The last thing, I am just going to kind of put this on your
    radar screen. I have always been interested in YouthBuild, I
    have visited--the Randolph County Housing Authority has a
    YouthBuild program that they have had for years. And then for
    some reason last year, no funding. And so it was kind of
    disruptive.
        If you could help me, kind of figure out--they did get
    their funding for this year, so we are very pleased about that.
    But we wanted to have the continuity that you need in a program
    like that. So if we could work with your office to try to
    figure out how to make sure they have an iron-clad application
    that they can continue this program.
        Secretary Walsh. Absolutely. I have been of supporter of
    YouthBuild for 25 years. When I was a legislator in
    Massachusetts we used to support it, and I know that YouthBuild
    got a--I think it was a $24 million dollar grant this year on
    YouthBuild, but also clean energy; so some of the transition as
    well.
        Senator Capito. Good. All right. Thank you.
        Secretary Walsh. Thank you. Thank you, Senator.
        Senator Murray. Thank you very much.

                  WORKER PROTECTION OVERSIGHT AND ENFORCEMENT

        Mr. Secretary, I really hugely appreciate the President's
    strong investment in DOL's proposed budget for the Wage and
    Hour Division. As you know, the Federal minimum wage has been
    frozen since 2009, at the rate of $7.25 cents per hour. Yet,
    even at that low rate some employers are denying their workers
    that unacceptably low wage, or their overtime, or both. And it
    really is our job to protect those workers and make sure they
    are properly paid for their work.
        But right now I know the agency does not have the resources
    to do their job when corporations flout the law. Can you talk a
    little bit about how the requested increase in Wage and Hour
    will allow you to improve the oversight on that?
        Secretary Walsh. Yes. There is no question about it. You
    know, when I came in here a year ago, March, as the Secretary
    of Labor, one of the first things I did was looking at the
    different departments and agencies to see how we are doing with
    carrying out the work. At that time you, and Congress, and the
    Senate, had just passed the American Rescue Plan, and the money
    was being--hadn't quite been diverted yet to the different
    agencies. And we found that there was a real, real shortfall in
    enforcement and in the ability for these different departments,
    Wage and Hour, and OSHA, and other places, to do their job.
        I don't view Wage and Hour, OSHA, and MSHA, I will use
    those three as example, as just an agency to go out and give
    corporations in America a hard time. I would love to get to the
    point where we can do education as well with companies, and
    what it means to pay people forward. But we were not there yet.
        So what this additional revenue would do, would allow us
    the opportunity to protect more American workers, and making
    sure that workers that are owed money, who did the job, worked
    for companies, and were undercut by somebody, that they pay
    their workers fairly. That is all we are asking for here.
        So that is, kind of, what would allow us the opportunity to
    do more, more enforcement of workers' rights, and making sure--
    and we are talking about workers who worked the work.
        Senator Murray. Yes.
        Secretary Walsh. We are not talking about people who didn't
    do the job. We are talking about people who actually worked the
    work, did the 30 hours, the 40 hours, the 8 hours, whatever it
    was, and didn't get paid, because their employer decided: I am
    not going to pay you.

                  STRENGTHENING YOUTH OUTREACH AND ENGAGEMENT

        Senator Murray. Right. Okay. Thank you. And finally, I just
    want to talk to you because I am--about our young people who
    are disconnected from educational workforce opportunities right
    now. I know that more than a million fewer students are
    enrolled in college now, compared to before the pandemic, and
    the decline of community colleges, also really significant.
        And high school graduation rates decreased in nearly half
    of all the States this past year, reversing really decades of
    progress. So work-based learning experiences are really
    integral to keeping young people connected to their school, and
    high quality workforce development programs can help
    successfully re-engage those young people who have, or are
    considering leaving school before graduation, and put them on
    pathways to success.
        Talk to us about how you are working to strengthen the
    links between education and workforce development systems to
    re-engage these young people.
        Secretary Walsh. I am going to just, for an observation,
    your relationship with Senator Blunt; we need more of that when
    we talk about how we are going to move our economy forward, how
    we are going to move our workforce forward. We need to be
    collectively working as Democrats and Republicans, to really
    make sure we are making investments in job training, workforce
    development apprenticeships.
        We can look at one side of the aisle, and as you just said,
    people not going to college, and dropping out of high school,
    and not having opportunity, as a challenge, and a difficult and
    sad challenge for America, but you can also look at the other
    side of the coin, it is an opportunity. How do we get to those
    young people? How do we connect them to the workforce
    development apprenticeships, job training opportunities that
    are out there?
        As I go around this country, I visited 36 States. I have
    visited probably 82 cities. I go to community colleges
    everywhere, and I am in different neighborhoods, I am talking
    to--I am talking to businesses, and leaders, and what is out
    there, whether it is electric boat in Connecticut, or it is
    Tinker Air Force Base in Oklahoma. These are public.
        And then private industry, there are so many opportunities
    out there for people in America, we need to really make sure
    that we are connecting young people to jobs, and we need to
    make sure that, not just connect them to jobs, we need to go
    out and find the young people.

                          JOB CORPS OUTREACH POTENTIAL

        We see it in Job Corps. Our Job Corps centers pre-pandemic
    had 57,000 young people in it, 57,000 people. Today we have--I
    think there is 20,000 online, 12,000 in person, we are getting
    there but we are not there. We have lost a lot. So we have to
    be more intentional, going out and recruiting, and finding
    young people, and finding people to let them know what is
    available. A lot of people, Senator Schatz talked about online
    presence.
        Senator Murray. Mm-hmm.
        Secretary Walsh. A lot of people, including myself, didn't
    know that we had American job Centers in America. I had two in
    the City of Boston, I had no idea they were there. We have to
    do a better job of explaining what those programs are.
        Senator Murray. Okay. Thank you. Senator Blunt.
        Senator Blunt. Thank you, Chair. I have a couple more
    questions, Secretary. One is looking at the proposed budget,
    and back to the topic of inflation. Sometimes the budget
    reflects big increases in programs on all of the veterans'
    programs at the Department of Labor. The increase was less than
    2 percent. There were a couple of programs where actually
    programs were reduced like State grants and transition
    assistance.

               VETERANS' PROGRAMS STRUCTURE AND INVESTMENT LEVEL

        What are you going to do about these veterans' programs
    that have a less than 2 percent increase in a more than 8
    percent inflation world?
        Secretary Walsh. Yes, no. One thing, that we are not
    cutting the veterans' budget, we are increasing the veterans'
    budget. The veterans, we work very closely----
        Senator Blunt. Well, I am not suggesting you are not
    increasing----
        Secretary Walsh. No, no. I am not saying you did that. I am
    not saying you do that. Sorry.
        Senator Blunt. This is a question of how much you are
    increasing if these programs lose attraction, particularly the
    couple of programs you are cutting. But I am, overall,
    interested in all of these programs that don't increase, but
    increase by less than 2 percent. Other programs in the
    Department increase by a lot. I mean you are asking for a 13
    percent increase in the overall budget, but the existing
    veterans' programs all grow by less than 2 percent. That is my
    question.
        Secretary Walsh. Yes. Well, we are asking--yes, thank you.
    So I am just trying to get my notes here. We are asking for a
    5.6 percent increase in our veterans' budget, the bottom line.
    And part of that is because the veterans' Department is when I
    talk about apprenticeship programs, we are including the
    veterans in the apprenticeship program.
        When I talk about workforce development and job training
    investments, we are including the veterans in that program as
    well. So it is not a----
        [Sneeze].
        Secretary Walsh. God bless you. It is not a directed line
    item in the Workforce Development for veterans, but we have
    veterans included in those conversations, and in that money. So
    when we think about like the trucking challenge, we have
    reached out--we did a trucking challenge, the Department of
    Labor made an investment because you gave us money, a little
    bit of discretionary funds to create this program. We did.
        The first place we reached out to is the veterans, to get
    veterans into the program. So we are integrating our veterans'
    office into everything that we are doing. So the veterans'
    money is specifically for vets, for them to do the outreach,
    and do all the work that they do, and then all the other money
    that we have, whether it is workforce development, job
    training, all this, the veterans are part of that as well.
        Senator Blunt. I want to say to that, Secretary, there is a
    reason that we had the veterans set aside in some of these
    areas. And I think when we did that the idea that: Well, the
    veterans are included in everything else, would not have been a
    very satisfactory answer, as you are trying to focus on
    veterans specifically. But we can talk about that some more.

                          AMERICAN RESCUE PLAN FUNDING

        And my other question is, the Department, in the American
    Rescue Plan, received $2.2 billion in March as part of that,
    less than 5 percent of that has been spent, $94 million has
    been spent, $335 million has been obligated. So less than 5
    percent has been spent, less than 20 percent, or so, has been
    obligated. What are you planning to do with that $2.2 billion?
        Secretary Walsh. I was just trying to--we are still
    spending it, and I was told behind me, we are still spending
    it.
        [Laughter].
        Secretary Walsh. I will have to get that out----
        Senator Blunt. That is a better answer, than we are not
    going to spend it. What are you planning?
        Secretary Walsh. Yes. Well, if you give me money I am going
    to spend it.
        Let me get back to you, specifically, on what it is, where
    we are going, and the reasons for it. Some of the--we are
    having challenges with hiring, we are having challenges with
    different pieces. Let me look into that, and get back to you
    with a better answer.
        Senator Blunt. Well, I would think some of the overall--
    this big increase you asked for in the overall budget, maybe
    there are some ways to justify this $2.2 billion to fill some
    of those gaps. But I look forward to talking to you about your
    plans on that money specifically.
        Secretary Walsh. Absolutely, and we also don't want to
    spend the money just for the sake of spending the money.
        Senator Blunt. Well, I agree with that.
        Secretary Walsh. You know, these are taxpayers' dollars,
    and we want to make sure we spend it correctly.
        Senator Blunt. Yes. Thank you, Secretary. Thank you,
    Chairman.
        Senator Murray. Thank you. That will end our hearing today.
        Secretary Walsh, thank you for a very thoughtful discussion
    about how we can support our working families, and build an
    economy that does work for everyone.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due June 24 at 5 p.m., the
    hearing record will 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
                 transparency of employers' anti-union spending
        Question. I have been heartened by successful votes to unionize
    across the country, even despite corporations union busting and
    launching expensive disinformation campaigns. The Department plays an
    important role in providing transparency on this type of spending,
    which is chronically underreported.
        What are your plans to boost transparency of employer spending on
    anti-union messaging in the workplace?
        Answer. The resources included in the President's Budget would
    strengthen Office of Labor-Management Standards' (OLMS) review of
    reports that employers and consultants file with the Department under
    the Labor-Management Reporting and Disclosure Act (LMRDA). The
    resources would complement current efforts and ensure that OLMS will
    continue to achieve its priority to adequately enforce the long-
    neglected employer and consultant reporting requirements. OLMS would
    enforce the LMRDA's reporting requirements on employers and their labor
    relations consultants in the same way it enforces reporting
    requirements governing labor organizations. The agency would review
    employer and consultant reports for completeness and accuracy and open
    investigations if compliance assistance efforts do not remedy any
    problems identified. The agency would also develop a methodology to
    identify employers and consultants who have engaged in reportable
    activity but failed to file a report, and open investigations as
    appropriate. As a result, whether the entity filing a given report is
    an employer, a labor consultant, or a labor organization, the agency
    will evaluate and investigate evidence that suggests they have not
    disclosed reportable activity. These undertakings will be standard
    investigations of anti-union expenditures and activities and, as with
    our Compliance Audit Program, will be conducted with the same level of
    scrutiny as audits of labor unions.
        OLMS is taking other, more immediate steps to ensure meaningful
    enforcement of employer and consultant persuader reporting activities.
    OLMS is making employer and consultant reports more visible and easily
    accessible on the OLMS website. OLMS staff are educating the public and
    directing individuals with knowledge of unreported activity to contact
    an OLMS tip line.
        The Department is also posting blogs, compliance assistance
    publications, and other materials to advance its efforts to obtain full
    compliance.
                infectious disease notice of proposed rulemaking
        Question. During the hearing, we discussed the need for the
    Occupational Safety and Health Administration to move quickly to
    finalize the permanent COVID-19 standard for healthcare workers and a
    permanent standard for infectious diseases. Secretary Walsh indicated
    the healthcare standard would be done within three to 6 months, while
    the next steps for infectious diseases would be done on the same
    timeline. The Spring 2022 Unified Agenda of Regulatory and Deregulatory
    Actions released on June 21, 2022 identifies September 2022 for
    issuance of the final rule for the healthcare COVID-19 standard and May
    2023 for the notice of proposed rulemaking (NPRM) for the infectious
    diseases standard.
        Please describe your actions and plans for issuing the NPRM on
    infectious diseases closer to the timeline you identified during the
    hearing.
        Answer. OSHA's current priority is issuing a final COVID-19
    standard. Unfortunately, COVID is still a threat to working people and
    we are focused on keeping our healthcare workers safe. We expect to
    finalize the COVID-19 standard in September of 2022 and will then turn
    our full attention to the infectious disease NPRM.
        COVID has shown us that we need a permanent infectious disease
    standard that will address all infectious disease hazards, including
    future pandemics. At this time, OSHA expects to publish an infectious
    disease NPRM in May of 2023. This is an aggressive timeline and
    somewhat dependent on our COVID work because the team of people working
    on the COVID standard also work on the infectious disease standard.
        Question. How has the Department used available funding from the
    American Rescue plan for this important work?
        Answer. Funding from the American Rescue Plan has been an extremely
    valuable resource for us to fund work on the COVID-19 and infectious
    disease standards in several ways. We are spending ARP money on staff
    time for economists, health scientists, industrial hygienists, and
    epidemiologists, as well as on legal assistance. We also utilize
    contracts to further the Agency's work. Contractors perform research,
    review literature, and engage in analysis.
        Question. How will the Department use available balances of such
    funding to accelerate promulgation of the NPRM?
        Answer. The Department will continue to use ARP funding to pay for
    staff such as economists, health scientists, industrial hygienists, and
    epidemiologists, as well as legal assistance. We will also use ARP
    funding for contracts to further our work so that we can move as
    quickly as possible on the NPRM.
                     protecting agricultural sector workers
        Question. The number of Wage and Hour investigations in agriculture
    fell to 1,000 in fiscal year 2021.
        This level is down by more than one-third from a decade ago.
    ``Labor Exploitation and Trafficking of Agricultural Workers During the
    Pandemic'' (https://polarisproject.org/wp-content/uploads/2021/06/
    Polaris_Labor_Exploitation_and_
    Trafficking_of_Agricultural--Workers_During_the_Pandemic.pdf) finds
    that labor trafficking victimization of H-2A Visa holders increased by
    70 percent comparing a 6-month period prior to the COVID pandemic and
    during the pandemic. The report further noted that nearly two-thirds of
    such trafficking victims suffered threats of reporting to immigration
    and excessive hours, while one-third suffered the withholding of
    earnings.
        Please describe the Department's actions and plans to protect
    workers in our agricultural sector.
        Answer. Farmworkers are among the lowest paid and most vulnerable
    workers in the country.
        Many of these workers are excluded from Federal collective
    bargaining protections under the National Labor Relations Act and from
    overtime protections under the Fair Labor Standards Act. As a result,
    farmworkers are uniquely susceptible to wage theft, unlawful
    retaliation, and human trafficking.
        For farmworkers with H-2A visas, these vulnerabilities are
    compounded by the fact that they are reliant on the employer for
    housing, transportation, access to food, and their temporary status in
    the country. While the number of workers with H-2A visas has grown from
    160,000 in fiscal year 2017 to more than 250,000 in fiscal year 2021,
    even without a corresponding increase in enforcement appropriations,
    the Department has continued to prioritize agricultural workers in its
    enforcement and outreach.
        The Department is committed to ensuring that the rights of
    farmworkers are protected. In fiscal year 2021, the Wage and Hour
    Division (WHD) recovered over $8.4 million for over 10,000 workers in
    the agricultural industry. To continue to achieve the greatest impact
    possible, WHD has launched a national initiative to focus enforcement
    and outreach efforts on the agricultural industry. When egregious
    violations are found, WHD uses every tool at its disposal, including
    program debarment, to protect workers and ensure that employers are
    held accountable.
        Through its investigations, WHD is uniquely positioned to detect
    potential human trafficking indicators, to make referrals to criminal
    law enforcement agencies, and to calculate restitution for victims when
    requested by the Department of Justice. WHD continues to support the
    updated U.S. National Action Plan to Combat Human Trafficking by
    committing resources, collaborating with criminal enforcement agencies,
    and providing outreach to combat labor trafficking. Wage and Hour is
    also a U & T-visa certifying agency, and its efforts significantly
    assist qualifying victims of these crimes who are seeking immigration
    relief from the Department of Homeland Security (DHS).
        WHD also plans to continue to strengthen its partnerships with
    employers, worker advocates, and community-based organizations. Since
    the beginning of this Administration, WHD has sponsored and
    participated in 787 outreach events focusing on H-2A compliance with
    agricultural workers and their advocates, as well as with employers,
    agents, recruiters, and partner agencies engaged in the H-2A program.
    Educating employers increases compliance while partnering with workers'
    trusted allies makes workers feel more comfortable filing complaints
    and participating in investigations.
        Finally, the Department is currently engaged in rulemaking to
    modernize the administration of the H-2A program and to increase
    protections for workers and has announced that it will engage in
    further rulemaking to promote worker voices and worker protections.
        Question. How will the budget proposal support implementation of
    these plans in fiscal year 2023?
        Answer. Over the course of the past year, WHD has been working to
    rebuild its enforcement workforce and target its hiring in the
    geographic areas where its services are most needed. As a priority
    industry, employment in agriculture is taken into consideration when
    allocating personnel to be hired. The fiscal year 2023 budget will
    support hiring in district offices that focus on agricultural
    investigations, including district offices in Alabama, California,
    Florida, Georgia, Mississippi, North Carolina, and Texas. These hiring
    efforts will enable WHD to continue to focus on essential outreach and
    enforcement in agricultural areas.
        Question. What steps will you take to ensure that unclaimed back
    wages collected, including for visa holders, are paid to those harmed
    workers?
        Answer. WHD's efforts to put wages back in workers' pockets
    transforms lives. In fiscal year 2021, WHD assessed an average of
    $1,211.70 for over 190,000 employees due wages, which can mean the
    difference in being able to meet the rent or pay a childcare bill.
    Returning these wages to workers is essential to the agency's mission,
    and WHD leverages partnerships with community-based organizations and
    foreign consulates while also engaging in innovative outreach
    strategies to ensure that back wages are paid to vulnerable workers.
        WHD has been working with worker advocates, unions, and foreign
    consulates to build trust and increase workers' access to the agency.
    These partners have been vital to the agency's efforts to locate
    workers and maintain relationships with workers over the length of the
    investigations. For example, WHD worked with community-based
    organizations in Pennsylvania to hold a back-wage clinic for unlocated
    mushroom farmworkers. The clinic resulted in the distribution of
    $68,377 in back wages to 66 workers that WHD had previously been unable
    to contact.
        Similarly, consulate partnerships amplify WHD's outreach and
    connect the agency with immigrant communities. As a trusted source of
    information and assistance, they help WHD reach more workers and
    deliver on the protections the law provides. They also play a vital
    role in locating workers due back wages after they have left their
    employment in the U.S.
        Finally, WHD has developed an online search tool, Workers Owed
    Wages (WOW) that allows workers to enter information to find out if
    back wages are being held on their behalf.\1\ The tool provides a quick
    and easy way for employees to find out if they are owed money and
    receive it. From January 2022 through June 2022, the WOW search tool
    facilitated the disbursement of over $2 million to workers owed wages.
    The WOW system is currently available in English and Spanish.
    ---------------------------------------------------------------------------
        \1\ https://www.dol.gov/agencies/whd/wow.
    ---------------------------------------------------------------------------
        Question. Please describe any barriers to back wage payments being
    made and plans to overcome them, including any needed legislative
    changes.
        Answer. Immigrant and low-wage workers face several obstacles in
    recovering wages that are owed to them. These workers are often
    difficult to locate because they move frequently or may return to their
    home countries. This problem is exacerbated by the fact that
    investigations, particularly agricultural investigations, are often
    long and complex and may include litigation, making it more likely that
    workers have moved or changed contact information between the time that
    the investigation was initiated and the time that back wages are
    recovered. Further, low-wage and vulnerable workers may fear
    retaliation for coming forward and claiming the wages that are owed to
    them.
        There are some statutory barriers as well, such as the current
    statutory requirement for any back wages to be sent to Treasury if they
    are not able to be delivered to the worker within 3 years. DOL believes
    that altering that requirement in some form could be beneficial to
    returning back wages to workers and is available to provide technical
    assistance and further briefing on the matter.
                    evaluation of ofccp contractor selection
        Question. The President's budget proposes $147 million, an increase
    of $39 million, for the important work of the Office of Federal
    Contract Compliance Programs (OFCCP).
        How does the OFCCP plan to evaluate and continue to improve its
    supply and service scheduling list for selection of contractors with
    the greatest risk factors for noncompliance with equal opportunity and
    affirmative action requirements?
        Answer. OFCCP is deploying its resources more strategically by
    strengthening its process for scheduling Federal contractors for
    compliance reviews. The agency is incorporating broader sets of data
    and information to identify risk factors for noncompliance and better
    align its selection process with enforcement priorities. OFCCP
    schedules employers for evaluation using a ``general administrative
    plan . . . derived from neutral sources,'' which includes various labor
    economic data and analytical procedures.\2\ This can include, for
    example, a focus on industries or sectors with high prior labor and
    employment law violation rates or particular geographic regions.
    ---------------------------------------------------------------------------
        \2\ See United Space Alliance, LLC v. Solis, 824 F. Supp. 2d 68, 91
    (D.D.C. 2011) (citing Marshall v. Barlow's, Inc., 436 U.S. 307, 320,
    321 (1978)).
    ---------------------------------------------------------------------------
        In May 2022, OFCCP issued a new supply and service scheduling list
    of Federal contractors and subcontractors. Using neutral criteria,
    OFCCP developed and implemented a statistical methodology to conduct
    predictive modeling for the purpose of selecting Federal contractors
    and subcontractors. This model incorporated an analysis of EEO-1
    Component 1 data to identify instances in which utilization of
    demographic groups differ from industry and local labor market
    averages. OFCCP focused on industries that have experienced employment
    growth during the pandemic and the industries expected to receive
    significant Federal investments for infrastructure and economic
    recovery, to ensure all workers have equal access to employment
    opportunities. The agency scheduled a larger proportion of
    establishments from those industries in which the average hiring rate
    increased after March 2020, the date of the onset of the economic
    impact of the pandemic, relative to a baseline established from hiring
    rates in the years before the pandemic (2014--2020).
        OFCCP developed this methodology to strengthen its ability to
    identify risk factors for noncompliance in order to focus agency
    resources where workforce utilization patterns may indicate the
    existence of barriers to hire or advancement. OFCCP further anticipates
    these changes will help the agency reach a broader universe of Federal
    contractors, as well as subcontractors. Historically, OFCCP has not
    scheduled subcontractors for compliance evaluations when there is a
    lack of data concerning subcontract dates. For this scheduling list,
    OFCCP included the prime contract date as a proxy for the subcontract
    dates and will examine the utility of this approach.
        In addition, where a parent company has three or four
    establishments on the May 2022 scheduling list, OFCCP has assigned
    these compliance reviews to the same region so that the agency and the
    contractor can engage in these reviews in a coordinated manner to
    increase efficiencies for all.
        OFCCP is continuing to strengthen its supply and service scheduling
    list for selection of contractors with the greatest risk of
    noncompliance, including by promoting contractor compliance with the
    requirement to develop and maintain written Affirmative Action Programs
    (AAPs). OFCCP developed and launched in early 2022 an online portal,
    the ``Contractor Portal,'' for supply and service contractors to self-
    certify electronically that they have developed and maintained AAPs for
    each establishment and/or functional unit, as applicable. Compliance
    with OFCCP's written affirmative action program requirements is
    essential because a complete AAP and the supporting personnel activity
    data provide the foundation for OFCCP's compliance evaluation of a
    contractor's employment practices. By June 30, 2022, existing
    contractors were required to certify whether they were in compliance.
    OFCCP has announced to contractors that those who fail to complete the
    certification though the Portal, or state that they have not developed
    or maintained an AAP, will be more likely to be on OFCCP's scheduling
    list than contractors that have certified that they are in compliance.
        Question. How would additional resources requested in the budget
    support this objective and increase contractor compliance with such
    requirements?
        Answer. Given the Federal Government's historic investments in the
    economy over the next decade, many more businesses will become Federal
    contractors and subcontractors. As a result, OFCCP will have
    substantially increased enforcement responsibility over this growing
    number of contractors. Additionally, contractors' workforce structures
    and employment selection and pay systems are rapidly evolving, becoming
    more sophisticated and complex and the pandemic has accelerated changes
    to workplace structures, including the increased reliance on remote
    work.
        The fiscal year 2023 funding request would allow OFCCP to increase
    its capacity to review a greater number of contractors and strengthen
    its investigation and resolution of systemic discrimination cases,
    which will increase contractor accountability and attention to
    proactive compliance. In particular, the fiscal year 2023 request would
    support 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. As the Agency rebuilds,
    OFCCP will continue robust engagement with a broad coalition of
    stakeholders, including contractors. The Agency will develop resources
    to highlight evidence-based research and promising practices to inform
    employers when developing actionable strategies to build inclusive
    workplace cultures and advance equity. The 2023 request would also
    provide the resources necessary to onboard new hires, develop and
    deliver in-depth employee training programs, and invest in the
    requisite workforce technological equipment and solutions. Investing in
    training and technology support along with hiring will help ensure
    long-lasting operational success and prevent attrition.
        OFCCP also will work to align its traditional review of single
    contractor ``establishments'' with the evolving reality of the
    workplace, where contractors often take a more enterprise-wide approach
    to evaluating their employment practices, including compensation. With
    increased funding, OFCCP would also enhance its database production,
    software expertise and research capabilities to support stronger
    coordinated enforcement.
        Where contractors refuse to provide access to data, witnesses, and
    other information that is necessary for OFCCP to conduct its compliance
    evaluations, OFCCP will use its fiscal year 2023 funding to prepare
    enforcement referrals for denial of access cases so that Federal
    contractors adhere to their responsibility to provide this information.
        Question. How would access to data collected by the Equal
    Employment Opportunity Commission advance the OFCCP mission and
    minimize data collection burden on covered contractors?
        Answer. OFCCP selects contractors for comprehensive compliance
    reviews by relying on a variety of data sources to focus the agency's
    enforcement resources. The EEO-1 report is a joint data collection to
    meet the enforcement needs of both the U.S Equal Employment Opportunity
    Commission (EEOC) and OFCCP, while avoiding duplicative information
    collections and minimizing the burden on employers. EEO-1 Component 1
    workforce demographic data has been shared between the two agencies for
    decades.
        Collecting and analyzing pay data from private employers is
    important to OFCCP's efforts to ensure pay equity. In 2014, OFCCP
    published a rule proposing a pay data collection to enable the agency
    to more effectively focus its enforcement resources to better identify
    potential pay inequities warranting compliance evaluations. During the
    rulemaking, OFCCP considered public comments from contractors urging
    EEOC and OFCCP to coordinate compensation data collection by using the
    EEO-1 report, thereby decreasing employer burden. Ultimately, OFCCP
    determined that, rather than publishing a final rule, it would
    collaborate with the EEOC to collect compensation data as part of the
    EEO-1 filing.
        In September 2016, the Office of Management and Budget (OMB)
    approved EEOC's final Paperwork Reduction Act notice to collect, from
    private employers and Federal contractors, workforce pay data by
    gender, race, ethnicity, job category and by pay bands via the EEO-1
    report (Component 2). In August 2017, OMB issued a memorandum
    initiating a review and immediate stay of the revised data collection
    regulation. As a result of a lawsuit against OMB and EEOC challenging
    the stay, in 2019 a Federal district court reversed the stay and
    ordered the EEOC to collect 2 years of pay data from employers. EEOC
    complied, however, it subsequently announced that it would no longer
    collect pay data via the EEO-1.
        OFCCP is interested in exploring opportunities to use the EEO-1
    Component 2 pay data that has been collected to inform OFCCP's
    scheduling methodology and identify potential pay gaps or patterns of
    occupational segregation that merit further investigation. Pay data
    could be used to conduct analyses to identify employers that are
    outliers and depart substantially from comparable benchmarks that may
    warrant further inquiry. Such analyses could inform the methodology for
    selecting contractors for further review where OFCCP would have the
    opportunity to review the full set of pay data. When combined with an
    analysis of utilization outliers, the identification of pay outliers
    lends significant marginal utility to the Component 2 pay data for
    OFCCP and could enhance OFCCP's scheduling process. OFCCP's desk audit
    also includes a three-year trend analysis of EEO-1 Component 1 reports
    to identify utilization outliers. A similar analysis of trends in the
    Component 2 pay data--separate or in conjunction with the EEO-1
    Component 1 data--may provide additional value in OFCCP investigations.
                             olms union protections
        Question. The Office of Labor-Management Standards also protects
    union members through its work to identify fraud and embezzlement of
    union assets.
        How would additional resources be used to target compliance audits
    on those at-risk of violating requirements without burdening unions
    that don't have any compliance issues?
        Answer. Additional resources to fund the Office of Labor-Management
    Standards' (OLMS) initiative to enforce and review for accuracy
    employer and consultant reports required under the Labor-Management
    Reporting and Disclosure Act (LMRDA) dovetail with its efforts to
    reduce burden on labor unions that are free of compliance issues. The
    resources requested would permit OLMS to continue audits of labor
    unions both to detect embezzlements and to promote compliance with the
    LMRDA. Because it is not feasible for OLMS to audit every union, and
    doing so would unfairly burden compliant unions, OLMS developed and
    applies a methodology to focus its auditing resources on unions whose
    objective metrics suggest that they may have been victimized by
    criminal activity. This targeting strategy conserves resources--of both
    unions and OLMS--that would have been wasted on audits of problem-free
    organizations. The effectiveness of this methodology is measured by the
    percent of conducted audits that result in the opening of a ``fallout''
    criminal case. If the fallout rate is high, it supports the conclusion
    that OLMS is successfully targeting its resources to labor unions that
    need it. Note: To be clear on a point that is sometimes misunderstood,
    we emphasize that the fallout rate measures only the ``efficiency'' of
    OLMS' targeting strategies. A high number does not suggest high
    criminal activity and a low number does not suggest low criminal
    activity. The fallout rate measures only the effectiveness with which
    the agency identifies and audits those unions that are vulnerable to
    fraud or embezzlement based on financial metrics that are often
    associated with fraud or embezzlement.
        Question. Please describe how the Voluntary Compliance Partnership
    program is improving compliance with the LMRDA and allowing OLMS to
    cost-effectively fulfill its mission.
        Answer. OLMS works with the nation's most prominent international
    and national unions through the Voluntary Compliance Partnership (VCP)
    initiative to assist their local and affiliate unions with LMRDA
    compliance, thus multiplying the effect of OLMS' efforts and allowing
    OLMS to more cost-effectively fulfill its mission. In 2021, the VCP
    program leveraged the resources of national/international labor unions
    to improve the compliance performance of over 16,000 of those
    international and national unions' affiliates. The same year, OLMS
    expanded the VCP program to 47 partner unions, an increase of two
    unions over the previous year. Over the years, VCP has solidified its
    platform as a national compliance assistance effort that measurably
    improves timely reporting, bonding coverage, accurate and complete
    reporting--including the submission of union constitutions and bylaws--
    and the implementation of financial safeguards to prevent unions from
    becoming victims of financial fraud. For example, the overall late-
    filing rate for unions under the VCP initiative is significantly lower
    than for non-VCP unions, and the late filing rate decreased
    significantly after increasing during fiscal year 2020, as the COVID-19
    pandemic began. VCP continues to assist partner labor organizations
    with OLMS procedures regarding mergers and terminations, regional and
    national training conferences, and other organizational development
    activities. In every instance where a labor union partner addresses the
    compliance problems of its affiliates, it reduces the demand for OLMS
    enforcement resources, saving money and permitting OLMS to more cost-
    effectively fulfill its mission.
                          bls youth cohort development
        Question. The budget proposes $14,500,000 for the Bureau of Labor
    Statistics to continue development of a new youth cohort for the
    National Longitudinal Surveys.
        How would these funds be used to support a new youth cohort and
    generate additional information on and support research about the
    experience and education of youth during the COVID-19 pandemic, their
    future education and training and transition to the workforce?
        Answer. The Bureau of Labor Statistics (BLS) began developing a new
    National Longitudinal Surveys (NLS) youth cohort in fiscal year 2021
    and since then has conducted extensive outreach to Federal agencies,
    user groups, and scientists with relevant areas of expertise.
    Information about these activities, including agencies and subject
    areas around which they were organized and topics they targeted for
    feedback, are available at https://www.bls.gov/nls/nlsy26.htm. These
    outreach efforts allowed BLS to form a conceptual and practical
    foundation. Building upon these activities, beginning in fiscal year
    2023, BLS would use the funding proposed in the President's Budget to
    build-out the new youth survey, which includes the following steps: (1)
    create management structures for coordinating the development of
    sampling procedures, questionnaire content, collection design, data
    processing systems, and dissemination tools; (2) design procedures for
    sampling and accessing the appropriate, high-quality sampling frame;
    (3) develop the collection instruments; and (4) initiate development of
    systems to manage, process, and disseminate the data that are collected
    or acquired from alternative sources. Also, outreach would continue
    throughout the development process. BLS would field its first round of
    collection in fiscal year 2026 and release the first set of data in
    fiscal year 2028.
        It is anticipated the new cohort would comprise a nationally
    representative sample of youth between the ages 12 to 16 and living in
    the United States at the first interview, who would be interviewed
    periodically through their life up to and including through retirement
    age. The youth comprising the group will have been born during 2010--
    2014, and thus experienced the COVID-19 pandemic during their
    elementary schooling years. In the early years of the survey, BLS would
    collect retrospective information to capture information about
    respondents' elementary schooling years, including their experiences
    during the COVID-19 pandemic. This, along with the extensive
    information collected from them through their teenage years and into
    adulthood, would enable a wide range of research about how the
    experiences of this generation during the COVID-19 pandemic influence
    their future education and training and their transition to the
    workforce. Due to the survey's longitudinal design; its focus on
    education, training, skill development, and employment; and the breadth
    of additional domains for which it collects information, the new NLS
    cohort would be uniquely well-suited to support research on various
    topics, including the impacts of the COVID-19 pandemic on the cohort's
    educational and professional experiences, yielding valuable insights
    for governments, businesses, and other decision-makers. Previous NLSY
    cohorts have provided a lens for in-depth study of race-, ethnicity-,
    gender-, and income-based differences, and a new cohort would advance
    these lines of research, allowing for comparisons across cohorts as
    well as incorporating potential adaptations to employment, education,
    and training resulting from economic and environmental changes over
    time.
                   office of the solicitor operations funding
        Question. The budget requests $178 million, an increase of $52
    million, for the Office of the Solicitor which is necessary to support
    the day-to-day operations of the Department's agencies and programs as
    well as the regulatory agenda and priorities of the Department.
        How would additional resources requested for the Office of the
    Solicitor reverse the trend over the past decade of the significant
    reduction in litigation opened and closed? What's the impact of this
    reduced litigation capacity on the ability of agencies to fulfill their
    statutory missions?
        Answer. With the additional resources provided in the fiscal year
    2023 President's Budget, the Office of the Solicitor (SOL) would
    greatly increase its enforcement litigation capacity, reversing the
    trend over the past decade of a steady and significant reduction in the
    number of litigation matters that SOL opens and closes. The decline in
    litigation correlates with the reduction in SOL FTE that has resulted
    from the combination of steadily increasing costs per FTE and
    insufficient direct appropriations, which for SOL have remained
    relatively flat. As reflected in the graph below, over the last 10
    years, staffing decreases have forced SOL to significantly reduce the
    number of litigation matters SOL opens; in fiscal year 2021, SOL opened
    just 35 percent of the litigation matters it opened in fiscal year
    2012.
        At the fiscal year 2023 President's Budget funding level, SOL
    anticipates an overall 25 percent increase in its litigation workload,
    with opened litigation matters increasing by 63 percent in comparison
    to the full-year results from fiscal year 2021 and concluded litigation
    matters increasing by 16 percent compared to fiscal year 2021. The
    following data, focused on the litigation portion of SOL's workload, is
    included in the fiscal year 2023 President's Budget submission. This
    does not capture the critical pre-litigation work, legal advice, and
    regulatory work that SOL undertakes to assist DOL's agencies:

    ----------------------------------------------------------------------------------------------------------------
                                                                FY 2022          FY 2023       Projected   Projected
                                                               Projected     Projected (with  Increase--  Increase--
                                            FY 2021 Actual   (Based on Flat    President's    FY 2022 to  FY 2021 to
                                                             Appropriation)      Budget)        FY 2023     FY 2023
    ----------------------------------------------------------------------------------------------------------------
    Litigation Opened....................           5,156            6,400            8,400         31%         63%
    Litigation Concluded.................           6,238            5,500            7,225         31%         16%
    ----------------------------------------------------------------------------------------------------------------

        The following graph illustrates the correlation between the decline
    in SOL's staffing levels and the decline in SOL's litigation matters
    over the past decade. This graph also illustrates the expected increase
    in litigation if the fiscal year 2023 President's Budget were enacted:

        The decline in SOL staffing has diminished the ability of DOL (and
    its constituent agencies) to enforce the laws Congress has written,
    leaving workers unprotected and tilting the economic playing field
    against law-abiding employers. For example, SOL is presently forced to
    decline roughly 60 meritorious Wage and Hour matters each month, and
    about 70 meritorious, contested OSHA cases each month. This diminution
    in legal services not only hampers DOL's ability to provide relief for
    the most vulnerable workers but harms the majority of employers that
    are complying with the law. For instance, construction contractors that
    pay overtime to their workers are harmed if competing employers reduce
    their labor costs by failing to pay overtime. The fiscal year 2023
    budget would enable SOL to litigate more cases generally, and in
    particular, more impactful, resource-intensive cases.
        Finally, while this question is specifically about litigation, it
    is important to emphasize the effect that insufficient staffing has
    upon the full range of legal services SOL provides. Presently, SOL is
    underfunding critical general counsel programs and has a reduced
    ability to support client agencies with compliance assistance
    documents, guidance, and letters. Staffing shortages also hamper DOL's
    ability to carry out good government initiatives, such as clearing its
    FOIA backlog, and provide compliance assistance to the regulated
    community.
        Question. Please share for the last five fiscal years and the
    fiscal year 2023 budget proposal amounts spent on or allocated for the
    Office of the Solicitor to:
      --Work on Department regulatory activities;
      --Support agency enforcement actions; and
      --Provide other legal services.
        Answer. The table below provides the requested information for the
    last 5 years and the fiscal year 2023 budget proposal. Because the vast
    majority of SOL's funding goes directly to salaries and expenses for
    the personnel that provide legal services,\3\ we have derived the
    allocations below from time spent on providing legal services. The
    dollar figures in the table were calculated by multiplying the
    percentage of total time spent by SOL personnel on a particular
    category of legal work (enforcement agencies, other worker protection
    agencies, departmental management and other agencies, and regulatory)
    by SOL's appropriated budget for a given year. The fiscal year 2023
    data is a forecast of the distribution of SOL's work and expenditures
    based upon a two-year average (fiscal year 2021 to fiscal year 2022
    Q3).
    ---------------------------------------------------------------------------
        \3\ The remaining funding goes to non-personnel expenses that
    support SOL legal services, such as Working Capital Fund, rent,
    security, stenography, travel, and subscriptions.
    ---------------------------------------------------------------------------
        Following is further explanation of the table and data:
      --To demonstrate the expenditures or amounts allocated to ``agency
            enforcement actions,'' we provide data regarding SOL legal
            support to the DOL agencies that engage in significant
            enforcement work: EBSA, MSHA, OFCCP, OSHA and WHD. This
            represents about 66 percent of SOL's workload on average over
            the period covered.
      --Many other DOL agencies engage in worker protection activities, but
            their work is not primarily enforcement. We labeled these the
            ``Other Worker Protection Agencies,'' which include: ETA, ILAB,
            OLMS, OWCP, and VETS. This represents about 20 percent of SOL's
            workload on average.
      --The requested data for other legal services is reflected in the
            table as allocations for Departmental Management and Other
            Agencies, which covers legal work performed for the
            Department's central management administrative agencies, and
            other agencies not included in the categories above. This
            represents about 11 percent of SOL's workload on average.
        The allocations in the table for regulatory work cover all DOL
    agencies and represent about 3 percent of SOL's workload on average.
    The regulations allocation is not duplicative of the other agency-
    specific categories listed above and in the table below.

                        international labor enforcement
        Question. The budget proposes $129 million, an increase of $23
    million, for the Bureau of International Labor Affairs (ILAB) to
    enforce labor commitments of trading partner countries; combat child
    and forced labor and human trafficking; and effectively carry out its
    mission. This increase would build on the increased investment of $10
    million provided to ILAB in last year's appropriations bill.
        How would requested funds be used to build on increased resources
    provided in last year's bill to include in the List of Goods Produced
    by Child Labor or Forced Labor those that are produced with inputs
    produced with forced labor or child labor? What actions have been taken
    and are planned to incorporate this information into the list?
        Answer. The implementation of the List of Goods Produced by Child
    Labor or Forced Labor, including listing goods that are produced with
    inputs produced with forced labor or child labor, requires significant
    resources. ILAB is grateful for the interest from Congress in this
    vital tool and has utilized its appropriation to make important
    investments in this mandated work.
    Recent Actions
        ILAB has added a limited number of goods that we have reason to
    believe are produced with inputs produced with forced labor or child
    labor to the 2022 TVPRA List, which will be released in late September.
    The additions were based on ILAB's improved knowledge base with respect
    to tracing supply chains, developed in part via two $4 million grants
    in fiscal year 2021 to examine tracing methodologies for the supply
    chains of cotton, thread/yarn, and textiles from India, cobalt from the
    Democratic Republic of the Congo, and cotton from Pakistan. The grants
    contributed to a preliminary basis for a credible and multi-sectoral
    supply chain tracing methodology that ILAB then used to identify the
    goods and inputs that will be added to the 2022 List.
        ILAB is currently fulfilling its required involvement in
    interagency efforts related to transparency and accountability in
    supply chains, such as those under the Uyghur Forced Labor Prevention
    Act (UFLPA). As a statutory and critical member of the Forced Labor
    Enforcement Task Force (FLETF), ILAB reassigned staff to work closely
    with the Department of Homeland Security (DHS) and other interagency
    partners to meet the initial six-month timeline for developing the
    UFLPA enforcement strategy. ILAB plans to continue to prioritize staff
    resources to support the FLETF's ongoing work, as well as to support
    the increasing interagency and external demand for ILAB's technical
    expertise and guidance on implementing strong due diligence.
        ILAB is uniquely placed to lead the U.S. Government's response on
    developing effective and worker-centered due diligence guidance and
    plans to continue leading and innovating in these priority areas using
    the requested funding. The requested funding would also allow ILAB to
    expand its preliminary supply chain tracing methodology by
    incorporating more complex trade data and developing and acquiring more
    specialized knowledge of supply chains--in particular, unique
    processing steps, which frequently act as a barrier to effecting supply
    chain tracing and transparency. ILAB would also incorporate private
    sector, multilateral and international organization, and other public
    sector efforts in this area. The requested funding would enable ILAB to
    expand its list of goods that include inputs made with forced or child
    labor, as well as to continue to strengthen and improve our list of
    goods made with forced or child labor in the direct production.
        ILAB notes that expanded mandates for reporting and increased
    demand for ILAB expertise have outpaced appropriations for several
    years and appreciates Senators' leadership and commitment to supporting
    ILAB's work. ILAB's ability to examine additional supply chains beyond
    the supply chains explored in the two grants identified above
    (especially supply chains which may feature abusive and exploitative
    conditions) will require intensive and expanded resources.
        Question. The USMCA Supplemental Appropriations Act, 2019
    appropriates an additional $180 million, available for obligation until
    December 31, 2023, for ILAB to support reforms of the labor justice
    system in Mexico, including grants to support worker-focused capacity
    building, efforts to reduce child labor and forced labor in Mexico, and
    other efforts related to implementation of the USMCA. These funds are
    supporting important progress in Mexico in the implementation of its
    labor law reforms and increase in the number of independent unions
    recognized in Mexico. How does the budget support further progress in
    this critical area? What future needs do you anticipate for this work
    particularly after the supplemental funds have been awarded?
        Answer. The number of independent labor unions is still a small
    percentage of all unions in Mexico, but it is slowly growing with
    implementation of the labor reform, supported by ILAB project
    interventions, expert support from ILAB's labor attaches in Mexico,
    ILAB engagement with Mexican labor ministry staff and officials, and
    efficient deployment of the Rapid Response Mechanism. A recent ILAB
    monitoring trip identified the need for continued support of awareness-
    raising about the new labor justice model, including among small to
    medium-sized enterprises. As ILAB works to build the capacity of the
    new labor justice institutions in Mexico, particularly at the local
    level, ongoing funding will be needed to ensure the continuity of
    current efforts. Though all of ILAB's USMCA-related technical
    assistance projects in Mexico are designed to build sustainable
    capacity, the magnitude of Mexico's labor reform will necessitate
    ongoing ILAB engagement--including extended labor attache presence as
    well as new and extended project investments, beyond December 31,
    2023--to consolidate and institutionalize achievements and progress and
    ensure an enduring transformation of Mexico's labor landscape.
        Question. Mathematica's ``Synthesis Review of OCFT work in Cocoa
    and Fishing/Seafood'' identified relationships between project features
    and effectiveness, recurring challenges and opportunities for improving
    future project success, including on sustainability of reductions of
    child and forced labor resulting from ILAB-funded projects. How will
    the conclusions and recommendations from this review be considered for
    fiscal year 2022 and fiscal year 2023 funding opportunity
    announcements? What steps are planned to strengthen project
    sustainability so that labor abuses don't re-emerge after projects
    conclude?
        Answer. ILAB aims to disseminate all evaluations across the Bureau
    and our grantee community to maximize access and usership, including by
    hosting open presentations on evaluations and distributing ILAB's
    ``Evaluation Roundup'' to the larger stakeholder community. ILAB is in
    the process of launching a Knowledge Management Portal on the ILAB
    website to enable stakeholders to search past evaluations and other
    project resources by keyword to find specific lessons learned and good
    practices.
        ILAB considers many conclusions and recommendations from the
    Mathematica Synthesis Review report on the cocoa and fishing/seafood
    sectors to be applicable to ILAB's broader technical assistance
    portfolio and is applying these recommendations across funding
    decisions and Funding Opportunity Announcements. Some examples of ILAB
    responses are listed below:
      --Mathematica Recommendation: Consider funding projects for longer
            periods of time/larger budgets or to consider a two-phase
            funding approach.
      --ILAB Response: ILAB will pilot a two-phase project approach in
            fiscal year 2022. In Phase I, the project will work to improve
            regional and national coordination, and, if successful, these
            efforts will be scaled up within the region during Phase II.
      --Mathematica Recommendation: Engage families, community leaders, and
            unions/workers to support effectiveness.
      --ILAB Response: ILAB fiscal year 2022 programming and funding
            opportunities include an amplified focus on workers and their
            families. New projects will prioritize strengthening local
            civil society organizations and formal and informal worker
            organizations and engaging community leaders to build trust
            with marginalized and vulnerable workers, foster sustainable
            local capacity, and better support workers and their families
            with wholistic and locally led interventions.
      --Mathematica Recommendation: Design projects with more feasible
            outcomes.
      --ILAB Response: Fiscal year 2022 funding opportunities draw on ILAB
            staff expertise, complementary labor diplomacy efforts, trade
            leverage, and complementary sector- or country/region-specific
            initiatives to designate project sectors and countries or
            coordinate with grantees to jointly select countries and
            sectors. This comprehensive design approach supports the
            achievement of ambitious outcomes and ensures that project
            interventions will be supported and complemented by mutually
            reinforcing efforts. ILAB also works with grantees to assess
            expected project outcomes to ensure alignment with project
            timelines and available resources.
      --Mathematica Recommendation: Integrate tripartite approaches to
            support project effectiveness.
      --ILAB Response: ILAB is incorporating tripartite approaches as a
            best practice to increase worker voice and dialogue with
            government and employer stakeholders and improve labor
            conditions. Several ongoing ILAB projects include labor and
            employer organizations as co-implementers (e.g., the Solidarity
            Center and Center for International Private Enterprise are
            jointly implementing a project on labor law enforcement in
            Georgia), and ILAB is an active partner in the ongoing and
            successful Tripartite Commission in Honduras.
      --Mathematica Recommendation: Adopt gender-conscious project design.
      --ILAB Response: ILAB now requires applicants to describe an
            integrated gender approach from design through implementation
            to ensure representation of women, children, and youth (boys
            and girls) throughout the life of the project. ILAB is working
            with grantees to increase attention to gender in project design
            and monitoring and evaluation systems, including requiring
            gender-disaggregated data and, where appropriate, requiring
            targets for gender disaggregation.
        ILAB is taking several steps to ensure the sustainability of
    project outcomes to prevent the re-occurrence of labor abuses once
    projects have concluded. ILAB encourages project designs that include
    robust engagement with existing host government and local community
    initiatives to tie project interventions and outcomes into ongoing,
    locally led initiatives. ILAB's Pilares project in Colombia, designed
    and driven by local civil society organizations, is a model approach
    that ILAB intends to scale-up using fiscal year 2022 funds.
        ILAB's approach to building the capacity and motivation of local
    stakeholders, including government, private sector, and civil society
    groups, equips local actors with the tools and information to monitor
    and address labor abuses after projects end. All ILAB Funding
    Opportunity Announcements (FOAs) require applicants to outline a
    sustainability strategy for the proposed project and describe how they
    will promote the sustainability of key elements, beginning in the early
    stages of project implementation. Grantees update their sustainability
    strategy annually to ensure continued relevance of project outcomes and
    adjust to changes in capacity of individuals, communities, and country.
                      evidence capacity investment survey
        Question. The Department's Evidence Capacity Investment, January
    2022, found that approximately half of survey respondents--which were
    restricted to occupations for which the use of evidence is relevant--
    reported they or their teams frequently use statistics, research, and
    analyses. Just less than one-third of respondents reported using
    evidence for service improvements, or research agendas or questions.
        Please share your plans for implementing the opportunities for
    improvement identified in this report.
        Answer. The Department's Chief Evaluation Office (CEO) has analyzed
    the findings of the Capacity Assessment for Research, Evaluation,
    Statistics and Analysis and identified fundamental gaps in skills and
    access to data that together prevent the Department from using evidence
    in their work. Based on that analysis, CEO has identified two priority
    areas of work:
      --Conducting Department-wide trainings and capacity-building support
            for both supervisors and non-supervisors to prepare them to
            understand and use internal and external research and data
            resources. This includes support for staff with no formal
            education or training in mathematics and statistics, who
            nonetheless need to interpret evidence, as well as training
            tailored to those staff who already analyze, interpret, and
            report data analyses in their current positions.
      --Launching a restricted use data (RUD) program and environment where
            DOL staff and trusted researchers can merge, analyze, and use
            DOL and other external data resources.
        CEO has launched substantial planning and work on both the
    trainings and the RUD program within its existing resources, including:
      --Establishing a Seminar Series for the Department's staff and
            Federal colleagues to learn about new and relevant research,
            data, and targeted evidence topics and resources, and to do so
            in an informal and accessible setting;
      --Launching a monthly internal research roundup newsletter to draw
            attention to the Department's work;
      --Creating an introductory webinar for all staff to be integrated
            into the Continuous Learning@Labor program;
      --Leading the development of the Department's Evidence Institute in
            collaboration with the Department's Evidence Officials and as
            well as the DOL Training Officer and LearningLink staff, taking
            first steps toward offering professional, high-quality adult
            learning opportunities for DOL staff on evaluation, data
            analytics, and other evidence-related technical topics;
      --Updating the Department's Scientific Integrity Policy--under the
            leadership of CEO and Scientific Integrity Official Dr.
            Christina Yancey--to ensure honesty, objectivity, transparency,
            and ethical behavior when it comes to science and scientific
            processes, in response to the Presidential Memorandum on
            Restoring Trust in Government through Scientific Integrity and
            Evidence-Based Policymaking; and
      --Mapping the characteristics of the Department's existing
            restricted-use data files that could support a RUD Program and
            developing initial mock-ups of a website interface and
            application processes, forms, and other administrative
            materials.
        CEO will continue to build upon these activities as possible within
    existing resources. With additional resources--both in staff and
    funding--the Department could expand and deepen the professional-
    quality trainings needed by staff as identified in the Capacity
    Assessment, as well as fully launch the RUD program, both of which are
    efforts that will make more meaningful capacity-building improvements
    across the Department's workforce.
        Question. How would the budget request support implementation of
    these plans?
        Answer. The Department proposed an increase to the Departmental
    Program Evaluation budget activity. In addition, robustly funding the
    Department's overall budget request could help support this work
    because CEO can access set-aside funds shared by DOL sub-agencies.
    Section 107 of the General Provisions in the President's Budget
    authorizes the reservation of not more than 0.75 percent from specific
    budget accounts for transfer to and use by the Office of the Chief
    Evaluation Officer for departmental program evaluation and related
    evidence-building activities. This authority offers an opportunity to
    repurpose a small portion of agency budgets for evidence- building.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
                 specialization of job corps center curriculums
        Question. Job Corps is an educational and workforce training
    program administered by the Department of Labor. The Job Corps program
    helps youth build the skills they need to succeed, complete their high
    school education and help students find employment after they leave.
    West Virginia is proud to be home to two Job Corps centers, one in
    Charleston and one in Harpers Ferry. The President's budget requests
    $1.7 billion in funding for Job Corps in fiscal year 2023, which is an
    increase over the previous fiscal year. This funding will allow the
    continued operation of all 121 Job Corps Centers, facilitate updates
    and rehabilitation projects at existing Job Corps Centers and support
    the hiring of necessary staff. While this funding is put to good use in
    training the next generation of workers, the Department of Labor should
    consider creating a streamlined process that will allow Job Corps
    centers to more quickly submit and have approved requests to change
    curriculums or offer new, specialized courses to students. This would
    help ensure students have access to courses and trainings that will
    allow them to compete now and enter competitive industries. Creating
    more opportunities for students only stands to benefit our nation.
        How can the Department streamline the process by which Job Corps
    centers create specialized curriculums, or offer new courses to
    students?
        Answer. Job Corps recently evaluated the process governing its
    change request protocols for curriculums, identifying pain points and
    areas for improvements. As a result, in August 2022, the program
    implemented several changes to ensure efficiencies in the process.
    Noteworthy changes to the process include:
      --Streamlined Information Requests.--Job Corps revised the process to
            provide clarity to all center operators, including additional
            information specific to establishing pre- apprenticeship
            curriculums.
      --Technical Assistance Enhancements.--The program added a means for
            proactive technical assistance to the process (including office
            hours) to ensure the timely arrival, completion, and National
            Office approval of change requests.
        These adjustments, in addition to process changes and ongoing
    guidance/training to center operators, were developed to continuously
    improve the quality of requests to the National Office and shorten the
    timeline for determinations. Job Corps' revised process and ongoing
    efforts to increase local and national partnerships will ensure that
    the program delivers high-quality curricula and training more
    efficiently and graduates are prepared for in-demand jobs with strong
    career paths and sustainable wages.
                      mental health parity law compliance
        Question. Each year, the Secretary of Labor is required to submit a
    report regarding compliance with mental health parity laws. Mental
    health parity laws generally prohibit restrictions on mental health
    services that are more restrictive than those for all medical and
    surgical benefits. In January, the Department of Labor, along with the
    Department of Health and Human Services and the Department of the
    Treasury, released a report showing that health insurers for the most
    part are failing to deliver parity for mental health and substance use
    disorder benefits to beneficiaries. Senator Manchin has heard from
    several constituents who work in the mental health and substance use
    disorder workforce that mental health parity laws are simply not being
    followed. What's worse, mental health parity laws are not really being
    enforced. The bad actors aren't seeing any consequences for their
    actions, which are limiting patient access to mental health and
    substance use disorder services.
        What is the Department doing to ensure employers are meeting their
    obligations to their employees, and that mental health parity laws are
    being enforced?
        Answer. The Biden-Harris Administration has made enforcement of the
    Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) a top
    priority. MHPAEA, as amended by the Consolidated Appropriations Act,
    2021 (CAA), specifies how group health plans and health insurance
    issuers to whom MHPAEA applies must perform and document comparative
    analyses of the non-quantitative treatment limitations (NQTLs) they
    impose on Mental Health and Substance Use Disorders (MH/SUD) coverage
    to demonstrate parity, and provide those analyses to the Secretaries of
    Labor, HHS, and Treasury or applicable state authorities upon request.
    This new enforcement authority continues to be the cornerstone of the
    Departments' heightened MHPAEA enforcement efforts. In light of the
    high priority placed on MHPAEA, the Employee Benefits Security
    Administration (EBSA) has redesigned its enforcement strategy and
    committed significant new resources to its MHPAEA enforcement efforts
    in order to best leverage the additional authority. The Department
    continues to devote greater resources to enforcement so as to take full
    advantage of these new and existing tools that Congress has provided to
    the Departments.
        EBSA's ten Regional Offices across the United States are actively
    involved in investigating multiple health plan service providers and
    issuers, as well as health plans, to assess MHPAEA compliance. EBSA
    identifies NQTLs through a review of plan document language, analysis
    of claims data, follow-up on leads from provider/participant
    complaints, and consideration of other sources. EBSA has developed
    specialized investigative tools to help identify potential NQTL red
    flags and analyze claims data for MHPAEA concerns. Additionally, EBSA
    works with consulting experts to develop approaches to evaluate
    comparative analyses.
        Each of EBSA's ten regional offices has a team of investigators
    dedicated to MHPAEA NQTL investigations and these teams were recently
    expanded to provide more resources and subject matter expertise for
    these investigations at the regional level. EBSA's NQTL Task Force
    continues to provide oversight and coordination of these
    investigations, and additional support is provided from the Office of
    Enforcement, Office of Field Administration, and Office of Outreach,
    Education and Assistance in the EBSA national office.
        As a result of the additional funding provided under the CAA, EBSA
    continues to hire additional investigators and other staff in support
    of EBSA's MHPAEA enforcement work. Since enactment of the CAA, EBSA
    onboarded new investigators and other staff using CAA- appropriated
    fundings. EBSA has held over 30 MHPAEA NQTL training programs for new
    and experienced investigators and other staff since April 2021. The
    funding provided under the CAA to support this critical work expires at
    the end of 2024.
        EBSA has also retained or is in the process of retaining additional
    outside consultants and experts in the areas of autism, reimbursement
    rates, network adequacy, substance use disorder treatment, and eating
    disorder treatment to assist investigators in the review and evaluation
    comparative analyses and with medical and behavioral health issues in
    these investigations.
        EBSA continues to conduct robust outreach initiatives and works
    extensively to improve the understanding of MHPAEA among plans, plan
    sponsors, issuers, consumer groups, participants and beneficiaries,
    healthcare providers, and state regulators. These initiatives include
    webcasts, in-person seminars, and nationwide compliance outreach events
    for the regulated community. In fiscal year 2022 through June 30, 2022,
    EBSA conducted 49 compliance assistance outreach events nationwide that
    covered MH/SUD parity, and which were attended by employers, employee
    benefit plan administrators, attorneys, accountants, and other plan
    officials. Attendees received information about their responsibilities
    under Federal laws affecting group health plans, including MHPAEA. In
    addition to the compliance assistance events, EBSA also conducted 103
    participant assistance and public awareness events that educated
    workers and other stakeholders about rights and benefits safeguarded
    under MHPAEA.
        EBSA currently has 229 open MHPAEA investigations as of July 1,
    2022, 124 of which involve one or more possible NQTLs. EBSA is
    increasingly focusing its investigative resources on service providers
    to multiple employer-sponsored health plans to obtain widespread
    corrections and relief impacting participants and beneficiaries of many
    plans across the service providers' books of business. These service
    provider investigations have focused on impermissible restrictions on
    medication assisted treatment (MAT) and exclusions of key services for
    autism and eating disorders, among other issues.
        From February 10, 2021, through June 30, 2022, EBSA requested
    comparative analyses for over 260 unique NQTLs across 97
    investigations. This far exceeded the 20 requests that the Secretary is
    required, by statute, to make each year (in addition to pursuing
    complaints received from the public).
        The comparative analyses EBSA has reviewed in response to these
    requests continue to lack sufficient information upon initial receipt.
    As of June 30, 2022, EBSA has issued insufficiency letters relating to
    182 NQTLs, identifying specific deficiencies in the comparative
    analyses and requesting additional information to remediate those
    deficiencies. In addition, EBSA has issued 54 initial determination
    letters citing plans/issuers for noncompliance related to 74 NQTLs (54
    unique NQTLs). As of June 30, 2022, EBSA has issued 2 final
    determinations of noncompliance.
        EBSA is prioritizing enforcement work on NQTLs impacting the
    adequacy of provider networks and impermissible exclusions of key MH/
    SUD treatments for conditions such as autism, eating disorders, and
    substance use disorder and addiction, while continuing to investigate
    NQTLs in the form of prior authorization and concurrent review
    requirements. EBSA will also continue to enforce MHPAEA's provisions
    related to annual and lifetime dollar limits, quantitative treatment
    limitations, financial requirements, disclosures, and coverage in all
    applicable classifications.
        The Office of the Solicitor (SOL) provides legal support for all
    aspects of the Department of Labor's work in enforcing MHPAEA. SOL
    heavily supports EBSA's MHPAEA efforts, which will increase in fiscal
    year 2023 and beyond. In addition to litigating enforcement actions as
    necessary, SOL advises on a wide range of projects, including related
    to regulatory and sub-regulatory initiatives and investigation and
    enforcement approaches. SOL has a substantial number of attorneys
    across the country working to support these efforts.
        This important and critical work advances the Department's
    commitment to serving the needs of the most vulnerable communities, as
    workers suffering from mental health and substance use disorder
    conditions are often economically and socially disadvantaged with
    limited resources to access and pay for care when benefits have been
    improperly denied or limited.
                          feca efforts to combat fraud
        Question. Recent reports estimate that more than 105,000 Americans,
    including more than 1,500 West Virginians, died from drug-related
    overdoses in the last year. This is the highest number ever recorded.
    West Virginia continues to have the highest rate of overdose deaths in
    the country with 90 deaths per 100,000 people. This is almost triple
    the national average of 31.5 deaths per 100,000 people. Fighting the
    drug epidemic is one of my highest priorities. The Department of
    Labor's Budget Request for fiscal year 2023 asks for $108.2 million to
    support the Office of the Inspector General. The Department notes this
    funding for the Office of the Inspector General will be used in part to
    continue oversight work on several ``key areas of risk.'' Specifically,
    the Budget Request notes this funding will be used to fight fraud
    against the Federal Employees' Compensation Act, or FECA, program, as a
    way to address the oversight crisis.
        How will fighting fraud in the FECA program help address the drug
    epidemic?
        Answer. Reducing fraud is a high priority in the FECA program.
    Fighting fraud is critically important to address the drug epidemic and
    prevent future epidemics by actively seeking out patterns of
    overprescribing and areas of potentially harmful prescribing practices
    before they become large scale problems.
        The FECA program utilizes a robust analytics platform to detect
    concerning trends from medical providers as well as anomalous billing
    patterns. The FECA program works closely with Inspectors General
    government-wide to support prosecution efforts. In order to keep pace
    with nefarious provider activity, the FECA program continues to detect
    new and emerging fraud schemes and to implement controls to curtail
    them. In fiscal year 2020, the FECA program's focus remained steadfast
    on fraudulent pharmaceutical practices by enforcing maximum quantities
    for certain prescriptions and drug kits. In fiscal year 2021, needed
    controls were placed on durable medical equipment rentals and platelet
    injection services. In fiscal year 2022, the program completed
    implementation of a pharmacy benefit manager (PBM) which provides
    additional tools to safeguard against opioid misuse and many other
    potentially harmful drug interactions.
        The Federal Government has statutory penalties for those who commit
    fraud within FECA's workers' compensation system. Pursuant to 18 U.S.C.
    Sec. 1347, it is a felony to engage in a scheme designed to defraud a
    Federal healthcare benefit program. Each violation can result in fines
    and up to 10 years imprisonment. The FECA program will continue to
    actively participate in ongoing auditing of medical billing, as well as
    work with the OIG and DOJ to fulfill its requirements to prosecute
    fraud and recoup illegal payments to stop fraudulent medical providers
    who contribute to the opioid drug epidemic.
        These and other collective policy controls and investments,
    beginning with those addressing compounded drugs in 2016, have had
    tremendous success in decreasing the use of opioids, including duration
    and dosage. Reducing fraud in the FECA program and addressing the
    opioid epidemic will remain a high priority of the Office of Workers'
    Compensation Programs.
        In addition, the following information was provided by the Office
    of Inspector General (OIG).
        Fraud, either by FECA medical providers or claimants, facilitates
    the drug epidemic through the illegal distribution of drugs that can
    increase or further addictions.
        The OIG currently has several Office of Workers' Compensation
    Programs (OWCP)-related reviews that focus on various fraud schemes
    involving opioids and other controlled substances including: the
    illegal prescription or distribution of controlled pain medications;
    illegal kickback schemes involving prescribers and pharmacies; and the
    unlawful distribution of controlled substances.
        In order to more timely detect fraud activity, the OIG is seeking
    data from OWCP and their contractors that captures digital information
    for each billing from the OWCP and their contractors. Early
    identification of anomalies in the data, specifically related to
    opioids, will allow the OIG to save taxpayer dollars and protect
    claimants by stopping fraud while it is happening, and illegal
    practices that lead to opioid misuse. This OIG function is independent
    from OWCP's programmatic responsibility to detect fraud and protect
    claimants. We are also working with the OWCP to gain access to these
    reports and findings of their contractors' fraud and analytics
    programs. This will enable the OIG to build on its own data analytic
    models and to identify potential fraud for further investigation.
        DOL's fiscal year 2023 budget request will allow the OIG to
    continue to focus investigative resources on OWCP fraud, particularly
    as it relates to provider fraud involving opioids and other controlled
    substances. Also, additional funding will enable us to thoroughly
    investigate those opioid matters referred to the OIG by the OWCP
    Program Integrity Unit.
        Question. What other initiatives can the Department undertake to
    help end the drug epidemic?
        Answer. The Department strongly supports the Office of the
    Inspector General's work in this area. In addition, the Department is
    addressing some of the root causes and is working to end the drug
    epidemic in various ways, both within the Department's authorities and
    by working with other agencies.
        DOL is committed to working with the Departments of Health and
    Human Services and Treasury (together, the Departments) to use their
    full statutory authority to support the Administration's response to
    address the nation's mental health and substance use disorder epidemics
    through enforcement of the Mental Health Parity and Addiction Equity
    Act (MHPAEA). MHPAEA facilitates access to treatment for substance use
    disorders by eliminating discriminatory restrictions in health coverage
    for substance use disorders (such as higher copayments, separate
    deductibles, lower annual visit limits) and other barriers placed on
    treatment (such as stricter preauthorization or medical necessity
    reviews). Under the Biden-Harris Administration, the Departments have
    committed to making mental health and substance use disorder parity a
    top enforcement priority. The Departments intend to issue additional
    rulemaking to further clarify MHPAEA's protections for individuals and
    the obligations it imposes on plans and issuers, to facilitate greater
    access to mental health and substance use disorder treatment.
        In the Office of Workers' Compensation Programs (OWCP), in addition
    to fighting fraud, the Federal Employees' Compensation Program (FECA)
    program also implemented a pharmacy benefit manager (PBM) in fiscal
    year 2022, which provides additional tools to safeguard against opioid
    misuse and many other potentially harmful drug interactions.
        Utilizing FECA's PBM, the FECA program has instituted thoughtful
    controls that allow up to a seven-day supply of an approved immediate
    release opioid prescription at a maximum of 90 MME (morphine milligram
    equivalents; the dosage strength) per day for claimants newly
    prescribed opioids, after which the provider must complete a prior
    authorization request to justify continued use. The prior authorization
    is reviewed by the PBM's pharmacists and other healthcare
    professionals, who will consider accepted conditions and surgeries,
    review medication profiles, assess drug-drug interactions and
    therapeutic duplications, assess the need for naloxone, and perform
    other clinical pharmacy checks to assist with optimizing prescribing
    based on nationally recognized guidelines as directed by the FECA
    program before approving continued opioid use.
        The Department will continue to build on existing initiatives to
    address the opioid epidemic and substance use disorder. After awarding
    six initial demonstration grants in 2018 to test innovative approaches,
    the Department has since awarded over $96 million to states, tribes,
    and local areas in response to the opioid crisis. These include 26
    National Health Emergency (NHE) Disaster Recovery Dislocated Worker
    Grants (DWGs) to states and tribal entities, including a grant of
    $10,000,000 to West Virginia, which was active July 1, 2019--June 30,
    2022. Currently, 21 grants remain active. The NHE Disaster Recovery
    DWGs 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 can
    immediately mitigate the impact of the crisis.
        In September 2020, the Department awarded $20 million in grant
    awards to pilot the Substance Use-Disorder Prevention that Promotes
    Opioid Recovery and Treatment (SUPPORT Act) grant. The SUPPORT Act
    grants were awarded to four States: Florida, Maryland, Ohio, and
    Wisconsin, and continue through 2024.
        The Department's Chief Evaluation Office conducted an
    implementation evaluation of the initial demonstration grantees, which
    it has since made available on its website and, in partnership with the
    Employment and Training Administration (ETA), shared broadly through
    webinars and conferences.\4\ The Department also continues to provide
    technical assistance, informed by its grants and the implementation
    evaluation, to share promising practices and information to assist
    States and local communities respond to the opioid epidemic and its
    impact on the workforce. This technical assistance includes an online
    community of practice, digital case studies from the evaluation, and a
    series of webinars from June--August 2022 on topics related to the role
    of the workforce system in serving individuals with substance use
    disorders, such as opioid use disorder in construction, recovery-
    friendly workplaces, peer recovery support careers, and training
    toolkits for serving individuals with substance use disorder.
    ---------------------------------------------------------------------------
        \4\ https://www.dol.gov/sites/dolgov/files/OASP/evaluation/pdf/
    NHE%20Opioid%20Final%20Report.pdf.
    ---------------------------------------------------------------------------
        Finally, the fiscal year 2023 President's Budget includes continued
    support for the areas listed above. It also includes resources within
    ETA for workforce training programs throughout the country, including a
    set-aside for workers in the Appalachian and the Lower Mississippi
    regions. Job Corps administers the Trainee Employment Assistance
    Program (TEAP) which includes counseling services and drug testing at
    Job Corps Centers. Additionally, the Department requests $100,000,000
    for economic revitalization and workforce training in communities
    impacted by changes in the energy industry through the POWER+
    Initiative. Expanding economic opportunities in these regions and
    throughout the country is a key component of addressing the opioid
    epidemic.
                   independent contractor rulemaking feedback
        Question. Earlier this month, the Department's Wage and Hour
    Division announced it would engage in rulemaking on whether a worker
    may be considered an independent contractor, or an employee. The rule
    the Department previously put together on this rule was delayed,
    withdrawn, then ultimately reviewed and decided by the courts. As part
    of its announcement, the Wage and Hour Division announced it would hold
    two public forums to hear feedback directly from both employers and
    workers. The public will also have an opportunity to provide comments
    on the rule once it is published in the Federal Register. While it is
    good the Department will consult with both employers and workers as it
    considers a new rule, it is important ensure that the Department fully
    engages with the small business owners and other employers that will be
    directly impacted by this rule.
        How does the Department plan to incorporate feedback from a wide
    array of stakeholders, from small businesses to workers?
        Answer. The Department has been engaging with a wide array of
    stakeholders on this topic since the beginning of this Administration.
    The Department worked with stakeholders to identify business owners and
    their representatives, employers, workers, and advocates, among others,
    to share their input about determining employee or independent
    contractor status for purposes of minimum wage and overtime pay
    protections under the Fair Labor Standards Act. We continued that
    engagement in widely announced public forums to provide opportunities
    for gathering additional input. During those forums, we heard from
    employers, workers, business owners-- including small business owners--
    advocates, freelance organizations, and others from across the country
    who provided valuable information. The Department appreciates the
    robust participation in these forums and took the views expressed
    during this outreach into consideration when drafting the proposal.
        On July 5, 2022, the Department transmitted a draft proposed rule
    on Employee or Independent Contractor Classification Under the Fair
    Labor Standards Act to the Office of Management and Budget (OMB) for
    review. The public will have the opportunity to review and comment
    after publication of any proposed rule in the Federal Register.
                    timeline for silica standard rulemaking
        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). As
    you are aware, in 2020 the U.S. Department of Labor's Office of
    Inspector General (OIG) produced a report that was critical of the Mine
    Safety and Health Administration's (MSHA) inadequate efforts to
    safeguard coal miners from crystalline silica exposure. That report
    found MSHA needed to update its regulations to: lower the legal
    exposure limit to silica, improve the ability of the agency to issue
    citations and fines for excess exposure to silica, and increase
    sampling protocols where were found to be too infrequent to protect
    miners adequately. While it is good MSHA announced actions last week to
    ramp up enforcement on silica exposure, more needs to be done.
        Last year your office informed my team that a Notice of Proposed
    Rulemaking on a Silica standard was scheduled for January 2022. It is
    now June and we have yet to see that proposal. When do you anticipate
    releasing the proposal?
        Answer. We are working hard to publish a Notice of Proposed
    Rulemaking (NPRM) as soon as possible and hope to issue one by the end
    of the year.
        Question. When do you anticipate finalizing that rule?
        Answer. In order to issue a final rule to better protect miners
    from health hazards related to exposure to respirable crystalline
    silica, MSHA must first complete its work and publish the proposed
    rule. At the close of the comment period, MSHA will go through all the
    necessary steps in the regulatory process--including reviewing and
    responding to stakeholder comments and feedback and holding public
    hearings--and include a projected publication date for the final rule
    in an appropriate future Unified Agenda of Regulatory and Deregulatory
    Actions.
        Assistant Secretary Williamson and MSHA are laser focused on the
    rise in cases of pneumoconiosis, including in parts of Appalachia where
    existing coal seams are thinner and layered in rock containing quartz.
    We know from investigative reporting by NPR and PBS, the National
    Institute for Occupational Safety and Health's (NIOSH) Coal Workers'
    Health Surveillance Program, and the works of other health experts that
    younger and less experienced miners are increasingly developing some
    form of pneumoconiosis, including the most severe forms of the disease.
    A growing number of experts and research point to respirable
    crystalline silica as the likely cause. Many metal and nonmetal miners
    also work in potentially dangerous mining environments where taking
    proper precautions to limit silica exposures are equally as important.
        In addition to working on an improved health rule, MSHA is taking
    action now under our existing authorities to better protect coal and
    metal and nonmetal miners' health by limiting their exposure to
    respirable crystalline silica. MSHA recently announced a silica
    enforcement initiative that has four primary components: inspections,
    sampling, compliance assistance, and miners' rights. Working together
    with the mining industry, MSHA can take important steps to better
    protect miners from overexposures to toxic levels of respirable dust
    now while the Agency continues to develop a new mandatory health
    standard for respirable crystalline silica. This effort will result in
    more inspections and sampling at mines with repeated silica
    overexposures and for occupations at coal and metal and nonmetal mines
    known to have a high risk of potential silica overexposures.
        Significant elements in the 2023 President's Budget request support
    for the silica enforcement initiative and the respirable crystalline
    silica rulemaking. The resources needed to support these efforts span
    multiple program areas and are presented relative to the 2022 Operating
    Plan:
      --In recent years, MSHA has focused its compliance and technical
            assistance efforts on reducing accidents caused by powered
            haulage equipment, which continue to be a leading cause of
            mining fatalities and serious injuries, and MSHA has increased
            the agency's emphasis on reducing health hazards in mines, such
            as respirable coal dust in coal mines, silica/quartz in mines,
            diesel particulate matter, and noise. The President's Budget
            requests an additional $34,046,000 in the Mine Safety and
            Enforcement program area for an additional 150 full time
            equivalents to continue the increase in health sampling and
            enforcement activities to ensure that miners' overexposure to
            respirable dust, quartz/silica, noise, and other health hazards
            are addressed by mine operators.
      --Compliance assistance, particularly to small operators, is provided
            through MSHA's Educational Policy and Development (EPD) program
            area. The Educational Field and Small Mine Services in EPD
            assists in the development or improvement of the health and
            safety programs of mine operators and contractors in the mining
            community. MSHA anticipates compliance assistance will play a
            key role in aiding operators who reach out for assistance in
            reducing silica overexposures. The President's Budget requests
            an additional $163,000 for training and compliance assistance.
      --The President's Budget includes an increase of $2,545,000 to the
            Office of Standards, Variances, and Regulations to support
            rulemaking activities, including publishing a proposed rule to
            protect miners' health from exposure to respirable crystalline
            silica. The proposal will address the control of respirable
            silica and the limit of permissible exposure. MSHA will
            consider the data and information gathered through working with
            NIOSH and mining stakeholders over the years and through a
            recent request for information, as well as any relevant
            information contained in the Occupational Safety and Health
            Administration's fiscal year 2016 final rule on respirable
            crystalline silica. Once the proposed rule is published, MSHA
            will hold public hearings to ensure that it receives feedback
            from miners and mine stakeholders across the U.S. As it
            develops the final rule, MSHA will review all public comments
            received through the comment period.
      --The Technical Support program area also plays a significant role in
            the silica initiative and the future implementation of the
            silica rule. The President's Budget requests a $2,315,000
            increase to the Technical Support budget activity to increase
            laboratory capacities to allow MSHA to handle an increase in
            sampling due to the silica enforcement initiative and the
            respirable crystalline silica health standard under
            development.
                         black lung disability 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 continuing to see a
    growing number of 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. Unfortunately, the 2021 rates expired on
    December 31, 2021, putting an indebted Trust Fund in a precarious
    financial situation.
        While Congress continues to work to find a path forward for Senator
    Manchin's bill that would extend the 2021 excise tax rate for 10 years,
    can we continue to count on the Department to protect and maintain
    these critical benefits?
        Answer. Yes, you and all miners and survivors who receive benefits
    under the Black Lung Benefits Act (BLBA) can continue to count on the
    Department of Labor to protect and maintain these critical benefits.
    The Department of Labor does not want miners already burdened with
    black lung disease or their families to feel uncertain about the
    future. The Department has made it clear that miners and their
    survivors will continue to receive their Federal black lung benefits.
    The Department is working hard to make sure that mining communities
    understand that the U.S. Treasury is required by law to provide the
    Trust Fund with sufficient money to pay all benefits due regardless of
    tax revenues.
        However, as you are aware, Congress intended that Federal black
    lung benefits primarily be paid by responsible coal mine operators, not
    the U.S. taxpayer. When coal excise tax shortfalls require the Federal
    black lung program to borrow from the U.S. Treasury to cover the cost
    of benefits, taxpayers are footing the bill, not the coal mining
    industry. Thus, the Department applauds Congress for permanently
    reinstating the coal excise tax rates of $1.10 per ton of underground-
    mined coal and 55 cents for surface-mined coal in the Inflation
    Reduction Act of 2022. Mining communities can rest assured that their
    benefits are not in jeopardy.
                                     ______

                    Questions Submitted by Senator Roy Blunt
               workforce opportunity for rural communities grants
        Question. The fiscal year 2018 LHHS bill began a $30 million set-
    aside from the Dislocated Worker Assistance National Reserve to provide
    employment assistance and workforce training to workers in the
    Appalachian and Lower Mississippi Delta regions, which increased to $45
    million in fiscal year 2022 and now includes the Northern Border
    Regional Commission. The fiscal year 2023 budget request includes $35
    million, and does not include the Northern Border Regional Commission
    in the set- aside. There have been three rounds of WORC grants awarded
    thus far; Missouri received more than $3.5 million in funding in the
    second grant round, but did not receive any funding in the first or
    third rounds.
        What is the application process for these grants, and how important
    is geographic diversity when making final award determinations?
        Answer. As in all competitive grants, the merit review and
    selection process for the Workforce Opportunity for Rural Communities
    (WORC) grant initiative is published within each year's Funding
    Opportunity Announcement (FOA). A technical merit review panel
    carefully evaluates applications against the selection criteria to
    determine the merit of applications. These criteria are based on the
    policy goals, priorities, and emphases set forth in the FOA. The final
    scores serve as the primary basis for selection of applications for
    funding, and the Grant Officer reserves the right to take into
    consideration other relevant factors when applicable, such as the
    geographic distribution of funds. The Employment and Training
    Administration (ETA) notes that each year we receive many high-quality,
    high-scoring applications, making the WORC funding opportunity highly
    competitive. Available Federal funding determines the number of grants
    that can be awarded each year under the WORC competition. Complete
    information regarding the WORC grant initiative, including awards
    funded in Rounds 1--3, is available at https://www.dol.gov/agencies/
    eta/dislocated-workers/grants/workforce-opportunity.\5\
    ---------------------------------------------------------------------------
        \5\ https://www.dol.gov/agencies/eta/dislocated-workers/grants/
    workforce-opportunity.
    ---------------------------------------------------------------------------
        The FOA for WORC contains all the information and links to forms
    needed to apply for grant funding and is published at www.Grants.gov
    and https://www.doleta.gov/grants/find_grants.cfm.\6\ At each of the
    links below for WORC Rounds 1--3, see the ``Related Documents'' tab for
    the published FOA:
    ---------------------------------------------------------------------------
        \6\ https://www.doleta.gov/grants/find_grants.cfm.
    ---------------------------------------------------------------------------
      --WORC 1: FOA-ETA-19-08 \7\
    ---------------------------------------------------------------------------
        \7\ https://www.grants.gov/web/grants/view-
    opportunity.html?oppId=315986.
    ---------------------------------------------------------------------------
      --WORC 2: FOA-ETA-20-04 \8\
    ---------------------------------------------------------------------------
        \8\ https://www.grants.gov/web/grants/view-
    opportunity.html?oppId=326678.
    ---------------------------------------------------------------------------
      --WORC 3: FOA-ETA-21-08 \9\
    ---------------------------------------------------------------------------
        \9\ https://www.grants.gov/web/grants/view-
    opportunity.html?oppId=333025.
    ---------------------------------------------------------------------------
        ETA also notes that the fiscal year 2023 Budget baseline and
    discretionary funding decisions were finalized before Congress
    completed its work on fiscal year 2022 appropriations in March,
    including the addition of the Northern Border Region as an eligible
    region for WORC grants. The Administration has committed to working
    with Congress going forward to adjust recommendations for fiscal year
    2023 appropriations where relevant.
        Question. Is the Department working with the Delta Regional
    Authority to provide technical assistance to ensure that entities
    applying have the necessary information and assistance to write the
    best grant application possible?
        Answer. Yes. ETA supports the Delta Regional Authority (DRA) and
    potential applicants in several ways. First, ETA transfers funding each
    year to DRA in order to host direct technical assistance sessions for
    potential applicants, which includes help with understanding the
    requirements of the WORC program and how applicants can best develop
    applications that can be competitive for funding. While DRA plans and
    hosts these events, ETA provides support for specific issue areas
    including grant requirements and performance reporting. ETA regional
    offices regularly share potential grant opportunities with local
    networks and provide technical assistance to grantees during the period
    of performance.
        Second, ETA--in partnership with both the Appalachian Regional
    Commission (ARC) and DRA--hosts an annual web-based technical
    assistance session that covers the requirements of the WORC program for
    that particular funding year and discusses the application
    requirements. For the 4th round of WORC this technical assistance
    webinar was held on May 23 for eligible applicants from both the
    Appalachian and Delta regions.
                      independent contractor proposed rule
        Question. The Department recently announced it is developing a new
    proposed independent contractor rule on determining employee or
    independent contractor status under the Fair Labor Standards Act. The
    Department held forums in June to hear from stakeholders from those who
    might be affected my employee or independent contractor classification.
    We need to ensure that our small businesses and relevant stakeholder
    industries have a seat at the table as the Department goes through the
    rulemaking process.
        What are your plans to ensure that a new rulemaking won't adversely
    impact small businesses or the broader economy?
        Answer. The Department has been engaging with a wide array of
    stakeholders on this topic since the beginning of this Administration.
    The Department worked with stakeholders to identify business owners and
    their representatives, employers, workers, and advocates, among others,
    to share their input about determining employee or independent
    contractor status for purposes of minimum wage and overtime pay
    protections under the Fair Labor Standards Act. We continued that
    engagement in widely announced public forums to provide opportunities
    for gathering additional input. During those forums, we heard from
    employers, workers, business owners--including small business owners--
    advocates, freelance organizations, and others from across the country
    who provided valuable information. The Department appreciates the
    robust participation in these forums and took the views expressed
    during this outreach into consideration when drafting the proposal.
        On July 5, 2022, the Department transmitted a draft proposed rule
    on Employee or Independent Contractor Classification Under the Fair
    Labor Standards Act to OMB for review. The public will have the
    opportunity to review and comment after publication of any proposed
    rule in the Federal Register.
        Question. What is your timeframe with respect to this rulemaking?
        Answer. On July 5, 2022, the Department transmitted a draft
    proposed rule on Employee or Independent Contractor Classification
    Under the Fair Labor Standards Act to OMB for review. The public will
    have the opportunity to review and comment after publication of any
    proposed rule in the Federal Register.
               proposed prohibited transaction exemption changes
        Question. I am concerned about the proposed regulations to change
    the procedures governing prohibited transaction exemptions. The
    proposal includes eliminating the ability to discuss an exemption with
    the Department prior to officially requesting one, as well as
    redefining ``independent fiduciary'' as someone who has never
    previously received funds, and will not receive funds, for performing
    independent fiduciary services. As part of the creation of the
    exemption process, Congress explicitly required that any exemption
    granted must provide a benefit to all parties involved.
        Will these proposed regulatory changes effectively eliminate the
    exemption process?
        Answer. On March 15, 2022, the Department published a proposed rule
    that, if adopted, would supersede the existing procedure governing the
    filing and processing of applications for administrative exemptions
    from the prohibited transaction provisions of the Employee Retirement
    Income Security Act of 1974 (ERISA), the Internal Revenue Code of 1986,
    and the Federal Employees' Retirement System Act of 1986 (FERSA). The
    rule proposes to update the Department's prohibited transaction
    exemption procedures, which the Department updated most recently in
    2011.
        The proposed rule would create more clarity, certainty, and
    transparency around the exemption application process. In doing so, it
    would promote the Department's prompt and efficient consideration of
    all exemption applications by, among other things: (1) clarifying the
    types of information and documentation required for a complete
    application; (2) revising the definitions of a qualified independent
    fiduciary and qualified independent appraiser in order to ensure their
    independence; (3) clarifying the content of specific reports and
    documents applicants must submit in order to ensure that the Department
    receives sufficient information to make the requisite findings under
    ERISA Section 408(a) to issue an exemption; (4) updating various timing
    requirements to ensure clarity in the application review process; (5)
    specifying items that are included in the administrative record for an
    application and when the administrative record is available for public
    inspection; and (6) expanding opportunities for applicants to submit
    information to the Department electronically.
        The public comment period for the rule has closed, and the
    Department is carefully reviewing the 29 comments that it received. The
    Department will use these comments to inform any revisions it makes to
    the proposal at the final rulemaking stage.
                                     ______

                   Questions Submitted by Senator Mike Braun
                     coastwide labor contract negotiations
        Question. Secretary Walsh, the International Longshore and
    Warehouse Union (ILWU) and the Pacific Maritime Association (PMA) are
    currently negotiating a new coastwide labor contract that will cover
    all 29 West Coast ports. The current contract is set to expire on July
    1. As we have seen from previous negotiations, it is unlikely that the
    parties will reach a new agreement before July. Previous negotiations
    have witnessed significant disruption issues which have negatively
    impacted the economy.
        What is the administration doing to ensure that the parties remain
    at the table, negotiate in good faith and don't engage in any kind of
    disruptive activity?
        Answer. We need to acknowledge that collective bargaining is a
    process in which the parties to the negotiation work out the terms and
    conditions of employment. In this case, the best role for government is
    to encourage the parties to commit themselves fully to collective
    bargaining that reaches an agreement. That's what this Administration
    is doing.
        As the Administration's point person on the negotiation, I have
    been in touch with the parties for months and have met with and talked
    to the various players--the ports, retailers, shippers, trucking
    companies, and unions--to get a sense of the issues relating to the
    supply chain.
        As you note, the current collective bargaining agreement expired on
    July 1, but the parties are still at the table making progress and have
    expressed their commitment to the bargaining process. In fact, on July
    26, the ILWU and PMA announced that they had reached a tentative
    agreement on terms for health benefits--a promising step. Meanwhile,
    cargo is still moving through the ports, and in fact, the Port of LA
    reached another record in June.
        The fact that the parties are still bargaining past the expiration
    date of their contract is not unusual--in fact, it is typical for their
    negotiations. I am in regular touch with the parties to support them in
    this process, and we feel positive about the parties reaching an
    agreement.
        Question. With all of the ongoing supply chain challenges we are
    facing, which is a significant cause of record inflation, how concerned
    is the administration about the potential for disruptions to cause
    further supply chain challenges? [Question background]
        Answer. The administration is very attuned to the potential impact
    of these major negotiations on supply chains. The port negotiations are
    not going to solve our supply chain challenges, which pre-date and are
    far larger than these negotiations. That said, we are working to
    support the parties in this collective bargaining process to help them
    reach an agreement, and we feel positive about the parties reaching an
    agreement.
               rulemaking for determining independent contractors
        Question. Independent Contractor Rules under the Fair Labor
    Standards Act (FLSA)--Recently, the Labor Department announced its
    intention to overturn workable, modernized rule that clarify whether
    certain workers are independent contractors or employees. Under the
    current rules, the Labor Department make the independent contractor vs.
    employee determination based on two main factors: the nature and degree
    of the worker's control over the work and the worker's opportunity for
    profit or loss based on initiative or investment. I've heard from many
    constituents that they like the flexibility of being an independent
    contractor.
        How does the Department plan to address this issue? Will you impose
    the so- called ``ABC Test'' which failed so spectacularly in
    California?
        Answer. On July 5, 2022, the Department transmitted a draft
    proposed rule on Employee or Independent Contractor Classification
    Under the Fair Labor Standards Act to the Office of Management and
    Budget (OMB) for review. The public will have the opportunity to review
    and comment after publication of any proposed rule.
        Because the Department is currently engaged in rulemaking and the
    proposed rule has been submitted to OMB for review, the Department
    cannot discuss the contents of the proposed rule at this time.
        Question. Do you believe the only way to implement an ``ABC'' style
    test would be through regulation?
        Answer. The Administration is committed to ending the abusive
    practice of misclassifying employees as independent contractors, which
    deprives these workers of critical protections and benefits. In
    addition to including funding in the Budget for stronger enforcement,
    the Administration intends to work with the Congress to develop
    comprehensive legislation to strengthen and extend protections against
    misclassification across appropriate Federal statutes. The President
    strongly endorses a comprehensive approach to ending the unlawful
    practice of misclassification and holding violators accountable. He has
    called on Congress to develop legislation to adopt the ABC test and
    create substantive violations for misclassifying workers across
    appropriate statutes, including the Fair Labor Standards Act and the
    Family and Medical Leave Act.
                          the joint employer standard
        Question. Joint Employer Standard under the FLSA--I have many small
    business franchise owners in my state. They provide employment
    opportunities to my constituents and serve the public in their
    respective communities. These franchise owners need a clear and
    workable joint employer standard. Businesses simply should not be
    liable for other businesses out of their control. The Administration
    has already begun to regulate on the issue of joint employment.
        Can you describe for the Committee the Administration plans for
    this area?
        Answer. On July 30, 2021, the Wage and Hour Division (WHD) issued a
    final rule rescinding the prior administration's Joint Employer Under
    the Fair Labor Standards Act rule because it introduced an unduly
    narrow standard that had been invalidated by a U.S. District Court for
    the Southern District of New York. That rescission took effect on
    October 5, 2021.
        WHD continues to apply applicable caselaw for determining joint
    employment under the FLSA. WHD pursues joint employer liability in
    appropriate cases where an employment relationship exists between the
    worker and the employer in order to ensure that workers receive the
    wages that are owed to them.
                     white collar overtime salary threshold
        Question. White Collar Overtime Salary Threshold--The Department
    has begun taking comment on the minimum threshold at which an employee
    is exempt from overtime protections. The Obama Administration issued a
    rule on this threshold, but it was struck down by a Federal court. If
    the Labor Department sets that threshold too high, I fear it could
    hinder employers seeking to fill middle-management positions.
        As you move forward with these new regulations, how will you
    determine where the threshold should be?
        Answer. The Fair Labor Standards Act (FLSA) exempts from overtime
    and minimum wage pay protections bona fide executive, administrative,
    and professional employees who meet certain requirements, including a
    salary level test. These exemptions are often called the ``white-
    collar'' exemptions. The current salary threshold is $684 per week, the
    equivalent of an annual salary of $35,568.
        The Department has committed to updating the salary level more
    frequently, and the Department of Labor's Wage and Hour Division
    previously announced that it plans to update the regulations that
    implement the FLSA's minimum wage and overtime exemptions for bona fide
    executive, administrative, and professional employees.
        This spring, the Department held a series of listening sessions
    across the country to hear diverse views of participants on possible
    revisions to the regulations, as we did prior to issuing proposed
    updates to these regulations in the past two administrations. This
    series of listening sessions is important as we review the white-collar
    exemption regulations. At this time, no proposed rule has been issued.
    Once a proposed rule is published in the Federal Register, there will
    be a notice and comment period allowing all interested parties an
    opportunity to review the proposal and provide formal written comments.
                        employer injury and illness data
        Question. The Occupational Safety & Health Administration has
    announced plans to force employers to submit injury and illness data to
    OSHA's Washington headquarters. OSHA plans to then publicize the data.
    Obviously, this could result in breach of confidentiality of workers'
    personal health information.
        What procedures are you planning to ensure that this will not
    occur? Will you take measures to ensure employers' confidential
    information will not be released?
        Answer. OSHA has preliminarily determined that the proposed data
    collection would adequately protect information that reasonably
    identifies individuals directly. For example, OSHA would not require
    employers to submit information from the recordkeeping forms that
    directly identifies an employee, such as an employee's name or Social
    Security Number. Further, OSHA plans to use the latest automated
    information technology to detect and remove information that reasonably
    identifies individuals directly before submitted information is posted
    online. This privacy scrubbing technology is capable of de-identifying
    certain information that reasonably identifies individuals directly
    (such as name, phone number, email address, etc.) that may be
    inadvertently submitted by employers to the system.
        OSHA does not intend to release any confidential employer
    information. Similar to current electronic submission requirements, the
    proposed rule would not require employers to submit their confidential
    information to OSHA.
        Question. Further, what usefulness will this information have to
    anyone? Is the Department's real goal to give this information to labor
    unions who will use this data to access workers' private information,
    foster support for their organizing efforts, and/or pressure employers
    in negotiations?
        Answer. OSHA intends to use the injury/illness case-specific data:
      --To support OSHA's statutory directive to ``assure so far as
            possible every working man and woman in the Nation safe and
            healthful working conditions and to preserve our human
            resources'' (29 U.S.C. 651(b)) ``by providing for appropriate
            reporting procedures with respect to occupational safety and
            health which procedures will help achieve the objectives of
            this Act and accurately describe the nature of the occupational
            safety and health problem'' (29 U.S.C. 651(b)(12)).
      --To help identify workplaces where workers are most at risk from
            specific hazards in order to assist OSHA in better targeting
            enforcement and compliance assistance resources.
      --To provide information that supports evaluation of OSHA's existing
            programs and development of new programs.
      --To make information available to all of the stakeholders in
            workplace health and safety, including employers, workers and
            prospective workers, customers and prospective customers,
            occupational safety and health professionals, and researchers
            so that they can better understand the nature of injuries and
            illnesses within industries, identify solutions for preventing
            these injuries, and make more informed decisions.
                  mental health parity requirement enforcement
        Question. DOL has championed civil monetary penalties to enforce
    mental health parity requirements. Unfortunately, employers are
    reporting that compliance guidance is lacking in this area.
        Mr. Secretary, will you commit to providing adequate guidance
    before assessing penalties upon employers?
        Answer. DOL, along with the Departments of Health and Human
    Services and the Treasury (together, the Departments), has issued
    multiple rounds of guidance for group health plans, health insurance
    issuers, and other stakeholders to facilitate the implementation and
    enforcement of the Mental Health Parity and Addiction Equity Act of
    2008 (MHPAEA), including 15 sets of FAQs with 96 questions, 7
    enforcement fact sheets, 6 compliance assistance tools and templates, 6
    reports to Congress, 6 press releases, and 7 publications. In addition,
    the Departments regularly conduct outreach initiatives to improve the
    understanding of MHPAEA among stakeholders, state regulators, and
    others, through annual webcasts, in-person seminars, and nationwide
    compliance assistance events. In addition to these initiatives, DOL
    provides informal compliance assistance to stakeholders on an ongoing
    basis, regularly assisting plans, issuers, and other stakeholders who
    contact DOL with compliance questions.
        As part of the Departments' ongoing efforts regarding mental health
    and substance use disorder parity, DOL maintains a compliance program
    guidance document entitled the MHPAEA Self-Compliance Tool, which is
    intended to help plans and issuers, state regulators, and other parties
    comply with MHPAEA. Section 13001(a) of the 21st Century Cures Act
    added section 2726(a)(6) of the Public Health Service Act, which
    directs the Departments to provide a publicly available compliance
    program guidance document that is updated every 2 years, and the
    Department has used its MHPAEA Self-Compliance Tool as the mechanism to
    fulfill this requirement. The most recent MHPAEA Self-Compliance Tool,
    issued in 2020, includes a process for conducting non-quantitative
    treatment limitations (NQTL) comparative analyses, a list of the types
    of documents and information that a plan or issuer should have
    available to support its analyses, and illustrations of specific fact
    patterns to aid in compliance.
        Moreover, the Departments issue subregulatory guidance on an
    ongoing basis to ensure that the regulated community has the guidance
    it needs to comply with MHPAEA. Most recently, on April 2, 2021, the
    Departments issued FAQs about Mental Health and Substance Use Disorder
    Parity Implementation and the Consolidated Appropriations Act, 2021
    Part 45 (FAQs Part 45) to provide guidance on the amendments to MHPAEA
    made by the Consolidated Appropriations Act, 2021 (CAA) and to promote
    compliance by plans and issuers. FAQs Part 45 describes the information
    that must be included in a sufficient NQTL comparative analysis, and
    notes that a comparative analysis that consists of conclusory or
    generalized statements, without specific supporting evidence and
    detailed explanations, or the production of a large volume of documents
    without a clear explanation of how and why each document is relevant to
    the comparative analysis, is insufficient. The FAQs also provide
    guidance as to the types of documents that plans and issuers should be
    prepared to make available to support the analysis and conclusions
    reached in their comparative analyses.
        In addition to FAQs Part 45, the Departments issued the 2022 MHPAEA
    Report to Congress in January 2022, highlighting notable compliance
    assistance efforts, including stakeholder outreach, webinars, and
    guidance for the regulated community. The Departments are working to
    issue another Report to Congress as required under Section 203 of Title
    II of Division BB of the CAA on enforcement efforts related to NQTL
    comparative analyses. Additionally, the Employee Benefits Security
    Administration expects to update its MHPAEA Self-Compliance Tool again
    in 2022.
        As explained in the 2022 MHPAEA Report to Congress, the
    Departments' enforcement efforts are and will continue to be informed
    by stakeholder feedback. Accordingly, in the Spring 2022 Unified
    Regulatory Agenda, the Departments announced their intent to issue
    notice and comment rulemaking to consider what amendments to MHPAEA's
    implementing regulations are warranted, in light of their experience
    enforcing the law as well as the subsequent amendments made to MHPAEA.
    The Departments look forward to additional stakeholder feedback on
    MHPAEA through comments received in response to this future rulemaking.
                       tree care industry osha standards
        Question. Many of my constituents in the Tree Care Industry are
    eager to see OSHA issue a standard that clarifies and codifies safe
    work practices for tree care operations. My understanding is the
    Federal Government currently regulates the tree care industry with a
    mishmash of standards intended for other industries and this has
    created confusion for enforcement officers, tree care companies and
    clients and workers. The industry has been pushing OSHA to address the
    problem for more than two decades. Some States have acted and issued
    tree care specific standards, but OSHA has been slow to do so as it
    pursues other priorities, most of which do not enjoy the same level of
    support. The Fall 2021 regulatory agenda listed June as the target date
    for a proposed standard.
        Will OSHA meet this target date and if not, when do you anticipate
    OSHA will issue the proposed standard?
        Answer. OSHA's standard-setting process is a long process that
    includes a multitude of procedural and legal requirements, as well as
    OSHA's evidentiary requirements and public participation. OSHA began
    working on a Tree Care Operations standard in 2008, with the
    publication of an Advanced Notice of Proposed Rulemaking (ANPRM). This
    document provided much background and gave stakeholders the opportunity
    to answer questions on work procedures, costs, and their experience
    with safety and health in the tree care industry. In 2016, OSHA
    continued with the rulemaking process and held a stakeholder meeting.
    In May 2020, OSHA completed the Small Business Advocacy Review (SBAR)
    Panel, a required step to obtain early input from small business
    representatives. These phases are crucial for OSHA to develop a
    complete and robust standard to protect all employees performing tree
    care. Transcripts and reports from the previous phases of rulemaking
    can be found on the OSHA website: Tree Care Operations Rulemaking.\10\
    ---------------------------------------------------------------------------
        \10\ https://www.osha.gov/tree-care/rulemaking.
    ---------------------------------------------------------------------------
        Due to pressing nature of the COVID-19 pandemic, since the
    beginning of this Administration, OSHA has focused its attention on
    COVID-19 Healthcare rulemaking--in addition to Heat Illness Prevention
    rulemaking. As a result, OSHA will not meet the target date of June
    2022 for the development of a rule for Tree Care Operations. OSHA is
    reevaluating the timeframe for rulemaking and anticipates publishing a
    proposed rule for Tree Care Operations in fiscal year 2023. The
    rulemaking team participates in monthly American National Standards for
    Arboricultural Operations--Safety Requirements (ANSI Z133) meetings
    with the tree care industry and has held several meetings with the Tree
    Care Industry Association (TCIA) providing updates as appropriate. OSHA
    also provides robust guidance for the industry on its Tree Care
    Industry Safety and Health Topics Page.\11\ Tree Care Operations
    rulemaking is a priority, and the Agency is consistently working
    towards a published proposed rule.
    ---------------------------------------------------------------------------
        \11\ https://www.osha.gov/tree-care.
    ---------------------------------------------------------------------------

                             CONCLUSION OF HEARINGS

        Senator Murray. This subcommittee is adjourned.
        [Whereupon, at 10:54 a.m., Wednesday, June 15, 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 2023

                                  ----------

                                           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 160 public television licensees,
    collectively operating 336 public television stations serving nearly 97
    percent of the American people, we appreciate the opportunity to submit
    testimony for the record on the importance of Federal funding for local
    public television stations and PBS. We urge the subcommittee to support
    $565 million in 2-year advance funding for the Corporation for Public
    Broadcasting (CPB) in FY 2025, $60 million for the Public Broadcasting
    Interconnection System in FY 2023 and $30.5 million for the Ready To
    Learn program at the Department of Education in FY 2023.
                     corporation for public broadcasting:
                  $565 million (fy 2025) 2-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 been critical during the COVID-19
    pandemic, as local public television stations in all 50 States have
    provided enhanced educational services and content to help support
    students, families, teachers, and schools throughout this challenging
    time.
        Federal funding for CPB, which enjoys the overwhelming support of
    the American people, is essential to making these services available to
    all Americans, including those in rural and underserved areas. 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 has increased
    the forward funded CPB appropriation in each of the last 3 years.
        While public broadcasting is grateful for these increases, the FY
    2024 enacted funding level of $525 million still leaves the public
    broadcasting system about $55 million, in inflation-adjusted dollars,
    behind where the system was 11 years ago. This shortfall continues to
    present a serious challenge at a time when the system 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.
        In addition, local stations are facing a growing backlog of over
    $300 million worth of infrastructure improvements we need but cannot
    afford to fund since the Public Telecommunications Facilities Program
    (PTFP) was defunded in FY 2011. The longer these improvements are not
    addressed, the more they threaten local stations' reliable broadcast
    services and public service missions.
        At the same time, public television stations are eager to make the
    transition to the new NEXT GEN TV broadcast standard, with its
    transformative potential for enhanced public service in telehealth,
    Smart Cities connections, precision agriculture, national security
    applications as well as remote learning and public safety
    communications. This transition will cost our system an additional $400
    million.
        Public broadcasting respectfully requests that Congress take
    another substantial step toward securing our current and future public
    service goals in the FY 2023 appropriations process.
        The $565 million that public broadcasting is requesting in FY 2023
    for FY 2025 will help restore lost purchasing power and help local
    stations begin to replace aging infrastructure, invest in new
    technology, and invent a 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 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.
        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,
    Smithsonian Institution, NASA and other high-quality sources.
        Additionally, local public television stations throughout the
    country have partnered with PBS to bring a first-of-its kind, free PBS
    KIDS 24/7 broadcast 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.
    During the COVID-19 pandemic, many stations have used 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, 13.5 million kids ages 2-8
    watched PBS KIDS content. Parents also looked to public television for
    educational resources, with PBS Parents users increasing by 80 percent
    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 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. Throughout the pandemic,
    public television has provided 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 19th year in a row, PBS was ranked the most trusted among
    national media institutions. That trust is more important than ever.
    Americans tune into their local public television station or view their
    online resources for trusted information that can 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 3 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 fiscal
    Year2025 is 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 2-year advance funding to raise State,
    local and private funds, ensuring the continuation of this strong
    public-private partnership. These Federal funds act as the seed money
    for fundraising efforts at every local station, no matter its size.
    Advance funding also benefits the partnership between States and
    stations since many States operate on 2-year budget cycles.
        Finally, the 2-year advance funding mechanism gives stations and
    producers, both local and national, the critical lead time needed to
    raise the additional funds necessary to sustain effective partnerships
    with local community organizations and engage them around high-quality,
    award-winning programs. Producers and directors like Ken Burns, Henry
    Louis Gates, Jr., Jamila Wignot, Stanley Nelson and others spend years
    developing programs like The Vietnam War, Country Music, Ben Franklin,
    Rita Moreno: Just a Girl Who Decided to Go For It, Amy Tan: Unintended
    Memoir, Asian Americans, Reconstruction: America after the Civil War, ,
    African Americans: Many Rivers to Cross and upcoming documentaries like
    The U.S. and the Holocaust, Becoming Frederick Douglass and Harriet
    Tubman: Visions Of Freedom. It would be impossible to produce this in-
    depth programming and the curriculum-aligned educational materials that
    accompany it without the 2-year advance funding.
                public broadcasting interconnection: $60 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 based on
    rapid advances in technology. In addition, to the interconnection
    system, this account also provides funding for other technologies and
    services that create infrastructure and efficiencies within the public
    media system.
        Public television is requesting $60 million for interconnection in
    fiscal Year2023 to support continued investments in the public
    television and radio interconnection systems and new shared
    technologies and services including: cybersecurity; data analytics and
    business intelligence; single sign on service, a content management
    system and a content delivery network.
        This funding request would help build out a suite of interoperable
    digital platforms and solutions which would effectively and efficiently
    help stations meet the growing and dynamic needs of digital audiences.
    This investment would help ensure that every public television and
    radio station, regardless of size or location, can provide its
    community with critical services and content on modern technology and
    platforms, meeting Americans where they are.
            ready to learn: $30.5 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 the RTL grant, CPB and PBS have delivered evidence-based,
    innovative, high-quality content to improve the math, science, and
    literacy skills of high-need children. CPB, PBS, and local stations
    have ensured that the kids and families most in need have access to
    these groundbreaking and proven effective educational resources. In
    addition to children, this outreach helps empower caregivers to 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.
        The current CPB and PBS RTL grant partnership is a 5-year
    comprehensive, learning and engagement initiative called ``Learn
    Together: Connecting Children's Media and Learning Environments to
    Build Key Skills for Success.'' CPB and PBS are creating dynamic, new
    learning experiences produced by diverse media makers that will expose
    young children to career and workforce opportunities; helping them
    build vital functional literacy, critical and computational thinking,
    collaboration, and ``World of Work'' skills and knowledge.
    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 3 months.\1\
    ---------------------------------------------------------------------------
        \1\ Kennedy, J. L., Christensen, C., Maxon, T., Gerard, S., Garcia,
    E., Hupert, N., Vahey, P., & Pasnik, S. (2021).
    ---------------------------------------------------------------------------
      --Ready To Learn-funded resources from the PBS KIDS series The Cat in
            the Hat Knows a Lot About That! increased science learning in
            children from low-income households and had a positive impact
            on children's understanding of core physical science concepts
            of matter and forces--equivalent to the difference in science
            knowledge an early elementary student develops over 5
            months.\2\
    ---------------------------------------------------------------------------
        \2\ (Grindal, T., Silander, M., Gerard, S., Maxon, T., Garcia, E.,
    Hupert, N., Vahey, P., Pasnik, S. (2019). Early Science and
    Engineering: The Impact of The Cat in the Hat Knows a Lot About That!
    on Learning. New York, NY, & Menlo Park, CA: Education Development
    Center, Inc., & SRI International.)
    ---------------------------------------------------------------------------
    An Excellent Investment
        In addition to being research-based and teacher tested, RTL also
    provides excellent value for our Federal dollars. In the last 5-year
    grant round, public broadcasting leveraged an additional $50 million in
    non-Federal funding to augment the $73 million investment by the
    Department of Education. RTL exemplifies how the public-private
    partnership that is public broadcasting can change lives for the
    better.
        A funding level of $30.5 million is requested in FY 2023 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 5 years and supported through annual
    appropriations. Funding in fiscal Year2023 would provide the fourth
    year of funding in the latest grant round. Providing $30.5 million for
    Ready to Learn in FY 2023 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
    percent of U.S. households, and it is CPB funding that makes this
    possible.
        For all of these reasons we request that Congress continue its
    commitment to the highly successful, hugely popular public-private
    partnership that is public broadcasting by providing $565 million in FY
    2025 for CPB in addition to $60 million in FY 2023 for public
    broadcasting's interconnection system and $30.5 million in FY 2023 for
    the Ready To Learn Program.

                           NONDEPARTMENTAL WITNESSES

     Prepared Statement of the Academy for Radiology & Biomedical Imaging
                                    Research
        Chair Murray, Ranking Member Blunt, 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 comprised of more than 200 academic
    research departments, patient advocacy groups, industry partners, and
    imaging societies, representing thousands of radiologists and
    researchers in all 50 States. We are 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 at least $49.048 billion for the National
    Institutes of Health's base appropriation. This figure represents an
    increase of $3.5 billion over FY2022 plus the release of the 21st
    Century Cures funds. The Academy also supports a proportional increase
    to the National Institute of Biomedical Imaging and Bioengineering
    (NIBIB), resulting in at least $458.5 million for FY2023--a $33.6
    million increase over the FY2022 enacted level. Further, should the
    Advanced Research Projects Agency for Health (ARPA-H) or pandemic
    preparedness efforts progress, funding should be designated separately
    from NIH's base and should supplement, not supplant, investment in
    basic research. While the Academy is supportive of ARPA-H and pandemic
    preparedness, and acknowledges they hold significant and exciting
    potential, investigator-initiated research is the foundation of basic
    science.
    ---------------------------------------------------------------------------
        \1\ https://www.acadrad.org/about-the-academy/.
    ---------------------------------------------------------------------------
        Moreover, Congress must work to ensure Federal appropriations are
    enacted on time to avoid disruptive interruptions to the research
    continuum. We must avoid relying on continuing resolutions, which are
    insufficient to meet evolving needs. At the end of FY2021 and beginning
    of FY2022, we received many examples of research left unpursued because
    funding was not available because of reliance on continuing
    resolutions. Delaying otherwise meritorious research only serves to
    further extend the time until we make lifesaving discoveries that help
    patients fighting deadly and debilitating diseases. Through consistent,
    robust funding for NIH and our National research infrastructure, we can
    continue to make advancements that will improve the lives of patients.
    The Academy is extremely grateful for the subcommittee's long-running
    support of NIH and encourages you to prioritize NIH for consistent and
    dependable funding levels for biomedical research, radiology, and
    imaging science.
               imaging advancements and innovations help patients
        Imaging serves as a necessary diagnostic tool that researchers and
    clinicians of all types use to help advance our understanding of
    biology and to develop and deliver treatments. This is particularly
    evident in the research examples provided below and through discussions
    about ARPA-H. A review of the past ARPA-H listening sessions and
    discussions with Congressional offices shows the value of improved
    imaging and diagnostics in support of a spectrum of biomedical research
    advances--resulting in direct benefits to patients. By improving our
    imaging tools and techniques, we broaden the resources available to
    address many challenging medical 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 to improve the diagnosis and treatment of multiple cancer
    types, including breast, prostate, and pancreatic. Imaging research
    serves many purposes and can significantly improve patient outcomes.
        Basic science advancements translate into a variety of clinical
    applications benefitting patients. Included below are examples of
    imaging applications to the Covid-19 pandemic, leveraging innovative,
    artificial intelligence technologies, and detecting and treating
    diverse types of cancer.
    Detecting Covid-19 Quickly and Easily: From 0 to 1 billion+
        Launched in April 2020 and led by the National Institute of
    Biomedical Imaging and Bioengineering, the Rapid Acceleration of
    Diagnostics (RADx)-Tech program has been instrumental in the Nation's
    Covid-19 testing strategy and response.\2\ This Congressionally
    supported program utilizes a competitive system to funnel the best
    ideas quickly toward implementation. In short, RADx-Tech accelerated
    the development and availability of Covid-19 tests. In September 2020,
    there were limited testing options, accounting for fewer than 700,000
    Covid-19 tests per day for laboratory and point of care use. As of
    February 2022--less than 18 months later-there were 41 FDA-approved
    tests, including at-home, point of care, and laboratory options,
    resulting in over 1.8 billion tests produced cumulatively. That same
    month, over 5.6 million tests per day were manufactured--over 168
    million in total for the month.\3\ These tests contributed directly to
    our understanding of a devasting pandemic and put tools directly into
    patient's hands. When coupled with strong support from policymakers,
    the funneling pipeline used by NIBIB can accelerate extraordinary
    advancements.
    ---------------------------------------------------------------------------
        \2\ https://www.nibib.nih.gov/covid-19/radx-tech-program.
        \3\ https://www.nibib.nih.gov/covid-19/radx-tech-program/radx-tech-
    dashboard.
    ---------------------------------------------------------------------------
    Machine Learning Technology Improves Diagnostic Imaging and Patient
            Outcomes
        Applying artificial intelligence and machine learning tools to the
    imaging space continues to improve our diagnostic capabilities. In my
    testimony last year, I highlighted the efforts of the Medical Imaging
    and Data Resource Center. MIDRC continues to apply artificial
    intelligence and machine learning technology for screening, detection,
    staging, and follow-up for Covid-19 patients. Throughout 2021 and into
    2022, MIDRC collected over 85,000 images and is progressing toward an
    artificial intelligence algorithm for automating image analysis to
    diagnose patients and provide a disease prognosis more quickly and
    efficiently.
        In further examples of AI/ML applications, the University of
    Washington is pursuing multiple strategies to improve mammography. A 7-
    year MERIT award from the National Cancer Institute has enabled
    building AI algorithms for breast cancer analysis, building off a
    crowdsourced challenge. UW also recently launched a 5-year initiative
    funded by NIH to create an academia-industry collaboration to validate
    multiple, commercial AI algorithms for automated mammography screening
    interpretation. Like in the Covid-19 context, reliably automating the
    review and evaluation of screenings, especially as it adapts to new
    variables, could significantly improve the detection, treatment, and
    outcomes of breast cancer.
        In a final example of AI-based applications, academic-industry
    partnerships are working to optimize imaging and diagnosis using AI-
    enabled Magnetic Resonance Imaging (MRI). This effort, which improves
    image quality and processes those images efficiently, is cutting exam
    times by over 30 percent. These advances are being disseminated broadly
    throughout the industry and are reshaping diagnostic capabilities and
    patient experience. Reducing the length of an examination accelerates
    the time to diagnosis and treatment, increases the efficiency of the
    imaging center to see more patients, and has a significant patient
    impact through reduced anxiety and increased satisfaction during a
    stressful time.
    Better Images, Less Radiation, Faster Results
        Finally, work conducted at the University of California-Irvine is
    improving a well-known and trusted tool, x-ray technology. The new
    imaging system, x-ray-induced acoustic computed tomography (XACT), is a
    promising alternative to traditional technology. Supported by an NIH
    grant, XACT can image the human body much faster while requiring a
    lower radiation dose for the patient. Moreover, a portable model is in
    development that can reach more patients, particularly in remote areas
    that may have difficulty accessing doctors' offices and care centers.
    XACT can be used for a wide range of image-guided procedures, such as
    biopsies, placement of drainage tubes, catheters, tumor ablation, and
    injections. The improved tool generates faster diagnosis and treatment,
    lowers radiation exposure, and reaches underserved communities, all
    leading to improved outcomes across a wide range of treatment or
    imaging interventions.
                             summary and conclusion
        Sustained and robust NIH funding is crucial to advancing our
    efforts to understand and treat a myriad of diseases and disorders. NIH
    investments are also a key economic driver. In 2022, NIH funds
    generated $2.60 in economic activity for every $1 of research and
    flowed to every State in the Nation.\4\ Funding NIH's base program with
    at least $49.048 billion will provide the robust support needed to
    sustain growth and secure advancements in biomedical research.
    ---------------------------------------------------------------------------
        \4\ https://unitedformedicalresearch.org/wp-content/uploads/2022/
    03/UMR_NIHs-Role-in-Sustaining-the-U.S.-Economy-FY21.pdf.
    ---------------------------------------------------------------------------
        Thank you for your strong, continued support of NIH, NIBIB, and all
    the Institutes and Centers working to advance our biomedical research
    efforts and to improve the lives of patients worldwide. On behalf of
    the Academy, I urge you to continue your strong support of our Nation's
    research and innovation enterprise.

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

                     Prepared Statement of Accessia Health
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least $49.
            billion and provide individual NIH Institutes and Centers with
            proportional discretionary increases.
        --Please provide additional, distinct funding for the emerging
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH, which would facilitate implementation of this
                important program without supplanting ongoing NIH research
                activities.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $11 billion to facilitate timely public health efforts
            along with proportional discretionary increases for CDC Centers
            and Divisions.
        --Please provide $6 million for the Chronic Disease Education and
                Awareness Program at CDC.
      --Provide the Health Resources and Services Administration (HRSA)
            with a funding level of at least $9.8 billion.
      --Please support the development and advancement of innovative
            payment models and efforts to effectively enhance coverage and
            access, including through additional resources for the Centers
            for Medicare and Medicaid Services (CMS).
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of
    Accessia Health and the community of patients we serve. Chairwoman
    Murray, Ranking Member Blunt, and distinguished members of the
    subcommittee, thank you for the significant ongoing investments in HHS,
    particularly medical research and public health programs that improve
    health for patients with debilitating and life-threatening conditions.
    Please maintain this commitment and further enhance support for medical
    research and public health programs as you work with your colleagues on
    appropriations for Fiscal Year (FY) 2023. Further, please continue to
    provide resources for the development and implementation of innovative
    models for payment and care delivery that prioritize patients while
    properly managing precious resources. Thank you again.
                             about accessia health
        Accessia Health pioneered the patient assistance model for people
    living with chronic medical conditions. To date, over $1.1 billion has
    been distributed to patients throughout the country, helping them
    navigate the complexities of the healthcare system.
        We understand the patient journey and we are blazing new trails by
    leveraging our three decades of success to expand patient assistance
    support to serve today's patients and healthcare consumers.
        Our patient assistance model includes healthcare education,
    financial assistance, specialized legal services, case management, and
    more. We are committed to serving diverse populations and seek partners
    who share our belief that all people deserve access to healthcare.
    Helping people is our mission and our passion.
                                    advocacy
        We advocate for greater access to affordable healthcare and
    treatment for patients with rare and chronic diseases. Working on both
    the State and Federal level, we strive to ensure patient voices are
    heard and patient assistance is protected. Accessia Health also joins
    with partner coalitions to advocate for increases funding for
    healthcare programs and for patient-centered healthcare reforms.
        We encourage you to adopt the aforementioned funding requests to
    better meet the unmet needs of patients with serious illness and to
    address gaps in care through systems innovation and scientific
    advancements. Our vision, is one where patients living with chronic
    illness, rare disease, or disability no longer struggle to access the
    treatment, and assistance they need to lead their best life.
        specialty drug carve out: one example of an area where patient
                             protections are needed
        Third Party Administrators have reached out to employers
    advertising a new way to save healthcare resources for the company. The
    employer contracts with the administrator, then the entities work
    together to curtail the prescription drug formularies that the company
    will offer to their employees, specifically leading to cutting out
    specialty drugs from the formulary. Typically, the price point for the
    formulary cutoff are treatments greater than $350. The employer is then
    told that the administrator will work with their employees to obtain
    any treatment if needed free of charge. The employee will then receive
    a concierge advocate who will work to obtain free treatments from the
    manufacturers. The self-insured plan saves massively on their
    healthcare spending less the contracted cost of the concierge workers.
    This is explained as a benefit to the employees that they will be
    receiving their treatments for free.
        There are several problems with the sustainability of this new
    model. First and foremost, manufacturer patient assistance programs
    impose major limitations on these free product patient assistance
    programs. Historically manufacturer patient assistance programs were
    created to serve uninsured patients for a limited period time. However,
    many manufacturers will provide compassionate drugs to patients with
    commercial coverage if the product is not covered on the plan drug
    formulary. Due to the limited time, the concierge advocate will try
    additional strategies such as non-medical drug switching and/or claims
    they can import drugs from outside the United States. These programs
    also may have an income requirement to qualify. Manufacturer patient
    assistance programs are not a long-term solution for patients with rare
    and chronic conditions to obtain needed treatments and therapies. Since
    manufacturer patient assistance program are a benefit they offer,
    continuing this practice could encourage them to severely curtail
    access to these programs.
        Congress needs to engage with the Biden-Harris Administration to
    end this practice that will clearly hurt patients with rare and chronic
    illnesses who need ongoing access to life sustaining treatments and
    therapies. In 2019, 44 percent of patient did not purchase a
    prescription due to cost. This practice, which is beginning to grow in
    the United States will further limit patient access to needed
    treatments and therapies. The Department of Labor, the agency with
    regulatory authority over ERISA plans, must work with Congress and also
    issue guidance restricting this practice.
                              patient perspectives
        I was diagnosed with Fabry 6 years ago and my husband was diagnosed
    with Pompe 3 years ago. I don't know what we would do without Accessia
    Health's help--we would be bankrupt. With both of us having rare
    diseases, the bills would be astronomical. Everyone at Accessia Health
    is so helpful. I haven't met one person who isn't kind.  --Lupe and
    Duane Austin
        Accessia Health is a lifesaver. I was diagnosed with a rare genetic
    disease, Fabry disease, right after I purchased my new home. My
    treatments are over $40,000 every two weeks. I wasn't sure how I was
    going to pay my mortgage, it's only with the help of Accessia Health
    that I'm able to stay in my home and afford my treatments, medical
    bills and nursing services.''  --Lisa Wright
        Accessia Health's ACCESS program helped me receive Social Security
    Disability, which let me adopt my son Jacob.  --Randy Russell

        [This statement was submitted by Gwen Cooper, President & CEO,
    Accessia Health.]
                                     ______

          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 $49.1 billion for
    NIH's base program level budget in FY 2023.
        As a result of the strong, bipartisan vision of the House and
    Senate Labor-HHS-Education subcommittees over the last 7 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 innovative prevention strategies, advanced diagnostics, pioneering
    treatments, and life-changing cures, , and in this time of
    unprecedented scientific opportunity, it is essential that Congress
    sustain long-term robust increases in the NIH budget.
        In FY 2023, the Ad Hoc Group for Medical Research supports at least
    $49.048 billion for the NIH base program level budget, which would
    represent an increase of $4.1 billion over the comparable FY 2022
    funding level (an increase of $3.5 billion or 7.9 percent in the NIH
    appropriation plus funding from the 21st Century Cures Act for specific
    initiatives). Importantly, the Ad Hoc Group strongly urges lawmakers to
    ensure that any funding for the new Advanced Research Projects Agency
    for Health (ARPA-H) supplement our $49 billion recommendation for NIH's
    base budget, rather than supplant the essential foundational investment
    in the NIH. This funding level, supported by nearly 400 stakeholder
    organizations, would provide real growth in the base budget above
    inflation, expanding NIH's capacity to support promising science in all
    disciplines. In addition, the coalition supports the president's
    proposal to supplement NIH's budget with additional mandatory funding
    to speed the pace of pandemic response and readiness.
        Importantly, we also recommend a funding allocation for the Labor-
    HHS-Education subcommittee in FY 2023 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.
        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, Washington, D.C., and U.S. territories. 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.
      --In 2020, the gene editing tool CRISPR was successfully used to
            treat the inherited blood disorders sickle cell anemia and
            beta-thalassemia, only 8 years after the primordial bacterial
            immune system was harnessed for therapeutic use in the
            laboratory.
      --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. The
            cancer death rate for men and women combined fell 32 percent
            from its peak in 1991 to 2019, the most recent year for which
            data were available.
        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 7 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 2021, NIH was able to fund more than 1,500 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,
    gender, and geographic 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 8 years. A $1 increase in public clinical research
    stimulates an additional $2.35 in private sector investments after 3
    years. According to a United for Medical Research report, in FY 2021,
    NIH-funded research supported more than 552,000 jobs across the U.S.
    and generated more than $94 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 2023, the Ad Hoc Group for Medical
    Research recommends that NIH receive at least $49.048 billion in base
    funding to advance the foundational research NIH supports and continue
    the momentum in our Nation's investment in medical research, and that
    any funding for ARPA-H supplement our $49 billion recommendation for
    NIH's base budget, rather than supplant the essential foundational
    investment in the NIH.
                                     ______

                 Prepared Statement of the Afterschool Alliance
        As you begin work on the Labor, Health and Human Services, and
    Education, and Related Agencies Appropriations bill for fiscal year
    2023, the Afterschool Alliance is joined by the organizations signing
    below in thanking you for increasing funding for the Nita M. Lowey 21st
    Century Community Learning Centers (21st CCLC) (Title IV Part B of the
    Every Student Succeeds Act) in fiscal year 2022, allowing an additional
    30,000 students to access quality afterschool, before-school and summer
    learning programs. The pandemic has shown how important robust
    afterschool and summer learning programs are to working families and
    our most vulnerable students, and how vital resources are to support
    these programs to ensure they are available and effective for the
    children who need them. With this in mind, we request that you support
    a funding level of $500 million for the 21st CCLC program in fiscal
    year 2023.
        Through the 21st CCLC initiative, which serves about 1.8 million
    students in all 50 States and the American territories, local school
    and community-based organizations provide students in kindergarten
    through 12th grade with a safe and supportive environment where they
    participate in academic enrichment opportunities, get excited about
    learning new things, and connect with caring mentors before school,
    afterschool, and during the summer months. 21st CCLC programs serve
    students attending high-poverty, low-performing schools, and prior to
    the COVID-19 pandemic, these programs were a vital source of support
    for underserved communities. Now, with students back in-person at
    school after having spent significant amounts of time out of the
    classroom since March 2020, feeling isolated from their teachers and
    peers, and in need of additional enrichment and learning opportunities,
    21st CCLC programs are more essential than ever.
        We are grateful that the American Rescue Plan Act (ARPA) included
    set-aside language allowing comprehensive afterschool and summer
    learning and summer enrichment programs to be eligible to receive
    emergency Covid-19 relief funds to help student recover missed
    instructional time; however, increased staffing and program costs as
    well as unprecedented demand for local afterschool programs have pushed
    programs to the brink. The most recent America After 3PM report from
    the Afterschool Alliance found an all-time high of 24.6 million
    children were unable to access a program, with cost and program
    availability as the leading factors.\1\ Additionally a fall 2021 survey
    of 1,000 afterschool program providers found that 54 percent had
    waiting lists, a significantly greater percentage than in the past.\2\
    While ARPA funds for out of school time programs are focused on the
    specific challenges related to the pandemic and are primarily directed
    to local school districts; community based providers including
    nonprofit, faith-based, park and recreation, library, and other non-
    school providers serving a wide range of vulnerable students continue
    to struggle to access the funding resources they need, with only 19
    percent of providers surveyed reporting the ability to access Federal
    Covid-19 relief funds.\3\
    ---------------------------------------------------------------------------
        \1\ America After 3PM, 2020 http://www.afterschoolalliance.org/
    AA3PM/.
        \2\ Afterschool in the time of Covid-19 tinyurl.com/362ff68f.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Federal 21st CCLC formula grants to States enable rural, urban and
    suburban communities to leverage local resources by providing 3-5 years
    of funding to support local partnerships among community-based
    organizations, faith-based partners, private industry, and school
    partners (public, private, and charters). This funding infrastructure
    provided by 21st CCLC is foundation of afterschool and summer
    programming and enables communities to attract other partners and
    resources for students including access to mentors, new learning
    opportunities, nutritious snacks and meals, as well as helping address
    student mental health programs. Funds also are used for training,
    evaluation, and assistance to ensure quality programming is offered.
    While reflecting the needs of local communities, 21st CCLCs expand
    student access to activities and services designed to reinforce and
    complement the regular academic program, such as hands-on learning,
    physical activity, workforce development opportunities including
    gaining knowledge and skills in science, technology, engineering, and
    math (STEM), drug and violence prevention programs, counseling
    programs, the arts, and more.
        In addition, the outcomes of 21st CCLC funded afterschool and
    summer learning programs are undeniable. Over a span of 20 years,
    researchers have built an evidence base for quality and effectiveness
    by studying afterschool programs across the Nation. An independent
    report published in March 2019 and supported by the Wallace Foundation,
    reviewed research from 2000 to 2017 and found programs improved a wide
    range of outcomes including student attendance, achievement in
    mathematics and English; grade promotion and graduation rates, and
    student health and fitness. This research spans the country, all age
    groups and a wide variety of indicators of well-rounded student
    success. Furthermore, the most recent Department of Education national
    annual performance report found that 70 percent of students increased
    their rates of homework completion and class participation while 63
    percent of students improved their classroom behavior. Increasing
    funding for this proven program will continue to reap benefits in the
    communities where the 10,500 21st Century Community Learning Centers
    currently thrive.
        We thank you for your continued support of afterschool and summer
    learning programs, and for your work on behalf of children and working
    families. We ask that the Labor, Health and Human Services, Education,
    and Related Agencies subcommittees ensure that the Nita M. Lowey 21st
    Century Community Learning Centers Program remains a vital resource to
    students and families moving forward. Contact Information: Erik
    Peterson, Afterschool Alliance epeterson@afterschoolalliance.org.

    Signed:
        Afterschool Alliance
        After-School All-Stars
        AlphaBEST Education, Inc.
        America SCORES
        Boys & Girls Clubs of America
        Camp Fire National
        Children's Defense Fund
        City Year, Inc.
        Collaborative for Academic, Social and Emotional Learning (CASEL)
        Committee for Children
        Communities In Schools
        Council of Administrators of Special Education
        EDGE Consulting Partners
        Every Hour Counts
        Food Research & Action Center
        Forum for Youth Investment
        Foundations, Inc
        Girls Inc.
        Institute for Educational Leadership
        integrate opportunity, LLC
        KP Catalysts, LLC
        MENTOR
        National AfterSchool Association
        National Alliance for Public Charter Schools
        National Association of Elementary School Principals
        National Association of School Psychologists
        National Association of Secondary School Principals
        National Girls Collaborative
        National Summer Learning Association
        National Urban League
        National Recreation and Park Association
        Outward Bound USA
        Public Advocacy for Kids (PAK)
        Save the Children
        Search Institute
        UnidosUS
        YMCA of the USA

    State and Local Organizations
    Alaska Afterschool Network AK
    Alaska Children's Trust AK
    California School-Age Consortium CA
    A WORLD FIT FOR KIDS! CA
    EduCare Foundation CA
    MENTOR California CA
    California Teaching Fellows Foundation CA
    California AfterSchool Network CA
    EDMO (Edventure More) CA
    Minga Education Group CO
    Onward! CO
    MENTOR Colorado CO
    Scholars Unlimited CO
    Sims-Fayola Foundation CO
    YMCA of Metropolitan Denver CO
    Academy of Arts and Knowledge CO
    Riverside Educational Center CO
    Brady High School CO
    Project Dream with the Lake County School District CO
    School Community Youth Collaborative CO
    WeldRE5J--Milliken Elementary CO
    Pagosa Arts Initiative CO
    Boys & Girls Clubs of Pueblo CountyCO
    EdAdvance CT
    Prime Time Palm Beach County FL
    Communities In Schools of Georgia GA
    Georgia Statewide Afterschool Network GA
    Voices for Georgia's ChildrenGA
    We Love Buford Highway GA
    Parents And Children Together HI
    Iowa Afterschool Alliance IA
    Girl Scouts of Silver Sage Council ID
    After School MattersIL
    ACT Now IL
    Brighton Park Neighborhood CouncilIL
    Chinese American Service League IL
    Fight Crime: Invest in Kids, Illinois IL
    ReadyNation, Illinois IL
    AYS--At Your School IN
    Boys & Girls Clubs in Indiana, Inc. IN
    Indiana Alliance of Boys & Girls Clubs IN
    Kentucky Out of School Alliance KY
    Covington Partners KY
    Kentucky/West Virginia Alliance of YMCAs KY
    Maryland Out of School Time Network MD
    Maine Mathematics and Science Alliance ME
    KYD Network MI
    Youth Development Resource CenterMI
    Michigan Afterschool Association MI
    Michigan's ChildrenMI
    MENTOR Minnesota MN
    YouthPrise MN
    MENTOR North Carolina NC
    Girls Inc. of Santa Fe NM
    New York State Network for Youth Success NY
    Ohio Afterschool Network C/O PAST Foundation OH
    The Opportunity Project OK
    Tula Public Schools OK
    MENTOR Independence Region PA
    North End OutreachRI
    MENTOR Rhode Island RI
    ALPHAS RI
    South Carolina Alliance of YMCAs SC
    South Dakota Afterschool Network SD
    United Way of West Tennessee TN
    Girls Incorporated of Kingsport TN
    Greater Kingsport Family YMCA TN
    United Way of Greater Kingsport TN
    United Way of Wilson County and the Upper Cumberland TN
    Memphis Music Initiative TN
    MENTOR Memphis Grizzlies TN
    Tennessee Afterschool Network TN
    United Ways of Tennessee TN
    Backfield in Motion TN
    Nashville After Zone Alliance/Nashville Public Library TN
    Nations Ministry Center TN
    YMCA of Middle Tennessee TN
    YMCA Y-Quest TN
    Dallas Afterschool TX
    BEACON Afterschool Program UT
    Utah Afterschool Network, Inc. UT
    Virginia Partnership for Out-of-School Time (VPOST) VA
    MENTOR Virginia VA
    MENTOR Vermont VT
    Vermont Afterschool VT
    Mentor Washington WA
    FuturesNW WA
    Empowering Youth Mentor Program WA
    Communities In Schools of Washington State WA
    Joyce L. Sobel Family Resource Center WA
    Change the Narrative WA
    Mentor Washington WA
    Lopez Island Family Resource Center WA
    Big Brothers Big Sisters of Southwest WA
    Hey MentorWA
    Youth Development Executives of King County WA
    School's Out Washington WA
    Youth in Focus WA
    Circle Faith Future WA
    Youth Rise of Washington WA

                                     ______

                    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 viral hepatitis programs in the FY 2023 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 programs combatting HIV and viral hepatitis. As you craft
    the FY 2023 L-HHS appropriations bill, we urge you to significantly
    increase funding for core public health programs that treat and prevent
    HIV and viral hepatitis in the United States, as well as fund newer
    programs that seek to end the HIV and viral hepatitis epidemics. These
    programs, many of which are a part of the safety net health system, are
    key to ending these epidemics and protecting our Nation from future
    infectious disease pandemics.
                            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. Today, HIV can be treated
    as a chronic health condition, and when that treatment is successful,
    it renders HIV untransmissible. People living with HIV who are able to
    get and stay in treatment can live a near normal life span, despite the
    impact of the virus. The toolbox for HIV prevention has grown
    substantially, with daily and now long-acting pre-exposure prophylactic
    (PrEP) medications in addition to traditional prevention techniques,
    such as condoms and syringe service programs. Despite these advances,
    progress toward ending the HIV epidemic has plateaued, with
    approximately 38,000 new infections each year since 2013.
        The progress made to date has been inequitable, as demonstrated by
    the fact that three quarters of new HIV infections now occur among
    people of color. Federal programs to prevent and treat HIV must address
    the racial and ethnic disparities that contribute to this greater risk,
    and Congress must invest new resources in innovative and effective
    prevention and treatment programs to end the HIV epidemic as a matter
    of racial justice.
        Congress must invest new resources in innovative and effective
    prevention and treatment programs to end the HIV epidemic. These new
    resources must support programs in communities that bear the greatest
    risk and impact of HIV. Ending the HIV epidemic has become a matter of
    racial justice.
                       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 10 years.
    In the last 3 years, your Committee provided $260 million, $404
    million, and $473 million respectively for the EHE Initiative.
    Resources are 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 over 389,000 new PrEP prescriptions for people at risk
    for HIV. Through this funding the Ryan White Program engaged over
    19,000 people in HIV care during 2020. 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 four of the EHE Initiative at the
    following levels: $310 million for the CDC Division of HIV/AIDS
    Prevention to conduct targeted testing, connection to treatment, and
    robust surveillance; $290 million for the Ryan White HIV/AIDS Program
    to increase access to high-quality HIV care and treatment; $172 million
    for HRSA's Community Health Center program to provide prevention
    services emphasizing PrEP; $26 million for NIH's Centers for AIDS
    Research to provide best practices to guide the plan; and $52 million
    for the Indian Health Service to provide HIV prevention, treatment,
    education, and hepatitis C (HCV) elimination in Native American
    communities.
                               cdc hiv prevention
        CDC's Division of HIV Prevention focuses resources on those
    populations and communities most affected by investing in high-impact
    prevention. Through partnerships with State and local public health
    departments and community-based organizations, the CDC has expanded
    targeted prevention programs that work to address racial and geographic
    health disparities. 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 $1.233 billion, including $100 million for
    school-based HIV prevention efforts and $310 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
    nearly 90 percent of clients achieve viral suppression (which is
    critical for HIV prevention, because people who have achieved viral
    suppression cannot transmit HIV to others). The cost of medical care
    has consistently increased over the last decade, yet Ryan White
    programs have not received increased funding. Because of this, flat
    funding is essentially a cut to Ryan White programs.
        The AIDS Institute requests that the subcommittee fund the Ryan
    White HIV/AIDS Program at a total of $2.942 billion in FY 2023,
    distributed in the following manner: Part A at $751.1 million; Part B
    (Care) at $509.4 million; Part B (ADAP) at $968.3 million; Part C at
    $231 million; Part D at $85 million; Part F/AETC at $58 million; Part
    F/Dental at $15.4 million; and Part F/SPNS at $34 million; Ending the
    HIV Epidemic Plan at $290 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.
                            pre-exposure prophylaxis
        This year will mark the ten-year anniversary of FDA approving the
    first medication for PrEP, potentially the greatest advent in the fight
    to prevent HIV. Despite the tremendous promise of PrEP, it is severely
    underutilized. Of the estimated 1.2 million people who could benefit
    from PrEP, only 23 percent have a prescription. Among racial and ethnic
    minorities, only 16 percent of Hispanic/Latino people and 9 percent of
    Black people who could benefit from PrEP have a prescription. This
    stark divide must be addressed if we are to end the HIV epidemic.
        President Biden's FY 2023 Budget Request included a proposal for a
    10-year, $9.8 billion mandatory program to provide PrEP at no cost for
    un-and-underinsured people and develop a comprehensive provider network
    to ensure that we fill the large gaps in PrEP coverage. A national PrEP
    program is desperately needed, and it must start right away by
    increasing funding for Community Health Centers, CDC-funded health
    departments, and HHS grantees to establish and expand PrEP programs in
    places where PrEP uptake is low. But to overcome barriers to PrEP
    uptake, we also urge the Committee to task and fund HHS with creating a
    national PrEP program based on the President's proposal, with input
    from the HIV community. This program should ensure that cost is not a
    barrier to PrEP; that people have access to the suite of PrEP services
    required to maintain a prescription; that providers and people at risk
    for HIV know about PrEP and how to get it; and it should combat the
    misinformation and stigma that impede demand for PrEP.
                           viral hepatitis in the u.s
        Viral hepatitis continues to have a dramatic impact on the health
    of some of the Nation's most vulnerable communities and show no signs
    of abating as lack of sterile equipment among people who use drugs
    creates perfect conditions for the viruses to thrive. There are highly
    effective vaccines to prevent hepatitis A (HAV) and B (HBV), yet cases
    of HAV have increased 1,300 percent since 2015 and the number of new
    cases of HBV have stubbornly plateaued for the past decade. CDC
    estimates there were 57,800 new HCV cases in 2019, with 70 percent of
    those cases a result of drug use. Since 2010, the country has
    experienced a nearly 500 percent increase in new HCV cases.
        Of the nearly 5 million people now living with HBV and/or HCV in
    the U.S., as many as 65 percent are not aware of their infection. 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. With so many Americans impacted by viral hepatitis, it is
    imperative the evidence-based prevention, testing, surveillance, and
    treatment programs have the resources they need to protect the
    country's health.
                 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 having 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 $150 million for the
    CDC's infectious diseases and opioid epidemic efforts.
                         cdc viral hepatitis prevention
        CDC's Viral Hepatitis program is the lead agency combating viral
    hepatitis at the National level by providing important technical
    assistance and funding to the States. The division is currently funded
    at only $41 million and has received only minor increases over the past
    decade. Current funding is nowhere near what 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, laid out in the Viral Hepatitis National Strategic Plan for
    the United States: A Roadmap to Elimination (2021--2025). However, only
    with a significant investment 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.
    This year, we request that the subcommittee appropriate $140 million to
    the CDC to address the rise in viral hepatitis and combat the
    infectious diseases consequences of drug use.
                            syringe service programs
        Syringe service programs (SSPs) are a critical tool in the fight to
    end the drug use epidemic and eliminate viral hepatitis. These
    important public safety programs reduce the spread of infectious
    disease, prevent overdose deaths, and connect clients to infectious
    disease and substance use 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.
        Thank you for your consideration of this written testimony. If you
    have questions or would like to discuss these issues further, please do
    not hesitate to contact Nick Armstrong at narmstrong@taimail.org or
    Frank Hood at fhood@taimail.org.

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

                       Prepared Statement of AIDS United
        Dear Chairwoman Murray, and Ranking Member Blunt:
        As the subcommittee continues its important deliberations on the
    Fiscal Year (FY) 2023 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 4 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 percent by 2030. Additionally, an
    updated National HIV/AIDS Strategy was recently released that expands
    upon and continues the bipartisan commitment to a whole-of-society
    approach addressing the HIV epidemic in the United States. We urge
    Congress to capitalize on the expertise developed by communities as
    part of the EHE Initiative so that we can improve and grow the
    Initiative. Ending HIV by 2030 is possible, but resources are needed to
    achieve this goal.
        Over the past 2 years, the COVID-19 pandemic has shone 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. But, at the same time, it has shown what is
    possible when we come together to confront a significant public health
    crisis with the energy and resources that are required. Below are
    detailed domestic HIV funding requests that we join our coalition
    partners in the Federal AIDS Policy Partnership in urging the committee
    to include in the fiscal year 2023 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 3 years, on a bipartisan basis, Congress has
    appropriated additional funding for the Ending the HIV Epidemic
    Initiative, which looks to reduce new HIV infections by 50 percent by
    2025, and 90 percent by 2030. We ask Congress to increase funding in FY
    2023 for the Ending the HIV Epidemic Initiative by at least the amounts
    listed below in the following divisions:
      --$310 million for CDC Division of HIV/AIDS Prevention for testing,
            linkage to care, and prevention services, including pre-
            exposure prophylaxis (PrEP) (+$115 million);
      --$290 million for HRSA Ryan White HIV/AIDS Program to expand
            comprehensive treatment for people living with HIV (+$165
            million);
      --$172 million for HRSA Community Health Centers to increase clinical
            access to prevention services, particularly PrEP (+$50 million)
                        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 percent 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.
        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 $2.942 billion in FY 2023, an increase of $447.5 million over
    FY 2022, distributed in the following manner: Part A: $751.1 million,
    Part B (Care): $509.4 million, Part B (ADAP): $968.3 million, Part C:
    $231 million, Part D: $85 million, Part F/AETC: $58 million, Part F/
    Dental: $15.4 million, Part F/SPNS: $34 million, EHE Initiative: $290
    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.
        The CDC's Division of HIV Prevention is the Federal leader in
    creating 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 address racial and geographic health disparities. We urge
    you to fund the CDC Division of HIV Prevention at $822.7 million in FY
    2023, an increase of $67.1 million over FY 2022. This is in addition to
    the $310 million for EHE Initiative work within the Division.
    CDC Infectious Diseases and Opioid Epidemic Funding
        The United States is in the midst of an unprecedented and horrific
    overdose crisis. Last year, over 100,000 Americans lost their lives to
    overdose. At the same time, HIV transmissions among people who use
    drugs have risen over the past 5 years and viral hepatitis transmission
    among people who inject drugs continues to skyrocket. Combatting the
    overdose crisis requires significant and sustained support for
    evidence-based harm reduction interventions, particularly for Syringe
    Services Providers (SSPs), who are the first responders to the overdose
    and infectious disease crisis and effectively help prevent drug
    overdoses and new HIV and hepatitis infections. Harm reduction workers
    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. And the CDC's
    Opioid Related Infectious Diseases program is best situated to support
    harm reduction programs and spearhead funding our syndemic approach to
    ending the overdose, HIV and viral hepatitis crises.
        We urge you to fund the CDC's Infectious Diseases and Opioid
    Epidemic program in FY 2023 at the $150 million, an increase of $132
    million over fiscal year 2022.
    Syringe Services Programs
        The Department of Health and Human Services, relying on the results
    of multiple studies, States 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 prevent
    overdose, connect people to substance use treatment, HIV and hepatitis
    testing, and other supportive services. SSPs have also been providing
    COVID-19 related services to vulnerable populations during the
    pandemic. The FY 2022 omnibus 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.
    Pre-Exposure Prophylaxis
        Pre-exposure prophylaxis, or PrEP, is a medication that effectively
    prevents HIV transmission when taken as prescribed. The first PrEP
    medication was approved by the FDA 10 years ago, and now there are
    multiple medications available, including generic medications and a new
    long-acting injectable version of PrEP. Increasing access to PrEP has
    been a key strategy in ending the HIV epidemic, yet more progress must
    be made.
        It is estimated that only 23.4 percent of people who could benefit
    from PrEP have received a prescription. PrEP coverage is highest among
    white people, at 63.3 percent, yet only 8.2 percent of black people and
    14 percent of Hispanic/Latino people who could benefit from PrEP in the
    United States are on a prescription. Additionally, PrEP coverage among
    women is only at 9.7 percent.
        We are thankful that there has been an increased focus on PrEP both
    in Congress and from President Biden. In his FY 2023 Budget Request,
    President Biden called for a new mandatory funding program to expand
    PrEP across the United States through providing medication to un and
    under insured individuals, as well as supporting and expanding PrEP
    programs across a variety of agencies. Additionally, there is a bill in
    Congress seeking to increase insurance coverage of PrEP and ancillary
    services (S. 3295) and a bill which seeks to provide grants to HHS
    entities to expand PrEP programs throughout the U.S. (H.R. 5605).
        As Congress moves through the regular appropriations cycle, we urge
    you to support funding for new and innovative programs to expand PrEP
    access, and ensure that those who want PrEP can easily access the
    medication without any costs or barriers.
    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.
        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 FY 2022, an increase of $48.1 million and
    $44 million over FY 2021 levels, respectively. We also urge you to fund
    Minority AIDS Initiative programs across HHS agencies at $610 million
    in FY 2023.
        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 Director of Advocacy Drew Gibson,
    at dgibson@aidsunited.org.
        Sincerely.

        [This statement was submitted by Carl Baloney, Jr., Vice President
    & Chief
    Advocacy Officer, AIDS United.]
                                     ______

       Prepared Statement of the Alliance to End Slavery and Trafficking
        The Alliance to End Slavery and Trafficking (ATEST) thanks you for
    your leadership in the fight to end child labor, forced labor and human
    trafficking. We appreciate your efforts to pass legislation and provide
    resources to Federal agencies engaged in combating these horrific
    crimes. Due to underlying vulnerabilities, those most at risk of, and
    victim to, trafficking and exploitation will experience
    disproportionate impacts as a result of COVID-19 in the short, medium,
    and long-term. With this in mind, we seek your assistance in funding
    essential programs in the fiscal year 2023 Labor, Health and Human
    Services, Education, and Related Agencies Appropriations bill. The
    number of trafficking victims significantly exceeds the availability of
    services at the Departments of Labor (DOL), Health and Human Services
    (HHS) and Education (ED). ATEST recommends robust funding and
    accountability for programs at these key departments to fulfill the
    highest priority mandates of the Trafficking Victims Protection Act of
    2000 and subsequent reauthorizations (TVPA) and related legislation.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                              department of labor
        International Labor Affairs Bureau: $168,000,000.--We request
    $168,000,000 for the Bureau of International Labor Affairs (ILAB) in
    the Department of Labor (DOL). Specifically, we request $27,000,000 for
    the administration of ILAB, $70,000,000 for the Child Labor and Forced
    Labor program, $48,000,000 for Workers' Rights Programs, and
    $23,000,000 for program evaluation.
        ILAB is an essential part of the U.S. government's international
    response to forced labor, human trafficking, and child labor. It is
    responsible for implementing Section 105(b)(2) of the TVPRA of 2005
    (Public Law109-164) and Section 110 of the TVPRA of 2008 (Public
    Law110-457). In the past, these requirements have not been funded.
    Funding provided would allow ILAB to fulfill its Congressional mandates
    including: producing annual findings on worst forms of child labor in
    certain U.S. trade beneficiary countries; the development and
    maintenance of a list of goods produced by child or forced labor,
    including inputs to goods made with child or forced labor; and
    increased responsibilities in enforcing the U.S. Mexico Canada
    Agreement (USMCA). Adequate funding will ensure that staff is able to
    travel to the countries with which ILAB has partnered or where
    important research is needed to accurately maintain the list of goods
    made with forced labor or child labor. In addition, a robust and
    expertly staffed entity within the U.S. government's foreign policy
    establishment--that sits outside of the diplomatic constraints of the
    State Department and focuses particularly on worker rights--is
    tremendously important to the government's ability to tackle human
    trafficking and address the underlying factors that place individuals
    at risk of trafficking.
        We request $48,000,000 for Workers' Rights Programs because they
    are essential to maintaining coherence with the U.S. trade agenda. ILAB
    provides technical assistance to countries on a variety of worker
    rights issues, many of which correspond directly to labor rights
    commitments under trade agreements. Project goals include adopting or
    reforming labor laws or standards, improving labor inspectorates'
    enforcement capacity, increasing awareness of fundamental labor rights,
    and improving occupational safety and health conditions. ILAB also
    provides technical advice and other support to labor ministries through
    workshops and exchange programs and hones in on areas of particular
    concern including the cocoa and fishing sectors as well as other supply
    chains with heightened risks of child labor or forced labor.
        Employment and Training Administration: $5,000,000.--The Department
    of Labor Employment and Training Administration (ETA) should conduct a
    review of all employment readiness, training, and other discretionary
    programs, and revise program guidance as needed to explicitly include
    eligibility for trafficking victims where possible, per Sec. 107(b) of
    the Trafficking Victims Protection Act (Public Law 106-386). The
    requested funds should be used to develop and implement a pilot grant
    program to deliver trauma-informed employment and training services
    that address particular barriers to service, and challenges to finding
    employment, faced by survivors of human trafficking. The U.S Advisory
    Council on Human Trafficking highlighted the need to provide access to
    employment and training programs to all survivors of human trafficking.
    In their inaugural report, released in 2016, the council noted that
    ``...after leaving their trafficking situations, survivors [...] can
    find it difficult to live financially independent. Career development
    programs help survivors become self-sufficient and provide for their
    families. When survivors are employed, it positively affects their
    lives and prevents dependence on public benefits.'' We also recommend
    that the DOL integrate training to identify potential signs of
    trafficking and referral options as a regular activity for State
    Farmworker Monitor Advocates, and during the provision of relevant
    services to particular at-risk populations, including through the Youth
    Build, Job Corps and Reentry Employment Opportunity programs.
        Employment and Training Administration: Report Language.--Labor
    trafficking affects both U.S. citizens and foreign nationals working
    across many industries, most commonly domestic work, agriculture,
    manufacturing, janitorial services, hotel services, construction,
    health and elder care, hair and nail salons, and strip club dancing.
    DOL needs resources to protect and support victims, particularly with
    much needed skills training and job placement services, as well as
    providing referrals to shelter, medical care, mental health services,
    legal services, and case management. ATEST members have also worked
    with human trafficking survivors who were forced to engage in criminal
    acts of labor, including forced activities related to gangs, weapons
    and narcotics. Victims impacted by this form of labor trafficking also
    require additional legal services in the realms of criminal law and
    immigration.
        Proposed Report Language: The Committee encourages the Employment
    and Training Administration to increase access and eligibility to
    employment and training services for survivors of all forms of human
    trafficking as required by Sec. 107(b) of the Trafficking Victims
    Protection Act (Public Law 106-386). The Committee also encourages the
    development and integration of training to identify potential signs of
    trafficking and referral options as a regular activity for State
    Farmworker Monitor Advocates, and during the provision of relevant
    services to particular at-risk populations, including through the Youth
    Build, Job Corps and Reentry Employment Opportunity programs. The
    Committee also encourages the Department to continue and expand its
    pilot initiative to develop and support networks of service providers
    in collaboration with HHS and DOJ.
                    department of health and human services
        Administration for Children and Families, Victim Services (ACF):
    $50,000,000.--ACF fulfills mandates of the Trafficking Victims
    Protection Act to (1) Identify and serve victims who are foreign
    nationals; and (2) Create specialized case management programs to
    assist U.S. citizen victims. The number of trafficking victims
    certified as needing comprehensive, trauma-informed, gender-specific
    services has risen dramatically but funding for services has not kept
    pace. Additionally, funding increases for victim services programs
    under HHS have never matched the increases provided to programs under
    DOJ. Both programs are essential to effectively assist victims and
    survivors and we encourage parity in funding for both programs. While
    HHS departments have worked efficiently with limited resources to
    support service providers, further funding would allow HHS to fulfill
    legislated and related needs of victims more fully. We encourage ACF to
    use a portion of increased funding for legal services for victims. We
    request that increased funds be utilized equally for services for both
    foreign national victims and U.S. citizen and legal permanent resident
    victims, consistent with demonstrated need.
        Service providers across the country have noted a significant
    increase in the services required by victims and survivors during the
    COVID-19 crisis. Data from one ATEST member organization providing
    services showed a 556 percent increase in emergency response cases to
    escaping survivors since 2019 at the start of the pandemic.
    Furthermore, this service provider has experienced a 455 percent
    increase in costs for basic necessities. A survey conducted by the OSCE
    Office for Democratic Institutions and Human Rights and the United
    Nations Entity for Gender Equality and the Empowerment of Women (the
    ``OSCE ODIHR Survey'') confirms the increased needs of service
    providers to effectively assist victims during the pandemic. The crisis
    has heightened vulnerabilities to exploitation and required providers
    to work with limited resources to provide expanded services. We have
    seen unprecedented unemployment rates and significantly heightened
    client financial needs in all areas. Both trafficking victims currently
    receiving services and those newly seeking services have shown an
    increased need for direct assistance to pay for basic necessities like
    food and shelter. With the pandemic impacting employment opportunities
    in all industries where human trafficking survivors have formerly
    sought employment and stability, we expect a significant increase in
    the coming years in the need for sustained comprehensive services for
    all survivors for longer periods of time. Specifically, data from the
    National Human Trafficking Hotline showed that in April 2020, the
    number of crisis trafficking situations increased by more than 40
    percent and the number of situations in which people needed immediate
    emergency shelter nearly doubled. We therefore request an increase in
    funds in fiscal year 2023 to $50,000,000, which will help keep up with
    the expected needs of trafficking victims and their family members.
    Relatedly, we also request that any portion of these funds that
    currently operate under a match requirement are exempted from the 25
    percent non-federal funding match requirement for fiscal year 2023.
        Administration for Children and Families, the National Human
    Trafficking Hotline: $6,000,000.--The National Human Trafficking
    Hotline (``Trafficking Hotline'') is a toll-free 24/7 center available
    to answer calls, text messages, online tips and email queries. The
    Trafficking Hotline connects victims with anti-trafficking services in
    their area (such as shelter, case management, and legal services),
    collects tips on human trafficking cases, and, where appropriate,
    reports actionable tips to law enforcement. The Trafficking Hotline
    serves both domestic and foreign victims inside the U.S. In fiscal year
    2021, the National Human Trafficking Hotline received 13,450 signals
    from victims and survivors themselves, a 26 percent increase from
    fiscal year 2019. The significant increase in signals from victims and
    survivors underscores what an important and trusted resource the
    hotline has become for people experiencing trafficking.
        As efforts to increase awareness, training, and education of the
    public and key industries on human trafficking generally and the
    National Human Trafficking Hotline specifically have succeeded, call
    volume on the hotline has increased thirty-fold since its inception in
    2007. From fiscal year 2019 to fiscal year 2021 the hotline has
    experienced a whopping 60 percent increase in total signal volume.
    Given the disruptive impact of the COVID-19 pandemic on social,
    economic, and health outcomes, call volume will continue to steadily
    increase throughout fiscal year 2023 and beyond. We request $6,000,000
    in fiscal year 2023 to support the National Human Trafficking Hotline
    to continue to meet the needs of victims and survivors of human
    trafficking.
        Administration for Children and Families, Runaway and Homeless
    Youth Act: $300,000,000.--We request a total of $300,000,000 for ACF to
    implement the Runaway and Homeless Youth Act (RHYA) programs, Title III
    of the Juvenile Justice & Delinquency Prevention Act. This is the
    amount to be included in the most recently introduced bill to fully
    reauthorize RHYA, the Runaway and Homeless Youth and Trafficking
    Prevention Act of 2021. RHYA programs have been chronically underfunded
    since its inception, despite these programs costing less than other
    systems that many youth experiencing homelessness and survivors of
    trafficking encounter. Everyone should have the opportunity to succeed
    regardless of their start in life, but young people who are trafficked
    and youth experiencing homelessness are not plugged into the networks,
    resources, and supports they need for healthy development.
        RHYA programs prevent trafficking, identify survivors, and provide
    housing and services to runaway, homeless, and disconnected youth. RHYA
    has been a necessary bridge for our youth, but more recently, it has
    supported us to meet the unprecedented need for safe and stable housing
    and supportive services for homeless youth. The COVID-19 pandemic
    significantly increased children and youth homelessness due to high
    unemployment, unstable living conditions, and job insecurity. Some of
    our sites, such as Covenant House Missouri, saw their waiting lists
    double.
        In a typical year, 4.2 million young people (ages 13-25) experience
    homelessness annually, including 700,000 unaccompanied youth ages 13 to
    17. Recent data from the National Human Trafficking Hotline also show
    that being a runaway homeless youth and living in unstable housing are
    two of the top risk factors for human trafficking. Numerous studies
    have found trafficking rates among youth experiencing homelessness
    ranging from 19 percent to 40 percent. Using the lower end estimate
    means that about 800,000 of the youth and young adults who experience
    homelessness in a year are also victims of sex trafficking or forced
    labor in cities, suburbs, rural communities, and American Indian
    Reservations across the country.
        The cost of not investing in the lives of youth experiencing
    homelessness is an economic burden that affects the young person,
    taxpayers, and society. Researchers have found that taxpayers face an
    estimated lump sum 2011 fiscal cost per youth of $248,182 and social
    cost of $613,182.\1\ Taking the modest taxpayer \2\ cost of $248,182
    per youth and applying it to only half of the 4.2 million youth who
    experience homelessness every year in America, the taxpayer cost is
    over $521 billion (2.1 million x $248,182). Through increased
    investments, all youth in need of safe and stable housing and
    supportive services will be able to connect to the networks of support
    and resources needed to stabilize, heal, and thrive. These connected
    youth in turn become part of the solution to trafficking and
    homelessness and contribute to the community's well-being.
    ---------------------------------------------------------------------------
        \1\ Foldes, Steven S. and Lubov, Andrea. (2015) The Economic Burden
    of Youth Experiencing Homelessness and the Financial Case for Investing
    in Interventions to Change Peoples' Lives: An Estimate of the Short-and
    Long-Term Costs to Taxpayers and Society in Hennepin County, Minnesota.
    https://www.youthlinkmn.org/wp-content/uploads/2016/04/the-economic-
    burden-of-homeless-youth-in-hennepin-county.pdf. Social cost is defined
    as the total costs to society including lost earnings, lost tax
    payments, public crime expenditures, victim costs, welfare support
    programs, education, excess tax burden and public housing support.
        \2\ Belfield, et. al., The Economic Value of Opportunity Youth.
    January 2012.
    ---------------------------------------------------------------------------
        RHYA has provided base funding to communities across the country to
    develop community-based responses to youth and young adult homelessness
    and trafficking. These local systems of care are based on the unique
    needs of each region, their available resources, and local priorities.
    When we support young people experiencing homelessness, we prevent
    trafficking. RHYA programs are also trained in identifying and serving
    survivors of trafficking. Specifically, RHYA funds: emergency shelters,
    family reunification when safe, aftercare, street outreach, education,
    employment training, behavioral and mental health care, transitional
    housing, and independent housing options. This support achieves the
    following successful outcomes for youth: (1) safe exit from
    homelessness and hopelessness; (2) family reunification and/or
    establishment of permanent connections in their communities; (3)
    education, employment, and sustainable independence; and (4) prevention
    of human trafficking. Further, these programs are best positioned to
    prevent trafficking and commercial sexual exploitation and provide
    early identification of and services to youth victims of crimes.
        Proposed Report Language: The Committee strongly encourages
    programs to have the ability to serve youth involved in other systems
    (such as child welfare and juvenile justice) that are not currently
    housed by that system.
        Administration for Children and Families, Office of Trafficking in
    Persons: Report Language.--In establishing the Office of Trafficking in
    Persons (OTIP), HHS underscored the importance of coordinating
    trafficking efforts across the Administration for Children and Families
    (ACF). ACF works directly with all victims of human trafficking--men,
    women, children, LGBTQ, foreign nationals and domestic clients--and the
    diverse needs and vulnerabilities of these populations can only be met
    by an effective coordinating body networked agency-wide. Additionally,
    the ongoing migration flows and refugee crises that swelled in scope
    around 2015 and have continued further highlight the need to develop
    responsible and robust parameters to ensure that unaccompanied minors
    working with ACF and the Office of Refugee Resettlement are not
    released to families or guardians who further exploit these vulnerable
    youth. Unaccompanied minors released to guardians after being
    identified as a victim of or at risk of human trafficking continue to
    report to service providers that they are exploited or labor/sex
    trafficked by those to whom they were entrusted. We also expect that
    the United States may well accept unaccompanied minors from Ukraine
    within the next year, and we strongly encourage ACF and ORR to
    implement and enforce strong protections for these youth to prevent re-
    trafficking or new forms of exploitation.
        Proposed Report Language: Within the funds provided, the Committee
    encourages ACF to hire sufficient full-time employees to support the
    Office of Trafficking in Persons and coordinate trafficking efforts
    across ACF. Furthermore, these funds should be used to develop robust
    and effective protective mechanisms to ensure that unaccompanied minors
    processed through the Office of Refugee Resettlement are not further
    exploited or trafficked by the guardians or families to whom they are
    entrusted after their release.
        Administration for Children and Families, Family Youth Services
    Bureau: Report Language.--The process of informing RHYA grantees has
    restricted the ways in which service providers are able to continue to
    provide services to vulnerable youth. For the past several years, RHYA
    grantees have been notified whether they will receive a grant or not
    within one day before a grant period is to begin. This lack of
    sufficient notice is extremely problematic for agencies and community-
    based organizations working to serve runaway and homeless youth who
    face higher risks of trafficking and violence. We recommend that the
    current bureaucratic process be streamlined, so that RHYA grant
    applicants are notified regarding whether they will receive a grant or
    not within at least 3 months in advance of the start date of a grant.
        Proposed Report Language: When awarding funds under the Runaway and
    Homeless Youth Act program, the Secretary shall notify all applicants
    if they were successful or not at least 30 days before the grant is to
    begin as well as 30 days before an existing grant is set to end.
                            department of education
        Department of Education Grants to Local Education Agencies, Title
    I: $2,000,000.--The Department of Education interfaces with
    approximately 50 million elementary and secondary school children each
    year, placing it in a unique position to identify victims of sex
    trafficking and forced labor and to prevent the victimization and
    exploitation of children who might be susceptible. While ED has been
    able to create some resources for educators without any dedicated
    Federal resources, dedicated funding for the prevention of child
    trafficking is essential. The funds should be used to develop materials
    regarding all forms of human trafficking, including sex trafficking and
    forced labor, to ensure that educators and students are aware of how to
    identify and address all types of trafficking. Further, we request that
    ED publish a white paper examining the appropriate role of educators
    and students, as well as the role of the education system, in
    preventing, identifying, and supporting child trafficking victims. The
    outcome of the white paper should inform the development of a model
    curriculum on the prevention of both sex trafficking and forced labor.
        McKinney-Vento Act Education for Homeless Children and Youth
    Program (EHCY): $300,000,000.--The EHCY removes barriers to the
    enrollment, attendance, and opportunity for success for homeless
    children and youth; all of whom are at high risk of human trafficking.
    The EHCY is effective in addressing youth homelessness. With the
    support of EHCY grants, local education agencies have provided
    identification, enrollment and transportation assistance, as well as
    academic support and referrals for basic services. Unfortunately, the
    resources directed to child and youth homelessness programs have not
    been sufficient in recent years. ED reported that during the 2017-2018
    school year, public schools identified 1.5 million homeless children
    and youth, a 15 percent increase over the 3 previous school years.
    However, only 22 percent of school districts receive support through
    the EHCY in any given year. As a result, homeless children and youth
    are under-identified and continue to face significant barriers to
    school enrollment and continuity.
        Under the McKinney-Vento Act's EHCY, all school districts are
    required to designate a homeless liaison, who proactively identifies
    homeless children and youth and connects them with vital resources,
    including food, housing, and clothing. Because all school districts-
    even those in communities without youth shelters-must designate a
    liaison for homeless students, schools are uniquely positioned to
    identify youth who are being trafficked, or are at risk of being
    trafficked, and provide connections to services. Yet many liaisons are
    designated in name only and lack the time and the training to carry out
    their duties. This lack of capacity is particularly severe in light of
    the increase in student homelessness due to the COVID-19 crisis.
    Increasing funding for the EHCY will support a dedicated infrastructure
    within the Nation's public schools to identify and serve children and
    youth who are at very high risk of human trafficking, both during the
    current public health and economic crisis and as the economy is
    rebuilt.
        As a champion for the victims of child labor, forced labor and sex
    trafficking, you understand the complexities of these issues and the
    resources needed to respond. We have carefully vetted our requests to
    focus on the most important and effective programs. We thank you for
    your consideration of these requests and your continued leadership. If
    you have any questions, please contact ATEST Director Terry FitzPatrick
    (terry.fitzpatrick@ATEST-US.org).

        Sincerely,

        Coalition to Abolish Slavery and Trafficking (CAST)
        Coalition of Immokalee Workers (CIW)
        Covenant House
        Free the Slaves
        HEAL Trafficking
        Human Trafficking Institute
        Human Trafficking Legal Center
        Humanity United Action
        McCain Institute for International Leadership
        National Network for Youth (NN4Y)
        Polaris
        Safe Horizon
        Solidarity Center
        T'ruah: The Rabbinic Call for Human Rights
        United Way Worldwide
        Verite
        Vital Voices Global Partnership
                                     ______

                  Prepared Statement of the Alpha-1 Foundation
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least $49.
            Billion, a $3.5 billion increase over Fiscal Year (FY) 2022.
        --Please provide proportional increases for individual NIH
                Institutes and Centers especially the National Heart Lung
                and Blood Institute (NHLBI) & the National Institute for
                Diabetes, Digestive and Kidney Diseases (NIDDK).
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $11 billion, a $2.55 billion increase over FY 2022.
        --Please provide CDC's National Center for Chronic Disease
                Prevention and Health Promotion (NCCDPHP) with systematic
                and meaningful annual increases to bring total funding up
                to $3.75 billion over the next 3 years.
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of the
    Alpha-1 Foundation. Chairwoman Murray, Ranking Member Blunt, and
    distinguished members of the subcommittee, the Alpha-1 community
    extends our thanks for the significant investments in HHS through the
    FY 2022 omnibus package, particularly the annual increases for the
    National Institutes of Health (NIH) and the Centers for Disease Control
    and Prevention (CDC). As you work with your colleagues on
    appropriations for FY 2023, please continue to invest in medical
    research programs that serve the rare disease community. Thank you
    again for your leadership on health funding issues and for the
    opportunity to present the views of the rare chronic disease community.
                      about alpha-1 antitrypsin deficiency
        Alpha-1 Antitrypsin Deficiency (Alpha-1) is a rare, genetic
    condition, passed from parents to their children through their genes.
    Alpha-1 may result in serious lung disease in adults and liver disease
    at any age. Alpha-1 occurs when there is a severe lack of a protein in
    the blood called Alpha-1 antitrypsin (AAT) which is mainly produced by
    the liver. The main function of AAT is to protect the lungs from
    inflammation caused by infection and inhaled irritants such as tobacco
    smoke. The low level of AAT in the blood occurs because the AAT is
    abnormal and cannot be released from the liver at a normal rate. This
    leads to a buildup of abnormal AAT in the liver that can cause liver
    disease.
        Alpha-1 lung disease has been called ``Genetic COPD''. Normal white
    blood cells in the lungs produce an enzyme called neutrophil elastase
    that destroys invading germs and digests damaged or aging cells. In
    most people, the alpha-1 protein neutralizes the enzyme after a short
    time. In Alpha-1 patients, there is not enough alpha-1 protein in the
    lungs; the enzyme then keeps working, attacking and destroying normal
    lung tissue. As the damage continues over years, lung diseases such as
    COPD can develop.
        There is no cure yet for Alpha-1 Antitrypsin Deficiency. However,
    there are treatments available for Alpha-1 lung disease. Augmentation
    therapy consists of intravenous infusions, usually weekly, of alpha-1
    antitrypsin protein purified from healthy plasma donors. The goal is to
    increase the level of alpha-1 protein in the blood and lungs to slow or
    stop the progression of Alpha-1 lung disease.
        Alpha-1 Antitrypsin Deficiency can cause liver problems in infants,
    children, and adults. Large amounts of abnormal alpha-1 antitrypsin
    protein (AAT) are manufactured in the liver; nearly 85 percent of this
    protein gets stuck in the liver. If the liver cannot break down the
    abnormal protein, the liver gradually gets damaged and scarred.
    Currently, there is no way to prevent the abnormal AAT from getting
    stuck in the liver. This highlights the need for additional research at
    the National Institutes of Health.
        The Alpha-1 Foundation supports the $3.5 billion increase for the
    National Institutes of Health being advocated by the Ad Hoc Group for
    Medical Research. This additional funding would make possible research
    priorities for the Alpha-1 Foundation such as working with NIDDK to
    help develop treatments for Alpha-1 Liver Disease since there is no
    treatment currently.
                       home-infusion for alpha-1 patients
        This year the Alpha-1 Foundation advocated to Congress regarding
    home infusion for the Alpha-1 patient community utilizing Medicare.
    Alpha patients with commercial health insurance coverage are allowed to
    receive their infusions of augmentation therapy at the home. Whereas
    Medicare beneficiaries are mandated to receive their infusions at
    infusion clinics, hospitals, and physician offices. With the onset of
    the COVID-19 pandemic, it is no longer safe for Alpha-1 Antitrypsin
    Deficiency patients to receive their infusions in the clinical setting.
        Early in the COVID-19 pandemic, the Alpha-1 Foundation petitioned
    the Centers for Medicare and Medicaid Services (CMS) to grant a
    temporary home infusion benefit for Alpha-1 patients utilizing coverage
    through Medicare. CMS issued a temporary benefit however the specialty
    pharmacies would not implement it so the community had to choose
    between skipping treatments or potentially exposing themselves to a
    fatal respiratory virus.
        The Alpha-1 Community is working to create a permeant home infusion
    benefit in Medicare Part B by supporting HR 7346, The John Walsh Alpha-
    1 Home Infusion Act. The legislation named for the legendary founder of
    The Alpha-1 Foundation would establish a permeant benefit in Medicare
    Part B. The pandemic has shown that precautions need to be taken to
    protect vulnerable populations such as the Alpha-1 Community from
    exposure to viruses such as COVID-19 and Influenza.
        The Alpha-1 patient community serves as an inspiration to the
    leadership of the organization. This year we lost a wonderful Alpha-1
    community member, Mr. Rich Lee. Rich Lee was a patient advocate, a
    social worker, and a congressional staffer but most importantly he was
    a husband and father. Rich passed away on February 13, 2022. Rich spent
    his career in service to our community, our state, and our country and
    all the lives he touched are better for that service.
        Rich served on the staff of our former colleague, Representative
    John LaFalce; helping families here in New York through the casework
    Rich spearheaded in the district office. The work he did with the
    families of the Love Canal environmental disaster was one of his most
    important contributions. During his tenure, Rich developed a respect
    and love for the House of Representatives as an institution that he
    carried and discussed for the rest of his life.
        Rich Lee would eventually be diagnosed with Alpha-1 Antitrypsin
    Deficiency. Rich Lee was an advocate for increased medical research for
    improved treatments and increased access to care for those like himself
    who battle this disorder. True to form Rich was working to advocate for
    the Alpha-1 community to the end by helping the foundation with the
    home infusion legislation. I am honored to acknowledge this life well
    lived in service to others.

        [This statement was submitted by Scott Santarella, President & CEO,
    Alpha-1 Foundation.]
                                     ______

       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) 2023 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 $226
    million increase for Alzheimer's research at the National Institutes of
    Health (NIH) and $30 million for implementation of the Building Our
    Largest Dementia (BOLD) Infrastructure for Alzheimer's Act (Public Law
    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. The Alzheimer's Impact Movement 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 which 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 $321 billion for health care,
    long-term care, and hospice care in 2022. The U.S. taxpayer-funded
    Federal health care programs Medicare and Medicaid are expected to
    cover $206 billion, or 64 percent, of the total health care and long-
    term care payments for people with Alzheimer's or other dementias this
    year. An estimated 6.5 million Americans aged 65 and older are living
    with Alzheimer's in 2022. By 2050, the number of people 65 and older
    with Alzheimer's may grow to a projected 12.7 million people. Unless a
    treatment to slow, stop, or prevent the disease is developed, in 2050,
    Alzheimer's is projected to cost nearly $1 trillion dollars.
    Alzheimer's and other dementia threaten to bankrupt families,
    businesses, and our health care system.
                      investing in alzheimer's treatments
        Last year, the Food and Drug Administration (FDA) 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, while not a cure, is a pivotal moment in
    addressing the disease. This is the first of a number of new treatments
    to come. We do recognize the drug may work differently for everyone who
    takes it, and may not work for some individuals. Importantly,
    aducanumab was studied in and is appropriate for people living with
    early Alzheimer's dementia and mild cognitive impairment 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.
        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 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 $226 million in Alzheimer's
    research at NIH in FY 2023 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 5 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 FY 2020, 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
    FY 2021 helped fund additional public health departments and expand the
    impact of this crucial work into more communities across the country.
    In FY 2022, Congress appropriated $25 million dollars for continuing
    its support for BOLD implementation, and will further enable the public
    health agencies to expand their activities.
        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 works 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 currently leading a 5-year clinical
    trial to evaluate a 2-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 $30 million authorized in the law
    for FY 2023 to ensure the meaningful impact that Congress intended. The
    Alzheimer's Association and AIM urge Congress to include the full $30
    million for the third year of BOLD's implementation at CDC in FY 2023.
    Activities supported by the requested $30 million in FY 2023 would
    enable CDC to 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 $226
    million for Alzheimer's research activities at NIH and $30 million for
    full implementation of the BOLD Infrastructure for Alzheimer's Act at
    CDC in FY 2023.
                                     ______

            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 2023 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: $30 million for Pediatric Subspecialty Loan
    Repayment (HRSA), $60 million for Firearm Injury and Mortality
    Prevention Research (CDC/NIH), $14 million for Pediatric Mental Health
    Care Access Grants (HRSA), $28.134 million for Emergency Medical
    Services for Children (HRSA), $205 million for the National Center for
    Birth Defects and Developmental Disabilities (CDC), $356 million for
    Global Immunizations (CDC), $12 million for implementation of
    Scarlett's Sunshine Act (CDC/HRSA), $26.2 million for the
    administrative component of the National Vaccine Injury Compensation
    Program (HRSA), and $15 million for provisions in the Vaccine Awareness
    Campaign to Champion Immunization Nationally and Enhance Safety
    (VACCINES) Act (CDC).
    Pediatric Subspecialty Loan Repayment Program (HRSA):
        FY 23 Request: $30 million; FY 22 Level: $5 million.--The AAP
    appreciates first-time funding of $5 million in FY22 for the Pediatric
    Subspecialty Loan Repayment Program, a Title VII health professions
    program designed 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. To expand the number of beneficiaries of this
    program, the Academy respectfully requests $30 million in FY23. The
    United States' current 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 percent 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 23 Request: $60 million total; FY 22 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 fiscal
    Year22. Gun violence remains a public health problem, but the dearth of
    research on how best to prevent firearm-related morbidity and mortality
    makes it difficult to address it. Federally funded public health
    research has a proven track record of reducing public health-related
    deaths, whether from motor vehicle crashes or smoking. This same
    approach should be applied to increasing gun safety and reducing
    firearm-related injuries and deaths, including suicides, and continuing
    and expanding CDC and NIH research will be critical to that effort. As
    such, for FY23, the Academy urges Congress to allocate $60 million for
    firearm injury and mortality prevention research, with $35 million
    dedicated to CDC and $25 million to NIH.
    Pediatric Mental Health Care Access Grants (HRSA):
        FY 23 Request: $14 million; FY 22 Level: $11 million.--The AAP
    appreciates the support Congress has shown for Pediatric Mental Health
    Care Access Grants, with $11 million in funding for the program in
    FY22, as well as robust funding in the American Rescue Plan in
    recognition of the impact of COVID-19 on child and adolescent mental
    health. The 45 States, Tribal organizations, and territories who are
    receiving grants through this program are providing tele-consultation,
    training, technical assistance, and care coordination for pediatric
    primary care providers to diagnose, treat and refer children with
    behavioral health conditions. Research shows pervasive shortages of
    child and adolescent mental/behavioral health specialists throughout
    the United States. 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. In fact, a recent RAND study found that 12.3
    percent of children in States with programs such as the ones funded
    under this HRSA program had received behavioral health services while
    only 9.5 percent of children in States without such programs received
    these services. In FY23, the AAP urges Congress to provide $14 million
    in funding for Pediatric Mental Health Care Access Grants so that his
    proven program can be extended to every State, Tribal organization, and
    territory.
    Emergency Medical Services for Children (HRSA):
        FY 2023 Request: $28.134 million; FY 22 Level: $22.334 million.--
    The AAP urges the committee to increase funding for the Emergency
    Medical Services for Children (EMSC) Program to $28.134 million in
    fiscal Year23. 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. An additional $5.8 million in funding in FY23 will allow the
    program to provide increased funding to States to address gaps in
    children's access to high quality emergency and trauma care as well to
    support States building mental health capacity for children in
    emergency departments.
    National Center for Birth Defects and Developmental Disabilities (CDC):
        FY 23 Request: $205 million; FY 22 Level: $177.06 million.--The AAP
    requests $205 million for fiscal Year23 for the National Center for
    Birth Defects and Developmental Disabilities (NCBDDD). 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.
    Increased FY23 funding would be used to build upon and expand work
    within the Center's priorities such as uniform data collection for
    neonatal abstinence syndrome; supporting the act Early: Children's
    Mental Health program, data collection around sickle cell disease, and
    expansion of the Surveillance for Emerging Threats to Mothers and
    Babies (SET-NET) program to allow more States to participate and gather
    needed information to protect pregnant individuals and infants from
    emerging public health threats.
    Global Immunization--Polio and Measles/Other (CDC):
        FY 23 Request: $356 million ($276 million for Polio and $80 million
    for Measles/Other); FY 22 Level: $228 million ($178 million for Polio
    and $50 million for Measles/Other).--The CDC's global immunization
    program is one of the most cost-effective and successful public health
    solutions available and U.S. investments have driven remarkable
    results. The CDC was a founding member of the Measles and Rubella
    Initiative, which has vaccinated over 2 billion children and prevented
    23.2 million deaths from measles since 2001. Since 1988, the CDC's
    global polio immunization work has reduced the number of polio cases
    globally by 99.9 percent, saving more than 10 million children from
    paralysis and bringing the disease close to eradication. Thanks to
    sustained funding by the U.S. government through the CDC and USAID and
    the coordinated efforts of the Global Polio Eradication Initiative
    (GPEI), the opportunity for a polio-free world is within reach.
    Unfortunately, the gains from global immunization are in jeopardy.
    Throughout the ongoing COVID-19 pandemic, many countries diverted
    resources set aside for polio and routine immunizations to fight the
    pandemic. While this was vital to many countries' ability to quickly
    respond to COVID-19, it has come at a terrible cost to polio
    eradication and routine child vaccination. In the first 2 months of
    2022, measles cases were up 79 percent compared with the year prior.
    The World Health Organization and UNICEF warned of a ``perfect storm''
    of conditions for measles outbreaks. Additionally, polio cases have
    increased, with Malawi experiencing its first wild polio case in three
    decades. To recover from pandemic-related disruptions, the Academy
    urges Congress to appropriate at least $276 million for polio and $80
    million for measles vaccination programs.
    Activities Authorized under Scarlett's Sunshine Act (CDC/HRSA):
        FY 23 Request: $12 million ($8.5 million at CDC for the Safe
    Motherhood and Infant Health account and $3.5 million at MCHB within
    the Special Projects of Regional and National Significance account); FY
    22: Level: $1 million at HRSA and $2 million at CDC.--In passing the
    Scarlett's Sunshine Act in late 2020, Congress recognized the need for
    Federal investments in research and prevention of sudden unexpected
    infant death (SUID) and sudden unexplained death in childhood (SUDC).
    The law authorized $12 million for HHS to award grants and improve data
    and monitoring. Full funding for this initiative will strengthen
    efforts to better understand SUID and SUDC, facilitate data collection
    and analysis to improve prevention efforts, and support children and
    families. Requested CDC funding would improve communities' responses to
    infant and child death cases, inform prevention and clinical care, and
    help standardize data collection and reporting, as well as procedures
    and protocols for death scene investigations and autopsies. The grants
    can also fund safe sleep outreach efforts, which can reduce the risk of
    SUID. The funds at MCHB would support the expansion and use of the Case
    Reporting System to provide data summaries and dashboards on all SUIDs
    and making datasets available to researchers. These MCHB funds can also
    support bereavement services for affected families, which MCHB cannot
    currently provide.
    National Vaccine Injury Compensation Program Administration (HRSA):
        FY 23 Request: $26.2 million; FY 22 Level: $13.2 million.--The
    Academy supports increased funding for the administrative component of
    the National Vaccine Injury Compensation Program (NVICP), which was
    established in 1988 to ensure an adequate supply of vaccines, stabilize
    vaccine costs, and establish and maintain an accessible and efficient
    forum for individuals found to be injured by certain vaccines. NVICP is
    an alternative to the traditional tort system for resolving vaccine
    injury claims and provides compensation to individuals found to be
    injured by certain vaccines. NVICP claims have increased more than
    fivefold from 402 claims filed in FY 2012 to 2,057 claims filed in FY
    2021 while the administrative funding barely doubled from $6.5 million
    to $11.2 million during the same period. The steep increase in claims
    filed is due in large part to the flu vaccine being administered to
    adults. In fact, most of all petitions filed are now adult claims for
    alleged injuries from the flu vaccine. Though the number of petitions
    has risen, the number of staff to administer the claims has not risen
    at the same level. By hiring more staff and thereby expediting the
    processing of claims filed in the NVICP, the children and families who
    have been injured by a vaccine will be able to receive their due
    compensation in a timely manner. It will also help prepare HRSA to
    administer the NVICP program if the COVID-19 vaccine is eventually
    transferred from the Countermeasures Injury Compensation Program and
    included in NVICP program.
    Activities Authorized under the VACCINES Act (CDC):
        FY 23 Request: $15 million; FY 22 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. Much of this funding was distributed to State
    and local public health departments to help promote the uptake of
    COVID-19 vaccines and to provide Americans with accurate information
    about these vaccines. As we pass 2 years of living through the
    pandemic, it is more important than ever to bolster American's
    confidence in vaccines and debunk misinformation and disinformation
    about vaccines. The VACCINES Act authorizes the development of a
    national vaccination rate surveillance system at CDC and allows data
    collected to be used to identify communities with low vaccination
    utilization or where vaccine misinformation may be targeted. It also
    authorizes research grants to better understand vaccine hesitancy,
    attitudes towards vaccines, and develop strategies to address
    nonadherence to the recommended use of vaccines. Additionally, the
    VACCINES Act authorizes an evidence-based public awareness campaign on
    the importance of vaccinations to increase vaccination rates, including
    targeting communities that have particularly low vaccination levels.
    The AAP urges Congress to allocate the authorized $15 million for CDC
    to ensure these activities take place to boost vaccine confidence in
    routine and COVID-19 immunizations and boost vaccination rates across
    the lifespan.
        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 2023 and beyond. If we may be of
    further assistance, please contact the AAP Department of Federal
    Affairs at 202-347-8600 or pjohnson@aap.org. Thank you for your
    consideration.

        [This statement was submitted by Moira A. Szilagyi, MD, FAAP,
    President,
    American Academy of Pediatrics.]
                                     ______

                Prepared Statement of the American Association
                        for the Study of Liver Diseases
        The American Association for the Study of Liver Diseases (AASLD)
    thanks this subcommittee for the opportunity to submit outside witness
    testimony on opportunities to support and improve the health of
    Americans living with various forms of liver disease, ranging from non-
    alcoholic fatty liver disease to liver cancer, in the Fiscal Year
    (FY)2023 Labor, Health and Human Services, Education and Related
    Agencies bill and report.
        The liver, the largest solid organ in the body, is a master
    regulator of a diverse array of life sustaining chemical processes. In
    liver disease, these processes are disrupted. The result is ongoing
    organ injury, progressive scarring, and the development of cirrhosis
    and liver cancer. Over 40,000 Americans die each year from these
    complications. In 2019, liver disease was the fourth leading cause of
    death for those 45 to 64 years of age, and that figure continues to
    grow. AASLD is calling on this subcommittee to support biomedical
    research and public health programs to reverse the growing public
    health burden of liver disease. We respectfully request that you
    provide at least $49.048 billion for the National Institutes of Health
    (NIH) and $140 million for the Centers for Disease Control and
    Prevention (CDC) Division of Viral Hepatitis (DVH).
                                funding for nih
        Robust, sustained, and predictable funding is important to advance
    the entire biomedical research enterprise, not just work related to the
    full spectrum of liver diseases. AASLD is deeply appreciative of the
    investment Congress has made to provide NIH with the resources for
    meaningful growth above inflation, and our request of $49.048 billion
    will ensure this trajectory can be maintained and meritorious research
    in liver disease will be supported.
        To meaningfully advance our understanding of liver diseases, all
    NIH Institutes and Centers (I/Cs) must receive a proportional increase
    in funding in FY 2023. Many I/Cs support the research our members
    perform, reinforcing the importance of providing a proportional
    increase across the NIH: the National Cancer Institute supports
    research in liver cancer, one of the most lethal cancers; the National
    Institute of Allergy and Infectious Diseases-funded projects are
    advancing our understanding of viral hepatitis and helping us move
    closer to its elimination; and the National Institute of Alcohol Abuse
    and Alcoholism (NIAAA) is funding projects to address the growing
    burden of alcohol-associated liver disease. AASLD would like to stress
    the importance of the National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK), the home for liver disease research, receiving
    at least a proportional increase to NIH. Unlike many other I/Cs, NIDDK
    did not receive any emergency COVID-19 funding, yet it supports many
    chronic conditions such as liver disease that increase a person's risk
    for severe COVID-19 and long COVID. The institute is already being
    forced to make difficult choices about funding COVID-19 related
    research and other research areas, which will only be exacerbated by
    receiving an increase that is not proportional to the broader NIH.
    Additionally, we are requesting this robust appropriation for NIH to
    provide for meaningful support of a diverse physician-scientist
    workforce. AASLD is concerned that the physician-scientist workforce is
    shrinking at a time when their expertise is needed to meet the needs of
    Americans living with liver diseases, especially as COVID-19 continues
    to pose an increased risk for these patients.
        AASLD would also like to take this opportunity to address the
    Advanced Research Projects Agency for Health (ARPA-H). The $49.048
    billion we are requesting for NIH should be separate from any
    appropriation made to ARPA-H in FY 2023; any funds appropriated to
    ARPA-H should supplement, not supplant, those for NIH. AASLD strongly
    supports and believes in the potential for ARPA-H to meaningfully
    improve the health of Americans living with liver disease by developing
    new tools to treat and potentially prevent these conditions. However,
    this work cannot be done at the expense of the basic science and
    investigator-initiated research in which NIH invests; AASLD strongly
    believes the best way to support both lines of inquiry is for Congress
    to authorize ARPA-H so that is housed outside of NIH.
              appropriate $140 million for cdc dvh to support the
                         elimination of viral hepatitis
        AASLD is committed to meeting the goal of eliminating viral
    hepatitis. We have vaccines to prevent Hepatitis A and Hepatitis B, and
    while we may not have a Hepatitis C vaccine, we now have the
    therapeutics to cure those infected. However, vaccines and effective
    therapeutics alone cannot move the country towards elimination;
    therefore, we urge Congress to provide the investment necessary to
    support this goal. The overall CDC budget has decreased in real dollars
    several times in the last decade. Despite recent pandemic-related
    investments across the agency, funding for DVH has remained relatively
    flat, leaving the Division unable to support the policies and programs
    necessary to bolster efforts towards the elimination of viral
    hepatitis. We therefore urge you to appropriate $140 million for DVH as
    a down payment on progress towards elimination.
        We recognize that this request represents a $99 million increase in
    DVH's funding, yet it does not come close to providing the funding that
    the CDC estimated would be required to put the United States on the
    path to eliminating viral hepatitis. In its 2016 Professional Judgement
    Budget, the CDC estimated it would take at least $316 million to do
    this. There is a critical need to enhance the capacity to detect and
    respond to outbreaks. Increased funding for DVH is also critically
    important to support adult vaccination programs for Hepatitis A and
    Hepatitis B and address the ongoing opioid epidemic, which has been
    exacerbated by the COVID-19 pandemic.
           support the formation of a national liver disease strategy
        The burden of liver disease is growing rapidly, imposing
    significant costs to the country's public health and health care
    systems. For example, liver cancer has emerged as one of the fastest
    rising causes of cancer deaths in the country, and with a forecasted
    40,000 new liver cancer diagnoses and 30,000 liver cancer deaths in
    2022, survival rates remain poor. Additionally, at least 5.3 million
    Americans are infected with viral hepatitis and the majority are
    undiagnosed while the disease destroys their liver.
        Despite the growing toll the full spectrum of liver diseases is
    imposing, there is no strategy to address the breadth of the health and
    economic effects of this disease in the United States. For these
    reasons, AASLD calls on Congress to direct the Department of Health and
    Human Services (HHS) to develop a department-wide strategic plan to
    combat liver disease, including viral hepatitis, fatty liver disease,
    alcohol-associated liver disease, cirrhosis, and liver cancer. HHS
    should seek input from across the government, including from the CDC,
    the NIH, the Food and Drug Administration, and the Health Resources and
    Services Administration (HRSA), as well as researchers, providers, and
    patients to formulate this strategy.
        Accordingly, the AASLD requests the inclusion of the following
    language in the report accompanying the FY 2023 LHHS Appropriations
    bill with regards to the HHS Office of the Secretary:
        National Liver Disease Strategy.--The Committee recognizes the
    growing burden of liver disease, including viral hepatitis, non-
    alcoholic fatty liver disease, cirrhosis, and liver cancer, and its
    significant costs to the country's health care system. In 2019, liver
    disease was the fourth leading cause of death for those 45 to 64 years
    of age. Despite the growing toll the full spectrum of liver diseases is
    imposing, there is no strategy to address the breadth of the health and
    economic effects of this disease in the United States. For these
    reasons, the Committee directs the Secretary of HHS to develop a
    department-wide strategic plan to combat liver disease. This strategy
    should include a framework to guide the development of policies and
    initiatives to prevent, diagnose, and treat liver disease across
    Federal agencies. Specifically, the strategy should coordinate efforts
    to prevent future cases of liver disease through improved disease
    surveillance and improve liver disease outcomes for current patients by
    addressing health disparities and inequities. The Committee provides $2
    million to support this effort and requests an update on the
    department's plans to begin this work within 180-days of enactment.
                   support universal hepatitis b vaccination
        Hepatitis B is a highly infectious disease with an estimated 20,700
    acute infections each year, and almost two million people are living
    with chronic hepatitis B in the US today. Today, some parts of the
    country, particularly those States most affected by the opioid
    epidemic, are experiencing sharp increases in infections. The hepatitis
    B virus can lead to serious complications, such as liver failure,
    cirrhosis, and liver cancer.
        For these reasons, the AASLD was pleased to see the CDC Advisory
    Committee on Immunization Practices (ACIP) recommendation for universal
    hepatitis B vaccination for adults aged 19 to 59. CDC will be formally
    supporting this recommendation in a forthcoming edition of the
    Morbidity and Mortality Weekly Report. This is a key step towards
    eliminating this vaccine-preventable and treatable disease. As such, we
    respectfully request the inclusion of the following report language in
    the report that accompanies the FY 2023 LHHS appropriations bill under
    the HHS Office of the Secretary:
        Universal Hepatitis B Vaccination.--The Committee believes the
    Centers for Disease Control and Prevention's Advisory Committee on
    Immunization Practices (ACIP) recommendation for universal hepatitis B
    vaccination for adults aged 19 to 59 is a crucial step towards the
    elimination of this vaccine-preventable virus. It comes as parts of the
    country, particularly those States most affected by the opioid
    epidemic, are experiencing sharp increases in hepatitis B infections.
    The Committee requests a report back on the specific steps being taken
    to implement this recommendation across the agency and departments,
    including but not limited to the CDC Division of Viral Hepatitis, the
    CDC Immunization Services Divisions, and the HRSA Health Center
    Program, and any barriers that have been encountered and assistance
    needed to overcome them within 120 days of enactment.
              advance research on alcohol-associated liver disease
        Alcohol-associated liver disease (ALD) represents a wide-range of
    liver injury resulting from alcohol use, including inflammation of the
    liver, cirrhosis, or permanent scarring of the liver, and other life-
    threatening complications. ALD is a major cause of liver disease and
    research advancements in this area are urgently needed, particularly
    due to the increased rates of alcohol consumption during the COVID-19
    pandemic. Preliminary data indicate a significant increase in alcohol
    consumption during the pandemic, and increased alcohol use has the
    potential to increase morbidity and mortality from ALD. Moreover, early
    data suggest that patients with ALD may experience worse COVID-19
    outcomes and complications. For these reasons, AASLD believes this area
    of research could benefit from a more comprehensive approach to
    research on ALD and alcohol use disorders at the NIH. Therefore, the
    AASLD respectfully requests that you include the following report
    language in the report that accompanies the FY 2023 LHHS appropriations
    bill under the NIH NIAAA:
        Alcohol-Associated Liver Disease.--The Committee is aware that
    alcohol use disorder and alcohol-associated liver disease are distinct
    diseases. However, it is rare for patients to have the latter without
    first having the former. Combining the research in this area in a
    holistic approach could lead to advancements for both, which are needed
    urgently given the increased rates of alcohol consumption during the
    pandemic. The Committee requests a report in next year's budget
    justification on the viability of this approach, including NIAAA's
    capacity to award related grants and the field's capacity to develop
    scientifically valid research projects.
                                   conclusion
        Thank you again for the opportunity to submit testimony to the
    Committee as you begin your work on the FY 2023 appropriations bills.
    We look forward to working with you to improve the health and well-
    being of all Americas living with liver disease.
                                     ______

       Prepared Statement of the American Association for Cancer Research
        Chair Murray, Ranking Member Blunt, and members of the
    subcommittee, thank you for the opportunity to submit testimony. I am
    Dr. Lisa Coussens, Associate Director for Basic Research at the Knight
    Cancer Institute, an NCI Comprehensive Cancer Center, and Chair of the
    Department of Cell, Developmental & Cancer Biology at Oregon Health &
    Science University. I am submitting testimony as President of the
    American Association for Cancer Research (AACR), the world's first and
    largest professional organization dedicated to advancing cancer
    research and its mission to prevent and cure all cancers. On behalf of
    the AACR's more than 50,000 members, who are scientists, physicians,
    other healthcare workers, and patient advocates, I ask for your support
    for at least $49 billion in Fiscal Year (FY) 2023 funding for the
    National Institutes of Health (NIH) and $7.766 billion for the National
    Cancer Institute (NCI).
        The AACR is grateful for your commitment to cancer research and the
    increase of $353 million Congress provided NCI in FY 2022. Today, as
    you begin work on FY 2023 appropriations, I humbly ask that you build
    on that support and address the urgent financial pressures at NCI.
        History shows what can be achieved when Congress prioritizes
    medical research. After years of underinvestment, former President
    Clinton embarked on a path of doubling NIH funding, a goal which
    Congress far exceeded. In 1999, success rates, i.e., the percent of
    research grant applications that receive funding, reached 32 percent
    across NIH and 28 percent at NCI. The NCI Director at the time, Dr.
    Richard D. Klausner, referred to this era as ``a golden age of
    discovery, one unique in human history.'' This funding fueled
    discoveries at an unprecedented rate.
        Thanks to these investments, truly remarkable progress has been
    made. For example, treating late-stage lung cancer and melanoma has
    been revolutionized with the development of a new class of
    immunotherapies that activate a patient's own immune system to fight
    cancer. In the 1990s and early 2000s, fewer than 1 in 6 patients
    diagnosed with metastatic melanoma lived 5 years after diagnosis. But
    now more than half of patients with metastatic melanoma who receive
    immunotherapy combinations live longer than 5 years, many without any
    signs of disease. These remarkable new therapies emerged out of Federal
    investments in basic science.
        And as a result, we see similar results playing out for the
    millions of Americans who otherwise might have lost their lives to
    cancer, as there are now nearly 17 million cancer survivors living in
    the United States. In the 50 years since the enactment of the National
    Cancer Act, cancer mortality rates have dropped by 27 percent. These
    drastic reductions are due to prevention efforts such as reduced
    smoking rates, more effective screening tools which detect cancer at an
    earlier, more treatable stage, and the success of better, more targeted
    drugs that allow patients with cancer to live longer after a diagnosis.
    These developments and therapies would not have been possible without
    decades of basic research funded by NCI and NIH to understand the
    causes and development of cancer, the immune system, and how cancer
    cells evade detection.
        Researchers are building on these discoveries to find additional
    anti-cancer drug targets within the immune system and to understand why
    some tumors do not respond as well to treatment. We are so close to
    unlocking new discoveries that could fundamentally change cancer care
    and survivorship, but to do so, we need Federal investments to keep up
    with the growing demands on basic research for cancer.
        The cancer research community's ability to understand, detect, and
    treat cancers is exploding with potential. Between 2013 and 2018, NCI
    witnessed a nearly 46 percent increase in grant applications, dwarfing
    the increase of other institutes at NIH which only increased by 4.9
    percent. And yet, NCI funding has not kept up with application growth
    or inflation. Even with the significant funding provided by Congress,
    NCI's success rate in FY 2021 was only 13 percent, less than half the
    rate that spurred historic success two decades ago. NCI's success rate
    is also among the lowest of all institutes at NIH. Currently, less than
    one-in-seven grant applications are approved, leaving well-reviewed
    science unfunded and jeopardizing our ability to spur further
    innovative approaches to cancer science. This extremely low funding
    rate is not only limiting scientific discovery, but it is also having
    an adverse impact on the financial and career security of cancer
    scientists, in particular, early-stage researchers who may be forced to
    choose other, more secure career paths.
        By meeting the NCI professional judgment budget level of $7.766
    billion in FY 2023, NCI can invest in more early-stage researchers,
    increase the availability of research grants, and accelerate the path
    to discoveries that will save lives. While financial constraints at NCI
    pre-date the emergence of COVID-19, the pandemic has exacerbated
    challenges within the cancer research community by closing
    laboratories, disrupting the implementation of clinical trials, and
    contributing to hiring freezes, forced staff turnovers, and delays and
    shortages of supplies. Many of these activities are yet to fully
    recover.
        In addition, we do not yet know the full scope of what COVID-19
    will mean for patients who delayed their cancer screenings, many of
    whom will be diagnosed with later stage disease that will be harder and
    costlier to treat. Former NCI Director, Dr. Norman ``Ned'' Sharpless,
    estimated that COVID-19 could result in 5,000 to 10,000 excess cancer
    deaths from breast cancer and colorectal cancer alone in the next
    decade due to delayed cancer screenings and medical appointments. The
    NCI's work will be crucial in rebuilding cancer science and ensuring
    that we emerge from this crisis with better tools to assist patients
    navigating a cancer diagnosis.
        Throughout my career, some truths about cancer have become
    abundantly clear. Cancer does not care where you live, or whether you
    are rich or poor. It forces a tremendous economic and social impact
    regardless of whom it touches. But with investments in medical
    research, it is my goal that one day, even advanced cancers will be
    treated as a chronic condition that a person can control and live with,
    but one that will not ultimately take their life. We have the power to
    achieve this goal within our grasp. Now is the time to put our foot on
    the gas and accelerate discoveries. We do not have a moment to spare.
        Thank you for the opportunity to submit testimony on behalf of the
    AACR and for your commitment to bringing us closer to our mutual goal
    of conquering cancer.

        [This statement was submitted by Lisa M Coussens, MD (hc), PhD,
    FAACR, President, American Association for Cancer Research.]
                                     ______

     Prepared Statement of the American Association for Dental, Oral, and
                             Craniofacial Research
        Chair Murray, Ranking Member Blunt, and members of the
    subcommittee, thank you for the opportunity to submit this testimony on
    behalf of the American Association for Dental, Oral, and Craniofacial
    Research (AADOCR). I am pleased to submit this statement describing
    AADOCR's funding requests for FY 2023. I currently serve as President
    of the Association. I am also a professor and former dean at the
    University of North Carolina-Chapel Hill Adams School of Dentistry and
    an adjunct professor at UNC's Gillings School of Global Public Health.
        For FY 2023, AADOCR--along with our colleagues in the oral health
    community--is seeking at least $540 million for the National Institute
    of Dental and Craniofacial Research (NIDCR) and a total of $49 billion
    for all of the Institutes and Centers at the National Institutes of
    Health (NIH). Funding at these levels is necessary for the entities'
    base budgets to keep pace with the biomedical research and development
    price index (BRDPI).
        The NIH, through the biomedical research it conducts and supports,
    plays a critical role in improving Americans' health and well-being.
    When the COVID-19 pandemic hit our Nation and the world, the NIH helped
    safeguard the public health through its significant contributions to
    the development of testing, vaccines and treatments. The NIH continues
    to develop and maintain the resources, both human and scientific, that
    provide our Nation with the tools it needs to address other diseases
    and disabilities.
        The NIDCR, established by President Harry S. Truman in 1948, is the
    largest institution in the world exclusively dedicated to researching
    ways to improve dental, oral, and craniofacial health for all.
    Investments in NIDCR-funded research during the past half-century have
    led to improvements in oral health for millions of Americans and
    continue to show promise in areas encompassing the prevention of dental
    caries (cavities) and periodontal disease (gum disease), new diagnostic
    methods of oral and dental conditions, pain biology and management,
    regenerative medicine, oral cancer, and in assessing the efficacy of a
    human papillomavirus (HPV) vaccine for oral and pharyngeal cancers.
        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. Poor oral health can
    affect activities that may be taken for granted--the ability to eat,
    drink, swallow, smile, speak, and maintain proper nutrition--and create
    economic burden that disproportionately harms older adults, low income,
    and underserved communities.
        The oral cavity also serves as a window into many 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. Additionally, researchers are
    exploring the debilitating loss of salivary gland functioning and
    saliva production stemming from radiation treatment for head and neck
    cancers and even from common medications and aging itself.
        The NIDCR played a critical role in responding to the COVID-19
    public health crisis funding approximately $3.9 million in high-impact
    coronavirus research. The Institute's research into minimizing
    infection risk in dental offices, the use of biosensors to detect SARS-
    CoV-2 in saliva, the role of periodontal disease in COVID-19
    complications, and exploring mechanisms of viral entry into the tissues
    of the oral cavity played a critical role in combatting COVID-19.
    Continued investment in NIDCR will allow the Institute to pursue these
    research efforts and expand into new areas of research, such as the
    interplay between the oral microbiome and immune system, to improve
    Americans' oral and overall health.
        In December 2021, NIDCR released ``Oral Health in America: Advances
    and Challenges'', a data-driven report with input from over 400
    contributors documenting 20 years of progress in oral health since the
    2020 Surgeon General's Report on Oral Health. The report provides
    insight into issues currently affecting oral health and serves as a
    call to action for a coordinated effort among oral health
    practitioners; researchers; and other stakeholders to improve oral
    health for all Americans.
        AADOCR deeply appreciates Congress' longstanding and bipartisan
    support for the public health research enterprise. The funding
    increases NIDCR has received since 2015 have allowed the Institute to
    build its data repository and registry in several disease and research
    areas to meet the increasing need for open-source data sharing. These
    include clinical registries and repositories related to head and neck
    cancers, orofacial birth defects and craniofacial anomalies, and
    craniofacial microsomia cohorts to identify genetic risk factors. The
    Institute also participates in trans-NIH and NIH Common Fund
    initiatives for data analysis and sharing.
        Despite NIDCR's impressive research agenda and scientific
    accomplishments, the Federal Government's annual investment in the
    Institute has not kept pace with the overall funding increases provided
    to NIH over the past several years. Funding of at least $540 million in
    FY 2023 would help bring NIDCR funding into alignment with the overall
    NIH appropriation and allow NIDCR to build on its myriad successes in
    its mission to improve dental, oral and craniofacial health.
        Recognizing that Federal research and public health efforts work in
    concert with one another and that success in one area can benefit
    another, we encourage Congress to support the full breadth of Federal
    agencies supporting oral health. Complementing our NIDCR and NIH
    requests, we urge you to provide $35 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, $500 million for the Agency for Healthcare Research and
    Quality (AHRQ), and $210 million for the National Center for Health
    Statistics (NCHS) in FY 2023.
        Finally, AADOCR strongly supports the establishment of the Advanced
    Research Projects Agency for Health (ARPA-H), which will help fill gaps
    in the biomedical research ecosystem by utilizing a bold new approach
    focused on the development of evidence-based, real-world-driven cures
    for a range of diseases. We urge you to support the Administration's
    request of $5 billion for ARPA-H in FY 2023, but not at the expense of
    funding for the NIH's base budget. It's critical that funding for this
    new agency complement--not supplant--the foundational investment in
    traditional NIH Institutes and Centers.
        We appreciate the opportunity to submit this testimony and thank
    the subcommittee for its support of biomedical research, including
    dental, oral and craniofacial research, in FY 2023 so our Nation's
    citizens can continue to enjoy the benefits of state-of-the-art and
    world-leading health care. We stand ready to assist the members of this
    subcommittee in any way we can and are happy to answer any questions
    you may have.
        Sincerely.

        [This statement was submitted by Jane Weintraub, DDS, MPH,
    President (2022-2023), American Association for Dental, Oral, and
    Craniofacial Research.]
                                     ______

     Prepared Statement of the American Association for the Study of Liver
                                    Diseases
        The American Association for the Study of Liver Diseases (AASLD)
    thanks this subcommittee for the opportunity to submit outside witness
    testimony on opportunities to support and improve the health of
    Americans living with various forms of liver disease, ranging from non-
    alcoholic fatty liver disease to liver cancer, in the Fiscal Year (FY)
    2023 Labor, Health and Human Services, Education and Related Agencies
    bill and report.
        The liver, the largest solid organ in the body, is a master
    regulator of a diverse array of life sustaining chemical processes. In
    liver disease, these processes are disrupted. The result is ongoing
    organ injury, progressive scarring, and the development of cirrhosis
    and liver cancer. Over 40,000 Americans die each year from these
    complications. In 2019, liver disease was the fourth leading cause of
    death for those 45 to 64 years of age, and that figure continues to
    grow. AASLD is calling on this subcommittee to support biomedical
    research and public health programs to reverse the growing public
    health burden of liver disease. We respectfully request that you
    provide at least $49.048 billion for the National Institutes of Health
    (NIH) and $140 million for the Centers for Disease Control and
    Prevention (CDC) Division of Viral Hepatitis (DVH).
                                funding for nih
        Robust, sustained, and predictable funding is important to advance
    the entire biomedical research enterprise, not just work related to the
    full spectrum of liver diseases. AASLD is deeply appreciative of the
    investment Congress has made to provide NIH with the resources for
    meaningful growth above inflation, and our request of $49.048 billion
    will ensure this trajectory can be maintained and meritorious research
    in liver disease will be supported.
        To meaningfully advance our understanding of liver diseases, all
    NIH Institutes and Centers (I/Cs) must receive a proportional increase
    in funding in FY 2023. Many I/Cs support the research our members
    perform, reinforcing the importance of providing a proportional
    increase across the NIH: the National Cancer Institute supports
    research in liver cancer, one of the most lethal cancers; the National
    Institute of Allergy and Infectious Diseases-funded projects are
    advancing our understanding of viral hepatitis and helping us move
    closer to its elimination; and the National Institute of Alcohol Abuse
    and Alcoholism (NIAAA) is funding projects to address the growing
    burden of alcohol-associated liver disease. AASLD would like to stress
    the importance of the National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK), the home for liver disease research, receiving
    at least a proportional increase to NIH. Unlike many other I/Cs, NIDDK
    did not receive any emergency COVID-19 funding, yet it supports many
    chronic conditions such as liver disease that increase a person's risk
    for severe COVID-19 and long COVID. The institute is already being
    forced to make difficult choices about funding COVID-19 related
    research and other research areas, which will only be exacerbated by
    receiving an increase that is not proportional to the broader NIH.
    Additionally, we are requesting this robust appropriation for NIH to
    provide for meaningful support of a diverse physician-scientist
    workforce. AASLD is concerned that the physician-scientist workforce is
    shrinking at a time when their expertise is needed to meet the needs of
    Americans living with liver diseases, especially as COVID-19 continues
    to pose an increased risk for these patients.
        AASLD would also like to take this opportunity to address the
    Advanced Research Projects Agency for Health (ARPA-H). The $49.048
    billion we are requesting for NIH should be separate from any
    appropriation made to ARPA-H in FY 2023; any funds appropriated to
    ARPA-H should supplement, not supplant, those for NIH. AASLD strongly
    supports and believes in the potential for ARPA-H to meaningfully
    improve the health of Americans living with liver disease by developing
    new tools to treat and potentially prevent these conditions. However,
    this work cannot be done at the expense of the basic science and
    investigator-initiated research in which NIH invests; AASLD strongly
    believes the best way to support both lines of inquiry is for Congress
    to authorize ARPA-H so that is housed outside of NIH.
      appropriate $140 million for cdc dvh to support the elimination of
                                viral hepatitis
        AASLD is committed to meeting the goal of eliminating viral
    hepatitis. We have vaccines to prevent Hepatitis A and Hepatitis B, and
    while we may not have a Hepatitis C vaccine, we now have the
    therapeutics to cure those infected. However, vaccines and effective
    therapeutics alone cannot move the country towards elimination;
    therefore, we urge Congress to provide the investment necessary to
    support this goal. The overall CDC budget has decreased in real dollars
    several times in the last decade. Despite recent pandemic-related
    investments across the agency, funding for DVH has remained relatively
    flat, leaving the Division unable to support the policies and programs
    necessary to bolster efforts towards the elimination of viral
    hepatitis. We therefore urge you to appropriate $140 million for DVH as
    a down payment on progress towards elimination.
        We recognize that this request represents a $99 million increase in
    DVH's funding, yet it does not come close to providing the funding that
    the CDC estimated would be required to put the United States on the
    path to eliminating viral hepatitis. In its 2016 Professional Judgement
    Budget, the CDC estimated it would take at least $316 million to do
    this. There is a critical need to enhance the capacity to detect and
    respond to outbreaks. Increased funding for DVH is also critically
    important to support adult vaccination programs for Hepatitis A and
    Hepatitis B and address the ongoing opioid epidemic, which has been
    exacerbated by the COVID-19 pandemic.
           support the formation of a national liver disease strategy
        The burden of liver disease is growing rapidly, imposing
    significant costs to the country's public health and health care
    systems. For example, liver cancer has emerged as one of the fastest
    rising causes of cancer deaths in the country, and with a forecasted
    40,000 new liver cancer diagnoses and 30,000 liver cancer deaths in
    2022, survival rates remain poor. Additionally, at least 5.3 million
    Americans are infected with viral hepatitis and the majority are
    undiagnosed while the disease destroys their liver.
        Despite the growing toll the full spectrum of liver diseases is
    imposing, there is no strategy to address the breadth of the health and
    economic effects of this disease in the United States. For these
    reasons, AASLD calls on Congress to direct the Department of Health and
    Human Services (HHS) to develop a department-wide strategic plan to
    combat liver disease, including viral hepatitis, fatty liver disease,
    alcohol-associated liver disease, cirrhosis, and liver cancer. HHS
    should seek input from across the government, including from the CDC,
    the NIH, the Food and Drug Administration, and the Health Resources and
    Services Administration (HRSA), as well as researchers, providers, and
    patients to formulate this strategy.
        Accordingly, the AASLD requests the inclusion of the following
    language in the report accompanying the FY 2023 LHHS Appropriations
    bill with regards to the HHS Office of the Secretary:

          National Liver Disease Strategy.--The Committee recognizes the
            growing burden of liver disease, including viral hepatitis,
            non-alcoholic fatty liver disease, cirrhosis, and liver cancer,
            and its significant costs to the country's health care system.
            In 2019, liver disease was the fourth leading cause of death
            for those 45 to 64 years of age. Despite the growing toll the
            full spectrum of liver diseases is imposing, there is no
            strategy to address the breadth of the health and economic
            effects of this disease in the United States. For these
            reasons, the Committee directs the Secretary of HHS to develop
            a department-wide strategic plan to combat liver disease. This
            strategy should include a framework to guide the development of
            policies and initiatives to prevent, diagnose, and treat liver
            disease across Federal agencies. Specifically, the strategy
            should coordinate efforts to prevent future cases of liver
            disease through improved disease surveillance and improve liver
            disease outcomes for current patients by addressing health
            disparities and inequities. The Committee provides $2 million
            to support this effort and requests an update on the
            department's plans to begin this work within 180-days of
            enactment.
                   support universal hepatitis b vaccination
        Hepatitis B is a highly infectious disease with an estimated 20,700
    acute infections each year, and almost two million people are living
    with chronic hepatitis B in the US today. Today, some parts of the
    country, particularly those States most affected by the opioid
    epidemic, are experiencing sharp increases in infections. The hepatitis
    B virus can lead to serious complications, such as liver failure,
    cirrhosis, and liver cancer.
        For these reasons, the AASLD was pleased to see the CDC Advisory
    Committee on Immunization Practices (ACIP) recommendation for universal
    hepatitis B vaccination for adults aged 19 to 59. CDC will be formally
    supporting this recommendation in a forthcoming edition of the
    Morbidity and Mortality Weekly Report. This is a key step towards
    eliminating this vaccine-preventable and treatable disease. As such, we
    respectfully request the inclusion of the following report language in
    the report that accompanies the FY 2023 LHHS appropriations bill under
    the HHS Office of the Secretary:
          Universal Hepatitis B Vaccination.--The Committee believes the
            Centers for Disease Control and Prevention's Advisory Committee
            on Immunization Practices (ACIP) recommendation for universal
            hepatitis B vaccination for adults aged 19 to 59 is a crucial
            step towards the elimination of this vaccine-preventable virus.
            It comes as parts of the country, particularly those States
            most affected by the opioid epidemic, are experiencing sharp
            increases in hepatitis B infections. The Committee requests a
            report back on the specific steps being taken to implement this
            recommendation across the agency and departments, including but
            not limited to the CDC Division of Viral Hepatitis, the CDC
            Immunization Services Divisions, and the HRSA Health Center
            Program, and any barriers that have been encountered and
            assistance needed to overcome them within 120 days of
            enactment.
              advance research on alcohol-associated liver disease
        Alcohol-associated liver disease (ALD) represents a wide-range of
    liver injury resulting from alcohol use, including inflammation of the
    liver, cirrhosis, or permanent scarring of the liver, and other life-
    threatening complications. ALD is a major cause of liver disease and
    research advancements in this area are urgently needed, particularly
    due to the increased rates of alcohol consumption during the COVID-19
    pandemic. Preliminary data indicate a significant increase in alcohol
    consumption during the pandemic, and increased alcohol use has the
    potential to increase morbidity and mortality from ALD. Moreover, early
    data suggest that patients with ALD may experience worse COVID-19
    outcomes and complications. For these reasons, AASLD believes this area
    of research could benefit from a more comprehensive approach to
    research on ALD and alcohol use disorders at the NIH. Therefore, the
    AASLD respectfully requests that you include the following report
    language in the report that accompanies the FY 2023 LHHS appropriations
    bill under the NIH NIAAA:

          Alcohol-Associated Liver Disease.--The Committee is aware that
            alcohol use disorder and alcohol-associated liver disease are
            distinct diseases. However, it is rare for patients to have the
            latter without first having the former. Combining the research
            in this area in a holistic approach could lead to advancements
            for both, which are needed urgently given the increased rates
            of alcohol consumption during the pandemic. The Committee
            requests a report in next year's budget justification on the
            viability of this approach, including NIAAA's capacity to award
            related grants and the field's capacity to develop
            scientifically valid research projects.
                                   conclusion
        Thank you again for the opportunity to submit testimony to the
    Committee as you begin your work on the FY 2023 appropriations bills.
    We look forward to working with you to improve the health and well-
    being of all Americas living with liver disease.
                                     ______

     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 would like 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 more than 850
    schools of nursing at private and public universities, who educate more
    than 565,000 students and employ more than 52,000 faculty.\1\
    Collectively, these institutions graduate our Nation's registered
    nurses (RN), advanced practice registered nurses (APRN), educators,
    researchers, and frontline providers.
    ---------------------------------------------------------------------------
        \1\ American Association of Colleges of Nursing. (2022) Who We Are.
    Retrieved from: https://www.aacnnursing.org/About-AACN/Who-We-Are.
    ---------------------------------------------------------------------------
        As we work to combat current public health challenges, such as
    COVID-19, and prepare for the future, ensuring a robust nursing pathway
    requires a strong and sustained Federal investment. For Fiscal Year
    (FY) 2023, AACN respectfully requests that you provide 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 $210 million for the National
    Institute of Nursing Research (NINR).
    Landscape Overview: 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 this public health emergency.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        From the classroom to the frontline, we have witnessed how critical
    a well-educated nursing workforce is to the provision of high-quality
    health care. This need is only expected to grow, as the Bureau of Labor
    Statistics projects a 9 percent increase in RN workforce demand through
    2030, representing the need for an additional 276,800 jobs.\3\ Demand
    for certain APRNs (NPs, CRNAs, and CNMs) is expected to grow even more,
    by 45 percent.\4\
    ---------------------------------------------------------------------------
        \3\ U.S. Bureau of Labor Statistics. (2022). Occupational Outlook
    Handbook- Registered Nurses. Retrieved from: https://www.bls.gov/ooh/
    healthcare/registered-nurses.htm.
        \4\ U.S. Bureau of Labor Statistics. (2022). 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.
    ---------------------------------------------------------------------------
        While AACN saw student enrollment in entry-level baccalaureate
    nursing programs increase by 3.3 percent in 2021, the increase was 2.3
    percent lower than 2020.\5\ Further, nursing schools saw enrollment
    decline in baccalaureate degree-completion programs and some graduate
    programs at the master's and PhD levels.\6\ For the first time since
    2001, enrollment in master's programs decreased by 3.8 percent, which
    translates to 5,766 fewer students enrolled in 2021 than in the
    previous year.\7\ This is concerning because graduate programs prepare
    individuals for a variety of advanced roles in administration,
    teaching, research, informatics, and direct patient care.
    ---------------------------------------------------------------------------
        \5\ American Association of Colleges of Nursing. (2022) Nursing
    Schools See Enrollment Increases in Entry-Level Programs, Signaling
    Strong Interest in Nursing Careers. Retrieved from: https://
    www.aacnnursing.org/News-Information/PressReleases/View/ArticleId/
    25183/Nursing-Schools-See-Enrollment-Increases-in-Entry-Level-Programs.
        \6\ Ibid.
        \7\ Ibid.
    ---------------------------------------------------------------------------
        There were bright spots in 2021, with enrollments in Doctor of
    Nursing Practice (DNP) programs up 4.0 percent.\8\ However, the fact
    remains that a total of 91,938 qualified applications (not applicants)
    were not accepted at schools of nursing nationwide in 2021 alone.\9\ As
    our annual survey found, ``the primary barriers to accepting all
    qualified students at nursing schools continues to be insufficient
    clinical placement sites, faculty, preceptors, and classroom space, as
    well as budget cuts.'' \10\
    ---------------------------------------------------------------------------
        \8\ Ibid.
        \9\ Ibid.
        \10\ Ibid.
    ---------------------------------------------------------------------------
        Educational pathways are just one piece of the puzzle. Strong and
    historic investments in the current nursing workforce are imperative,
    especially as we contend with an aging nursing workforce and the
    lasting impact COVID-19 has had on the profession. In fact, registered
    nurses age 65 and older already make up 19 percent of the workforce,
    and ``more than one-fifth of all nurses reported they plan to retire
    from nursing over the next 5 years.'' \11\ Not to mention a recent
    study which found 52 percent of nurses considered leaving their
    position during the pandemic, up from 40 percent a year earlier.\12\ We
    must minimize the loss of experienced nurses who may prematurely leave
    the profession, and at the same time support nursing education to meet
    the current and future demand for nurses.
    ---------------------------------------------------------------------------
        \11\ National Council of State Boards of Nursing and the National
    Forum of State Nursing Workforce Centers (2021) The 2020 National
    Nursing Workforce Survey. Retrieved from: https://
    www.journalofnursingregulation.com/article/S21558256(21)00027-2/
    fulltext.
        \12\ American Nurses Foundation. (2022). Pulse on the Nation's
    Nurses Survey Series: COVID-19 Two-Year Impact Assessment Survey.
    Retrieved from: https://www.nursingworld.org/492857/contentassets/
    872ebb13c63f44f6b11a1bd0c74907c9/covid-19-2-year-impact-assessment-
    written-report-final.pdf.
    ---------------------------------------------------------------------------
        With increasing demands, an aging population, nursing retirements,
    and an increase in workplace stress,\13\ bold investments in Title VIII
    Nursing Workforce Development Programs and NINR are imperative, not
    only as we confront existing health challenges, but as we provide
    tomorrow's equitable and innovative healthcare solutions.
    ---------------------------------------------------------------------------
        \13\ 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.
    ---------------------------------------------------------------------------
    Investments in Nursing Education Lead to a Strong Nursing Workforce
        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 8,800 students in Academic Year 2020-2021
    alone.\14\ In addition, the Nurse Faculty Loan Program (NFLP) supported
    2,763 graduate nursing students who intend to serve as nurse
    faculty.\15\ ``By the end of the Academic Year, the programs graduated
    779 trainees, 92 percent of whom intended to teach nursing.'' \16\
    ---------------------------------------------------------------------------
        \14\ Health Resources and Services Administration. Fiscal Year 2023
    Budget Justification. Pages 164-170. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2023.pdf.
        \15\ Health Resources and Services Administration. Fiscal Year 2023
    Budget Justification. Page 181. Retrieved from: https://www.hrsa.gov/
    sites/default/files/hrsa/about/budget/budget-justification-fy2023.pdf.
        \16\ Ibid.
    ---------------------------------------------------------------------------
        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 into 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. A recent HHS Assistant Secretary for
    Planning and Evaluation (ASPE) report makes the recommendation to
    ``optimize existing workforce development programs to support diversity
    in the health professional workforce and further support the
    development of a diverse workforce though pipeline programs.'' \17\ 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 2020-2021, the NWD program awarded grants
    supporting 10,155 nursing students from disadvantaged backgrounds.\18\
    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 in FY 2023.
    ---------------------------------------------------------------------------
        \17\ Assistant Secretary for Planning and Evaluation, Office of
    Health Policy. Impact of the COVID-19 Pandemic on the Hospital and
    Outpatient Clinician Workforce Challenges and policy responses. (2022)
    Retrieved from: https://aspe.hhs.gov/sites/default/files/documents/
    9cc72124abd9ea25d58a22c7692dccb6/aspe-covid-workforce-report.pdf.
        \18\ Health Resources and Services Administration. Fiscal Year 2023
    Budget Justification. Pages 171-174. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2023.pdf.
    ---------------------------------------------------------------------------
    From Research to Reality: Nursing Science Protects Americans' Health
        AACN recognizes that scientific research and discovery are 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. In fact, a recent ASPE's report
    recommends to ``support research that investigates long-term workforce
    trends arising from the pandemic and how they can be addressed
    including entry and departure issues, impact on facility staffing, and
    factors associated with health worker morale.'' \19\
    ---------------------------------------------------------------------------
        \19\ Assistant Secretary for Planning and Evaluation, Office of
    Health Policy. Impact of the COVID-19 Pandemic on the Hospital and
    Outpatient Clinician Workforce Challenges and policy responses. (2022)
    Retrieved from: https://aspe.hhs.gov/sites/default/files/documents/
    9cc72124abd9ea25d58a22c7692dccb6/aspe-covid-workforce-report.pdf.
    ---------------------------------------------------------------------------
        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 percent of research-focused educational training grants at
    nursing schools are funded by NINR.\20\ Through these grants and
    others, nurse scientists, often working collaboratively with other
    health professionals, are generating groundbreaking findings and
    leading translation research that works to address strategic
    imperatives, to include health equity, social determinants of health,
    population health, health promotion, and models of care. To further
    this vital work, we are requesting a total of at least $210 million for
    the National Institute of Nursing Research.
    ---------------------------------------------------------------------------
        \20\ Journal of Professional Nursing (2019) 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? Retrieved from https://www.sciencedirect.com/science/article/
    abs/pii/S8755722319301164?via=ihub.
    ---------------------------------------------------------------------------
                                   conclusion
        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 support in FY 2023 of at least $530 million for
    the Title VIII Nursing Workforce Development Programs and at least $210
    million for the National Institute of Nursing Research. Together, we
    can ensure that such investments promote innovation and improve health
    care in America.

        [This statement was submitted by Cynthia McCurren, PhD, RN, 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) appreciates the opportunity to highlight priorities for the
    osteopathic medical education (OME) community in the LHHSE fiscal year
    (FY) 2023 budget.
        AACOM 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 38 accredited
    colleges of osteopathic medicine (COMs)--educating nearly 34,000 future
    physicians, 25 percent of all U.S. medical students--at 60 teaching
    locations in 34 U.S. States, as well as osteopathic graduate medical
    education professionals and trainees at U.S. medical centers,
    hospitals, clinics and health systems.
        AACOM supports FY23 funding for the following priority programs:
      --$49 billion for the National Institutes of Health (NIH)
      --$11 billion for the Centers for Disease Control and Prevention
      --$9.8 billion for discretionary Health Resources and Services
            Administration
      --$1.51 billion for the PHSA Title VII and Title VIII health
            professions workforce programs
      --$500 million for Teaching Health Center Graduate Medical Education
      --$500 million for the Agency for Healthcare Research and Quality
      --$375 million for Children's Hospital Graduate Medical Education
      --$210 million for discretionary National Health Service Corps
            Scholarship and Loan Repayment programs
      --$75 million for the Medical Student Education Program
      --$67 million for the Area Health Education Center Program
      --$59 million for the Primary Care Training and Enhancement Program
      --Permanent funding for the Rural Residency Planning and Development
            Program
        Osteopathic medicine plays an essential role in our Nation's
    healthcare delivery system and is the fastest growing medical field in
    the country according to the U.S. Bureau of Health Professions.
    Osteopathic physicians are trained to see the body as a unit of
    interdependent systems which promotes healing through a dynamic
    interaction of body, mind, and spirit. DOs have expertise in the
    musculoskeletal system, receiving extensive training in osteopathic
    manipulative treatment, a hands-on technique and non-pharmacological
    solution to pain management.
        AACOM is concerned that scientists at osteopathic medical schools
    are underutilized in NIH research and underrepresented on NIH Advisory
    Councils and study sections. The Joint Explanatory Statement
    accompanying the Consolidated Appropriations Act, 2022 (Public Law 117-
    103) highlighted this concern and requires NIH to report on the status
    of NIH funding to colleges of osteopathic medicine and the
    representation of DOs on NIH National Advisory Councils and study
    sections. We thank you for acknowledging this disparity and urge the
    subcommittee to ensure swift implementation.
        If this disparity in funding and representation continues, NIH will
    miss a key opportunity to bolster its capacity to address some of the
    Nation's most pressing health threats. COMs have a commitment to
    serving rural and underserved communities: 58 percent are located in
    Health Professional Shortage Areas and almost all schools have a
    mission to address these populations. Moreover, nearly 40 percent of
    physicians practicing in medically-underserved areas are DOs. They
    serve as the backbone of the primary care system with more than half of
    DOs practicing in primary care specialties. Finally, COMs routinely
    train osteopathic medical students in community-based settings, which
    aligns with the U.S. Department of Health and Human Services Initiative
    to Strengthen Primary Health Care. Maintaining a focus on this issue
    will benefit the public by ensuring increased NIH research on these
    disadvantaged populations.
        AACOM appreciates the opportunity to share our LHHSE FY23 funding
    priorities 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 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) 2023 appropriations for the
    National Institutes of Health (NIH). AAI recommends an appropriation of
    at least $49 billion for NIH's base budget for FY 2023. In addition,
    AAI recommends providing substantial funding for the Advanced Research
    Projects Agency for Health (ARPA-H), though it is crucial that this
    funding supplements, and does not supplant, NIH's base budget. Robust
    investment in NIH will support needed research to prevent and treat
    dangerous infectious and debilitating chronic diseases, fund
    meritorious research proposals and scientists at all career stages, and
    ensure the continuity of our Nation's robust, preeminent biomedical
    research enterprise. Because the COVID-19 pandemic continues, AAI also
    strongly supports an infusion of supplemental funds to address ongoing
    COVID-19 needs, help scientists whose work was adversely impacted by
    pandemic-related interruptions, and prepare for future pandemics.
       how investment in immunological research transformed the covid-19
                                    response
        Immunological research, including understanding how vaccine-induced
    immunity and memory are formed, has been vital to the development and
    use of safe and effective vaccines to protect against coronavirus
    disease 2019 (COVID-19). While the current vaccines against severe
    acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that
    causes COVID-19, continue to provide strong protection against severe
    disease, hospitalization, and death, the emergence of variants like
    delta have resulted in surges of infections, leading to significant
    morbidity and mortality and placing great strain on our health care
    system. Although the latest variants (omicron and its subvariants)
    spread much more easily, they have generally caused less serious
    disease. Nevertheless, we must be vigilant and prepared for new
    variants and continue to invest significantly in research aimed at
    understanding the immune response to the virus and whether--and when--
    these new variants are able to evade vaccine-induced immunity.
        As a result of three substantial coronavirus outbreaks across the
    globe [SARS, Middle East respiratory syndrome (MERS), and COVID-19] in
    the last two decades, scientists are working to discover new approaches
    for vaccinating against coronaviruses. One such approach currently
    being explored by NIH is the development of universal coronavirus
    (``pan-coronavirus'') vaccines that could protect against these and
    other types of coronaviruses and viral variants.\1\ Another approach
    that shows great promise is an intranasal vaccine, currently being
    tested against COVID-19. Delivering the vaccine intranasally could
    generate robust mucosal immunity at the site of infection, potentially
    resulting in long-term protection from infection. There are over a
    dozen intranasal vaccine candidates in various stages of clinical
    trials; preliminary data from one recent preclinical study showed the
    potential utility of using an intranasal vaccine as a booster dose to
    our current COVID-19 vaccines to induce long lasting, protective immune
    responses.\2\
    ---------------------------------------------------------------------------
        \1\ https://www.nih.gov/news-events/news-releases/niaid-issues-new-
    awards-fund-pan-coronavirus-vaccines.
        \2\ https://www.nytimes.com/2022/02/02/health/covid-vaccine-
    nasal.html.
    ---------------------------------------------------------------------------
        Advances have also been made in the development of effective
    treatments for active COVID-19. Various therapeutics are now available
    to those who test positive for COVID-19, often preventing the
    development of serious disease. In other areas, treatment is lacking.
    There are few therapeutics available for those who experience post-
    acute sequelae of SARS-CoV-2 (PASC, or ``long COVID''), a chronic
    condition that can affect almost every part of the body and
    incapacitate individuals who have recovered from initial infection.
    While research is ongoing, particularly through the NIH Researching
    COVID to Enhance Recovery (RECOVER) Initiative,\3\ there is currently
    limited understanding of what causes long COVID and why only some
    patients develop the condition. Some individuals, even those who had
    mild infections, experience lingering health problems that can severely
    limit their activity for months. More research is needed to investigate
    the cause and pathology of long COVID and discover treatments for this
    enigmatic and often debilitating condition.
    ---------------------------------------------------------------------------
        \3\ https://recovercovid.org/.
    ---------------------------------------------------------------------------
                        other important vaccine advances
        Malaria: Every year, malaria infects millions and kills hundreds of
    thousands of vulnerable people around the world, in particular young
    children living in poor countries with inadequate health systems. The
    development of the first World Health Organization (WHO)-recommended
    vaccine for malaria represents a major scientific advance with the
    potential to significantly improve health outcomes and was the result
    of decades of basic research funded in part by NIH.\4\ In addition, an
    NIH-funded phase 1 clinical trial found that a novel monoclonal
    antibody conferred unprecedentedly high levels of durable protection
    against malaria.\5\
    ---------------------------------------------------------------------------
        \4\ https://www.nih.gov/news-events/news-releases/investigational-
    malaria-vaccine-gives-strong-lasting-protection; https://
    www.ncbi.nlm.nih.gov/pmc/articles/PMC7227679/.
        \5\ https://www.nih.gov/news-events/nih-research-matters/
    monoclonal-antibody-prevents-malaria-early-trial.
    ---------------------------------------------------------------------------
        Influenza: The Centers for Disease Control and Prevention (CDC)
    estimates that influenza has caused between 9 and 41 million
    infections, 140,000 and 710,000 hospitalizations, and 12,000 and 52,000
    deaths each year in the United States over the last decade.\6\ Annual
    vaccination is currently the most effective way to prevent illness due
    to flu; however, these vaccines must be updated annually and their
    ability to protect against infection varies widely from year to year
    due to seasonal shifts in the type of influenza viruses that circulate.
    NIH is currently supporting research to develop new types of vaccines,
    including universal flu vaccines (currently in phase 1 clinical
    studies), that would protect more broadly and effectively against
    multiple strains of flu, including newly emerging strains that pose a
    pandemic risk.\7\
    ---------------------------------------------------------------------------
        \6\ https://www.cdc.gov/flu/about/burden/index.html.
        \7\ https://www.niaid.nih.gov/news-events/nih-launches-clinical-
    trial-universal-influenza-vaccine-candidate.
    ---------------------------------------------------------------------------
        Tuberculosis (TB): In 2020, 10 million people were infected with,
    and 1.5 million people died from, TB.\8\ Although TB is the second
    leading infectious cause of death in the world, the only available
    vaccine against TB is the BCG (Bacillus Calmette-Guerin) vaccine, which
    has variable efficacy against pulmonary disease. NIH-supported research
    is seeking to understand how the TB bacterium interacts with its human
    host. Recently, NIH-funded researchers identified a method to
    dramatically improve the efficacy of the BCG vaccine in non-human
    primates by changing the route of administration.\9\
    ---------------------------------------------------------------------------
        \8\ https://www.who.int/news-room/fact-sheets/detail/tuberculosis.
        \9\ https://www.nih.gov/news-events/news-releases/changed-route-
    immunization-dramatically-improves-efficacy-tb-vaccine.
    ---------------------------------------------------------------------------
        Opioid Use Disorder: The opioid epidemic has devastated families
    and communities across America, with 1.6 million people diagnosed with
    opioid use disorder and more than 70,000 people dying from opioid-
    related overdoses in the past year alone.\10\ NIH is currently funding
    cutting-edge research seeking to prevent addiction by generating
    antibodies to block opioid molecules from entering the brain and by
    developing a vaccine that could combat opioid use disorder.\11\
    ---------------------------------------------------------------------------
        \10\ https://www.hhs.gov/opioids/about-the-epidemic/index.html.
        \11\ https://heal.nih.gov/news/stories/OUD-vaccine; https://
    www.gao.gov/assets/gao-19-706sp.pdf.
    ---------------------------------------------------------------------------
        Alzheimer's Disease: Alzheimer's disease, which afflicts more than
    six million Americans, is a devastating illness that deprives its
    victims of their lifelong memories and ultimately destroys their brain
    function.\12\ NIH-funded basic research has revealed how the immune
    system can contribute to the formation of amyloid plaques in the brains
    of Alzheimer's patients, causing irreversible neuronal damage.
    Currently, there are multiple novel vaccine candidates, all currently
    in different stages of clinical studies, that aim to prevent
    Alzheimer's disease from ever developing.\13\
    ---------------------------------------------------------------------------
        \12\ https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet.
        \13\ https://www.beingpatient.com/there-are-9-alzheimers-vaccines-
    in-trials-right-now/.
    ---------------------------------------------------------------------------
                immunology and other diseases, including cancer
        While immunology has been in the news because of its extraordinary
    role in understanding and combatting COVID-19, critically important
    immunological research continues--and is advancing--in many other
    areas. Research on the immune system is improving our understanding of
    how to treat chronic conditions such as multiple sclerosis and
    cardiovascular disease; how to ensure successful organ or tissue
    transplantation; and how to protect against natural or man-made agents
    of bioterrorism.
        Cancer research is also advancing, as immunologists have been able
    to effectively leverage the immune system's ability to recognize and
    eliminate tumor cells into treatments called immunotherapies.
    Scientists continue to unravel the complicated interaction between
    immune cells and cancer, with the hope that this will lead to the
    discovery of effective new cancer treatments. Recently, the Food and
    Drug Administration (FDA) approved the first KRAS inhibitor (sotorasib)
    to treat advanced KRAS G12C-mutant non-small cell lung cancer (NSCLC),
    which accounts for 82 percent of all lung cancer cases.\14\ With lung
    cancer one of the three most common cancers diagnosed in U.S. adults,
    and with mutations to the KRAS gene one of the most common genetic
    alterations observed in NSCLC, this approval marks a major breakthrough
    in oncology.\15\
    ---------------------------------------------------------------------------
        \14\ https://www.cancer.net/cancer-types/lung-cancer-non-small-
    cell/statistics.
        \15\ https://www.cancer.gov/news-events/cancer-currents-blog/2021/
    fda-sotorasib-lung-cancer-kras.
    ---------------------------------------------------------------------------
    the role of a robust nih in the nation's biomedical research enterprise
        The nation's major funding agency for biomedical research, NIH is
    also a key source of economic activity in every U.S. state and in
    countries around the world. More than 80 percent of its $45 billion
    budget is distributed, following a competitive peer review process, to
    more than 300,000 researchers at more than 2,500 universities, medical
    schools, and other research institutions across the Nation,\16\ while
    approximately 10 percent of its budget supports 6,000 researchers and
    clinicians who work at NIH facilities around the country.\17\ This
    funding supports both scientific research and local economies; in 2021,
    NIH funding supported more than 552,000 jobs and accounted for $94
    billion in economic activity across the U.S.\18\ The basic research
    that NIH funds is also critical to the biomedical research pipeline; it
    contributed to the discovery of all 210 new drugs that were approved by
    the FDA from 2010-2016.\19\
    ---------------------------------------------------------------------------
        \16\ https://www.nih.gov/about-nih/what-we-do/budget.
        \17\ https://irp.nih.gov/about-us/research-campus-locations.
        \18\ https://www.unitedformedicalresearch.org/wp-content/uploads/
    2022/03/UMR_NIHs-Role-in-Sustaining-the-U.S.-Economy-FY21.pdf.
        \19\ https://directorsblog.nih.gov/2018/02/27/basic-research-
    building-a-firm-foundation-for-biomedicine/.
    ---------------------------------------------------------------------------
        NIH is the indisputable leader of biomedical research in the world,
    and its scientists play an indispensable role in responding to both
    emerging and ongoing health threats. Together with scientists from the
    CDC and other Federal health and science agencies, NIH scientists have
    been essential to guiding the Nation through the coronavirus pandemic,
    in part by providing timely and candid scientific advice to the
    President, Congress, and the American public.
        For many years, strong bipartisan support for biomedical research
    has led to substantial increases in the NIH budget. Although these
    increases have largely restored the purchasing power that NIH had lost
    to inflation and inadequate budgets since 2003, meaningful budget
    growth is needed to enable NIH to invest not just in important research
    priorities across its Institutes and Centers, but also in its most
    valuable resource: the research workforce. While NIH should continue to
    support meritorious senior scientists, it is essential that it have the
    ability to support a sufficient cadre of trainees and early to mid-
    career scientists who are able to both address increasingly complex
    scientific challenges and eventually lead the research enterprise.
    Congress must, therefore, provide NIH with the resources needed for the
    training, development, and support of our next generation of
    researchers, doctors, professors, and inventors--and give them the
    dynamic research environment they need to pursue these careers.
                                   conclusion
        AAI greatly appreciates the subcommittee's strong, continuous, and
    bipartisan support for NIH and urges an NIH base budget of at least $49
    billion for FY 2023 to help the agency invest in vital immunologic
    research, support meritorious biomedical scientists at all career
    stages, and help researchers and doctors discover new ways to prevent,
    treat, and cure disease. In addition, AAI recommends the appropriation
    of substantial funding for ARPA-H, which has the potential to greatly
    advance human immunology in an era of unprecedented scientific
    opportunity.

        [This statement was submitted by Peter E. Jensen, M.D., Chair of
    the Committee on Public Affairs, American Association of
    Immunologists.]
                                     ______

        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
    House Committee on Appropriations, subcommittee on Labor, Health and
    Human Services, Education, and Related Agencies. We thank Chairman
    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.
        ACOG commends Congress for making great strides in advancing
    research and data collection to advance the health of women and
    families. Looking ahead, we urge you to make funding of the following
    programs and agencies a priority in FY23:
    Title V Maternal and Child Health Block Grant at the Health Resources
            and Services Administration (HRSA):
        The Title V Maternal and Child Health (MCH) Block Grant at HRSA is
    the only Federal program that exclusively focuses on improving the
    health of mothers and children. The Block Grant is a cost-effective,
    accountable, and flexible funding source used to address critical,
    pressing, and unique needs of maternal and child health populations in
    each State, territory and jurisdiction. Notably, through the Special
    Projects of Regional and National Significance (SPRANS) discretionary
    grant, the Block Grant supports the Alliance for Innovation on Maternal
    Health (AIM)--a program that works with States and hospital systems to
    implement evidence-based toolkits to improve maternal outcomes and
    reduce rates of maternal mortality and severe morbidity. For FY23, ACOG
    requests $15.3 million for SPRANS to support continued implementation
    of AIM.
        HRSA has also invested in the Women's Preventive Services
    Initiative (WPSI), supporting the WPSI multidisciplinary committee's
    development of guidelines for preventive services that are specific to
    women and improve women's health across the lifespan. More than 150
    million people with private insurance--including 58 million women and
    37 million children--currently can receive preventive services without
    cost-sharing. Additionally, 20 million Medicaid adult expansion
    enrollees and 61 million Medicare beneficiaries receive preventive
    services. ACOG recommends an investment of $3,000,000 in FY23 to
    support the ongoing and expanding work of WPSI, to include data
    collection to gauge performance and progress in implementing preventive
    services guidelines and assessing utilization across clinical sites.
    Safe Motherhood and Infant Health Program; Maternal Mortality Review
            Committees and Perinatal Quality Collaboratives at Centers for
            Disease Control and Prevention (CDC):
        The United States has the highest rate of maternal mortality and
    severe morbidity of any developed country. The Safe Motherhood
    Initiative at CDC works with State health departments to collect
    information on pregnancy-related deaths, supports maternal mortality
    review committees, 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 maternal
    mortality review committee. We must continue to build on this progress
    and improve maternal health outcomes. ACOG requests that you fund the
    Safe Motherhood Initiative at $164 million to help States expand or
    establish maternal mortality review committees and State-based
    perinatal quality collaboratives.
    Women's Health Research at the National Institutes of Health (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 the Eunice Kennedy Shriver National Institute
    of Child Health and Human Development (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 its
    existing initiatives to produce new insights and solutions to benefit
    women and families. ACOG supports an appropriation of $49 billion for
    the NIH in FY23, including $1.816 billion for NICHD.
    Advancing Maternal Therapeutics at the NIH:
        Each year, more than 4 million women give birth in the United
    States and more than 3 million breastfeed. However, little is known
    about the effects of most drugs on the woman and her child. In 2015 as
    part of the 21st Century Cures Act (Sec. 2041 of Public Law 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 2018, PRGLAC produced a report to the Secretary
    outlining 15 recommendations to facilitate the inclusion of this
    population in clinical research, and in 2020 an implementation plan was
    published. 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 within the Office of Population Affairs
            (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, particularly as we
    prepare for the likely event of the U.S. Supreme Court overturning the
    protections afforded by Roe v. Wade. ACOG requests $512 million for
    Title X in FY23 to ensure individuals in need have access to evidence-
    based care. ACOG urges Congress to show its strong support for
    transparent, respectful, evidence-based, and comprehensive reproductive
    health care by funding this critical program.
        Thank you again for the opportunity to submit our recommendations
    to the subcommittee, and for your commitment to improving women's
    health.

        [This statement was submitted by Rebecca Lauer, Federal Affairs
    Manager.]
                                     ______

            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)
    2023. ACP is the largest medical specialty organization and the second-
    largest physician group in the United States. ACP members include
    161,000 internal medicine physicians, 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 FY2023, ACP is urging funding for the following
    proven programs to receive appropriations from the subcommittee:
      --Health Resources Services Administration (HRSA), $9.8 billion;
            Health Workforce, National Health Service Corps (NHSC), $860
            million in total program funding; Primary Care Training and
            Enhancement (PCTE), $71 million; Maternal and Child Health,
            Maternal and Child Health Block Grant, $1 billion; Title X
            Family Planning Program, $400 million;
      --Agency for Healthcare Research and Quality (AHRQ), $500 million;
      --Centers for Medicare and Medicaid Services (CMS), Program
            Operations, Private Health Insurance, $145.3 million;
      --Centers for Disease Control and Prevention (CDC), $11 billion;
            Injury Prevention and Control, Firearm Injury and Mortality
            Prevention Research, $35 million; Chronic Disease
        Prevention and Health Promotion, Social Determinants of Health,
    $153 million;
      --National Institutes of Health (NIH), $49 billion; Office of the
            Director, Firearms Research, $25 million;
      --Public Health and Social Services Emergency Fund (PHSSEF), $3.8
            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
    17,800 to 48,000 primary care physicians by 2034. Without critical
    funding for vital workforce programs, this physician shortage will only
    grow worse. Therefore, we urge the subcommittee to provide $9.8 billion
    for HRSA programs for FY2023 to improve the care of medically
    underserved Americans by strengthening the health workforce. The
    College urges at least $860 million in total program funding for the
    NHSC in 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 FY 2021, with a field strength of almost 20,000
    primary care clinicians, NHSC members are providing culturally
    competent care to a target of almost 20 million patients at over 18,000
    NHSC-approved health care sites in urban, rural, and frontier areas.
    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 clinicians 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, to expand the pipeline for
    individuals training in primary care. 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.
        Also, within HRSA, ACP supports $1 billion for the Title V Maternal
    and Child Health (MCH) Services Block Grants within FY2023 Maternal and
    Child Health funding. ACP believes that policies--such as MCH Block
    Grants-must be implemented to address and eliminate disparities in
    maternal mortality rates among Black, Indigenous, and other women who
    are at greatest risk. MCH Block grants helped give access to health
    care and public health services for 60 million people in FY2020. ACP
    also supports the administration's request for $400 million for Title X
    Family Planning in FY2023. The College has extensive policy supporting
    programs that provide access to essential family planning services,
    such as Title X. ACP believes that it is essential for women to have
    access to affordable, comprehensive, nondiscriminatory public or
    private health care coverage that includes evidence-based care over the
    course of their lifespans. Accordingly, women should have sufficient
    access to evidence-based family planning and sexual health information
    and the full range of medically accepted forms of contraception which
    can be accessed through Title X Family Planning programs.
        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, to help
    restore the agency to its FY2010 enacted level adjusted for inflation.
    This amount will allow AHRQ to help clinicians 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 $145.3 million in discretionary funding
    within CMS' Program Operations for private health insurance protections
    and programs. This funding would allow CMS to continue overseeing
    State-based Marketplaces (SBMs) and operating the Federally-facilitated
    Marketplaces (FFMs) 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. Specifically, ACP
    supports the administration's request for $11.2 million for market
    oversight and $134.1 million to operate and administer Federal
    marketplaces. Without these funds it will be much more difficult for
    the Federal Government to operate and manage a FFM, 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 $11 billion overall for this mission, especially considering
    the ongoing COVID-19 public health emergency (PHE). The College also
    supports $35 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, FY2021, and FY2022 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 Social Determinants of Health
    within Chronic Disease Prevention and Health Promotion programs. 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.
        The College strongly supports $49 billion for the NIH in FY2023 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. ACP also supports the
    administration's request for $25 million for research related to the
    prevention of firearms injury and mortality within the NIH Office of
    the Director.
        Lastly, as the Federal Government continues to respond to COVID-19,
    ACP supports the administration's request of $3.8 billion for the
    PHSSEF in FY2023 to fund programs such as the Strategic National
    Stockpile and the Biomedical Advanced Research and Development
    Authority. The PHSSEF must be funded adequately enough to maintain a
    robust pandemic response, especially when emergency supplemental funds
    are no longer available.
        The College greatly appreciates the support of the subcommittee on
    these issues and looks forward to working with Congress during the
    FY2023 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 84,000 members of the American
    College of Surgeons (ACS), thank you for the opportunity to submit
    written testimony addressing fiscal year (FY) 2023 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 2023:
    Fully Fund the 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). The MISSION ZERO Act
    acts upon 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.
        ACS thanks Congress for providing $2 million in funding for the
    program in FY 22. However, ACS strongly encourages Congress to fully
    fund the Military and Civilian Partnership for the Trauma Readiness
    Grant Program at the authorized amount of $11.5 million for FY 2023.
    Building on previous funding will allow for implementation of military-
    civilian trauma partnerships, 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.
    Cancer Prevention Research
        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 2023.
        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 $49.048 billion including $7.776
    billion for the National Cancer Institute (NCI). The ACS also urges the
    inclusion of $462.6 million for cancer programs at the Centers for
    Disease Control and Prevention (CDC), including $30 million for the
    National Comprehensive Cancer Control Program, and $61.4 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 45,000 firearm-related fatalities in 2020, a
    measured increase over previous years. ACS believes that the number of
    firearm-related fatalities can be reduced through federally funded
    public health research into firearm morbidity and mortality. 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. ACS supports a total of $60 million-35 million for
    the U.S. Centers for Disease Control and Prevention (CDC) and $25
    million for the National Institutes of Health (NIH) to conduct public
    health research into firearm morbidity and mortality prevention.
    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 Senior Congressional Lobbyist, at
    asuermann@facs.org, if you have any questions or would like additional
    information.
        Sincerely.

        [This statement was submitted by Patricia L. Turner, MD, MBA, FACS,
    Executive Director, American College of Surgeons.]
                                     ______

        Prepared Statement of the American Dental Education Association
        The American Dental Education Association (ADEA) represents all 68
    U.S. dental schools; more than 800 dental hygiene, dental therapy and
    other allied dental programs, as well as advanced dental education
    programs; over 50 corporate partners; and more than 18,000 individuals.
    ADEA submits this testimony on the Department of Health and Human
    Services and the Department of Education budgets for the record and for
    your consideration as you begin prioritizing fiscal year 2023 (FY23)
    appropriation requests.
        ADEA's 68 U.S. member dental institutions' clinics and extramural
    dental school facilities provide dental care to more than 2.7 million
    patients annually. America's dental schools are one of the nation's
    largest dental care safety nets, providing more than $74 million in
    uncompensated health care annually to the uninsured and underinsured.
        According to the Health Resources and Services Administration
    (HRSA), 67 million Americans live in one of the 6,946 dental care
    Health Professional Shortage Areas (HPSAs). To close this gap, HRSA
    estimates that over 11,567 new practitioners are needed. When you
    consider there are slightly more than 201,000 practicing dentists in
    the United States and more than 72,500 of them are over age 50, and
    that U.S. dental schools graduate about 6,300 students per year, it is
    clear that additional work needs to be done to ensure all citizens have
    access to culturally competent, comprehensive and quality oral health
    care.
        For dental students, the patient care experience begins in dental
    clinics, which are in all dental schools. These clinics must include
    most of the major service areas of a hospital and adhere to the
    rigorous guidelines that protect the health and safety of the public,
    much like hospitals do. Dental schools operate full clinical facilities
    with all the necessary treatment rooms and surgical suites, including
    areas for sterilization, diagnostic services such as radiology and
    pathology, and business operations. In contrast, medical schools
    conduct the majority of their clinical teaching and training in
    separate hospitals or affiliated academic medical centers and are not
    required to adhere to the stringent protective guidelines in their
    education buildings that are in place at dental school clinics.
        Many dental schools are part of the same campuses as the medical
    schools, which are often in underserved communities. Dental schools
    also exist within minority-serving institutions. Dental schools are
    part of their local communities' health care safety net and have been a
    previously untapped health care resource, as demonstrated during the
    COVID-19 pandemic, and will be again in future pandemics. Dental school
    clinics serve the same geographic patient populations as their medical
    colleagues, providing care at reduced rates. A large number of the
    individuals who receive dental care in dental school clinics are
    members of underserved populations and do not have private insurance or
    the ability to pay private practice fees.
        As you deliberate funding for FY23, ADEA respectfully urges your
    support for the following funding requests.
    $46 million: Oral Health Training Programs
        The dental programs in Title VII provide critical education for
    predoctoral dental, dental hygiene and dental therapy students and
    training for post-doctoral advanced dental education residents in
    general, pediatric and public health dentistry. Support for these
    programs will help ensure an adequately prepared and culturally
    competent dental workforce. The program also expands access to care for
    underserved areas in community-based settings located in HPSAs.
        HRSA programs address the dental school faculty shortage with
    Dental Faculty Development and Dental Faculty Loan Repayment Program
    grants to those who teach pediatric, general or public health dentistry
    and dental hygiene. Currently, more than 200 open, budgeted faculty
    positions exist in dental schools. The Primary Care Dental Faculty
    Development Program assists schools with recruiting and retaining both
    full-time and part-time faculty and community-based faculty to develop/
    enhance training focused on improving care for vulnerable and
    underserved populations.
        Increased support is needed for the Oral Health Training Programs
    so the Federal Government can continue to assist in educating and
    training oral health professionals in areas where access to quality
    care is difficult. The positive impact of these programs is clear. In
    academic year 2020-21, 9,562 dental and dental hygiene students were
    educated in predoctoral degree programs, 736 dental residents and
    fellows in primary care dental residency and fellowship programs
    received post-doctoral training in advanced care, and 847 dental
    faculty members participated in faculty development activities and
    programs. Of the dental residents and fellows, 89 percent received
    training on COVID-19 and 79 percent received training on health equity
    or the social determinants of health. Awardees were offered experience
    and training opportunities at 483 sites. Over 60 percent of these sites
    were in medically underserved communities and over 60 percent were in
    primary care settings. Almost 40 percent of the sites offered COVID-19-
    related services, demonstrating oral health professionals' ability to
    provide such care.
        In addition to the Oral Health Training Programs, other Title VII
    programs play a key role in furthering the ability of the health
    professions workforce to respond to the changing makeup of those who
    need care. The Diversity and Student Aid programs play a critical role
    in ensuring the future health professions workforce reflects the
    Nation's changing demographics. These programs must receive adequate
    funding to sustain the progress necessary to meet the challenges of an
    increasingly diverse U.S. population.
        The Health Careers Opportunity Program (HCOP) provides a vital
    source of support for dental professionals serving underserved and
    disadvantaged patients by providing a career pathway for individuals
    from these populations. This unique workforce program encourages young
    people from diverse and disadvantaged backgrounds to explore careers in
    health care generally, and dentistry specifically. One criticism often
    heard is that budget analysts do not know if the program is impactful.
    That is simply because the participants are not tracked to see what
    their future career path becomes. The success of the following career
    pathway program demonstrates that these programs can be effective.
        ADEA and the Association of American Medical Colleges, through
    funding from the Robert Wood Johnson Foundation, operate a
    complimentary program, the Summer Health Professions Education Program
    (SHPEP). SHPEP is a six-week academic enrichment program for rising
    college sophomores and juniors from historically underrepresented
    racial and ethnic (HURE) populations who are interested in the health
    professions. A study of participants from 2006 to 2015 found that 65
    percent of those who participated in the program's dental portion
    applied to dental school and, as of 2015, 589 graduated from dental
    school. These pathway programs are effective in attracting HURE
    individuals. ADEA requests that funding for HCOP be continued and we
    encourage the greatest possible support for the HCOP program.
        The Area Health Education Centers (AHEC) program enhances high-
    quality, culturally competent care in community-based interprofessional
    clinical training settings. The infrastructure development grants, and
    point-of-service maintenance and expansion grants, ensure that patients
    from underserved populations receive quality care and health
    professionals receive experience working with diverse populations. ADEA
    strongly encourages the Committee to continue funding the vitally
    important AHEC program.
    $540 million: National Institute of Dental and Craniofacial Research
        Dental research serves as the foundation of the dental professions.
    Discoveries stemming from dental research have reduced the burden of
    oral diseases, led to better dental health for millions of Americans,
    and uncovered important links between oral and systemic health. ADEA
    and dental school researchers are grateful for the increase NIDCR
    received in FY22; however, we note that NIDCR continues to have the
    smallest budget of all the Institutes, while evidence of the link
    between oral health and overall systemic health continues to grow.
        The requested increase for FY23 will not bring us to parity, but it
    will bring us closer and provide the stable and consistent growth in
    research sought by former NIH Director Dr. Francis Collins, and shared
    by the NIH Acting Director, Dr. Lawrence Tabak, who is a dentist,
    dental educator and researcher, and former NIDCR Director. Through
    NIDCR grants, dental researchers in academic dental institutions have
    enhanced the quality of the Nation's dental and overall health. Dental
    researchers are poised to make dramatic breakthroughs, such as
    restoring natural form and function to the mouth and face as a result
    of disease, accident, or injury; and diagnosing systemic disease (such
    as HIV and certain types of cancer) from saliva instead of blood and
    urine samples. These breakthroughs, and countless others that bolster
    America's role as a global scientific leader, require adequate funding.
    $35 million: Centers for Disease Control and Prevention (CDC) Division
            of Oral Health
        The CDC Division of Oral Health expands the coverage of effective
    prevention programs. The division increases the basic capacity of state
    oral health programs to accurately assess the needs of the state,
    organize and evaluate prevention programs, develop coalitions, address
    oral health in State health plans, and effectively allocate resources
    to the programs. This strong public health response is needed to meet
    the challenges of dental disease affecting children and vulnerable
    populations. The current path of decreased funding will have a
    significant negative effect on the overall health and preparedness of
    the Nation's States and communities.
    $18 million: Ryan White HIV/AIDS Treatment and Modernization Act, Part
            F: Dental Reimbursement Program (DRP) and Community-Based
            Dental Partnerships Program
        Patients with compromised immune systems are more prone to oral
    infections, such as periodontal (gum) disease and caries (tooth decay).
    The DRP is a federal/institutional partnership that provides partial
    reimbursement to academic dental institutions for costs incurred from
    providing dental care to people living with HIV/AIDS. Simultaneously,
    the program provides educational and training opportunities to dental
    students, residents and allied dental students. However, DRP
    reimbursement only averages 26 percent of the dental schools'
    unreimbursed costs. The current reimbursement rate is unsustainable
    long term. Adequate funding of the Ryan White Part F programs will help
    ensure that people living with HIV/AIDS receive necessary dental care.
        ADEA thanks you for your consideration of these funding requests
    and looks forward to working with you to ensure the continuation of
    these critical programs and improve the oral and systemic health and
    well-being of the Nation. Please consider ADEA a resource on any matter
    under your purview pertaining to academic dentistry and education of
    the dental workforce.
                                     ______

      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 at least $815 million for fiscal year
    2023, aligned with the request from the Friends of IES coalition, for
    which we are a leading member. In addition, AERA recommends $49 billion
    in base funding for the National Institutes of Health (NIH) in fiscal
    year 2023. Within NIH, we recommend proportional increases for
    important research supported by 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.
                        institute of education sciences
        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.
        Our members, as well as State and Federal policymakers and
    practitioners, rely on IES to provide reliable education statistics,
    support research to improve academic and non-academic outcomes, and
    develop evidence-based practices to inform instruction and support
    student learning at all educational levels into the workforce. We
    appreciate the increases to IES appropriations over the past few fiscal
    years, which has helped support unanticipated costs for the National
    Assessment of Educational Progress (NAEP) in the delay in administering
    the 4th and 8th grade reading and math assessments due to the COVID-19
    pandemic. We are also thankful for the inclusion of a specific line
    item within IES for program administration in the fiscal year 2022
    omnibus appropriations legislation. This allocation is an important
    step in providing additional flexibility and resources for IES to hire
    staff. Program officers and statistical staff are critical to carrying
    out IES's mission, and particularly for the National Center for
    Education Statistics (NCES), which has seen the attrition of 23 staff
    positions since fiscal year 2015.
        Since IES was created in 2002, it has made scientifically-based
    contributions to the progress of education that are used in classrooms
    across the country. For example, research findings supported by the
    National Center for Special Education Research (NCSER) have informed
    supports for implementing positive behavior interventions and supports,
    including Team-Initiated Problem Solving, used in over 1,000 schools.
    Recent work supported by the National Center for Education Research
    (NCER) has led to the development of measurements of reading used in
    schools across the Nation, including the Lexia(r) RAPID(tm) Assessment
    program, Capti Assess with ETS(r) ReadBasix(tm), and the Phonological
    Awareness Literacy Screening in Spanish (PALS espanol). Innovations in
    NAEP have led to the examination of process data to better understand
    how students arrive at responding to assessment questions, with
    implications for future test item development.
        Throughout the pandemic, IES has served as an important resource in
    providing information about distance learning; pursuing interventions
    to address socioemotional needs; and collecting data from schools on
    learning modes, school staffing, and COVID-19 mitigation strategies
    through the School Pulse Panel. The increased demand for evidence-based
    programs since the onset of COVID-19 and the need to address persistent
    and exacerbated learning gaps only further speak to the priority
    importance of supporting education research and statistics at IES to
    inform policy and practice.
        We were pleased to see IES enlist the National Academies of
    Science, Engineering, and Medicine (NASEM) to conduct three studies to
    inform future directions for IES assessment, research, and statistical
    activities. The Future of Education Research at IES report included
    several recommendations to build on the current strengths of the
    research and training programs within NCER and NCSER. These
    recommendations called on IES to advance heterogeneity and knowledge
    mobilization as project types, fund additional mixed-methods and
    qualitative research, support research focusing on teacher- and system-
    level outcomes alongside student outcomes, and collect data on and
    measure impact of NCER and NCSER training programs.
        As one overarching recommendation, the NASEM committee called upon
    Congress to reexamine the IES budget in light of comparative funding
    for other Federal research agencies with purposes no more salient than
    that of IES. We encourage the subcommittee to provide additional
    resources in the Research, Development, and Dissemination and Research
    in Special Education line items for IES to expand support for these
    emerging priorities and foundational research areas.
        The Statistics line item supports NCES administrative data
    collections and longitudinal surveys, as well as participation by our
    Nation's students in important international assessments such as the
    Programme for International Student Assessment. Data from NCES,
    including from the Integrated Postsecondary Education Data System and
    the National Teacher and Principal Survey, are frequently cited and
    used to describe the condition of education in the United States. NCES
    also has an essential leadership role in implementing the Foundations
    of Evidence-based Policymaking Act, which directs Federal agencies to
    leverage data and evaluations to inform policy decisions.
        Despite NCES' significant roles in producing, disseminating, and
    using these important education indicators, funding for NCES
    statistical activities remains below fiscal Year2016 levels. In A
    Vision and Roadmap for Education Statistics, the NASEM committee that
    examined NCES statistical work referenced the limited capacity that
    NCES has in both funding and staff. Additional resources are essential
    to carry out several of the report's key recommendations, including
    developing a strategic plan, broadening outreach to data users to
    gather feedback on their needs, and establishing a joint statistical
    research program in partnership with IES. We strongly recommend
    providing sufficient funding for the Statistics line that would address
    the 15 percent loss of purchasing power for this account over the past
    decade and increase the capacity of NCES to conduct these activities.
        Alongside the important survey work NCES supports, 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. The most recent SLDS grants are also providing
    States the opportunity to partner in the development of meaningful
    measures-in this case, to pilot an NCES-developed indicator to measure
    poverty using school geocoded addresses as an alternative to using
    free-and-reduced lunch eligibility. States participating in this pilot
    have provided feedback on this NCES initiative and have also noted
    strengthened data capacity and integrity within their data systems as a
    result.
        To date, NCES has been unable to meet the State demand for SLDS
    grants. For the fiscal year 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 fiscal year
    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. Inadequacies in funding
    reduce the vitality of this Federal-State partnership to support
    evidence-based policy work within and across States.
        In A Vision and Roadmap for Education Statistics, the NASEM
    committee recommended that NCES strengthen State capacity to link data,
    adopt shared data standards, and provide actionable information to
    State and local education agencies to help improve student learning
    outcomes. Additional funding for SLDS would help enhance NCES technical
    assistance and ongoing efforts to promote best practices for State data
    governance structures and data interoperability, including through the
    voluntary Common Education Data Standards.
        In sum, sustained, robust investment in the education research and
    statistical infrastructure at IES is necessary to support the success
    of our Nation's students, teachers, and education leaders.
                         national institutes of health
        AERA recommends $49 billion for the National Institutes of Health
    (NIH) in fiscal year 2023 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. Providing $1.816 billion for NICHD in fiscal
    year 2023 will allow the institute to expand research to increase
    understanding of how best to support executive functioning, support
    additional research on early language and motor development, 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 in terms of prevention, intervention, and the
    health-risk consequences of a lack of or limited educational exposure.
    We recommend no less than the fiscal year 2022 funding level for OBSSR,
    including a proportionate increase in its fiscal Year2023 budget as
    provided to the NIH.
        Thank you for the opportunity to submit written testimony in
    support of at least $815 million for IES and $49 billion in base level
    funding for NIH in fiscal year 2023. AERA welcomes working with you and
    your subcommittee on strengthening investments in essential research,
    data, and statistics related to education and learning.

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

             Prepared Statement of the American Geriatrics Society
        The American Geriatrics Society (AGS) greatly appreciates the
    opportunity to submit this testimony. The AGS is a 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. The AGS
    believes in a just society--one where we all are supported by and able
    to contribute to communities and where ageism, ableism, classism,
    homophobia, racism, sexism, xenophobia, and other forms of bias and
    discrimination no longer impact healthcare access, quality, and
    outcomes for older adults and their caregivers. As the subcommittee
    works on its fiscal year (FY) 2023 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 2023:
      --At least $82 million to support the GWEP and GACA program (PHS Act
            Title VII, Sections 750 and 753(a))
      --At least $49 billion, an increase of no less than $4.1 billion over
            the enacted FY 2022 level, in the FY 2023 budget for total
            spending at NIH for current institutes and operations; a
            minimum increase of $60 million for the Brain Research Through
            Advancing Innovative Neurotechnologies (BRAIN) Initiative; and
            a minimum increase of $226 million for research on Alzheimer's
            disease and related dementias over the enacted FY 2022 level in
            the FY 2023 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 nearly double from 52.4 million today \1\ to more than 94
    million by 2060, while those 85 and older is projected to almost triple
    from 6.6 million today to 19 million by 2060.\2\ 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. 2020 American Community Survey 5-Year
    Estimates Subject Tables. Published 2020. Accessed April 25, 2022.
    https://data.census.gov/cedsci/table?t=Populations
    %20and%20People&tid=ACSST5Y2020.S0101.
        \2\ U.S. Census Bureau. An Aging Nation: Projected Number of
    Children and Older Adults. Updated October 8, 2019. Accessed April 25,
    2022. https://www.census.gov/library/visualizations/2018/comm/historic-
    first.html.
    ---------------------------------------------------------------------------
        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 $82 million)
        Our healthcare workforce receives little, if any, training in
    geriatric principles,\3\ which leaves us ill-prepared to care for older
    Americans as health needs evolve. 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 2022 levels would help ensure that HRSA receives the funding
    necessary to expand these critically important programs commensurate
    with the increasing need.
    ---------------------------------------------------------------------------
        \3\ Only 3 percent of medical students take even one class in
    geriatric medicine and fewer than 1 percent of RNs, pharmacists,
    physician assistances and physical therapists are certified in
    geriatrics or gerontology. Yet estimates are that by 2030, 3.5 million
    additional health care professionals and direct-care workers will be
    needed to care for older adults. 2018 Issue Brief, Eldercare Workforce
    Alliance, Available at https://eldercareworkforce.org/wp-content/
    uploads/2018/03/GWEP_OnePager_v2.pdf.
    ---------------------------------------------------------------------------
        The GWEP is currently the only Federal program designed to increase
    the number of providers, in a variety of disciplines, with the skills
    and training to care for older adults. The GWEP awardees educate and
    engage the broader frontline workforce, including the caregiving
    workforce and 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 3-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. Additional
    funding would allow 80 GWEPs at $950,000 per program, enabling every
    State to have a GWEP and ensure that more rural and underserved areas
    of the country can have access to geriatrics training and expertise.
        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 4 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.
    Additional funding would allow 60 GACAs at $100,000 per award, ensuring
    we have a larger and more geographically diverse pipeline of geriatrics
    research and training expertise with the incentives and resources
    needed to grow the field.
        GWEPs and GACAs have been successfully leading and preparing the
    healthcare workforce, caregivers, and their communities, and most
    recently on the frontline throughout the COVID-19 pandemic, including
    working with health systems to participate in the outreach to
    vulnerable and hard-to-reach populations, preventing widening the
    health disparity gap exacerbated by the pandemic. These programs are
    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 2023
    appropriation of at least $82 million for the GWEP and GACA program.
    This increase in funding over FY 2022 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. Given
    the increasing diversity among older people \4\ and rapid growth of the
    older population,\5\ the need for a diverse workforce as well as
    training in geriatrics and gerontology will continue to increase. 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.
    ---------------------------------------------------------------------------
        \4\ Matthews KA, Xu W, Gaglioti AH, et al. Racial and Ethnic
    Estimates of Alzheimer's Disease and Related Dementias in the United
    States (2015-2060) in Adults Aged >=65 Years. Alzheimers Dement.
    2019;15(1):17-24. doi:10.1016/j.jalz.2018.06.3063.
        \5\ U.S. Census Bureau. An Aging Nation: Projected Number of
    Children and Older Adults. Updated October 8, 2019. Accessed April 25,
    2022. https://www.census.gov/library/visualizations/2018/comm/historic-
    first.html.
    ---------------------------------------------------------------------------
                          research funding initiatives
    National Institutes of Health/National Institute on Aging (additional
            $60 million for the Brain Research Through Advancing Innovative
            Neurotechnologies Initiative and a minimum increase of $226
            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 $60 million in the FY 2023 budget for the BRAIN
    Initiative and a minimum increase of $226 million for research on
    Alzheimer's disease and related dementias over the enacted FY 2022
    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.\6\ Further, chronic diseases related to aging, such as
    diabetes, heart disease, and cancer continue to afflict 80 percent of
    people age 65 and older.\7\ Forty percent of Medicare beneficiaries
    have four or more chronic conditions and account for 78 percent of
    Medicare expenditures.\8\ 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.
    ---------------------------------------------------------------------------
        \6\ Alzheimer's Association. 2021 Alzheimer's Disease Facts and
    Figures. Alzheimers Dement. 2021;17(3):327-406. doi:10.1002/alz.12328.
        \7\ National Prevention Council. Healthy Aging in Action: Advancing
    the National Prevention Strategy. Published November 2016. Accessed
    April 25, 2022. https://www.cdc.gov/aging/pdf/healthy-aging-in-
    action508.pdf.
        \8\ Centers for Medicare and Medicaid Services. Chronic Conditions
    Charts: 2018. Published 2018. Accessed April 26, 2022. https://
    www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
    Reports/Chronic-Conditions/Chartbook_Charts.
    ---------------------------------------------------------------------------
        Additionally, the AGS supports at least $49 billion, no less than a
    $4.1 billion increase over the enacted FY 2022 level, in the FY 2023
    budget for total spending at NIH for current institutes and operations.
    We also urge you to ensure that any funding for the Advanced Research
    Projects Agency for Health (ARPA-H) supplement, not supplant, the total
    $49 billion base budget recommendation. 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, as President of the American Heart Association, I would
    like to submit my written testimony on behalf of our 40 million
    volunteers and supporters. My name is Dr. Donald Lloyd-Jones, and as
    the President of the American Heart Association, I serve as the chief
    volunteer scientific and medical officer, responsible for the oversight
    of all medical, scientific, and public health matters, and those
    related to public policy. I am also the Chair of the Department of
    Preventive Medicine, the Eileen M. Foell Professor of Heart Research,
    and Professor of Preventive Medicine, Medicine, and Pediatrics at
    Northwestern University's Feinberg School of Medicine in Chicago.
        As an epidemiologist and board-certified practicing cardiologist
    for more than 23 years, I understand firsthand the burden of
    cardiovascular disease. I have a broad and deep understanding of what
    individuals and families need to promote health, prevent disease, cure
    illness, and manage chronic health conditions. As a volunteer with the
    American Heart Association for more than 24 years, I have been proud to
    advance the organization's mission to be a relentless force for a world
    of longer, healthier lives for all. I am also proud to represent the
    American Heart Association as a major advocate for population health at
    the Federal, State, and local levels, as a supporter of healthy
    communities, and as a champion for health equity.
        The American Heart Association is the largest nonprofit funding
    source for cardiovascular and cerebrovascular disease research, next to
    the Federal Government. We have funded 14 Nobel Prize winners and
    several important medical breakthroughs, including techniques and
    standards for cardiopulmonary resuscitation (CPR), the first artificial
    heart valve, implantable pacemakers, cholesterol inhibitors,
    microsurgery, and drug-coated stents. Of note, the American Heart
    Association is also the largest and most experienced provider of CPR
    training-training millions of individuals, first-responders, and health
    care workers worldwide each year through a vast network of more than
    3,500 Authorized Training Centers and more than 400,000 instructors.
        As Congress works to draft the Labor, Health and Human Services,
    Education and Related Agencies (Labor-HHS-ED) appropriations
    legislation for fiscal year (FY) 2023, the American Heart Association
    respectfully requests that the subcommittee provide $25 million over no
    more than the next five fiscal years to the Centers for Disease Control
    and Prevention (CDC) Division for Heart Disease and Stroke Prevention
    to expand an existing, national sudden cardiac registry to capture data
    from all States, nationwide. Annually, more than 350,000 people fall
    victim to sudden cardiac arrest outside of a hospital environment. It
    is the single leading mechanism of death in the US, and yet it is not
    well recognized as a major public health challenge. When a person
    experiences a sudden cardiac arrest, seconds count in the response of
    bystanders and the emergency system to restore a normal heart rhythm
    and blood pressure. Indeed, these seconds determine the difference
    between life and death, and the chance for a meaningful neurological
    recovery. Unfortunately, only about 1 in 10 victims survive a sudden
    cardiac arrest, and many survivors are left with permanent heart and
    brain damage.
        During an emergency response to an out-of-hospital cardiac arrest,
    the victim's chances depend entirely on a team of volunteers and
    professionals that span laypersons, emergency dispatch, law
    enforcement, medical first responders, EMS providers, and later
    hospital-based nurses and physicians. The team must work together to
    resuscitate the cardiac arrest patient by quickly recognizing the
    cardiac arrest event, providing early CPR and early defibrillation,
    delivering expert advanced care, and downstream post-resuscitation
    critical care and rehabilitation.
        Traditionally, these efforts have been well-intentioned but have
    not leveraged quality improvement strategies that measure care and
    outcome. Consequently, there is marked disparity across emergency
    systems with survival varying as much as 10-fold across different
    communities.\1\ The disparity is unacceptable and can be addressed with
    key programmatic implementation designed to impact local performance.
    The effective strategy for improvement was detailed in the National
    Academies of Science publication: Cardiac Arrest Resuscitation: A Time
    to Act.\2\ Since its publication, there has been substantial effort to
    provide high-traction, accessible resources that can impact
    resuscitation quality improvement, and in turn, advance public health.
    ---------------------------------------------------------------------------
        \1\ Cardiac Arrest Registry to Enhance Survival (CARES), 2020
    Annual Report, Page 38, https://mycares.net/sitepages/uploads/2021/
    2020_flipbook/index.html?page=1.
        \2\ Institute of Medicine. 2015. Strategies to Improve Cardiac
    Arrest Survival: A Time to Act. Washington, DC: The National Academies
    Press. https://doi.org/10.17226/21723.
    ---------------------------------------------------------------------------
        The cornerstone of quality improvement--as highlighted in the
    National Academies document--is the need for consistent, broadly-
    accessible, scientifically-informed registry data to measure the care
    and outcome of cardiac arrest and identify opportunities for
    programmatic improvement. The Cardiac Arrest Registry to Enhance
    Survival (CARES) was first established by the CDC in 2004 in
    collaboration with the Department of Emergency Medicine at the Emory
    University School of Medicine to meet this need and provide
    informative, high-fidelity surveillance that can direct quality
    improvement. CARES is the only national out-of-hospital cardiac arrest
    (OHCA) registry in the United States and currently includes 31 State-
    based registries covering 51 percent of the U.S. population and
    representing more than 2,500 EMS agencies and 2,000 hospitals. To date,
    CARES has published more than 100 articles in peer-reviewed journals
    and has supported countless quality improvement efforts in
    participating communities, resulting in an increase in cardiac arrest
    survival and a more thorough understanding of OHCA treatment and
    survival in the field of emergency medicine. CDC's funding for the
    CARES registry was eliminated in 2012 because of sequestration and
    other budget cuts. The CARES registry operations have continued in the
    absence of Federal funding for 10 years through an infusion of private
    funding each year. This is an unsustainable model for this critically
    important work. In addition, expansion of the registry to all remaining
    States and to cover the remaining half of the US population will
    require Federal support.
        The CARES registry allows communities and public health
    organizations to monitor their quality of care, compare patient
    populations, measure interventions and outcomes, and ascertain whether
    resuscitation is provided according to evidence-based guidelines.
    Without uniform and reliable data collection in every State,
    communities cannot ascertain the effectiveness of their sudden cardiac
    arrest response systems, nor can they assess the impact of
    interventions designed to improve survival rates. In other words, one
    cannot improve what one does not measure, and every State across the
    Nation should be collecting these data in a unified, harmonized, and
    standardized central registry to best serve their communities.
        Multiple systems--large and small--now use CARES as they move
    forward with program improvements. The emergence of CARES corresponds
    to dynamic programmatic opportunities to improve care for
    resuscitation. Implementation of these innovative programs to improve
    early CPR, defibrillation, and advanced treatment can accelerate with
    the use of CARES to evaluate how local implementation impacts
    prognosis. Early evaluation of this ``measure and improve'' quality
    approach has highlighted some remarkable success, ranging from outcome
    improvement in rural communities in North Carolina and Washington State
    to lives saved in urban centers such as Chicago and Detroit.
        Now is the time to scale the registry to be an inclusive and truly
    national initiative that will leverage CARES measurement to achieve
    wide-ranging ``best-practices'' implementation that can improve care
    across emergency systems and in turn benefit community health and save
    many more lives from sudden cardiac arrest. We thank you for the
    consideration of our request to include $25 million for the CDC
    Division for Heart Disease and Stroke Prevention to enable national
    access to CARES and its consequent strategy to measure and improve
    resuscitation, address substantial system disparities, and in turn
    improve the Nation's health.

        [This statement was submitted by Donald M. Lloyd-Jones, MD, ScM,
    FACC, FAHA, President, American Heart Association.]
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        On behalf of the Nation's 35 accredited Tribal Colleges and
    Universities (TCUs), which collectively are the American Indian Higher
    Education Consortium (AIHEC), we thank you for the opportunity to share
    our fiscal Year2023 funding requests. The following is a list of
    recommendations including Department, program, and funding requests.
    Department of Education--Office of Postsecondary Education
      --Strengthening Tribal Colleges and Universities (HEA Title III-Part
            A (Sec. 316): $70,000,000 (discretionary)
      --Perkins Career and Technical Education Programs (Sec. 117):
            $16,000,000
    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: $10,000,000

    Tribal Colleges and Universities: Serving Students Across Indian
            Country and Rural America
        Currently, 35 accredited TCUs operate more than 75 campuses and
    sites in 15 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 fiscal Year2023 funding requests.
                          u.s. department of education
    Strengthening Tribal Colleges (HEA Title III--Part A--Section 316):
            TCUs urge the subcommittee to provide $70,000,0000 for the
            Strengthening Tribal Colleges and Universities 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 accredited TCUs through two funding sources Part A
    discretionary funding: FY 23 request $70 million (FY 2022, $43.895
    million) and Part F mandatory funding (FY 2022, $28.29 million).
        In 2019, TCUs feared losing nearly half of Title III funding when
    Part F funding temporarily expired. Fortunately, the ``Fostering
    Undergraduate Talent by Unlocking Resources to Education Act (Public
    Law 116-91) was signed into law on December 20, 2019, permanently
    authorizing Part F mandatory funding at $30 million for TCUs. With
    increased Part A funding, TCUs will be able to expand critical student
    support programs, meet accreditation requirements, and address ongoing
    infrastructure needs, which are all essential in supporting
    institutional development.
    Carl D. Perkins Career and Technical Education Programs
                Tribally Controlled Postsecondary Career and Technical
                        Institutions: AIHEC requests $16,000,000 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 fiscal Year2020, 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 fiscal year 2023.
                  u.s. department of health and human services
        Administration for Children and Families--Office of Head Start:
    Tribal Colleges and Universities Head Start Partnership Program: AIHEC
    requests $10,000,000 for the TCU-Head Start Partnership program. The
    TCU-Head Start Partnership program was re-established in fiscal
    Year2020 with $4,000,000, continued in fiscal Year2021 with $4,000,000,
    and increased in fiscal year 2022 with $6,000,000. TCUs have had
    demonstrated success in training early childhood educators and Head
    Start teachers who are urgently needed across Indian Country. In 2021,
    71.7 percent of Head Start teachers nationwide held a bachelor's degree
    or higher as required by Federal law; but only 42 percent of Head Start
    teachers met the requirement in Indian Country (Head Start Region 11);
    only 39 percent of assistant teachers in Region 11 met the associate-
    level requirements, compared to 76 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 Partnership Program (42 U.S.C. 9843g), which
    helped TCUs build capacity in Early Childhood Education (ECE) by
    providing scholarships and stipends for Head Start teachers and
    assistant teachers to enroll in TCU ECE 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 teachers and assistant
    teachers. However, recent reports revealed high turnover rates for Head
    Start workers. Many ECE teachers cited leaving their Head Start
    positions for higher paying jobs or retirement, due to pandemic-related
    stress, and other reasons.
        In the 18 months since the program was re-established, six TCUs
    have accomplished incredible success in supporting the early childhood
    teacher pipeline. Recently, Stone Child College (Box Elder, MT)
    expanded its Early Childhood Education program to offer a bachelor's
    degree, in addition to an associate degree, in response to student
    requests for in-person classes. Cankdeska Cikana Community College
    (Fort Totten, ND) offers an ECE associate degree and has an
    articulation agreement allowing students to transfer into the ECE
    bachelor's degree program at Mayville State University (Mayville, ND).
    Many of the current ECE students are full-time Head Start teachers
    while balancing part-time course work in addition to meeting family
    responsibilities. Through this program, TCUs are able to provide
    students with mental and emotional health resources to support and
    retain these resilient ECE students. Likewise, Navajo Technical
    University (Crownpoint, NM), Salish Kootenai College (Pablo, MT), Fond
    Du Lac Tribal and Community College (Cloquet, MN), and White Earth
    Tribal and Community College (Mahnomen, MN) have developed ECE student
    support programs to meet similar student needs. However, due to limited
    funding, only six of the 25 TCUs with ECE programs are funded to
    provide these transformative opportunities to advance early childhood
    education careers. With increased funding, TCUs can leverage resources
    to aid in building an early childhood education workforce to better
    serve the education needs of AI/AN children.
                                   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 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 2023 appropriations requests. Thank you.
                                     ______

             Prepared Statement of the American Library Association
        The American Library Association (ALA) urges the subcommittee to
    include in its Fiscal Year (FY) 2023 appropriations bill at least $50
    million for Innovative Approaches to Literacy (IAL) under the
    Department of Education (DOE).
        As the Nation struggles with the lingering effects of COVID-19, we
    are beginning to see the troubling consequences on early literacy
    development. Librarians work heroically to continue needed services for
    all students and assist classroom teachers and administrators in new
    and innovative ways. During the pandemic, school librarians continued
    to support access to education and tutoring sites for homework help.
    School libraries lent books, eReaders, computers and hotspots to
    students, many of whom did not have access to these basic services at
    home. Some libraries are even streaming story times and author visits
    to encourage young children and their families to keep up reading in
    their homes.
        School library services are in great demand yet face tightening
    budgets and reduced staff at many schools, which limits their ability
    to provide literacy training and support.
        Innovative Approaches to Literacy is the only Federal program
    providing dedicated support to school libraries. Authorized in the
    Every Students Succeeds Act (ESSA), IAL provides competitive awards to
    school libraries as well as national not-for-profit organizations,
    including partnerships that reach families outside of local educational
    agencies (LEAs), to support children and families in high-need,
    underserved communities. By providing age-appropriate books, supporting
    parental engagement programs, and reinforcing professional development,
    the IAL program helps to support literacy skills to ensure that
    children enter school ready to learn and best positioned for success.
        Since its inception in FY 2012, more than 200 IAL grants have been
    awarded to national non-profit organizations and school districts
    across every region of the U.S., delivering critical literacy resources
    in these communities. In light of interrupted learning this past year
    due to the pandemic, it is even more urgent to support children's
    literacy at home and in school. This is particularly acute for minority
    and low-income students. The IAL program is designed to provide the
    kind of support children and families need. Some examples of IAL grant
    activities include:
      --In 2021, an IAL grant was awarded to Tuscaloosa (AL) City Schools,
            a midsize urban city school district serving 10,500 K-12
            students in 20 locations. This collaborative grant with school
            libraries will provide a learning environment that is racially,
            ethnically, culturally, disability status and linguistically
            responsive. The grant will allow the district to implement the
            Alabama Literacy Act to improve reading proficiency of public-
            school kindergarten through grade 3 students. The district will
            be able to provide early literacy services and distribute high-
            quality books on a regular basis to children from low-income
            communities. Tuscaloosa schools have set goals that include a
            minimum of 85 percent of librarians will receive literacy
            training; 100 percent of participating schools will develop,
            improve, or expand their K-12 literacy plan; a 4 percent
            increase over baseline; and 100 percent of students will
            receive personal books and/or access to online books.
      --The Yakama Nation Tribal School in Washington state joined
            community partners to receive an IAL grant in 2021. Their
            Reading Through Mirrors & Windows IAL grant targets 14 schools
            with a large percentage of Native American and Hispanic
            students and will support literacy programs for educators,
            students, and parents designed to improve literacy skills. The
            grant will promote book distribution, mobile libraries, out-of-
            school time literacy activities, reader/writer theaters, and
            read-a-loud events. The 3-year grant has established laudable
            goals for the schools to achieve each year.
        A strong learning environment begins with literacy skills in early
    childhood. However, only 35 percent of fourth grade students, 34
    percent of eighth grade students, and 37 percent of twelfth grade
    students performed at or above the proficient level on the 2019 NAEP
    reading assessment (National Center for Education Statistics, 2019).
    This was exacerbated during the pandemic by school building closings
    and remote learning, which challenged students and educators alike. A
    study by McKinsey & Company found that students taking formative
    assessments in spring 2021 lost the equivalent of 4 months of learning
    in reading on average, but the unfinished learning was especially for
    students of color and those from low-income households. Without
    immediate and sustained interventions, researchers estimate that
    pandemic-related unfinished learning could reduce lifetime earnings for
    K-12 students by an average of $49,000 to $61,000.
        The American Academy of Pediatrics reports that children introduced
    to early reading and literacy support tend to read earlier and excel in
    school compared to children who lack the same access to books and
    literacy activities. Early literacy mastery is a strong indicator of
    future success in school and in life. Unfortunately, more than one in
    three American children start kindergarten without foundational skills
    to learn to read.
        Recent studies and articles demonstrate the challenges facing out
    youngest students. One article notes that early reading skills in
    Virginia are at a 20-year low while 60 percent of high-poverty students
    in Boston are high-risk for reading problems. Goldstein, Dana (2022,
    March 8) New York Times. Another article reports that more than one in
    three children who started school during the pandemic need
    ``intensive'' reading help. Sparks, Sarah (2022, February 16) Education
    Week.
        Providing books and childhood literacy for such children is crucial
    to their learning to read, which is crucial to their--and our
    Nation's--economic futures. IAL is an important literacy support
    program that is urgently needed to address reading decline. IAL grants
    have been awarded during the life of the program to almost every State
    in the Nation. Schools across the country have received grants,
    including Dillingham (AK) City School District; Savannah (GA) Chatham
    City Public School System, Ypsilanti (MI) Community Schools, Cottonwood
    (OK) School, and as well as many others.
        For families living in poverty, access to reading materials is
    severely limited. Children in such households have fewer books in their
    homes than their peers, which hinders their ability to prepare for
    school and to stay on track. IAL helps bridge that gap. Accordingly, we
    urge the subcommittee to foster this work by continuing to invest at
    least $50 million in IAL.
        ALA asks for a modest, but critical, Federal investment of $50
    million in the FY 2022 Innovative Approaches to Literacy (IAL) program,
    authorized under the Every Student Succeeds Act. IAL provides
    competitive awards to high-need school libraries and national not-for-
    profit organizations (including partnerships that reach families
    outside of local educational agencies) to put books into the hands of
    children and their families.
        ALA understands the tight fiscal constraints on the subcommittee,
    and we appreciate its continued dedicated support of IAL. Thank you for
    your commitment to sustaining and strengthening our communities and our
    Nation by supporting America's school libraries.
                                     ______

              Prepared Statement of the American Liver Foundation
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least $49.
            billion and provide individual NIH Institutes and Centers, such
            as NIDDK, NIMHD, and NCI with proportional discretionary
            increases.
        --Please provide additional, distinct funding for the emerging
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH, which would facilitate implementation of this
                important program without supplanting ongoing NIH research
                activities.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $11 billion to facilitate timely public health efforts
            along with proportional increases for CDC Centers and
            Divisions, such as NCCDPHP and NCHHSTP.
        --Please provide $54.5 million for the Division of Viral Hepatitis
                at CDC.
        --Please provide $150 million for the Opioid and Infectious
                Diseases Program at CDC.
        --Please provide $6 million for the Chronic Disease Education and
                Awareness Program at CDC.
      --Provide the Health Resources and Services Administration (HRSA)
            with a funding level of at least $9.8 billion and ensure that
            the agency has sufficient resources to enhance organ donation
            through awareness activities and partnerships.
      --Please support the communities Think Liver, Think Life awareness
            campaign and include timely committee recommendations
            prioritizing liver health efforts.
    _______________________________________________________________________

        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 CDC and the emerging Chronic Disease Education and
    Awareness program, provided over recent years. Please maintain this
    commitment and further enhance support for public health programs as
    you work with your colleagues on appropriations for FY 2023. Thank you
    again.
                              about the foundation
        The American Liver Foundation is the Nation's largest non-profit
    organization focused solely on promoting liver health and disease
    prevention. The American Liver Foundation achieves its mission in the
    fight against liver disease by funding scientific research, education
    for medical professionals, advocacy, information and support programs
    for patients and their families as well as public awareness campaigns
    about liver wellness and disease prevention. The mission of the
    American Liver Foundation is to promote education, advocacy, support
    services and research for the prevention, treatment and cure of liver
    disease. Additional information and support can be found at
    www.liverfoundation.org or by calling 1 800 GO LIVER (800-465-4837)
                                  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. Nearly 100 million people in the U.S. are
    affected by liver disease. Approximately 30 percent of adults and 3-10
    percent of children have excessive fat in the liver or NAFLD which can
    lead to a severe liver disease called non-alcoholic steatohepatitis
    (NASH). Approximately 4.4 million Americans are living with Hepatitis B
    or C but most do not know they are infected. More than 2 million
    Americans are living with alcohol related liver disease. Approximately
    5.5 million Americans are living with chronic liver disease or
    cirrhosis. Vaccinations for hepatitis A and B and treatments for
    hepatitis C are helping to change the course of this chronic life
    altering disease for the patient community.
               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 and then doubling that support for $3 million for FY 2022.The
    first round of funding is now supporting four cooperative agreements in
    key areas, but 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 and it is only growing more
    popular. Since there is tremendous demand in this area, and no shortage
    of quality opportunities for CDC, we ask that funding be systematically
    increased again with $6 million provided for FY 2023.
                                 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 percent increase in
    rates of hepatitis C among 20--29 year olds an 300 percent increase
    among 30--39 year olds. The elimination initiative has been well-
    supported since its establishment, but much more can be done. We ask
    that this allocation be systematically increased along with the annual
    funding for the Division of Viral Hepatitis (which saw is first modest
    funding increase in many years for FY 2022) 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 5 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 10 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 percent of people age 18 and over have enrolled in the New York
    State Donate Life Registry. But every 10 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 2023 appropriations recommendations
    _______________________________________________________________________

    $11 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 $6 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 $40 million for CDC's National Asthma Control Program
                (NACP)

    $49 billion for the National Institutes of Health (NIH)
      --Provide $4.015 billion for the National Heart, Lung, and Blood
            Institute (NHLBI)
      --Provide $932 million for the National Institute of Environmental
            Health Sciences (NIEHS)
    _______________________________________________________________________

        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 Murray, Ranking Member Blunt, 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 FY 2023. The American Lung Association
    also asks for your leadership in opposing all policy riders that would
    weaken key lung health protections.
        The ongoing COVID-19 pandemic continues to underscore 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, the consequences of
    the failure to adequately invest in both cross-cutting and individual
    programs at CDC has become evident. The pandemic has taken the lives of
    more than one million people in the U.S. and lung disease deaths this
    past year have increased 80 percent due to COVID-19. We ask that CDC
    funding be increased to at least $11 billion for FY 2023. 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 suggests possible
    links between long-term exposure to air pollution and 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
    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 FY23, 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 and biomedical research.
        Provide $11 billion for the Centers for Disease Control and
    Prevention (CDC): 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 $11 billion for CDC for FY23 and sustained, robust and
    predictable funding moving forward annually for both cross-cutting
    initiatives such as workforce and data modernization, as well as
    individual lines as outlined below.
        Provide $3.75 billion for National Center for Chronic Disease
    Prevention and Health Promotion (NCCDPHP): 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 percent 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 3 years (FY23-FY25) to $3.75 billion. 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 those experiencing
    the long-term effects of COVID-19, or ``long COVID.'' 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 $4
    million increase in funding for OSH in FY22 and asks for an additional
    $68.5 million for FY23. OSH works with State and local governments to
    prevent youth tobacco use and to promote evidence-based methods to help
    smokers quit; for example, OSH's ``Tips from Former Smokers'' campaign
    has successfully prompted one million Americans to quit smoking. 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 $6 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 and unaware of the
    warning signs that would prompt earlier treatment. 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 fiscal year 2021 and the increase
    in FY22. In FY23, the Lung Association asks for this program to be
    increased to $6 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 stand-alone 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 providing guidance
    to States in adaptation. The Climate and Health Program includes the
    Climate Ready States and Cities Initiative (CRSCI) that utilizes a
    five-step Building Resilience Against Climate Effects (BRACE) program
    to protect communities. The CRSCI program is a valuable tool for
    States, localities, Tribes and territories, but it has received
    insufficient funding. Just recently, funding for a number of States was
    actually cut. The President's budget requests $110 million, which would
    allow CDC to implement a climate and health program across all States
    and territories.
        Provide $40 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. We thank
    Congress for the increase in funding of $500,000 in FY22. Additional
    funding would allow increased surveillance in States, including where
    pediatric asthma surveillance is not available. At present, 24 States,
    Puerto Rico, and Houston, TX, receive funding, and additional entities
    are funded to collect detailed surveillance data so that public health
    interventions are more focused and effective. Additional funding of $40
    million in FY23 would also allow for the NACP to continue its efforts
    to develop public health interventions aimed at protecting people with
    asthma from wildfire smoke.
        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. As
    the Nation waits to know if COVID-19 vaccines will be made available
    for children under 5, and if research shows that booster shots for non-
    immunocompromised adults are a viable way to reduce the effects of
    COVID-19, it is crucial that national vaccine programs remain prepared
    and well-funded as we enter the third year of the COVID-19 pandemic.
    The National Immunization Program must receive strong and sustained
    funding. The Lung Association asks for $1.13 billion for NCIRD to
    enhance COVID-19 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 $49 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. Although lung cancer remains the leading cause
    of cancer deaths in the United States, the lung cancer survival rate
    has increased 33 percent in the past 10 years due to improvements in
    treatment. It is important that funding for lung cancer research
    increase concurrently in order to continue to make life-saving
    advancements in research.
        Provide $4.015 billion for the National Heart, Lung, and Blood
    Institute (NHLBI): The Lung Association supports increased funding for
    the National Heart, Lung, and Blood Institute in FY23. NHLBI is a
    global leader in lung, heart and blood disease research, and invests in
    prevention programs and new treatments for chronic lung conditions.
    NHLBI currently conducts research on improving early identification and
    treatment of COPD, and on new asthma treatments for the half of all
    severe asthma patients who do not respond to conventional medication.
    As the COVID-19 pandemic continues, NHLBI research also addresses the
    uncertainty regarding the long-term impacts of COVID-19 on patients on
    the heart, lungs and blood. Additional funding of $4 billion would
    allow NHLBI to bolster these crucial projects.
        Provide $932 million for the National Institute of Environmental
    Health Sciences (NIEHS): The Lung Association requests funding of $932
    million for NIEHS. Research at NIEHS studies and identifies links
    between chronic diseases and patients' environmental surroundings,
    which is fundamental to treating lung diseases such as asthma and COPD.
    Patients with asthma can be triggered by extreme weather events such as
    wildfires, underscoring the importance of research that prepares
    patients and providers for the health impacts of a changing climate.
    The Lung Associations supports $100 million for climate change and
    human health research within NIEHS.
        Thank you for your consideration of our recommendations.

        [This statement was submitted by Harold P. Wimmer, 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 a Statement to the Senate subcommittee on Labor,
    Health and Human Services, and Education, and Related Agencies in
    support of continued robust funding in the FY 2023 budget for the
    National Center for Complementary and Integrative Health (NCCIH) within
    the National Institutes of Health (NIH). We also encourage additional
    support for the Centers for Medicare and Medicaid Services (CMS) to
    implement and disseminate the recommendations of the 2019 HHS ``Pain
    Management Task Force (PMTF)'', which include utilization of massage
    therapy for pain management.
        Established in 1943 and numbering over 95,000 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.
        The impact of COVID restrictions on patient access to health care
    for a variety of pain conditions is being felt now throughout the
    health care system. Opioid and substance abuse rates have increased.
    While there is no single solution to the opioid crisis, massage therapy
    demonstrably reduces reliance on opioids to address pain.
        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.
        As well, massage therapy is specifically supported in the May 2019
    final report of the PMTF, and is part of the ``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.
        We would like to highlight that massage has been specifically noted
    in guidelines for non pharmacologic opioid alternatives issued by the
    Attorney General of West Virginia; and, it is among a list of four non-
    pharmacologic approaches to pain in a September 18, 2017 letter to
    American's Health Insurance Plans, signed by 37 Attorneys General,
    which urges health insurance companies to encourage health care
    providers to prioritize non-opioid pain management options for chronic
    pain, as follows:

          ``When patients seek treatment for any of the myriad conditions
            that cause chronic pain, doctors should be encouraged to
            explore and prescribe effective non-opioid alternatives,
            ranging from non-opioid medications (such as NSAIDs) to
            physical therapy, acupuncture, massage, and chiropractic
            care.''

        Despite the demonstrated value and efficacy of massage therapy
    through research, we know that more needs to be done. Research will
    continue to identify the optimal benefits of massage for particular
    demographic groups, including patients as young as infants up to
    Medicare beneficiaries. And, we need to better understand the
    underlying mechanisms of pain, and how and why pain manifests
    differently for different patients.
        Maintaining a robust Federal research program at NCCIH dedicated to
    advancing massage therapy is vital, and health care providers need to
    be aware of the value of massage therapy in order for research findings
    to be put in action. For this reason, we believe it is critical that
    NCCIH continue to drive forward the most promising science surrounding
    massage and other integrative therapies to address both acute and
    chronic pain conditions. It is equally important that public and
    provider awareness of the known benefits of massage therapy be
    optimized, and we encourage additional support by this Committee for
    CMS to implement and disseminate the PMTF's report and recommendations.
        Thank you again for the opportunity to provide this statement.
                                     ______

            Prepared Statement of the American Physiological Society
        The American Physiological Society (APS) thanks the subcommittee
    for its ongoing support of the National Institutes of Health (NIH). The
    sustained budget increases over the past several years have allowed the
    agency to support biomedical discoveries and innovations that drive the
    development of the next generation of therapies. The existing
    Institutes and Centers at the NIH rely on consistent and steady funding
    growth to keep pace with the inflation of research costs and it is
    absolutely essential that the NIH continues to provide robust support
    for such investigator-driven research. Therefore, the APS urges you to
    sustain this vital effort by providing the NIH with a base budget of at
    least $50 billion in fiscal year (FY) 2023.
        While APS supports the goals of the new Advanced Research Project
    Agency for Health (ARPA-H) (ARPA-H), it is critical that any funding
    provided for this new program does not come at the expense of the NIH's
    fundamental research efforts. The ARPA-H budget should therefore be in
    addition to the $50 billion base budget.
        The NIH is the Nation's largest funder of biomedical research. More
    than 80 percent of the agency's funding supports extramural research,
    largely awarded through competitive grants. These grants fuel economic
    activity and job creation in every State. NIH funding in 2021 supported
    over 550,000 jobs and generated an estimated $94 billion in economic
    activity.\1\ The discoveries that emerge from NIH-supported basic and
    translational research provide the foundation for new drugs and
    therapies and prepare our Nation to confront challenging public health
    threats such as obesity and diseases associated with an aging
    population.
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    2022/03/UMR_NIHs-Role-in-Sustaining-the-U.S.-Economy-FY21.pdf.
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        The historically robust support of the NIH and other Federal
    research agencies by Congress is a primary reason the US is the global
    leader in biomedical research. However, the rate of growth of Federal
    funding for research lags behind that of some other countries,
    including China.\2\ Unless the US prioritizes investments in science,
    the Nation risks losing its edge in highly competitive technology
    driven industries.
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        While the private sector brings the majority of new treatments to
    the market, it relies on the breakthroughs from federally funded
    research to identify new targets and strategies to treat diseases. This
    partnership between industry and academic research has been key for
    decades of success of the American biomedical industry. A study
    published in the Proceedings of the National Academy of Sciences found
    that every single one of the 210 new pharmaceuticals approved by the
    FDA between 2010 and 2016 depended on research funded by the NIH.\3\
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        \3\ https://www.pnas.org/doi/10.1073/pnas.1715368115.
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        The NIH has proven its value as an institution over the past
    several decades. The rapid development of effective and safe COVID-19
    vaccines was possible only because of many previous years of
    fundamental research supported by NIH. Other achievements include
    improvements in diagnostics, new cancer treatment options, and a better
    understanding of antibiotic resistance. The NIH also plays an important
    role in training the next generation of scientists by supporting
    trainees with individual fellowships and institutional grants as they
    complete their graduate degrees and seek the post-doctoral training
    necessary to pursue successful independent research careers.
        Our public health system continues to face significant challenges.
    COVID-19 cases have decreased, but hospitals continue to see new
    infections. Millions of Americans potentially face long-term health
    effects due to COVID-19. In addition, our aging population will face
    increasing rates of conditions such as heart disease, diabetes,
    arthritis, kidney failure, and cancer. If we are to continue to advance
    new and innovative ways to address these and other challenges on the
    horizon-including developing the workforce necessary to do so--the NIH
    will need stable and predictable funding increases in future years.
        The APS joins the Federation of American Societies for Experimental
    Biology (FASEB) in urging that NIH be provided with no less than $50
    billion in FY 2023, with additional funds for ARPA-H provided in
    addition to that amount.
        Physiology is a broad area of scientific inquiry that focuses on
    how molecules, cells, tissues and organs function in health and
    disease. The American Physiological Society connects a global,
    multidisciplinary community of more than 10,000 biomedical scientists
    and educators as part of its mission to advance scientific discovery,
    understand life and improve health. The Society drives collaboration
    and spotlights scientific discoveries through its 16 scholarly journals
    and programming that support researchers and educators in their work.
                                     ______

     Prepared Statement of the American Psychological Association Services
        The American Psychological Association (APA) is the largest
    scientific and professional organization representing psychology in the
    United States, with more than 133,000 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 fiscal year 2023 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 $40.048 billion for NIH in fiscal year 2023,
    an increase of $4.1 billion ($3.5 billion or 7.9 percent in NIH
    appropriation plus funding from the 21st Century Cures Act for specific
    initiatives) above the fiscal year 2022 funding level. This is a
    critical year for NIH to expand its support of youth mental health
    research, including work on the potential harms and benefits of social
    media. 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. As an association with a longstanding history of devoting
    attention to and advancing diversity, equity, inclusion, and
    accessibility related issues, APA strongly believes these factors are
    critical to advancing biomedical, behavioral, and psychological
    research supported by the NIH.
        APA recommends at least $815 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. This sum is
    necessary to fully support the education research and statistical
    infrastructure essential to education policy and practice.
        Finally, APA urges the Committee to provide $60 million for gun
    violence research in fiscal year 2023, $35 million to the CDC and $25
    million to the 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 populations 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)
    and 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. Recent funding cycles 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 $30 million for the Graduate Psychology
    Education Program; $225.8 million for the Behavioral Health Workforce
    Education and Training (BHWET) Programs; and $38 million for the Mental
    and Substance Use Disorder Workforce Training Demonstration, including
    the Integrated Substance Use Disorder Program (ISTP). 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 $25 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 $1.7 billion for SAMHSA's Community Mental Health
    Block Grant (MHBG) and $3 billion for the Substance Abuse Prevention
    and Treatment (SAPT) Block Grant in fiscal year 2023. APA is also
    asking the Committee to include a new 10 percent set aside for
    prevention and early intervention in the MHBG, similar to the SAPT set-
    aside. This would include growing school-based and community
    initiatives to address mental health before a person is deemed SED/SMI,
    which is the current statutory language for using block grant funding.
        To address rising suicide rates and ensure proper implementation of
    988 as the Nationwide number for the National Suicide Prevention
    Lifeline network, we urge the Committee to provide $140 million for the
    National Suicide Prevention Lifeline, $560 million for the 988/Lifeline
    Crisis Call Centers, $10 million for the Behavioral Health Crisis and
    988 Coordinating Office, $200 million for the 988 Public Awareness
    Campaign, and $100 million for the Mental Health Crisis Response
    Partnership Program. Additionally, we ask the Committee to include $37
    million for the State/Tribal Youth Suicide Prevention Program, $12
    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 and
    $244 million for Project AWARE. Additionally, to increase the number of
    mental health providers working in school settings, APA requests $1
    billion 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 $16.2
    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.
        To prevent maternal deaths, eliminate inequities in maternal health
    outcomes, and improve maternal health, APA urges the committee to
    prioritize the highest possible funding level for essential public
    health programs, including the Maternal and Child Health Services Block
    Grant and Healthy Start at CDC; Safe Motherhood and Infant Health at
    CDC; and research into pregnancy at NIH. In addition, APA requests $100
    million for maternal mental health equity grant programs.
        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 $27.5 million for MHPAEA enforcement, with
    10 percent allocated to the Office of the Solicitor for parity
    litigation. To support MHPAEA enforcement within HHS, APA requests $125
    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 $12.2 billion for the Head Start Program, $7.6
    billion for the Child Care and Development Block Grant, $450 million
    for Preschool Development Grants, and $500 million for CAPTA Title I to
    support State child abuse prevention and treatment.
        To expand the reach of Federal school-based health education, 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.
                   fiscal year 2023 requested report language
    Health Resources and Services Administration
                Graduate Psychology Education [GPE] Program
        U.S. Department of Health & Human Services Health Resources and
    Services Administration (HRSA) Interdisciplinary Community-Based
    Linkages
    Mental and Behavioral Health
        The Committee recommendation includes $30 million for the
    interprofessional Graduate Psychology Education (GPE) Program to
    increase the number of health service psychologists trained to provide
    integrated services to high-need, underserved populations in rural and
    urban communities. The Committee recognizes the severe impact of COVID-
    19 on Americans' mental and behavioral health and urges HRSA to
    strengthen investments in the training of health service psychologists
    to help meet these demands.
    National Institutes of Health
                NIMH: Research on Youth Mental Health and Disparities
        The Committee is encouraged by the work of NIMH to support research
    on issues related to youth mental health, including among youth of
    color and underserved LGBTQ+ and those with disabilities, and
    appreciates NIMH's work on a 10-year strategic plan to eliminate racial
    mental health disparities. From within the increase of $---- that the
    Committee has provided NIMH, the Institute is directed to use $50
    million to lead a multi-institute research collaboration including
    NICHD and NIMHD to guide preventive measures, targeting of
    interventions, improved treatments, and long-term recovery. This
    collaboration should sponsor fundamental and applied research including
    social, behavioral, cognitive and developmental research, to build
    resilience, increase our communities' capacity to identify and care for
    young people at risk and those in crisis, and improve the targeting and
    delivery of clinical and community-based mental health interventions.
    Centers for Disease Control and Prevention
        The Committee is encouraged by the Administration's National COVID-
    19 Preparedness Plan strong emphasis on COVID-19 health equity and data
    collection. According to the plan, the Administration will continue to
    prioritize providing equitable access to COVID-19 health care and
    public health resources. Central to achieving this goal is continued
    progress in modernizing national disease surveillance and building the
    capacity at Centers for Disease Control and Prevention (CDC) and State
    and local health jurisdictions. The committee asks the Department of
    Health and Human Services (HHS) to provide a report detailing the CDC's
    progress toward disaggregating COVID-19 surveillance data by race,
    ethnicity, geography, disability status, sexual orientation, gender
    identity and other factors, including mental health conditions and
    substance use.

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

          Prepared Statement of the American Psychological Association
        The American Psychological Association (APA) is the largest
    scientific and professional organization representing psychology in the
    United States, with more than 133,000 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 fiscal Year23 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 $40.048 billion for NIH in FY 23, an increase
    of $4.1 billion ($3.5 billion or 7.9 percent in NIH appropriation plus
    funding from the 21st Century Cures Act for specific initiatives) above
    the FY 22 funding level. This is a critical year for NIH to expand its
    support of youth mental health research, including work on the
    potential harms and benefits of social media. 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. As an association with a
    longstanding history of devoting attention to and advancing diversity,
    equity, inclusion, and accessibility related issues, APA strongly
    believes these factors are critical to advancing biomedical,
    behavioral, and psychological research supported by the NIH.
        APA recommends at least $815 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. This sum is
    necessary to fully support the education research and statistical
    infrastructure essential to education policy and practice.
        Finally, APA urges the Committee to provide $60 million for gun
    violence research in FY 23, $35 million to the CDC and $25 million to
    the 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 populations 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)
    and 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. Recent funding cycles 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 $30 million for the Graduate Psychology
    Education Program; $225.8 million for the Behavioral Health Workforce
    Education and Training (BHWET) Programs; and $38 million for the Mental
    and Substance Use Disorder Workforce Training Demonstration, including
    the Integrated Substance Use Disorder Program (ISTP). 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 $25 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 $1.7 billion for SAMHSA's Community Mental Health
    Block Grant (MHBG) and $3 billion for the Substance Abuse Prevention
    and Treatment (SAPT) Block Grant in fiscal Year23. APA is also asking
    the Committee to include a new 10 percent set aside for prevention and
    early intervention in the MHBG, similar to the SAPT set-aside. This
    would include growing school-based and community initiatives to address
    mental health before a person is deemed SED/SMI, which is the current
    statutory language for using block grant funding.
        To address rising suicide rates and ensure proper implementation of
    988 as the Nationwide number for the National Suicide Prevention
    Lifeline network, we urge the Committee to provide $140 million for the
    National Suicide Prevention Lifeline, $560 million for the 988/Lifeline
    Crisis Call Centers, $10 million for the Behavioral Health Crisis and
    988 Coordinating Office, $200 million for the 988 Public Awareness
    Campaign, and $100 million for the Mental Health Crisis Response
    Partnership Program. Additionally, we ask the Committee to include $37
    million for the State/Tribal Youth Suicide Prevention Program, $12
    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 and
    $244 million for Project AWARE. Additionally, to increase the number of
    mental health providers working in school settings, APA requests $1
    billion 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 $16.2
    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.
        To prevent maternal deaths, eliminate inequities in maternal health
    outcomes, and improve maternal health, APA urges the committee to
    prioritize the highest possible funding level for essential public
    health programs, including the Maternal and Child Health Services Block
    Grant and Healthy Start at CDC; Safe Motherhood and Infant Health at
    CDC; and research into pregnancy at NIH. In addition, APA requests $100
    million for maternal mental health equity grant programs.
        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 $27.5 million for MHPAEA enforcement, with
    10 percent allocated to the Office of the Solicitor for parity
    litigation. To support MHPAEA enforcement within HHS, APA requests $125
    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 $12.2 billion for the Head Start Program, $7.6
    billion for the Child Care and Development Block Grant, $450 million
    for Preschool Development Grants, and $500 million for CAPTA Title I to
    support State child abuse prevention and treatment.
        To expand the reach of Federal school-based health education, 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.
                   fiscal year 2023 requested report language
    Health Resources and Services Administration
          Graduate Psychology Education [GPE] Program
          U.S. Department of Health & Human Services Health Resources and
            Services Administration (HRSA) Interdisciplinary Community-
            Based Linkages
    Mental and Behavioral Health
        The Committee recommendation includes $30 million for the
    interprofessional Graduate Psychology Education (GPE) Program to
    increase the number of health service psychologists trained to provide
    integrated services to high-need, underserved populations in rural and
    urban communities. The Committee recognizes the severe impact of COVID-
    19 on Americans' mental and behavioral health and urges HRSA to
    strengthen investments in the training of health service psychologists
    to help meet these demands.
    National Institutes of Health
                NIMH: Research on Youth Mental Health and Disparities
        The Committee is encouraged by the work of NIMH to support research
    on issues related to youth mental health, including among youth of
    color and underserved LGBTQ+ and those with disabilities, and
    appreciates NIMH's work on a 10-year strategic plan to eliminate racial
    mental health disparities. From within the increase of $---------- that
    the Committee has provided NIMH, the Institute is directed to use $50
    million to lead a multi-institute research collaboration including
    NICHD and NIMHD to guide preventive measures, targeting of
    interventions, improved treatments, and long-term recovery. This
    collaboration should sponsor fundamental and applied research including
    social, behavioral, cognitive and developmental research, to build
    resilience, increase our communities' capacity to identify and care for
    young people at risk and those in crisis, and improve the targeting and
    delivery of clinical and community-based mental health interventions.
    Centers for Disease Control and Prevention
        The Committee is encouraged by the Administration's National COVID-
    19 Preparedness Plan strong emphasis on COVID-19 health equity and data
    collection. According to the plan, the Administration will continue to
    prioritize providing equitable access to COVID-19 health care and
    public health resources. Central to achieving this goal is continued
    progress in modernizing national disease surveillance and building the
    capacity at Centers for Disease Control and Prevention (CDC) and State
    and local health jurisdictions. The committee asks the Department of
    Health and Human Services (HHS) to provide a report detailing the CDC's
    progress toward disaggregating COVID-19 surveillance data by race,
    ethnicity, geography, disability status, sexual orientation, gender
    identity and other factors, including mental health conditions and
    substance use.

        [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 $11 billion for the Centers for Disease
    Control and Prevention and at least $9.8 billion for the Health
    Resources and Services Administration in FY 2023. 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 2023.
                   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 percent of CDC's budget supports public health and prevention
    activities by State and local health organizations and agencies,
    national public health partners and academic institutions. We urge a
    funding level of at least $11 billion in FY 2023. We are grateful for
    the important increases provided for CDC programs in FY 2022 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 nearly 11 percent of CDC's budget.
        CDC serves as the command center for the Nation's public health
    defense system against emerging and reemerging infectious diseases as
    well as man-made and natural disasters. From playing a leading role in
    aiding in the surveillance, detection and mitigation of the COVID-19
    pandemic in the U.S. and globally, to monitoring and investigating
    other disease outbreaks, to pandemic flu preparedness, CDC is the
    Nation's--and a global--expert resource and response center,
    coordinating communications and action and serving as the laboratory
    reference center. States, communities and international partners rely
    on CDC for accurate information, direction and resources to ensure they
    can prepare, respond and recover from a crisis or disease outbreak.
        We strongly support the president's budget request for an
    additional $400 million, for a total of $600 million, in 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 2023 to
    $35 million for CDC and $25 million for NIH, as requested in President
    Biden's FY 2023 budget proposal. This will allow CDC to continue to
    support 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 $401.85 million for NCEH in FY 2023,
    including $110 million for CDC's Climate and Health program, as
    requested in President Biden's FY 2023 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
    2022 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 FY 2022 and provide at least $9.8 billion for the
    Health Resources and Services Administration in FY 2023.
        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 to build upon these successes and
    pave the way for new achievements by supporting critical HRSA programs,
    including:
      --Primary Health Care that supports more than 13,500 health center
            sites which provide high quality primary care services to
            nearly 29 million people and reduce barriers such as cost, lack
            of insurance, distance and language for their patients.
      --Health Workforce supports the health workforce across the 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 support patient-centered,
            evidence-based programs that optimize health, minimize
            disparities and improve health promotion and health care access
            for medically and economically vulnerable women, infants and
            children.
      --Ryan White HIV/AIDS programs provides medical care and treatment
            services to over half a million people living with HIV. Ryan
            White programs effectively engage clients in comprehensive care
            and treatment, including increasing access to HIV medication,
            which has resulted in 89.4 percent of clients achieving viral
            suppression, compared to just 65.5 percent of all people living
            with HIV nationwide.
      --Title X Family Planning program reduces unintended pregnancy rates,
            limits transmission of sexually transmitted infections and
            increases early detection of breast and cervical cancer by
            ensuring access to family planning and related preventive
            health services to millions of women, men and adolescents.
      --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 over $18 billion for testing and treatment
    provided 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 Red Cross and the United Nations
                                   Foundation
        Chair Patty Murray, Ranking Member Roy Blunt, and Members of the
    subcommittee, the American Red Cross and the United Nations Foundation
    appreciate the opportunity to submit testimony. We are grateful for the
    leadership that Congress has shown in funding CDC global health
    activities in prior years, and we urge Congress to protect and
    strengthen funding for the agency's global measles elimination
    activities for FY 2023 at $80 million, which is part of CDC's overall
    Global Immunization Division line.
                  covid-19 pandemic and global health security
        COVID-19 has had an unprecedented impact on global immunization
    programs. From 2019 to 2020 the number of children receiving a first
    dose of measles containing vaccine (MCV1) decreased in five out of the
    six world regions, resulting in an overall drop in the global
    vaccination coverage rate from 86 percent to 84 percent over the
    period. It is estimated that more than 22 million children did not
    receive MCV1 through routine immunization, the highest increase in
    missed children since 2000. In addition, at least 93 million
    individuals did not receive MCV1 because of COVID-19-related
    postponements of 24 preventative measles vaccination campaigns
    scheduled during the year.
        The pandemic also significantly disrupted measles surveillance and
    disease reporting. The number of lab specimens for suspected measles
    cases submitted for testing was the lowest in over a decade. Many
    countries did not provide reports to WHO and UNICEF on measles
    incidence, and of those that did report, only 32 percent achieved the
    measles surveillance sensitivity indicators needed to consistently
    detect cases and outbreaks. Thus, while available data indicates the
    number of reported measles cases did not increase over the past 2
    years, this is likely due to underreporting that has led to significant
    surveillance gaps.
        These factors paint an alarming picture of a growing immunity gap
    setting the stage for an increase in measles outbreaks and accompanying
    loss of life from an easily preventable disease. 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, as well
    as increasing the likelihood of the virus infecting U.S. communities.
    Global measles investments through the CDC Global Immunization Division
    will quickly close these global immunity gaps and strengthen
    surveillance systems. These investments will also help protect progress
    over the last decade in reducing maternal and child mortality and
    morbidity, as well as preserve and enhance the broader global
    immunization infrastructure. 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 played a pivotal role in saving the lives of
    31.7 million children between 2000 and 2020, partnering with the
    Measles & Rubella Initiative to drive measles deaths down by 94
    percent. Measles is a highly contagious disease that can cause
    blindness, swelling of the brain, and death. Nine out of 10 people who
    are not immune to measles will contract the disease if they come in
    contact with a contagious person, and the measles virus can cause long-
    term damage to the immune system. Every day, roughly 166 children still
    die of measles-related complications.
        The rubella virus is a leading infectious cause of birth defects in
    the world despite availability of an affordable, effective vaccine
    since 1969. 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 vaccine 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 due to inadequate resources.
                             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 were
    linked to importation of the disease by unvaccinated U.S. residents
    returning from trips abroad from countries with active outbreaks.
    Controlling measles and rubella around the world reduces the likelihood
    of similar disease importations in the future.
        Responding to measles outbreaks is resource intensive for health
    systems. In the U.S. outbreaks are costly for State and local health
    departments to detect and respond to and have economic productivity
    costs. In 2019, in response to the measles outbreak in New York City,
    the NYC Department of Health spent over $6 million and dedicated more
    than 500 staff members to halt the spread of the disease which began
    with a single imported cases from outside the country.
                        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 over
    3 billion individuals in 88 countries since 2001, saving the lives of
    more than 31.7 million children. In part due to M&RI, global measles
    mortality has dropped 94 percent, from an estimated 1,072,800 deaths in
    2000 to an approximately 60,700 in 2020 (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 95 percent.
        Thanks to M&RI leadership, the majority of measles vaccination
    campaigns have been able to reach more than 90 percent of their target
    populations with health equity at the forefront to ensure that the most
    vulnerable children are reached in communities that are underserve and
    difficult to access. 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, integrated 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, as in a low-income
    country it costs roughly $2 to administer the combined measles and
    rubella vaccine to a child. 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 percent, the
    required level to establish herd immunity. 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
        The CDC plays an essential role 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 is urgently needed to prevent
    needless childhood deaths around the globe.
        In 2020, thanks in part to U.S. funding through CDC, M&RI supported
    the vaccination of approximately 129 million children 32 countries.
    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.
        The CDC Global Immunization Division, through which the M&RI 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. As was
    seen during the response to COVID-19, resources like the Global Measles
    and Rubella Laboratory Network can be repurposed to quickly responded
    other critical health issues. By building the capacity for measles and
    rubella resources the U.S. is also building capacity for future
    response efforts.
                                   conclusion
        Since fiscal Year2001, 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. U.S. government
    funding for global measles and rubella efforts, however, has remained
    level since FY 2010 at $50 million, which due to inflation has
    significantly lost purchasing power. Furthermore, 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.
        Because of these factors, for fiscal Year2023 the American Red
    Cross and United Nations Foundation respectfully request an increase of
    $30 million to raise funding to $80 million, as part of the overall
    funding for the entire Global Immunization Division account in FY 2023.
    This investment will allow the CDC to help countries to close the
    immunization gap created by COVID-19, strengthen global disease
    detection capacity, safeguard the progress made over the last decade to
    reduce maternal and child mortality, and protect Americans by
    preventing measles cases and deaths in the U.S. 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 the
    American National Red Cross and Peter Yeo, Senior Vice President United
    Nations Foundation.]
                                     ______

      Prepared Statement of the American Society for Engineering Education
                                    summary
        This written testimony is submitted on behalf of the American
    Society for Engineering Education (ASEE) to the Senate subcommittee on
    Labor, Health and Human Services, Education, and Related Agencies for
    the official record. ASEE appreciates the Committee's support for the
    Department of Education (ED) in Fiscal Year (FY) 2022 and asks you to
    robustly fund student aid, teacher preparation, and STEM programs in FY
    2022. Additionally, ASEE requests continued 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 2022 was greatly
    appreciated and ASEE requests continued support of NIH. In addition,
    ASEE is excited about the establishment of ARPA-H and its potential to
    support transformative, high-reward technologies to transform health
    and medicine.
                               written testimony
        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 and support programs like Pell Grants, Federal Work-
    Study (FWS), Graduate Assistance in Areas of National Need (GAANN), 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 FY 2023 president's budget
    request, which proposed doubling the Pell Grant by 2029. ASEE joins the
    higher education community in requesting funding to support doubling
    the maximum Pell Grant award to $13,000. 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 $1.52 billion and
    $1.09 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 also requests funding of $35 million 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 to pursue graduate
    education in critical areas of need for the U.S. workforce such as
    engineering.
    7Teacher 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 budget request proposal to invest $132
    million in the Teacher Quality Partnership grant program and $20
    million in the Augustus F. Hawkins Centers of Excellence grant program
    in fiscal Year2023. Having a well-prepared, diverse K-12 STEM educator
    workforce is absolutely essential to strengthening and growing the
    domestic STEM workforce. Furthermore, Congress should consider efforts
    to support teaching skills for STEM postsecondary faculty and 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 2022. 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 and needs
    to be grown and diversified in the United States. These and other
    programs targeted towards increasing the representation of historically
    underrepresented populations, including women, will ensure a healthy
    STEM workforce pipeline. Furthermore, ASEE supports the
    Administration's proposal from the fiscal Year2023 budget request to
    provide a $282 million increase above fiscal Year2021 enacted levels to
    enhance institutional capacity at Minority-Serving Institutions and to
    create a new $450 million grant program to expand the research capacity
    of institutions that are historically underrepresented in the research
    and development enterprise.
    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. 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 and engineering technology 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 4-year institutions of higher education, ASEE
    urges Congress to robustly fund the Perkins Basic State Grant funding
    program in fiscal Year2023 and encourage the program to build
    connections with NSF's ATE program.
    National Institutes of Health
        The National Institutes of Health are a strong supporter of
    engineering research through many institutes, especially the National
    Institute of Biomedical Imaging and Bioengineering (NIBIB), the
    National Cancer Institute (NCI), the National Institute of General
    Medical Sciences (NIGMS), and the National Heart, Lung, and Blood
    Institute (NHLBI). ASEE is grateful to the committee for its strong
    bipartisan support of the NIH over many years and most recently in FY
    2022 appropriations. NIBIB is the major NIH Institute focused on
    engineering applications to human health and training the next
    generation of biomedical engineers. 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, diagnosis techniques, 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 $49.048 billion in base funding FY 2023
    so that NIBIB and other NIH institutes can continue to support critical
    biomedical engineering research and training.
                  advanced research project agency for health
        ASEE is excited about the establishment of the Advanced Research
    Project Agency for Health (ARPA-H) and believe it will enable new
    models for disruptive health innovation and enable development of
    transformative health technologies. ASEE is encouraged by initial
    planning at the Department of Health and Human Services (HHS) to give
    ARPA-H independence, ensure it has a unique culture, and focus its
    efforts on disease-agnostic platform technologies that have high
    potential across many disease and health areas. Congress should
    continue to encourage the development of a true risk-taking culture at
    ARPA-H to enable high reward outcomes. ASEE urges the subcommittee to
    ensure that any funding provided for ARPA-H supplements, and does not
    supplant, the NIH's base budget funding. As noted above NIBIB and other
    NIH institutes continue to support critical research and need robust
    funding.
                                   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 Adrienne R. Minerick 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 $49 billion for the
    National Institutes of Health (NIH) and $11 billion for the Centers for
    Disease Control and Prevention (CDC) in fiscal year (FY) 2023. Within
    the CDC budget, we request $175 million for the Advanced Molecular
    Detection (AMD) program in the National Center for Emerging and
    Zoonotic Infectious Diseases.
           continuing to lead 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 Chair Murray, 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 several
    years, during which they and their House 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 percent 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 antimicrobial 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
    had to be restarted, animal colonies repopulated, and fieldwork
    rescheduled. While our Nation's research capacity has demonstrated it
    can absorb shocks, the scale of this one was unprecedented in duration
    and impact. We must continue to nurture the research pipeline and
    workforce of tomorrow through sustained support for NIH and the
    training it provides to the next generation of scientists.
       cdc's indispensable role in preventing and controlling infectious
                                    disease
        The programs and activities supported by CDC are instrumental in
    protecting the health of the American people. ASM appreciates the
    extraordinary emergency funding provided to the agency in FY 2021 and
    FY 2022 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 2023, 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 SARS-CoV-2, to foodborne illness, 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, state/local public health
            agencies and commercial entiti. ASM requests $175 million for
            AMD in FY 2023.
      --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 $397
            million, the National Healthcare Safety Network at $100
            million, and the Division of Global Health Protection at $842.8
            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, Chief Advocacy
    Officer, American Society for Microbiology.]
                                     ______

            Prepared Statement of the American Society for Nutrition
        Dear Chairwoman Murray and Ranking Member Blunt:
        Thank you for the opportunity to provide testimony regarding Fiscal
    Year (FY) 2023 appropriations. The American Society for Nutrition (ASN)
    respectfully requests at least $49.048 billion dollars for the National
    Institutes of Health (NIH) and $210 million dollars for the Centers for
    Disease Control and Prevention/National Center for Health Statistics
    (CDC/NCHS) in FY 2023. 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 in nutrition and obesity research in FY 2021.
    Although nutrition and obesity research make up only about 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.
    Nevertheless, healthcare costs and risk factors for diet-related
    diseases remain high. In fact, from 2019 to 2020, age-adjusted death
    rates rose 4.1 percent for heart disease, 4.9 percent for stroke, 8.7
    percent for Alzheimer disease, and 14.8 percent for diabetes.\1\ With
    additional support for NIH, additional breakthroughs and discoveries to
    improve the health of all Americans and reduce the economic burden of
    diet-related diseases will be made possible.
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/nchs/products/databriefs/db427.htm.
    ---------------------------------------------------------------------------
        Investment in biomedical research generates new knowledge, improved
    health, and leads to innovation and long-term economic growth. ASN
    recommends at least $49.048 billion dollars for the NIH base budget in
    FY 2023 to support NIH nutrition-related research that will lead to
    important disease prevention and cures. This represents an increase of
    $4.1 billion over the comparable FY 2022 funding level (an increase of
    $3.5 billion or 7.9 percent in the NIH appropriation plus funding from
    the 21st Century Cures Act for specific initiatives). ASN requests that
    any funding for the new Advanced Research Projects Agency for Health
    (ARPA-H) supplement our $49 billion recommendation for NIH's base
    budget, rather than supplant the essential foundational investment in
    the NIH.
        A budget of $49 billion will allow NIH to provide adequate support
    for the 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. ASN strongly supports the
    President's budget proposal of $97 million for the NIH Office of
    Nutrition Research to advance nutrition science. This is an increase of
    $96 million above FY 2022 enacted to promote health and reduce the
    burden of diet-related diseases. By centrally coordinating
    implementation of the Strategic Plan for NIH Nutrition Research, the
    Office of Nutrition Research can support cross-cutting NIH nutrition
    research developed in collaboration with Institutes and Centers that
    already fund nutrition research. Increased support for nutrition
    research will provide solutions ensuring nutrition security and access
    to healthy food to prevent diet-related health disparities and promote
    health equity for a variety of diet-related diseases and conditions,
    such as cardiovascular disease, obesity, diabetes, and cancer. The
    complexity of human nutrition demands that cutting edge data science
    and system science methods be employed to move this field forward.
    Funds will support new training programs in Artificial Intelligence for
    Precision Nutrition that will focus on integration of related domains,
    including machine learning, systems biology, systems science, Big Data,
    and computational analytics to tackle complex biomedical challenges in
    nutrition science. 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 FY 2023 funding level of
    $210 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 but more than a decade of flat funding has taken
    a significant toll on NCHS's ability to keep pace. $210 million
    reflects an increase to NCHS's base budget of $30 million from its FY
    2022 appropriation, reversing a decade of sequestration and restoring
    the program to its FY 2010 funding level, adjusted for inflation.
        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. The U.S. Department of Agriculture uses this data to develop
    nutrition policies that guide multibillion dollar Federal food
    assistance programs, and nutrition researchers use this valuable data
    as well.
        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 underrepresented
    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 2023
    appropriations for the National Institutes of Health and the CDC/
    National Center for Health Statistics. Please contact John E. Courtney,
    Ph.D., ASN Executive Officer, at 9211 Corporate Boulevard, Suite 300,
    Rockville, Maryland 20850, jcourtney@nutrition.org.
        Sincerely.

        [This statement was submitted by Paul M. Coates, Ph.D., 2021-2022
    President, American Society for Nutrition.]
                                     ______

            Prepared Statement of the American Society of Hematology
        The American Society of Hematology (ASH) represents more than
    18,000 clinicians and scientists committed to the study and treatment
    of blood and blood-related diseases, including malignant disorders such
    as leukemia, lymphoma, and myeloma, as well as non-malignant conditions
    such as sickle cell disease (SCD), thalassemia, bone marrow failure,
    venous thromboembolism, and hemophilia.
                      national institutes of health (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 field of hematology continues to make great strides in
    conquering blood diseases thanks to novel technologies, mechanistic
    insights, and cutting-edge therapeutic strategies. Groundbreaking
    scientific research highlighted at the December 2021 ASH Annual Meeting
    and Exposition, much of which was either funded by NIH or derived from
    NIH-funded research, presented information on advances in gene therapy,
    practice-changing discoveries in immunotherapies, and advances in
    patient care for a wide range of hematologic diseases and conditions.
    Moreover, the Society's regularly updated ASH Agenda for Hematology
    Research 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, extraordinary research that has occurred over the
    past 2 years to identify and develop 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 significant hematologic complications from COVID-19 infection, ASH
    developed the ASH 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. The questions outlined in the document identify significant
    questions about the biology, pathophysiology, and underlying clinical
    implications of COVID-19 as they relate to hematology science and
    clinical care and are meant to inspire research that leads to enhanced
    understanding of the disease process, decreased hematologic
    complications in COVID-19, and improved care of patients with
    hematologic disease. The original document outlined hematology-related
    basic science and clinical research questions that emerged in the first
    few months of the pandemic; the research agenda continues to be updated
    as our understanding of the natural history and treatment of COVID-19
    improves.
        ASH thanks Congress for the robust bipartisan support that has
    resulted in seven consecutive years of welcome and much needed funding
    increases for NIH. For fiscal year (FY) 2023, 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 $49.048 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. ASH also joins the community in strongly
    urging lawmakers to ensure that any funding for the new Advanced
    Research Projects Agency for Health (ARPA-H) supplement the $49 billion
    recommendation for NIH's base budget, rather than supplant the
    essential foundational investment in the NIH. In addition, ASH supports
    the Administration's proposal to supplement NIH's budget with
    additional mandatory funding to speed the pace of pandemic response and
    readiness.
                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 (Public
    Law 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 11 States participate in the data collection
    program, with data being collected from multiple sources (e.g., newborn
    screening programs and Medicaid) in order to create individual health
    care utilizations profiles. Funding through the CDC Foundation has
    allowed Georgia and California to collect data since 2015; additional
    CDC Foundation funding, along with discretionary funding from CDC and
    the Department of Health and Human Services (HHS) and $2 million in
    funding provided by Congress in fiscal Year2021 has allowed nine
    additional States (Alabama, Colorado, Indiana, Michigan, Minnesota,
    North Carolina, Tennessee, Virginia, and Wisconsin) to begin their data
    collection programs. These 11 States are estimated to include just over
    35 percent of the U.S. SCD population.
        ASH thanks Congress for the $3 million provided for the data
    collection program in fiscal Year2022. This funding will allow CDC to
    continue to support data collection efforts in all of the States
    currently participating in the program. ASH also appreciates the
    Administration's request for $4.5 million in funding for the program in
    fiscal Year2023. However, the Society strongly supports providing CDC
    with at least $10 million in FY 2023 for the Sickle Cell Data
    Collection program. This additional funding is necessary to allow the
    program to continue in the States currently participating in the
    programs and to also expand the programs to include additional States
    with the goal of covering the majority of the U.S. SCD population over
    the next 5 years.
        To further support CDC's sickle cell data collection efforts, ASH
    urges the inclusion of the following report language under CDC's
    National Center on Birth Defects and Developmental Disabilities
    (NCBDDD):
      --Public Health Approach to Blood Disorders/Sickle Cell Disease
        The Committee includes $10,000,000 for the Sickle Cell Data
    Collection program to allow for data collection and analysis in States
    currently participating in the program and to allow for expansion to
    additional States. The Committee encourages CDC to provide technical
    assistance to additional States with a higher prevalence of SCD, so
    that they can successfully participate in this grant program to better
    identify affected individuals in their States and better meet their
    needs.
        Additionally, ASH supports the public health community's request
    for at least $11 billion in overall funding for the CDC in FY 2023.
    Strong funding for CDC is critical to supporting all of CDC's
    activities and programs, which are essential to protect the health of
    our communities. In addition to ensuring a strong public health
    infrastructure and protecting our communities from public health
    threats and emergencies, CDC programs are crucial to reducing health
    care costs and improving health. However, due to years of underfunding,
    many CDC programs have not received the resources that are needed to
    address the many health challenges we face as a nation. A funding level
    of at least $11 billion would build upon the funding increase Congress
    provided CDC in FY 2022 and strengthen all of CDC's programs.
              health resources and services administration (hrsa)
        ASH supports funding for the SCD programs within HRSA's Maternal
    and Child Health Bureau, including $9.205 million for the SCD Treatment
    Demonstration Program (SCDTDP) and at least $6 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 2023 appropriations bill recognizing the
    importance of the Sickle Cell Disease Treatment Demonstration Program
    in supporting the growth of comprehensive sickle cell disease centers:
      --Sickle Cell Disease Treatment Demonstration Program
        The Committee includes $9,205,000 for this program, a $2,000,000
    increase above the FY 2022 enacted level. The Committee recognizes the
    importance of the program in supporting the comprehensive sickle cell
    disease (SCD) centers in the provision of coordinated, comprehensive,
    culturally competent, and family-centered care to people with SCD. The
    Committee affirms the goals of the program to improve care delivery and
    access to high quality care for people with SCD, with a focus on
    increasing access to SCD specialists; increase the number of providers
    with SCD expertise and knowledge of SCD treatment methods; and enable
    access to the latest treatment options following evidence-based
    guidelines
        Finally, ASH joins many others in the physician community in
    supporting funding for HRSA's Preventing Burnout in the Health
    Workforce program. Health care professionals have long experienced high
    levels of stress and burnout, and our members have shared that COVID-19
    has only exacerbated the problem. Burnout has been shown to reduce job
    performance, increase turnover, and, in its most extreme instances,
    lead to mental health issues. This important program, established by
    the American Rescue Plan Act and modeled after provisions in the Dr.
    Lorna Breen Health Care Provider Protection Act, provides grants to
    health care organizations to support evidenced-based and evidence-
    informed programs, practices, and trainings with the goal of reducing
    burnout and promoting mental health and wellness among the health care
    workforce. As the U.S. continues to deal with the COVID-19 crisis, ASH
    respectfully urges Congress to provide robust funding for the
    Preventing Burnout in the Health Workforce program in order to expand
    access to vital programs to address the growing mental health
    challenges facing our health care workforce.
        Thank you again for the opportunity to submit testimony. Please
    contact ASH Senior Manager, Legislative Advocacy, Tracy Roades at
    troades@hematology.org, if you have any questions or need further
    information concerning hematology research or ASH's FY 2023 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 $2.03 billion increase
    provided for Fiscal Year (FY) 2022 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 more important than
    ever.
        ASHG urges the subcommittee to appropriate $49 billion for NIH's
    base budget in FY 2023, with any additional funding for the newly
    established Advanced Research Projects Agency for Health (ARPA-H) to
    supplement, not supplant, the core investments in the NIH base budget.
          extraordinary progress in human genetics & genomics research
        Federal funding for human genetics and genomics research is
    enabling new insights into the structure of, and variation in, the
    human genome, and leading to new discoveries in preventing, diagnosing,
    and treating disease.\1\ Through the development of powerful DNA
    sequencing and computational tools, in the past year, an NIH-supported
    consortium generated the first complete assembly of a human genome,
    greatly expand our understanding of genomic variation and providing an
    essential tool for exploring the genetic underpinnings of disease.\2\
    Researchers are also developing new 'polygenic score' tools to assess
    one's risk for many of the leading causes of death in the United
    States, including cardiovascular diseases, immune disorders, and
    cancers.\3\ Such tools hold promise for enabling a personalized
    approach to preempting and preventing disease.
    ---------------------------------------------------------------------------
        \1\ American Society of Human Genetics. (2021). Success Stories in
    Human Genetics and Genomics Research (Chronic Diseases) [Fact sheet].
    https://www.ashg.org/wp-content/uploads/2022/01/The-Benifits-of-human-
    genetics-Noncommunicable-Diseases-factsheets-v3.pdf.
        \2\ Nurk, S. et al. The Complete Sequence of a Human Genome.
    Science 376(6588): 44-53 (2022). https://doi.org/10.1126/
    science.abj6987.
        \3\ https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.
    ---------------------------------------------------------------------------
        Genetic science is delivering major advances in the detection and
    treatment of chronic diseases, notably cancer. Through 'liquid biopsy'
    blood tests, clinicians can identify genetic changes in cancerous
    tumors in a non-invasive way to guide targeted treatments; this testing
    method is being further developed for the early screening and detection
    of multiple cancers. Because of federally funded research findings, we
    now have novel cancer treatment options such as CAR-T gene therapies.
    As of this year, the FDA currently lists 23 approved cellular and gene
    therapy products to treat cancers and other diseases.\4\
    ---------------------------------------------------------------------------
        \4\ https://www.fda.gov/vaccines-blood-biologics/cellular-gene-
    therapy-products/approved-cellular-and-gene-therapy-products.
    ---------------------------------------------------------------------------
        Human genetic and genomic research is also delivering hope for the
    millions of people in the United States living with rare diseases. For
    example, results from NIH-funded trials investigating gene therapies
    and gene editing technologies indicate that genetic approaches will
    allow patients afflicted with sickle cell disease to live pain-free and
    no longer in need of frequent blood transfusions. Effective gene
    therapy is now available for spinal muscular atrophy, a rare childhood
    disease characterized by progressive muscle weakness, and is being
    tested to treat other devastating diseases like Huntington's disease
    and familial amyotrophic lateral sclerosis (Lou Gehrig's disease).
     genetics & genomics: striving for equity and research cohort diversity
        Genetic science can advance health equity through the deliberate,
    meaningful inclusion and participation of individuals from diverse
    groups in human genetics and genomics research. The inclusion of
    populations representing diverse ancestries helps us gain a fuller
    understanding of the genetics of health and disease, knowledge which
    can be used to develop more accurate diagnostic tests and more
    effective treatments that benefit all Americans.\5\ Diverse
    participation in research is essential if we are to realize the full
    promise of human genetics and genomics research and the equitable
    application of genetic discoveries in healthcare and society.
    ---------------------------------------------------------------------------
        \5\ 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 384: 1-4 (2021).
    ---------------------------------------------------------------------------
        Genetics research studies illustrate the importance of research
    cohorts reflecting humanity's diversity.\6\ For example, because most
    individuals participating in genetics research are of European
    ancestry, polygenic risk score tests are more effective for assessing
    disease risk in people of European ancestry than for individuals with
    Hispanic, South Asian, East Asian or African ancestries.\7\ The Society
    commends NIH's efforts to advance diverse participation in research,
    particularly the All of Us Research Program.\8\ Significantly, in 2022,
    this program released a database of health information and whole-genome
    sequences from almost 100,000 individuals,\9\ half of whom are from
    historically underrepresented racial or ethnic backgrounds.\10\
    ---------------------------------------------------------------------------
        \6\ Wojcik G., et al. Genetic Analysis of diverse populations
    improves discovery for complex traits. Nature 570(7762): 514-518
    (2019). https://doi: 10.1038/s41586-019-1310-4.
        \7\ Ibid.
        \8\ https://allofus.nih.gov/.
        \9\ https://www.researchallofus.org/.
        \10\ https://www.nih.gov/news-events/news-releases/nih-s-all-us-
    research-program-releases-first-genomic-dataset-nearly-100000-whole-
    genome-sequences.
    ---------------------------------------------------------------------------
          return on investment: genetics research benefits the economy
        As the United States moves towards recovery from the COVID-19
    pandemic, economic activity across all sectors remains key for our
    return to normalcy. In addition to its importance for addressing health
    care needs in the United States, Federal investments in research and
    development have been shown to drive economic activity. A 2021 study
    commissioned by ASHG and conducted by TEConomy Partners highlights the
    growth of a dynamic ecosystem derived from human genetics and genomics
    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.'' \11\ The report
    estimates that the human genetics and genomics sector supports 850,000
    jobs and generates $265 billion in total economic activity
    annually,\12\ demonstrating that this sector has grown around five-fold
    in the last decade.
    ---------------------------------------------------------------------------
        \11\ Tripp, S., and Grueber, M. 2021. The Economic Impact and
    Functional Applications of Human Genetics and Genomics.
        \12\ Ibid.
    ---------------------------------------------------------------------------
     broad data sharing: essential for human genetics and genomics research
        Broad sharing of human genome data from NIH-funded research is
    essential for advancing science and maximizing the public's return on
    investment in biomedical research. Since the human genome houses
    sensitive information, the genetics and genomics research community is
    a leader in developing best practices for sharing data while protecting
    individuals' privacy. We strongly support policies including the Common
    Rule, the Genetic Information Nondiscrimination Act (GINA), the 21st
    Century Cures Act, the NIH Genomic Data Sharing Policy, and HIPAA,
    which together act to protect individuals from the inappropriate
    disclosure of data for non-research purposes.\13\ As Congress
    encourages NIH to explore the National security risks associated with
    the sharing of individuals' health information, we urge the Committee
    to recognize the privacy protections already established by Congress
    and NIH for genetic research data, and to ensure that broad data-
    sharing can continue to fuel scientific progress.
    ---------------------------------------------------------------------------
        \13\ American Society for Human Genetics. (2021). Perspectives:
    Research and Privacy [Fact sheet]. https://www.ashg.org/wp-content/
    uploads/2021/08/Factsheet-DataPrivacy.pdf.
    ---------------------------------------------------------------------------
                                    summary
        ASHG joins the Ad Hoc Group for Medical Research in recommending at
    least a $49 billion base budget for NIH for FY 2023. 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. ASHG also recognizes the important and
    catalytic role of ARPA-H for advancing science and biomedicine,
    building on the foundation of basic research supported by NIH. Funding
    to establish ARPA-H should complement NIH's current investments in
    basic research.
        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 Brendan Lee, MD, PhD, President-
    Elect,
    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)
    2023 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.
    Dialysis, while an important tool to manage kidney failure, has
    outcomes worse than most cancers: 50 percent of people starting
    dialysis today will die within 5 years.
        The COVID-19 pandemic is especially deadly for kidney patients.
    Americans with kidney diseases are the most at risk among Medicare
    beneficiaries for severe outcomes from COVID-19--including
    hospitalization and death--and COVID-19 damages the kidneys of 30
    percent of all hospitalized COVID-19 patients, even those without a
    prior history of kidney diseases.
        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 $125 billion, or 25 percent of all
    traditional Medicare fee-for-service spending, to the care of all
    kidney diseases, including $37 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 67 innovators across
    5 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 and xenotransplantation.
    Further, KidneyX is delivering on its pledge to catalyze private
    markets to invest in the advancement of kidney care. For instance,
    investors contributed more than $300,000,000 to multiple winners of
    KidneyX's first prize competition, Redesign Dialysis.
        FY 23 funding will support Phase 2 of the Artificial Kidney Prize,
    which seeks to promote the integration and advancement of prototype
    bioartificial kidneys. With $25,000,000 in funding, KidneyX can support
    additional innovators in the Artificial Kidney Prize competitions and
    run prizes in other priority areas, such as refining the diagnosis of
    kidney diseases-currently more than 90 percent of people with kidney
    diseases are unaware they have the condition-and developing tools to
    prevent kidney diseases altogether. Recent advances in regenerative
    medicine and xenotransplantation have demonstrated the promise
    innovation can bring to kidney health.
        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 providing kidney health care 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
      --Groundbreaking technologies that may lead to a fully implantable or
            bioartificial kidney, such as an implantable silicon filter
            cartridge paired with a bioreactor with kidney cells that
            together provide continuous treatment without needing to be
            tethered to a dialysis machine, or a method to genetically
            engineer pig kidneys to make them perform life-sustaining
            functions when transplanted in humans, both seeded through the
            Artificial Kidney Prize competition
        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
    program total of $250 million. KidneyX has received $15 million since
    fiscal Year20 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 2023 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
    percent of Medicare spending (approximately $37 billion) in CY 2019,
    yet therapeutics for kidney failure remain limited and 50 percent 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 2023 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 at the
    American Society of Nephrology, at zkribs@asn-online.org.
                    about the american society of nephrology
        Since 1966, ASN has been leading the fight to prevent, treat, and
    cure kidney diseases throughout the world by educating health
    professionals and scientists, advancing research and innovation,
    communicating new knowledge, and advocating for the highest quality
    care for patients. ASN has more than 20,000 members representing 132
    countries. For more information, visit www.asn-online.org and follow us
    on Facebook, Twitter, LinkedIn, and Instagram.

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

         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) 2023 and
    asks that the subcommittee encourage increased support for plant-
    related research with relevance to health within the agency, including
    within the newly established Advanced Research Projects Agency for
    Health (ARPA-H).
        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, nutraceuticals, 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. 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.\1\ Plants can be
    harnessed as biofactories to produce vaccines against infectious
    diseases such as Ebola, hepatitis B, cholera, and coronavirus. Indeed,
    in February 2022, a plant-derived vaccine developed by GlaxoSmithKline
    and Medicago, trademarked as Covifenz, was approved by regulatory
    authorities in Canada for the prevention of COVID-19.\2\ Clinical
    trials showed that Covifenz was between 69-78 percent effective in
    preventing COVID-19 infection, demonstrating that this vaccine could be
    a valuable asset in ending the ongoing COVID-19 pandemic.\3\ 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\ Page 19, Decadal Vision, https://
    plantsummit.files.wordpress.com/2013/07/plantscience
    decadalvision10-18-13.pdf.
        \2\ https://medicago.com/en/press-release/covifenz/.
        \3\ https://www.nejm.org/doi/full/10.1056/NEJMoa2201300.
    ---------------------------------------------------------------------------
              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'' because they are, like humans, complex
    multi-cellular organisms yet afford ease of genetic manipulation, a
    lesser regulatory burden, and maintenance requirements that are less
    expensive and burdensome 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 immune 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 percent or more of the human genome. More recently,
    plants are among organisms that have been used to develop revolutionary
    technologies such as gene editing (such as the CRISPR-Cas9 system),
    capable of precisely editing genomes to potentially correct mutations
    that lead to disease. These technologies are being deployed to produce
    more nutritious food and to sustainably increase production.
    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.
        Use-Inspired Research.--In addition to their role in expanding our
    understanding of the basic mechanisms of biology, plants have been
    enormously beneficial in advancing use-inspired research aimed at
    developing breakthrough technologies, platforms, and solutions for
    health and medicine. The newly established Advanced Research Projects
    Agency for Health (ARPA-H) within NIH is a promising avenue for
    bringing new plant-based breakthroughs from idea to reality. The ARPA
    model for funding research has already proved to be an excellent fit
    for plant biology as shown by successful programs funded through the
    Defense Advanced Research Projects Agency (DARPA) and the Advanced
    Research Projects Agency--Energy (ARPA-E). As ARPA-H develops, ASPB
    supports the inclusion of plant-related research within the agency's
    portfolio.
        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
    percent 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; \4\ 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 percent 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.
    ---------------------------------------------------------------------------
        \4\ https://www.who.int/bulletin/archives/78(10)1207.pdf.
    ---------------------------------------------------------------------------
        Obesity, cardiac disease, and cancer also take striking tolls
    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 percent 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 small-molecule 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 that, similar to the ``Genomes
    to Natural Products'' initiative, will enhance new plant-related
    medicinal research.
        Plant biology is also contributing to the advancement of new agents
    for cancer immunotherapy, a newer treatment strategy that uses the
    body's own immune system to fight disease. Research funded by NIH has
    shown that nanoparticles containing cowpea mosaic virus--which infects
    legumes but is harmless to humans--can be injected into tumors to bait
    the immune system into attacking and destroying cancerous cells.
    Ongoing support from NIH is enabling researchers to determine the
    mechanisms behind the efficacy of these nanoparticles in attacking
    tumors, research that will, in turn, pave the way for these and similar
    plant-derived treatments to enter clinical trials.\5\
    ---------------------------------------------------------------------------
        \5\ https://pubs.acs.org/doi/10.1021/acs.molpharmaceut.2c00058.
    ---------------------------------------------------------------------------
                                   conclusion
        Plants play unique and pivotal roles in nutrition and health,
    agriculture, and the 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 all components of
    the NIH and direct the agency to support additional plant research 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
        Chair 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) 2023 Labor, Health and Human
    Services, Education and Related Agencies appropriations bill. My name
    is Judy Rich, EdD, CCC-SLP, BCS-CL, ASHA's President for 2022.
        As the subcommittee begins its work on this critical legislation, I
    offer ASHA's support for the following programmatic funding requests
    for the U.S. Department of Education (ED):
        1.  $16.76 billion for the Individuals with Disabilities Education
            Act (IDEA) Part B State Grants, $503 million for IDEA Part B
            Section 619 Preschool Grants, $932 million for IDEA Part C
            Infants and Toddlers with Disabilities, and $250 million for
            IDEA Part D section 662 personnel preparation grants within ED.
        2.  $1 billion for the Administration's proposed School-Based
            Health Professionals program to support efforts to address
            shortages of school-based health professionals. ASHA also urges
            the subcommittee to ensure that speech-language pathologists
            (SLPs) and audiologists are eligible for this program.
        In addition, ASHA encourages the subcommittee to include report
    language to establish issue-specific technical assistance (TA) centers
    within ED to improve the ability of school-based SLPs and educational
    audiologists to meet the needs of students with communication
    disorders. Specifically, ASHA urges the subcommittee to create TA
    centers focused on Communications/Speech Disorders; Medicaid Services
    and Reimbursement; Workload Mitigation; and Telepractice 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 percent 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 that the American Rescue Plan Act
    provided $2.58 billion for IDEA Part B State Grants, $200 million for
    IDEA Preschool Grants, and $250 million for Part C Infants and
    Toddlers, and that the Consolidated Appropriations Act, 2022 (Public
    Law 117-103) increased IDEA funding above FY 2021 levels for the
    remainder of the current fiscal year. However, additional funding is
    necessary to build on this progress.
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Education. (n.d.). About IDEA. https://
    sites.ed.gov/idea/about-idea/.
    ---------------------------------------------------------------------------
        These additional resources are essential to support States and
    local education agencies in providing FAPE to all students with
    disabilities. 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 necessary services and
    supports for children with disabilities. ASHA supports the
    Administration's FY 2023 budget request for IDEA at the levels
    identified above to ensure students with disabilities can continue to
    access the services that they are legally entitled to.
                          technical assistance centers
        Speech-language pathology services are highly utilized by students
    served under IDEA. According to ED's 43rd Annual Report to Congress on
    the Implementation of IDEA, 2021, speech or language impairments
    represent the most prevalent disability category of services provided
    under IDEA Part B: 39.9 percent of children ages 3 through 5, and 16.3
    percent of students ages 6 through 21.\2\
    ---------------------------------------------------------------------------
        \2\ U.S. Department of Education, Office of Special Education and
    Rehabilitative Services, Office of Special Education Programs. (2021).
    43rd Annual Report to Congress on the Implementation of the Individuals
    with Disabilities Education Act, 2021. https://sites.ed.gov/idea/files/
    43rd-arc-for-idea.pdf.
    ---------------------------------------------------------------------------
        ASHA's 2020 Schools Survey found that school-based SLPs' top two
    challenges identified were excessive paperwork (81.7 percent) and high
    workload/caseload (56.5 percent), while educational audiologists rated
    those as their second (53 percent) and fifth greatest challenges (41.7
    percent).\3,4\ Both SLPs and audiologists also identified challenges in
    Medicaid billing for eligible students.
    ---------------------------------------------------------------------------
        \3\ American Speech-Language-Hearing Association. (2020). 2020
    Schools survey. Survey summary report: Numbers and types of responses,
    SLPs. www.asha.org.
        \4\ American Speech-Language-Hearing Association. (2020). 2020
    Schools survey. Survey summary report: Numbers and types of responses,
    educational audiologists. www.asha.org.
    ---------------------------------------------------------------------------
        Establishing TA centers focused on key issues impacting school-
    based SLPs and educational audiologists would provide them valuable
    support; thereby, helping to ensure a FAPE for students with challenges
    that SLPs and audiologists can help address. The TA centers would:
        1.  provide resources, guidance, and best practices pertaining to
            the assessment and treatment to habilitate the communication
            disorder(s);
        2.  identify and develop free or low-cost evidence-based tools,
            model programs, and best practices to address clinical and
            professional practice issues; and
        3.  offer support and guidance for utilizing Federal funding
            sources to support capacity to address staffing shortages of
            speech-language providers within the school, community, or home
            setting to ensure the delivery of effective services for all
            students and their families.
        The specific mission for each TA center would include:
        1.  Communications/Speech Disorders Center: Provide resources,
            guidance, and best practices pertaining to the assessment and
            treatment to habilitate the communication disorders for
            clinicians and other members of the school community and
            provide support and guidance regarding the utilization of
            Federal funding sources to support capacity to ensure access to
            such services for all students.
        2.  Medicaid Services and Reimbursement Center: Provide resources
            to ensure that students who qualify for services under Medicaid
            receive such services, and to streamline the reimbursement
            process for providers, schools, and local and State education
            agencies.
        3.  Workload Mitigation Center: Provide resources to mitigate the
            workload burden for SLPs, audiologists, and other specialized
            instructional support personnel to best serve students, and
            support the State and local education agency's capacity
            building of providers.
        4.  Telepractice Services Center: Provide resources to support
            telepractice and the application of telecommunications
            technology to the deliver audiology and speech-language
            pathology professional services at a distance by linking
            providers to students, and build capacity among State and local
            education agencies to appropriately access services though a
            range of venues.
        The establishment of one or more of these centers would support
    SLPs and audiologists in ensuring that all students have access to
    FAPE; and ensure that State and local education agencies, school
    administrators, and other educators have access to resources to support
    students and providers. ASHA strongly encourages the subcommittee to
    establish TA centers to support the ability of school-based SLPs and
    educational audiologists to support students with disabilities,
    particularly a Communications/Speech Disorders TA center to help
    address the needs of the significant population of students receiving
    speech-language services, and a Medicaid TA center to ensure that
    schools, districts, and States are able to receive reimbursement for
    services provided to Medicaid-eligible students.
                                   conclusion
        Thank you for the opportunity to provide this testimony for the
    record. ASHA appreciates the subcommittee's past investments in IDEA
    and other critical education programs and urges continued support at
    the recommended funding levels. These investments are crucial to
    ensuring SLPs and audiologists can meet the hearing, balance, speech,
    language, swallowing, and cognition-related needs of students who are
    receiving special education services in schools.
        If you or your staff have any questions, please contact Eric
    Masten, ASHA's director of Federal affairs for education, at
    emasten@asha.org.
                                     ______

              Prepared Statement of the American Thoracic Society

                        SUMMARY: FUNDING RECOMMENDATIONS
                                 (in millions $)
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    National Institutes of Health..............................     $49,048
        National Heart, Lung, and Blood Institute..............       $4,05
        National Institute of Allergy and Infectious Diseases..      $6,806
        National Cancer Institute..............................      $7,766
        National Institute of Environmental Health Sciences....        $909
        National Institute on Minority Health and Health               $660
         Disparities...........................................
        National Institute of Nursing Research.................        $199
    Centers for Disease Control and Prevention.................     $11,000
        National Institute for Occupational Safety and Health..        $375
        Asthma Programs........................................         $40
        Division of Tuberculosis Elimination...................        $225
        Office on Smoking and Health...........................        $310
        Global Climate Change Program..........................        $110
        Chronic Disease Awareness Education Program............          $6
        National Center for Environmental Health...............     $401.85
    ------------------------------------------------------------------------

                           american thoracic society
        The American Thoracic Society (ATS) is the world's leading medical
    society dedicated to accelerating the advancement of global respiratory
    health through multidisciplinary collaboration, education, and
    advocacy. Core activities of the Society's more than 16,000 members are
    focused on leading scientific discoveries, advancing professional
    development, impacting global health, and transforming patient care.
    National Institutes of Health
        The NIH is the world's leader in groundbreaking biomedical health
    research into the prevention, treatment, and cure of diseases such as
    lung cancer, chronic obstructive pulmonary disease (COPD), and asthma.
    The coronavirus pandemic has revealed the critical national public
    health security leadership role that the NIH holds in scientific
    expertise to guide the Nation and in critical biomedical research to
    develop new diagnostics, therapeutics, and prevention interventions,
    including vaccines.
        To continue to accelerate the development of life-saving cures and
    treatments and innovative prevention interventions, it is essential for
    Congress to continue to provide robust, predictable funding increases
    across the full spectrum of NIH-supported research. We ask the
    subcommittee to provide at least $49.048 billion in funding for the NIH
    in FY 2023.
        In addition, while the American Thoracic Society supports the
    Advanced Research Projects Agency for Health (ARPA-H), we feel strongly
    that funding for this new agency should complement--not supplant--NIH
    funding.
    National Heart, Lung, and Blood Institute
        As the worldwide leader in research on heart, lung, blood, and
    blood vessel diseases as well as sleep disorders, the NHLBI effectively
    translates research results to the American public. To continue
    important advances in research, the NHLBI is investing in prevention
    programs and new treatments for cardiovascular disease including
    congenital heart disease, developing novel therapies for lung diseases
    such as COPD, asthma, cystic and pulmonary fibrosis, and driving
    precision medicine that is tailored to individual patient needs through
    data science.
    National Institute of Allergy and Infectious Diseases
        ``Long COVID'' or Post-Acute Sequelae of SARS-CoV-2 Infection
    (PASC) refers to the prolonged symptoms or new or returning symptoms
    that people may develop after recovery from initial SARS-CoV-2
    infection. NIAID is conducting and supporting research, such as natural
    history studies, to understand what factors (e.g., age, sex, existing
    co-morbidities, and host genetic factors) may impact the development of
    post-acute symptoms, as well as the incidence and prevalence of long
    COVID. A better understanding of long COVID is essential to identifying
    and evaluating interventions to prevent and treat these long-term
    symptoms. The ATS supports the NIAID's evaluation of promising
    therapeutic and prevention strategies.
    National Cancer Institute
        In 2022, lung and bronchus cancer were estimated to represent 12.3
    percent of all new cancer cases in the U.S. The ATS looks forward to
    continuing collaboration with the NCI, the Federal Government's lead
    agency for cancer research, on lung-cancer related research
    initiatives, including lung cancer screening, lung nodule management,
    lung cancer prevention, and the interaction between COPD and lung
    cancer.
    National Institute of Environmental Health Sciences
        NIEHS-funded scientists are poised to make major fundamental
    discoveries that will help us appreciate the impact of a warming
    climate on public health. Furthermore, additional NIEHS-funded research
    is necessary to design and tailor interventions that will reduce the
    impact of climate change on the incidence and severity of disease, for
    disadvantaged communities that may not have resources to mitigate the
    effects of climate change.
    National Institute on Minority Health and Health Disparities
        With the Administration's commitment to addressing health
    disparities, the ATS is committed to ongoing collaboration on the
    implementation of evidence-based interventions to address health
    disparities, including, for example, pulmonary rehabilitation, lung
    cancer screening, access to curative procedures for early-stage lung
    cancer and asthma home visiting programs.
    National Institute of Nursing Research
        The American Thoracic Society's Assembly on Nursing represents a
    wide variety of clinical areas including treatment of pulmonary
    disease, critical illness, and sleep disorders. The ATS will continue
    its long history of collaboration with the NINR to support a research
    focus on studies to understand and develop communication strategies and
    technological advances to help vulnerable populations that experience
    disparities of care in COVID related health outcomes.
    NIH Sleep Research Plan
        The NIH continues to lead global efforts to support research,
    innovation, education, and scientific advances related to sleep
    disorders and circadian biology through the National Center on Sleep
    Disorders Research (NCSDR). Last year, NCSDR released a five-goal Sleep
    Research Plan that aims to address sleep-related health disparities,
    facilitate clinical sleep and circadian research, and advance the
    scientific understanding and health impacts of sleep deficiency and
    circadian misalignment. The plan identifies nine Critical Opportunities
    (CO) related to the strategic goals, including working to develop tools
    for the early prediction, detection, and treatment of sleep deficiency,
    and identifying people-driven approaches to promote healthy sleep
    behaviors.
        As the NCSDR begins its work to implement the 2021 Sleep Research
    Plan, Congress must ensure that NIH is provided with adequate resources
    to achieve each of the five strategic goals and comprehensively explore
    each Critical Opportunity.
                   centers for disease control and prevention
        Strong funding for CDC is critical to support essential public
    health programs that serve a wide range of U.S. communities. Due to
    years of underfunding, many CDC programs have not received the
    resources needed to address the myriad health challenges we face as a
    nation, resulting in many of CDC's most effective prevention programs
    not reaching all States.
    National Institute for Occupational Safety and Health
        NIOSH is a Federal leader in research on occupational health. NIOSH
    also provides support of respiratory masks and other occupational
    protective technologies, occupational health research training, and
    provides technical assistance in cases of workplace exposure outbreaks.
    Asthma Program
        Currently, twenty-three States, Houston, Texas, and Puerto Rico
    receive critical funding from the National Asthma Control Program to
    support State and local efforts to reduce the burden of asthma. Our
    request for $40 million in funding for the National Asthma Control
    Program would enable CDC to continue to fund these programs to combat
    the terrible human and economic burden caused by asthma. This increase
    in funding would also allow CDC to expand the Asthma Call-Back Survey
    to more States, thereby facilitating the collection of critical asthma
    surveillance data necessary for effective policy planning and
    implementation.
    Division of Tuberculosis Elimination
        The COVID response has diverted staff and funds from TB control
    funding, resulting in missed opportunities to control TB in the U.S.
    Additional funding is needed to restore local TB control programs and
    to restore TB Trials Consortium (TBTC) trials sites that are conducting
    vital TB clinical drug trials critical to halting the TB pandemic.
    Office on Smoking and Health
        Tobacco use is the leading cause of preventable disease,
    disability, and death in the United States. In 2020, 12.5 percent of
    U.S. adults (an estimated 30.8 million people) currently smoked
    cigarettes: 14.1 percent of men, 11 percent of women. Every day, about
    1,600 young people under age 18 smoke their first cigarette, and 235
    begin smoking cigarettes daily. Over 16 million people live with at
    least one disease caused by smoking, and fifty-eight million nonsmoking
    Americans are exposed to secondhand smoke. The CDC is at the forefront
    of the Nation's efforts to reduce deaths and prevent chronic diseases
    that result from tobacco use.
    Global Climate Change Program
        Climate change continues to impact public health in a myriad of
    ways, including, smoke from wildland fires, droughts, intense heat,
    floods, and increased vector borne disease. Funding is needed to
    provide local communities the necessary funding to develop strategies
    for responding to health challenges posed by global climate change.
    Chronic Disease Education Awareness Program
        CDC continues to be challenged to respond appropriately to the
    growth of chronic diseases in the U.S. CDC does not have an established
    program for major chronic diseases such as COPD as well as less
    prevalent chronic diseases. CDC has created a competitive grants
    program to fund public education efforts on important chronic disease
    that CDC has not yet addressed. Funding is needed to expand grant
    opportunities to conditions like COPD and other chronic respiratory
    diseases.
    National Center for Environmental Health
        According to the CDC, over 25 million people, including over 5
    million children, live with asthma in the United States. Asthma
    disproportionately impacts women and minority communities who bear the
    brunt of the disease. Individuals living in poverty, as measured by the
    Federal poverty line, are also more likely to suffer from asthma. In
    addition, asthma imposes significant economic burdens, costing the
    United States over $80 billion in medical and indirect costs in the
    form of missed days of school and work. The ATS looks forward to
    further collaborations with the NCEH in highlighting asthma as a
    priority health condition with evidence-based interventions, which can
    prevent the need for costly emergency department visits.
                                     ______

           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 2023 report language recommendations on two conditions that
    pose a significant personal burden for millions of women in this
    country and a significant financial burden on the U.S. healthcare
    system. 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.
    1. Overactive Bladder
        Overactive bladder is a sudden, intense urgency to urinate often
    followed by an involuntary loss of urine. It causes people to
    frequently go to the bathroom through the day and wake at night to
    urinate due to altered nerve signaling between the bladder and the
    brain. 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 percent higher health care utilization than matched
    counterparts without this condition. The Centers for Disease Control
    and Prevention estimated that the direct and indirect costs of
    overactive bladder in the U.S. was approximately $76 billion in 2015,
    with a projected increase to $82.6 billion by 2020.
        Anticholinergic medications are commonly prescribed to treat
    overactive bladder. These therapies are the most studied, most
    frequently used, and the most widely covered by insurance companies.
    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 Dementia (ADRD). 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 ADRD development and to determine if the
    risks substantially outweigh the benefits of these therapies. Such
    studies would have a vast public health impact, given the millions of
    people impacted by overactive bladder, the increasing number of people
    developing dementia, and the substantial social and economic impact
    that these conditions have on our country.
        For these reasons, the American Urogynecologic Society urges the
    subcommittee to adopt the following report language in the report
    accompanying the Fiscal Year 2023 Labor-HHS-Education appropriations
    bill that directs the National Institute of Diabetes, Digestive and
    Kidney Diseases (NIDDK) and the National Institute on Aging (NIA) to
    coordinate further study of anticholinergic medications and alternative
    treatments to determine the safety and efficacy of these medication for
    overactive bladder and their potential risks related to ADRD.
                         national institutes of health
    National Institute on Diabetes, Digestive and Kidney Diseases/National
            Institute on Aging
        Overactive Bladder.--The Committee remains concerned about the
    safety of medications used to treat overactive bladder, which may be
    increasing risk of Alzheimer's Disease and Related Dementia (ADRD).
    Overactive bladder affects 38 million Americans, and one in three older
    adults in this country. Overactive bladder has a significant impact on
    quality of life and the healthcare system. The anticholinergic
    medications typically used first-line to treat overactive bladder have
    been shown to increase the risk of developing dementia. Dementia
    continues to grow as a prevalent and serious public health issue. The
    Committee urges the National Institute on Diabetes, Digestive and
    Kidney Diseases (NIDDK) and the National Institute on Aging (NIA) to
    coordinate further study of anticholinergic medications and alternative
    treatments to determine the safety and effectiveness of medications for
    overactive bladder, and their potential risks related to ADRD. The
    Committee requests an update on the status of research activities
    focused on this issue in the fiscal year 2024 Congressional Budget
    Justification.
    2. Pelvic Floor Disorders
        AUGS recommends report language to address pelvic floor disorders
    in minority populations. Pelvic floor disorders, which include pelvic
    organ prolapse and urinary and bowel incontinence, impact more than 25
    million women annually in the United States. Pelvic organ prolapse
    occurs when the pelvic floor muscles and connective tissue supporting
    the pelvic organs (the bladder, uterus and cervix, vagina, and rectum)
    weaken or tear and can no longer support these organs. The risk factors
    and causes of pelvic floor damage leading to pelvic organ prolapse
    include pregnancy and childbirth, aging and menopause, health
    conditions that involve repeated straining (such as obesity, chronic
    cough, and chronic constipation) and genetics.
        Pelvic organ prolapse is a common problem, with 1 out of 8 women
    undergoing surgery for prolapse at some point in their life. Studies
    have shown a prevalence difference in racial and ethnic populations.
    Pelvic organ prolapse can occur in reproductive age women but becomes
    more common as women age and after menopause. Treatment of pelvic organ
    prolapse requires significant healthcare resources. Non-surgical
    treatments require frequent health care visits and surgical treatments
    are imperfect with approximately 20 percent of women experiencing
    recurrences within 10 years. Surgical repair of prolapse is the most
    common inpatient procedure performed in women older than 70 years.
        Urinary incontinence and accidental bowel leakage are two
    additional pelvic floor disorders that impact over half of people aged
    65 and older living at home. In fact, these conditions are leading
    causes for admission to nursing homes as families are challenged for
    caring for their loved ones. Patients who suffer from pelvic floor
    disorders such as these experience a significant adverse impact on
    quality of life, resulting in restrictions in activities, social
    isolation, depression, and physical discomfort.
        Studies have shown that women from underrepresented backgrounds are
    much less likely to receive treatment for pelvic floor disorders. More
    research is needed to identify trends in clinical care and the efficacy
    associated with treatments for pelvic floor disorders. Furthermore, we
    need to better understand the role that medical literacy and barriers
    to care may play into the differences noted in outcomes amongst
    underrepresented populations who suffer from pelvic floor disorders.
    Families in this country with a loved one who suffers from a pelvic
    floor disorder will benefit from research that decreases barriers to
    effective identification and treatment of these impactful conditions.
        For these reasons, the American Urogynecologic Society urges the
    subcommittee to adopt the following report language in the report
    accompanying the Fiscal Year 2023 Labor-HHS-Education appropriations
    bill that directs the Eunice Kennedy Shriver National Institute on
    Child Health and Human Development to prioritize research activities
    that study pelvic floor disorders in minority populations.
    Eunice Kennedy Shriver National Institute on Child Health and Human
            Development
        Pelvic Floor Disorders.--Pelvic floor disorders including urinary
    incontinence, accidental bowel leakage and pelvic organ prolapse,
    negatively impact the quality of life of more than 25 million US women
    each year. There are socioeconomic disparities amongst women suffering
    from pelvic floor disorders, with differences in symptoms, knowledge,
    access to care, availability of treatments, and treatment outcomes
    noted in patients from different backgrounds. Recent studies have shown
    that minority women are much less likely to receive treatment for
    pelvic floor disorders. A better understanding of disparities among
    women with pelvic floor disorders can help guide the development of
    initiatives for education, outreach, and treatment of women with pelvic
    floor disorders. Therefore, the Committee urges the National Institute
    on Child Health and Human Development (NICHD) to prioritize research
    activities into underrepresented patient populations and pelvic floor
    disorders. Such activities should include the development of
    educational programs for general practitioners, the evaluation of
    effectiveness of screening protocols for pelvic floor disorders in the
    primary care setting, investigating medical literacy amongst minority
    women as it pertains to pelvic floor disorders, as well as assessing
    socio-economic and socio-cultural disease perspectives by designing
    qualitative studies using focus groups of women with varying socio-
    economic, cultural and ethnic backgrounds, evaluating current
    educational resources, determining gaps in patient knowledge, and
    designing culture-specific educational materials and resources. The
    Committee requests an update on this issue and on research activities
    to advance pelvic floor disorders prevention and treatment in the FY
    2024 Congressional Budget Justification.
        Thank you in advance for your favorable consideration of these
    report language requests. Your support will positively impact
    knowledge, access to care and treatment for overactive bladder and for
    pelvic floor disorders and improve the lives of the millions of
    American women affected by these devastating conditions.
                                     ______

               Prepared Statement of the Animal Welfare Institute
    Report Language Request
        The National Child Abuse and Neglect Data System (NCANDS) was
    established in response to the Child Abuse Prevention and Treatment Act
    of 1988. It is a voluntary data collection system that gathers
    information from all 50 States, the District of Columbia, and Puerto
    Rico about reports of child abuse and neglect. The data are used to
    examine trends in child abuse and neglect across the country, and its
    key findings are published in its Child Welfare Outcome Reports, which
    are submitted to Congress, and in its annual Child Maltreatment
    Reports. In light of the acknowledged close relationship between child
    maltreatment and animal abuse, and with exposure to animal abuse
    considered an Adverse Childhood Event (ACE), the Committee encourages
    the Department of Health and Human Services to expand its NCANDS
    reports to add a category of ``animal abuse'' to the child and
    caregiver characteristics and environmental factors that may place the
    child at risk for maltreatment. Moreover, the Committee asks DHHS to
    provide a report to the Committee within 90 days on any steps it may
    have taken to make this change.
    Justification
        This language encourages DHHS to expand the data collected around
    child abuse cases to include animal abuse. To more accurately examine
    trends in child abuse and neglect, it is critical to pay attention to
    animal abuse as a risk factor in the family. Having such information
    will provide a better foundation for child abuse screening, prevention,
    and treatment programs and would benefit children, families, and pets.
        Animal abuse is a serious crime in and of itself, and well-
    documented evidence has identified a strong link between it and many
    forms of interpersonal violence. For example, committing animal abuse
    is a better predictor of sexual assault conduct than previous
    convictions for homicide, arson, or weapons offenses. In a violent
    household, companion animals are often victims of the very same abuse
    that children, intimate partners, and vulnerable adults are suffering.
    A survey of families in New Jersey who had been referred for physical
    child abuse found that animal abuse was also present in 88 percent of
    those homes. As Dr. Lynn Loar wrote, ``The behavior that harms the
    animal is the same behavior that harms the human.'' Decades of research
    and practical experience have firmly established this link. In fact,
    the first person to suspect that a family may be in crisis could well
    be a law enforcement officer responding to an animal cruelty call.
        There is growing understanding that being alert to the presence of
    abused animals will help to protect not only the animals themselves but
    also other members of the family.
        Besides the direct abuse to which they may be subjected, children
    are particularly vulnerable to suffering long-term adverse effects from
    witnessing-or even being forced to participate in-the mistreatment of
    their pets.
        There is substantial evidence linking child and animal well-being:
      --Children form close bonds with their pets, often referring to them
            as their ``best friends,'' or reporting that they turn to them
            when troubled.
      --Threatening or actually harming a pet by a caretaker traumatizes
            the child. Traumatized children are more likely to become
            victims or perpetrators of violence.
      --The threat of animal abuse to silence child sex abuse victims has
            been a factor in a number of criminal convictions.
      --Children who are cruel to animals are more likely to have been
            maltreated than other children. Cruelty to animals as an
            indicator of child maltreatment increases with the child's age,
            persistence of behavior, and poorer social background.
      --Children are exposed to a variety of traumatic experiences,
            referred to as ``poly- victimization'' or Adverse Childhood
            Experiences (ACE). To successfully intervene and treat children
            and families, all forms of polyvictimization need to be
            recognized. Animal abuse is one of them.
      --Evidence of animal abuse has been introduced during child custody
            hearings and in many of those cases, it has been one of the
            factors leading to removal of children from one or both
            parents. In one such case involving sexual abuse and neglect of
            the children, the appellants motioned the court to sever the
            animal cruelty charges from the sexual abuse charges; however,
            the court declined, stating that the offenses were intertwined,
            and evidence of ``animal cruelty was essential to establish the
            physical abuse offenses.'' In reaching this conclusion, the
            court considered that the animal abuse led to discovering the
            child abuse, and that ``mistreatment of the animals greatly
            reflected upon [the defendants'] state of mind when they
            committed the physical and sexual abuse.'' Schambon v.
            Commonwealth, 821 S.W.2d 804 (Ky. 1991)
        The National Council of Juvenile and Family Court Judges has gone
    all in in taking up this issue, working with the Animal Legal Defense
    Fund to bring a wide array of training opportunities to judges to
    expand their understanding of the relationship between animal cruelty
    and child abuse and how important this understanding is to the work
    they do with families. In a recent letter to her colleagues, Judge
    Katherine Tennyson (ret.) let them know that NCJFCJ ``has developed a
    resource, Toolkit for Starting a LINK Coalition in Your Community for
    Guidance (https://nationallinkcoalition.org/wp-content/uploads/2013/01/
    TOOLKIT.pdf) for community leaders, including judges, to help with the
    skills and steps needed to form and sustain a coalition for addressing
    the pressing, but underacknowledged, issues relating to the link
    between animal abuse and interpersonal violence.''
        NCJFCJ notes on its website that ``[t]hrough their authority to
    issue protection and restraining orders, to remove children from
    abusive homes, and to order youthful offenders into treatment or secure
    placement, judges use the power of the courts to respond to cruelty and
    abuse, to protect victims and prevent future harm. Judges also have the
    opportunity to take measures to safeguard the wellbeing of an
    overlooked member of the household and the community--pets and animals.
    To do this effectively, they need to understand the links between
    behavior involving violence against animals and interpersonal
    violence.''
        Thus, there is an urgent need for more complete information about
    these patterns so that child welfare agencies and the courts can
    understand how to intervene safely and effectively.
                     current data collected on child abuse
        State child protection agencies voluntarily provide data to the
    Federal Government under the National Child Abuse and Neglect Data
    System (NCANDS), which tracks trends in child abuse and neglect across
    the country. Case reports on the nearly 700,000 children abused
    annually in the U.S. include a variety of details--such as the type of
    abuse a child suffered or whether the caregiver had a substance abuse
    disorder--that help researchers and service providers better understand
    the factors associated with child abuse. There can be no doubt that
    cruelty to animals, especially family pets, is such a factor. These
    data help to inform the need for screening and preventive services and
    to ``allow analysis of victim, caretaker, and perpetrator
    characteristics, as well as responses to abused/neglected children in
    need of services.''
        Information collected under NCANDS has been used to determine, for
    example, that children whose families face multiple stressors are at a
    higher risk of being repeatedly referred to Child Protective Services,
    and that some types of maltreatment are more likely to recur than
    others. Adding animal abuse to the range of stressors that are measured
    will give service providers and others a window into the lives of
    abused children that they currently do not have and may help identify
    children at risk who otherwise may have gone undetected.

        [This statement was submitted by Submitted by Nancy Blaney,
    Director,
    Government Affairs.]
                                     ______

                 Prepared Statement of the Arthritis Foundation
        On behalf of the more than 58 million adults and 300,000 children
    living with doctor-diagnosed arthritis in the United States, the
    Arthritis Foundation thanks Chairwoman Murray and Ranking Member Blunt
    for the opportunity to provide written testimony to the Appropriations
    subcommittee on Labor, Health and Human Services (HHS), and Education
    and Related Agencies for Fiscal Year 2023. We respectfully request: $11
    billion in funding for the Centers for Disease Control and Prevention
    (CDC)--and within that $54 million for the CDC Arthritis Program--and
    $30 million for the Pediatric Subspecialty Loan Repayment Program to be
    administered by the Health Resources and Services Administration
    (HRSA).
                             cdc arthritis program
        Arthritis affects 1 in 4 Americans and is the leading cause of
    disability in the United States, according to the CDC. It limits the
    daily activities of over 23 million Americans and causes work
    limitations for 40 percent of the people with the disease. This
    translates to over $300 billion a year in direct and indirect costs.
    There is no cure for arthritis, and for some forms of arthritis like
    OA, there is no disease-modifying pharmaceutical therapy, making
    evidence-based self-management programs critical for managing the
    disease. The CDC is critical for the dissemination of evidence-based
    programs, data collection and disease surveillance, and public health
    research. The COVID-19 pandemic has exacerbated the challenges of
    disease management, making interventions like exercise programs more
    difficult to access and maintain. In FY 2023, Congress should increase
    CDC funding to $11 billion to support key public health programs,
    bolster critical infrastructure, improve disease surveillance and data
    collection, and strengthen pandemic preparedness. Within that $11
    billion, Congress should allocate $54 million for the Arthritis Program
    to expand the reach of its services and resources.
        The CDC Arthritis Program is the only Federal program dedicated
    solely to arthritis. Today, the program provides grants to 13 States to
    support evidence-based disease management programs. The program aims to
    connect all Americans with arthritis to resources to help them manage
    their disease. Evidence-based programs like EnhanceFitness help keep
    older adults active, and have shown a 35 percent improvement in
    physical function, resulting in fewer hospitalizations and lower health
    costs compared to non-participants. In addition, Walk With Ease is an
    evidence-based group walking program that encourages people with
    arthritis to start walking and stay motivated to keep active. The
    program allows participants to meet a few times per week to receive
    health education on an arthritis or exercise-related topic followed by
    stretching activities, and a group walk. A recent CDC-funded randomized
    controlled trial found that the program can help reduce arthritis
    symptoms, reduce disability, and improve strength and balance.
        Given the high prevalence and severity of this disease, the
    Arthritis Program is woefully under-funded compared to the investment
    in other chronic diseases. It is currently funded at $11 million, and
    due to either reduced funding or flat funding in recent years, the
    program has lost millions of dollars in purchasing power over the last
    decade.
        With full funding of $54 million, the program would be able to:
      --Provide funding to all 50 States to fully operationalize a National
            Arthritis Program. Today, the CDC Arthritis Program funds only
            13 State programs around the country (AR, KS, MA, MN, MO, NH,
            NY, NC, OR, RI, UT, VA, and WA). These programs play a vital
            role in the dissemination of proven strategies and programs,
            and all States should receive funding to operate an arthritis
            program;
      --Expand national partnerships that are critical to promoting
            awareness, increasing primary provider referrals for non-
            pharmacologic management of chronic pain, and providing access
            to arthritis self-management and physical activity programs;
            and
      --Invest in robust data and intervention and prevention research to
            better understand arthritis.
             pediatric subspecialty loan repayment program (pslrp)
        An estimated 300,000 children have arthritis, yet there are fewer
    than 450 board-certified practicing pediatric rheumatologists in the
    United States, mainly clustered in big cities and urban metro areas.
    Shockingly, seven States have no pediatric rheumatologists and five
    States have only one. Early diagnosis and treatment of arthritis is
    critical for disease management, and it can be difficult for providers
    untrained in pediatric rheumatology to diagnose arthritis.
        The pediatric rheumatology workforce is stretched now more than
    ever due to the pandemic. Serious shortages are causing decreased
    access to care for young people, resulting in myriad complex
    challenges, including entire days of missed work and school for the
    child, siblings, and parents because of the length of time traveling to
    the nearest specialist; families deciding to move to a different state
    to be closer to a specialist, and having to travel by airplane to reach
    the closest specialist.
        The Pediatric Subspecialty Loan Repayment Program (PSLRP) was
    funded for the first time in FY 2022 and will make loan repayment
    available for pediatric subspecialists like pediatric rheumatologists
    to practice in underserved areas. With initial funding of $5 million,
    the number of applications HRSA can fund will be severely limited, yet
    we anticipate demand will be high among pediatric subspecialists. We
    urge the inclusion of $30 million in the FY 2023 appropriations bill to
    build upon this important investment and address the ever-growing and
    critical pediatric workforce shortage.
        We thank the subcommittee for its commitment to the health and
    wellbeing of all Americans. As you write the FY 2023 Labor-HHS-
    Education appropriations bill, we urge the inclusion of $11 billion for
    the CDC and $54 million within that for the CDC Arthritis Program, and
    $30 million for the Pediatric Subspecialty Loan Repayment Program in
    order to continue investments that improve the lives of people with
    chronic diseases like arthritis. Please contact Anna Hyde, Vice
    President of Advocacy and Access, at ahyde@arthritis.org, with any
    questions.
                                     ______

                    Prepared Statement of the Aspira Women's
        Thank you for the opportunity to comment on the National Institutes
    of Health (NIH) budget priorities for fiscal year (FY) 2023. We commend
    the efforts of the NIH to identify gaps and barriers in women's health
    and modernize priorities for research on the complete health of women.
    We provide this testimony in support of increased funding within the FY
    2023 Labor, Health and Human Services, and Education Appropriations
    bill for endometriosis and ovarian cancer, with an increased focus and
    attention on access and equity so all women can benefit from innovative
    and transformative healthcare advancement.
        As a women-led transformative women's health company, Aspira
    Women's Health is focused on bringing innovative and proprietary
    technologies to women where the healthcare system overall has failed to
    address their unmet healthcare needs. Specifically, Aspira Women's
    Health is currently the sole provider of OVA1, an innovative and the
    only FDA-cleared blood test for ovarian cancer risk assessment when a
    woman presents with a pelvic mass. We are also focused on a non-
    invasive endometriosis blood-based detection test, as women suffering
    from this debilitating condition are also severely underserved. Current
    diagnostic and treatment options for endometriosis represent sub-
    optimal care for women with this chronically painful condition that
    often is mis-diagnosed or diagnosed years after the onset severe
    symptoms.
        Women's health issues continue to be under-represented in terms of
    NIH resource allocation, with dire consequences. As it specifically
    relates to endometriosis, there are several specific important issues
    that need to be addressed. Foremost among them is that endometriosis is
    an irreversibly debilitating disease known to cause a wide spectrum of
    physical and psychological symptoms from chronic pain to infertility to
    increased risk of suicide, yet it is regularly mis-diagnosed or
    diagnosed up to 7-9 years after the onset of painful symptoms despite
    it impacting 10-20 percent of the overall female population and 5-50
    percent among women with infertility. These symptoms are extremely
    painful and uncomfortable and range from pain during intercourse and
    bowel movements to excessive bleeding. If this chronic pelvic pain is
    detected and treated early, laparoscopy surgery may be avoided, saving
    patients from invasive surgery and our healthcare system from
    preventable expenditures. The total expenditures per patient are
    similar to a Type 2 Diabetic patient, yet this condition is a silent,
    pervasive, irreversible, and chronically painful and debilitating
    disease impacting millions of women.

        A non-invasive biomarker-based blood test would be a significant
    improvement over surgery, and non-invasive methods for diagnosing
    endometriosis would reduce related costs. However, these advancements
    can't be realized unless funding for women's health issues is increased
    exponentially, particularly for debilitating and deadly conditions like
    endometriosis and ovarian cancer, respectively.
        In addition to endometriosis, ovarian cancer also deserves
    increased attention and investment. Ovarian cancer is pervasive, often
    fatal and is frequently missed or mis-diagnosed, especially among Black
    women. It is the only sex-specific cancer with greater than a 50
    percent mortality rate. Comparatively, breast cancer and prostate
    cancer have mortality rates lower than 10 percent. Today, Ovarian
    Cancer accounts for more deaths than any other cancer of the female
    reproductive system. In terms of public funding for research, there are
    major disparities. An example is prostate cancer, which has a 2 percent
    mortality rate, yet receives 50 percent more funding than ovarian
    cancer from the NIH. Ovarian cancer disproportionately affects women of
    color. For example, the all-cause mortality of Black women with ovarian
    cancer is 1.3 times higher than white women, even when access to care
    is equal. Furthermore, studies have shown that the risk of not
    receiving surgical intervention remains high among Black women and
    Hispanic women when compared to white women, and Black, Asian Pacific
    Islander, and Hispanic women were all at significantly greater risk of
    dying within the first 12 months of cancer diagnosis when compared to
    white women. A way to address these key disparities is an increase in
    funding for ovarian cancer research, especially among women of color,
    as it is critical to improving patient outcomes in the populations that
    suffer the most.
        A clear example as to why research dollars are key to expanding
    innovation is CA-125, the most widely used blood test for ovarian
    cancer detection, discovered in the early 1980s. This biomarker has low
    sensitivity for early-stage disease, approximately 50 percent, and may
    be even lower among women of color. Between CA125's poor sensitivity
    and the often asymptomatic nature of early-stage disease, as well as
    other factors, it is estimated that over three quarters of ovarian
    cancers are not discovered until they are in advanced stage. In
    addition to this, CA125 can be elevated in many benign conditions,
    resulting in false positives which can cause women to endure
    unnecessary exploratory, invasive, and costly surgery.
        Fortunately, there are innovations that improve outcomes, such as
    the only multivariate index assay for assessing the risk of ovarian
    cancer on the market, OVA1. OVA1 has an overall sensitivity of 92
    percent and an early-stage sensitivity of 91 percent. In Black women, a
    group for whom CA125 often provides inadequate risk assessment, OVA1
    detected 79 percent of malignancies, compared to 63 percent by CA125.
    When ovarian cancer is discovered and treated early, survival rates can
    be greater than 90 percent. In advanced stage disease, however, the 5-
    year survival can be under 20 percent. Furthermore, evidence suggests
    that detecting ovarian cancer early costs nearly 84 percent less than
    treating late-stage disease, based on the increased costs of
    unnecessary care, making innovations in early detection of ovarian
    cancer a cost-effective solution. Increased NIH funding would enable
    additional advancements in ovarian cancer diagnoses and care, while a
    focus on minority women would ensure improved patient outcomes for
    those most likely to die of this disease.
        As you draft the Labor Health, and Human Services appropriations
    bill, I ask that you consider increased funding for endometriosis and
    ovarian cancer. With additional Federal research funding, innovators
    across the Nation can make significant improvements for women suffering
    from these dehabilitating and deadly diseases. We appreciate your
    consideration and your attention to endometriosis and ovarian cancer
    when making funding allocations and policy decisions, while providing
    increased focus and attention on access and equity so all women can
    benefit from innovative and transformative healthcare advancement.

    References

    American Cancer Society (2021) https://report.nih.gov/funding/
    categorical-spending#/

        Oral E, Sozen I, Uludag S, et al. The prevalence of endometrioma
    and associated malignant transformation in women over 40 years of age.
    Journal of Gynecology Obstetrics and Human Reproduction.
    2020;49(5):101725. doi:10.1016/j.jogoh.2020.101725.
        Mu F, Rich-Edwards J, Rimm EB, Spiegelman D, Missmer SA.
    Endometriosis and Risk of Coronary Heart Disease. Circ Cardiovasc Qual
    Outcomes. 2016;9(3):257-264. doi:10.1161/CIRCOUTCOMES.115.002224.
        Arion K, Orr NL, Noga H, et al. A Quantitative Analysis of Sleep
    Quality in Women with Endometriosis. Journal of Women's Health.
    2020;29(9):1209-1215. doi:10.1089/jwh.2019.8008.
        Warzecha D, Szymusik I, Wielgos M, Pietrzak B. The Impact of
    Endometriosis on the Quality of Life and the Incidence of Depression-A
    Cohort Study. International Journal of Environmental Research and
    Public Health. 2020;17(10):3641. doi:10.3390/ijerph17103641.
        Lorencatto C, Petta CA, Navarro MJ, Bahamondes L, Matos A.
    Depression in women with endometriosis with and without chronic pelvic
    pain. Acta Obstetricia et Gynecologica Scandinavica. 2006;85(1):88-92.
    doi:https://doi.org/10.1080/00016340500456118.
        Endometriosis: Thousands share devastating impact of condition. BBC
    News. https://www.bbc.com/news/health-49897873. Published October 6,
    2019. Accessed April 13, 2021.
        Fairbanks F, Abdo CH, Baracat EC, Podgaec S. Endometriosis doubles
    the risk of sexual dysfunction: a cross-sectional study in a large
    amount of patients. Gynecological Endocrinology. 2017;33(7):544-547.
    doi:10.1080/09513590.2017.1302421.
                                     ______

        Prepared Statement of the Association for Career and Technical
                           Education and Advance CTE
        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 are writing to respectfully request
    that the subcommittee increase funding for the Carl D. Perkins Career
    and Technical Education Act's (Perkins V) Basic State Grant program,
    administered by U.S. Department of Education's Office of Career,
    Technical, and Adult Education, by $200 million- an overall amount of
    $1.58 billion in the forthcoming Fiscal Year 2023 (FY23) Labor, Health
    and Human Services, Education, and Related Agencies appropriations
    bill. It is vital that Congress continues to build upon the recent
    investments made in Perkins V in order to fully support the
    implementation of the law and the over 11 million secondary,
    postsecondary, and adult learners it serves across the Nation.
        As you are aware, the Biden Administration formulated its FY23
    Congressional budget request before Congress had yet finished work on
    FY22 appropriations legislation. As a consequence, the Administration
    used fiscal year 2021 funding levels as the starting point for
    developing its FY23 request for Perkins V. For this reason, the
    Administration proposed an ``artificial cut'' to Perkins V's basic
    State grant program of $25 million dollars. Officials from the U.S.
    Department of Education (ED) have since contended they support level-
    funding for this program. Yet, as Congress continues to debate economic
    competitiveness legislation and oversees the implementation of last
    year's bipartisan infrastructure law, the need for highly skilled
    workers has never been greater. Flat-funding for Perkins V's State
    grant program would therefore be inadequate given the growing employer
    need for skilled talent and learner demand for CTE programs that
    provide on-ramps into these opportunities.
        In addition, the Administration has also proposed the creation of a
    new $200 million competitive grant program-roughly 15 percent of the
    total size of all Perkins V funding-which the Administration has dubbed
    the ``Career Connected High Schools'' initiative. This competitive
    funding proposal would serve limited students overall, and unfairly
    favor funding for eligible entities that already have the capacity to
    write grants while penalizing smaller and more rural districts and
    institutions. Distributing funding in this manner would likely further
    exacerbate many longstanding inequities in our Nation. Given that this
    proposal would fund activities that are largely duplicative of how
    Perkins V State grant funding is already used, this additional funding
    would be more efficiently and effectively deployed as part of the
    Perkins Basic State Grant allocation instead. Doing so would ensure far
    more learners are able to access high-quality CTE programs supported by
    Perkins V formula dollars- which go to every State and Congressional
    district-rather than this new competitive grant program which, by the
    Administration's own estimates, would only support 32 grantees.
        CTE at the secondary and postsecondary levels is an integral part
    of ensuring an equitable and efficient implementation of last year's
    bipartisan infrastructure legislation. According to the Brookings
    Institution, at least 15 million new workers will be needed for United
    States infrastructure in the next decade. In order to make good on
    Congress's promise to rebuild America's infrastructure, CTE will
    require robust funding to reskill the workforce in critical areas such
    as construction, transportation, housing, utilities, and
    telecommunications. CTE serves a critical role in preparing learners to
    enter into in-demand sectors of the economy which have immediate and
    longer-term hiring needs. CTE also is central to efforts to reskill and
    upskill learners who have been displaced by economic forces outside of
    their control or who have been sitting outside of the labor market for
    one reason or another. Examining 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.
        Just as all education programs have been hit hard by the pandemic,
    so have CTE programs. This has been exacerbated by the lack of
    dedicated CTE funding within any of the pandemic response 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 pandemic 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
    of the 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. Each of these activities are resource-intensive
    and even more challenging as a consequence of the pandemic.
        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. To achieve this, CTE programs need to
    be adequately resourced. Jobs that require more than a high school
    diploma but less than a baccalaureate degree were growing quickly
    before the pandemic and this trend is only expected to further
    accelerate. Further, the twin forces of automation and globalization
    require nimble, proactive, and responsive programs that provide
    specific technical skills as well as more transferable competencies. 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 these needs, no pandemic aid package passed by Congress in
    response to the public health emergency has included dedicated CTE
    funding. At a time of record-inflation, CTE programs are
    disproportionately impacted by pandemic-related financial challenges
    because of the need to purchase and maintain the industry-standard
    equipment required to adequately serve learners. Congress has an
    opportunity to provide much-needed resources to CTE programs as part of
    the FY23 appropriations process to begin to remedy some of these
    ongoing challenges.
        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.
    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. Furthermore, those students are more
    likely to continue their education-91 percent of high school graduates
    who earned two to three CTE credits enrolled in college.
        The outcomes for adult learners are also significant: 84 percent of
    adults concentrating in CTE programs either continued their education
    or were employed within 6 months of completing their program. In fact,
    90 percent of Americans agree that apprenticeships and skills training
    programs prepare individuals for a good standard of living.
        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, while individuals who
    receive a certificate or degree from California Community Colleges
    almost double their earnings within 3 years. In Wisconsin, taxpayers
    receive $12.20 in return for every dollar invested in the technical
    college system. Oklahoma's economy reaps a net benefit of $3.5 billion
    annually from graduates of the CareerTech System. 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 $1.58 billion in the Perkins
    V CTE State Grant program.
        CTE programs are also preparing individuals with the skills that
    employers seek. A recent 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 as part of our shared economy.
        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. Half of all STEM
    occupations, which offer students high-skilled, high-wage career
    opportunities, require less than a bachelor's degree. 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.
    Moreover, CTE programs can be leveraged as an important talent pipeline
    for occupational fields that are experiencing critical labor shortages
    due to the pandemic and other factors, such as nursing and teaching.
    CTE programs themselves can be harnessed to meet these needs directly,
    via ``Grow Your Own'' programs, that would help to alleviate labor
    shortages in these critical sectors of our economy.
        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. 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. 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. Meanwhile, 89 percent of executives agree there is a
    talent shortage in the U.S. manufacturing sector, 5 percent higher than
    2015 results. Other industries are also facing significant skilled
    labor shortages as they emerge from the pandemic.
        Funding Perkins V at adequate levels will ensure that educators can
    equip students with the skills and related credentials they will need
    for in-demand fields. This will become increasingly pressing as the
    country continues to recover from the current public health and related
    economic crisis. Already, healthcare jobs are projected to have the
    largest increase of any occupational sector. Filling these and other
    positions created as a result of the pandemic, as well as ensuring that
    each individual is able to access the training needed for employment,
    is critical.
        CTE programs can serve even more learners and employers--but only
    if they receive more resources. According to the most recent Job
    Openings and Labor Turnover (JOLTS) Survey from the Bureau of Labor
    Statistics, the ratio of unemployed workers to job openings is 0.6,
    meaning that there are nearly two open jobs for every unemployed
    person. This tight labor market underscores the immense demand for
    skilled workers, especially as we seek to implement last year's
    bipartisan infrastructure legislation. CTE remains a critical component
    of the workforce pipeline for key industries that are needed to sustain
    a long-term economic growth and recovery, such as health care, STEM,
    manufacturing, construction and transportation distribution and
    logistics.
        However, 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.
        And there's widespread support for CTE: 94 percent of parents
    approve of expanding access to CTE. 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. As
    our recent analysis demonstrates, funding for CTE State Grants remains
    $403 million below fiscal Year2004 enacted levels when using the Bureau
    of Economic Analysis' (BEA) Personal Consumption Expenditures (PCE)
    Price Index to adjust for inflation-the most conservative measure of
    inflation over time.
        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. Congress recognized the need to begin to reverse
    this trend and from FY18 to FY22 provided an additional $262 million
    for CTE State Grants, bringing the total investment to $1.38 billion.
    While these budgets represented initial down payment 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 wider
    American economy. Congress should build on the momentum from recent
    years and continue to strengthen the investment in CTE State Grants in
    FY23. And, Americans agree: 93 percent of voters support increasing the
    investment in skills training.
        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 forthcoming FY23 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 redouble our collective commitment to these
    valuable programs and ensure CTE opportunities are available for every
    learner.
        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, Zach Curtis
    (zcurtis@acteonline.org) or Advance CTE's Policy Advisor, Steve Voytek
    (svoytek@careertech.org).
                                     ______

          Prepared Statement of the Association for Clinical Oncology
        The Association for Clinical Oncology (ASCO), the world's leading
    professional organization representing nearly 45,000 physicians and
    other professionals who treat people with cancer, thanks this
    subcommittee for its long-standing commitment to support federally
    funded research at the National Institute of Health (NIH) and National
    Cancer Institute (NCI). ASCO is extremely grateful for the $2.25
    billion increase for the NIH in fiscal year (FY) 2022. 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 FY 2023 funding to build
    on our Nation's investment in biomedical research:

      --National Institutes of Health (NIH): $49.048 billion
        --National Cancer Institute (NCI): $7.766 billion
          --Beau Biden Cancer Moonshot Initiative: $216 million

      --Centers for Disease Control and Prevention's (CDC) Division of
            Cancer Prevention and Control (DCPC): $462.6 million
        --Cancer Registries Program: $61.4 million
                          the nih: a great investment
        In FY 2020, 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 in 2020.\2\
    ---------------------------------------------------------------------------
        \1\ National Institutes of Health; https://www.nih.gov/about-nih/
    what-we-do/impact-nih-research.
        \2\ United for Medical Research; https://
    www.unitedformedicalresearch.org/wp-content/uploads/2021/03/NIHs-Role-
    in-Sustaining-the-U.S.-Economy-FINAL-3.23.21.pdf.
    ---------------------------------------------------------------------------
        The importance of federally funded biomedical research has never
    been clearer than during the COVID-19 pandemic as scientists from all
    corners of the country worked to quicky develop effective COVID-19
    vaccines. Researchers racing towards a vaccine were not starting from
    scratch; years of federally funded research 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--built on years of research and scientific
    discovery--is a testament to the need for continued investment.
        Despite recent funding increases, the 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. While our research
    infrastructure is recovering, the funding levels we are requesting for
    FY 2023 would continue to aid the recovery from these setbacks and
    allow meaningful growth above biomedical inflation. The investment
    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
        Over the last 30 years the cancer death rate has fallen 31 percent.
    This includes a 2.4 percent decline from 2017 to 2018--a record for the
    largest 1-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. Almost 1.9 million new cancer cases will be
    diagnosed, and more than 609,000 people will die from cancer in
    2022.\3\
    ---------------------------------------------------------------------------
        \3\ American Cancer Society, Cancer Facts and Figures 2022; https:/
    /www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-
    statistics/annual-cancer-facts-and-figures/2022/2022-cancer-facts-and-
    figures.pdf.
    ---------------------------------------------------------------------------
        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. ASCO is grateful to Congress for the FY 2022 funding provided
    to the NCI. The increase is an important step towards increasing the
    amount of R01 grants the NCI is able to fund. Despite the FY 2022
    increase, however, the NCI's funding has not kept up with the growth of
    research grant applications as compared to other NIH Institutes or
    Centers. In 2021, the NCI was only able to fund 11 percent of viable
    applications, compared to 28 percent 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 percent of grant applications by 2025. The
    NCI's Professional Bypass Budget, released in December 2021, indicated
    the Institute needs $7.766 billion in FY 2023 to stay on course to
    reach this goal.
        The Beau Biden Cancer Moonshot Initiative has provided a much
    needed, albeit temporary, predictable increase in funding for the NCI.
    In its 7 years, the Cancer Moonshot has initiated many new clinical
    trial networks and established an infrastructure to conduct cancer
    research and share resources on a massive scale. Funding for the
    Moonshot will expire after this fiscal year, however. To leverage the
    infrastructure created by the Cancer Moonshot requires sustained
    investments beyond FY 2023.
        President Biden has announced a reignited Moonshot, without
    requesting any additional funding for the NCI. In fact, the
    Administration's FY 2023 Budget included a cut to the NCI's budget.
    These cuts would jeopardize our Nation's existing biomedical research
    infrastructure and undercut ongoing efforts to advance scientific
    knowledge for the treatment of cancers, and other important basic and
    translational research. ASCO supports the President's reignited
    Moonshot goals ``to reduce the death rate from cancer by at least 50
    percent over the next 25 years, and improve the experience of people
    and their families living with and surviving cancer--and, by doing this
    and more, end cancer as we know it today.'' The toll COVID-19 will have
    on cancer incidences in the future is not yet known. It is clear
    already that the disruption of health services resulted in millions of
    people who missed or postponed screenings or follow-ups as well as
    patients already diagnosed who experienced treatment delays due to the
    pandemic. The consequences of this interruption in care will become
    evident in our cancer statistics in the years to come. The
    Administration's ambitious goals simply cannot be met without
    significant funding increases for NCI in anticipation of the end of the
    authorized Cancer Moonshot funding and the threat of a cancer incidence
    increase as a result of COVID-19.
                      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 12 and older identified as candidates to
    benefit 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 2022, the TAPUR study has over 2,400 patients
    enrolled at 250 clinical sites in 28 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).
    These programs expand clinical research beyond the academic environment
    and allow access to clinical trials to a larger, more diverse patient
    population, by bringing trials to the community setting. Just last
    year, the NCI awarded 53 grants to researchers at 46 NCORP sites, 14 of
    which are designated as minority/underserved community 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.\4\ 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.
    ---------------------------------------------------------------------------
        \4\ National Cancer Institute; https://ncorp.cancer.gov/about/.
    ---------------------------------------------------------------------------
                     harnessing data & reducing disparities
        A long-standing priority for ASCO is to ensure cancer treatments
    and care considers patient demographics and social determinants of
    health. While diverse, accessible clinical trials often offer the best
    clinical treatment option for cancer patients, trials are not always
    available, especially for smaller patient populations, such as
    pediatric or rare disease groups.
        As a compliment to inclusive trials, cancer providers and
    researchers also need accessible data to understand cancer at a broader
    level. The Centers for Disease Control and Prevention's (CDC) cancer
    programs play an indispensable role in the prevention, detection, and
    treatment of cancer. Approximately 50 percent of cancer deaths can be
    prevented and the substantial cost of the treatment of advanced disease
    could be reduced through the use of existing evidence-based prevention
    and early detection strategies supported by CDC's Division of Cancer
    Prevention and Control (DCPC).
        Unfortunately, Federal funding for DCPC has remained almost flat
    for many years. Between FY 2010 and FY 2022, DCPC funding increased by
    just $19.5 million, or 5.3 percent, from $370.3 million to $389.8
    million. Excluding funding for the WISEWOMAN heart disease program,
    which is housed within the DCPC, the FY10- FY22 increase is just $8
    million, or 2.9 percent. That's about $100 million less than if DCPC
    funding had merely kept up with inflation.
        To that end, ASCO joins the cancer community in requesting $462.6
    million for the DCPC, and $61.4 million for the CDC's Cancer Registries
    Program. Cancer registries are a critical tool for providers and
    researchers, providing cancer surveillance, identifying trends among
    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 toward 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
    creation of the 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 of clinically impactful
    products is vital to helping patients. Additionally, efforts to
    establish ARPA-H or otherwise 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.
        The 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 and 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. All
    patients should have access to 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 the agency should implement strategies to encourage
    decentralization of trials and ensure diversity and equity in research.
        ASCO recognizes and appreciates the work of Congress and the
    Administration to establish ARPA-H and stands ready as a resource
    throughout its creation and growth. ASCO does not have a specific
    funding request for ARPA-H for FY 2023; we stand firmly by our
    principles that the agency's funding should not come at the expense of
    robust, predictable annual funding increases for the NIH, NCI, or other
    existing research agencies.
        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
    FY 2023 budget that continues to advance U.S. cancer research. Please
    contact Kristin Stuart at Kristin.Stuart@asco.org with any questions.

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

     Prepared Statement of the Association for Professionals in Infection
                            Control and Epidemiology
        The Association for Professionals in Infection Control and
    Epidemiology (APIC) and the Society for Healthcare Epidemiology of
    America (SHEA) urge appropriators to prioritize investments in the
    following Federal programs:

    ------------------------------------------------------------------------
                                                           FY 2023  Funding
            LHHS  Programs                 Agency              Request
    ------------------------------------------------------------------------
       National Healthcare Safety                     CDC      $100 million
                           Network
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
            Antibiotic Resistance                     CDC      $397 million
              Solutions Initiative
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
     Advanced Molecular Detection                     CDC      $175 million
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
                                 Center for ForecastinCDCnd     $50 million
                Outbreak Analytics
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Agency for Healthcare Research                AHRQ         $500 million
                       and Quality
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
             BARDA Broad Spectrum                 ASPR         $300 million
        Antimicrobials Program and
                                  CARB-X Search
    ------------------------------------------------------------------------

        Although significant progress has been made to have fewer reported
    cases of COVID-19 in most States and hospitalizations decreasing, we
    must continue to take this pandemic seriously. Planning and investing
    for the next public health emergency must start today. While rapid
    advances were made in treatments and vaccines to combat the virus,
    severe gaps in healthcare were exposed and exploited by the virus.
    Further, during the pandemic, healthcare facilities saw significant
    increases in healthcare-associated infections (HAI) tracked by the
    National Healthcare Safety Network.\1\ Additionally, CDC highlighted
    reports of sporadic antibiotic resistant outbreaks in COVID-19 units
    and higher rates of hospital-onset infections.\2\ It is believed,
    nearly a decade worth of progress preventing these infections was lost
    during the pandemic.
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/hai/data/portal/covid-impact-hai.html.
        \2\ https://www.cdc.gov/drugresistance/covid19.html.
    ---------------------------------------------------------------------------
        As integral components of the Nation's public health
    infrastructure, these programs must be funded at levels demanded by the
    growing threat of existing and emerging infectious diseases. Moreover,
    these programs will be important to improve the quality of care
    delivered to Americans and crucial in preparing for the next public
    health emergency.
        We urge you to invest $100 million in the National Healthcare
    Safety Network (NHSN). As the CDC's domestic tracking and response
    system, NHSN equips healthcare facilities, public health departments,
    and Federal agencies with accurate and actionable data to identify
    emerging and persistent threats, such as COVID-19, HAIs, and antibiotic
    resistant infections (ARI), as well as to deploy targeted infection
    prevention interventions. NHSN is also the chosen platform for how
    hospitals and nursing homes submit their monthly healthcare personnel
    (HCP) COVID-19 vaccination data, to support CMS reporting requirements,
    as well as for Hospital Compare. NHSN has played a key role in the
    reduction in various HAIs over the 5 years prior to the pandemic (18 to
    42 percent).\3\ Within 2 months of the National emergency declaration
    for COVID-19,\4\ CDC swiftly adapted NHSN to track COVID-19 in nursing
    homes where outbreaks have been the most severe.\5\ CMS relies on NHSN
    data for public reporting and incentive payments for healthcare quality
    performance, with NSHN data contributing to at least $350 million in
    Federal savings.\6\ By leveraging electronic health records and
    commercial infection control surveillance systems, NHSN innovates our
    existing healthcare data infrastructure while bolstering our public
    health data infrastructure. The stagnation in Federal funding over the
    last 10 years cannot sustain the exponential expansion of NHSN from 300
    in 2005 to more than 37,000 participating healthcare facilities in
    2020--including hospitals, nursing homes, dialysis facilities, and
    ambulatory surgical centers (ASCs) across the country. An increased
    investment in NHSN would ensure CDC can provide adequate technical
    support to participants, modernize NHSN to produce faster data while
    reducing the administrative burden for healthcare facilities, and adapt
    NHSN to respond to the current and future pandemics. Through greater
    NHSN participation, CDC can leverage the data needed to establish
    reliable national benchmarks, allowing healthcare facilities to measure
    the progress of their HAI and ARI prevention efforts and ultimately
    optimize antibiotic prescribing practices and eliminate HAIs.
    ---------------------------------------------------------------------------
        \3\ https://www.cdc.gov/nhsn/pdfs/NHSN-FactSheet-
    508.pdf?ACSTrackingID=USCDC_425-
    DM47349&ACSTrackingLabel=Weekly%20Summary%3A%20COVID-19%20Healthcare%20
    Quality%20and%20Worker%20Safety%20Information%20%E2%80%93%20February%201
    %
    2C%202021&deliveryName=USCDC_425-DM47349.
        \4\ https://www.federalregister.gov/documents/2020/03/18/2020-
    05794/declaring-a-national-emergency-concerning-the-novel-coronavirus-
    disease-covid-19-outbreak.
        \5\ https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/cms-covid19-req-
    508.pdf
        \6\ https://www.cdc.gov/nhsn/pdfs/NHSN-FactSheet-
    508.pdf?ACSTrackingID=USCDC_425-
    DM47349&ACSTrackingLabel=Weekly%20Summary%3A%20COVID-19%20Healthcare%20
    Quality%20and%20Worker%20Safety%20Information%20%E2%80%93%20February%201
    %
    2C%202021&deliveryName=USCDC_425-DM47349.
    ---------------------------------------------------------------------------
        We urge you to invest $397 million in the Antibiotic Resistance
    Solutions Initiative (ARSI). Even with the accelerated development of
    new antibiotics, therapeutics, and vaccines, the growing trend in
    antibiotic resistance underscores the urgency for the U.S. to increase
    its investments in ARSI. Antibiotic resistance undermines medical
    breakthroughs in life-savings drugs by quickly making new antibiotics
    obsolete and threatening the success of cutting-edge treatments for
    cancer, organ transplants, and other medical conditions that can be
    complicated by infections. In addition, during the pandemic an alarming
    number of Candida auris outbreaks emerged. This strain of yeast is
    highly resistant to antibiotics and can target long-term care
    settings.\7\ ARSI supports 50 State health departments, four large city
    health departments, and Puerto Rico to detect, respond, and contain
    antibiotic-resistant pathogens.\8\ CDC bridges the gap in local
    laboratory capabilities and data-driven responses to antibiotic-
    resistant threats through ARSI's Antibiotic Resistance Lab Network,
    which equips the 55 States and localities with comprehensive lab
    capacity and facilitates coordination of activities through seven
    regional labs and the National Tuberculosis Molecular Surveillance
    Center.\9\ Prior to the pandemic, the aggressive strategies of ARSI
    have reduced deaths and hospitalizations from antibiotic resistance (18
    percent and 28 percent fewer since 2013, respectively).\10\ Boosting
    investments in ARSI would further strengthen the Nation's epidemiology,
    laboratory, and diagnostics capacity to combat emerging antibiotic
    resistance.
    ---------------------------------------------------------------------------
        \7\ https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2022/04/
    20/mdhhs-announces-select-specialty-hospital.
        \8\ https://www.cdc.gov/drugresistance/solutions-initiative/ar-lab-
    network.html.
        \9\ https://www.cdc.gov/drugresistance/pdf/cdc-ar-lab-network-
    final-H.pdf.
        \10\ https://www.cdc.gov/drugresistance/pdf/threats-report/
    Prevention-Works-More-Action-Needed-508.pdf.
    ---------------------------------------------------------------------------
        We urge you to invest $175 million in the Advanced Molecular
    Detection (AMD) Initiative. AMD supports the integration of genomic
    sequencing with bioinformatic and epidemiology to detect diseases
    faster, identify and respond to outbreaks sooner, and protect people
    from emerging and evolving disease threats. Through partnerships with
    State and local health departments, public health laboratories, and
    academic institutions, AMD increases access to the specialized
    technologies and expertise necessary to empower public health
    professionals at the frontlines to take action before disease-causing
    pathogens become more widespread. As the Nation responded to the to the
    COVID-19 pandemic, AMD was crucial to robustly tracking and combatting
    emerging variants of COVID-19 in real-time. An increased investment in
    AMD will better position the U.S. to respond more strategically and
    effectively to endemic COVID-19 and future pandemics.
        We urge you to invest $50 million in the CDC's new Center for
    Forecasting and Outbreak Analytics. The Center for Forecasting and
    Outbreak Analytics (CFA) is a new center established under the American
    Rescue Plan. The Center was created to improve the Nation's ability to
    prepare for and respond to infectious disease threats using data,
    modeling, and analytics. It will bring together next-generation public
    health data, disease experts, and public health emergency responders to
    meet the needs of policymakers. While a new program, CFA already had an
    impact during the COVID-19 pandemic by assembling models anticipating
    the omicron wave. Continuously investing in these types of innovative
    programs will allow policymakers to make better data-driven and timely
    decisions during the current and future public health emergencies.
        We urge you to invest $500 million for the Agency for Healthcare
    Research and Quality (AHRQ). As the lead agency for health services
    research and primary care research, AHRQ provide policymakers, health
    system leaders medical providers, and patients with evidence-based
    policies and practices to improve health care quality, safe, and value.
    AHRQ also funds research at academic medical centers and other research
    institutions, generating new knowledge and enhancing the effectiveness
    of interventions to promote patient safety, prevent HAIs, and improve
    patient outcomes. Greater investments in the evaluation of our
    healthcare delivery system are critical to closing the gaps in
    healthcare quality, spending, and outcomes.
        We urge you to invest $300 million for Broad Spectrum
    Antimicrobials and Combating Antibiotic-Resistant Bacteria
    Biopharmaceutical Accelerator (CARB-X) at the Biomedical Advanced
    Research and Development Authority (BARDA). Novel broad-spectrum
    antimicrobials are vital to ensure timely, appropriate treatment of
    infections, especially as antibiotics are becoming increasingly
    ineffective due to drug resistance. The BARDA Broad Spectrum
    Antimicrobials Program and CARB-X, programs within the office of the
    Assistant Secretary for Preparedness and Response (ASPR), have
    successfully supported the development of new FDA-approved antibiotics.
    An investment in these programs will sustain the Nation's pipeline of
    robust medical countermeasures to antimicrobial resistance.
        The ongoing COVID-19 pandemic has highlighted the importance of
    sustained investments in the Nation's infrastructure to protect combat
    emerging infectious disease threats. With the growing prevalence in AR,
    the challenges we face today will worsen without new investments.
    Preventing infections, improving antibiotic use, detecting threats, and
    implementing interventions are essential to ensuring public health. The
    societies thank you for this opportunity to submit testimony on behalf
    of clinicians and researchers who champion infection prevention and
    antibiotic resistance.
                                     ______

     Prepared Statement of the Association for Professionals in Infection
    Control and Epidemiology and the Society for Healthcare Epidemiology of
                                    America
        The Association for Professionals in Infection Control and
    Epidemiology (APIC) and the Society for Healthcare Epidemiology of
    America (SHEA) urge appropriators to prioritize investments in the
    following Federal programs:

    ------------------------------------------------------------------------
                                                            FY 2023 Funding
                LHHS Programs                  Agency           Request
    ------------------------------------------------------------------------
     National Healthcare Safety Network                CDC     $100 million
        Antibiotic Resistance Solutions                CDC     $397 million
                              Initiative
           Advanced Molecular Detection                CDC     $175 million
                                       Center for ForecCDCing an$50 million
                               Analytics
     Agency for Healthcare Research and            AHRQ        $500 million
                                 Quality
    BARDA Broad Spectrum Antimicrobials            ASPR        $300 million
                            Program and CARB-X Search
    ------------------------------------------------------------------------

        Although significant progress has been made to have fewer reported
    cases of COVID-19 in most States and hospitalizations decreasing, we
    must continue to take this pandemic seriously. Planning and investing
    for the next public health emergency must start today. While rapid
    advances were made in treatments and vaccines to combat the virus,
    severe gaps in healthcare were exposed and exploited by the virus.
    Further, during the pandemic, healthcare facilities saw significant
    increases in healthcare-associated infections (HAI) tracked by the
    National Healthcare Safety Network.\1\ Additionally, CDC highlighted
    reports of sporadic antibiotic resistant outbreaks in COVID-19 units
    and higher rates of hospital-onset infections.\2\ It is believed,
    nearly a decade worth of progress preventing these infections was lost
    during the pandemic.
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/hai/data/portal/covid-impact-hai.html.
        \2\ https://www.cdc.gov/drugresistance/covid19.html.
    ---------------------------------------------------------------------------
        As integral components of the Nation's public health
    infrastructure, these programs must be funded at levels demanded by the
    growing threat of existing and emerging infectious diseases. Moreover,
    these programs will be important to improve the quality of care
    delivered to Americans and crucial in preparing for the next public
    health emergency.
        We urge you to invest $100 million in the National Healthcare
    Safety Network (NHSN). As the CDC's domestic tracking and response
    system, NHSN equips healthcare facilities, public health departments,
    and Federal agencies with accurate and actionable data to identify
    emerging and persistent threats, such as COVID-19, HAIs, and antibiotic
    resistant infections (ARI), as well as to deploy targeted infection
    prevention interventions. NHSN is also the chosen platform for how
    hospitals and nursing homes submit their monthly healthcare personnel
    (HCP) COVID-19 vaccination data, to support CMS reporting requirements,
    as well as for Hospital Compare. NHSN has played a key role in the
    reduction in various HAIs over the 5 years prior to the pandemic (18 to
    42 percent).\3\ Within 2 months of the National emergency declaration
    for COVID-19,\4\ CDC swiftly adapted NHSN to track COVID-19 in nursing
    homes where outbreaks have been the most severe.\5\ CMS relies on NHSN
    data for public reporting and incentive payments for healthcare quality
    performance, with NSHN data contributing to at least $350 million in
    Federal savings.\6\ By leveraging electronic health records and
    commercial infection control surveillance systems, NHSN innovates our
    existing healthcare data infrastructure while bolstering our public
    health data infrastructure. The stagnation in Federal funding over the
    last 10 years cannot sustain the exponential expansion of NHSN from 300
    in 2005 to more than 37,000 participating healthcare facilities in
    2020--including hospitals, nursing homes, dialysis facilities, and
    ambulatory surgical centers (ASCs) across the country. An increased
    investment in NHSN would ensure CDC can provide adequate technical
    support to participants, modernize NHSN to produce faster data while
    reducing the administrative burden for healthcare facilities, and adapt
    NHSN to respond to the current and future pandemics. Through greater
    NHSN participation, CDC can leverage the data needed to establish
    reliable national benchmarks, allowing healthcare facilities to measure
    the progress of their HAI and ARI prevention efforts and ultimately
    optimize antibiotic prescribing practices and eliminate HAIs.
    ---------------------------------------------------------------------------
        \3\ https://www.cdc.gov/nhsn/pdfs/NHSN-FactSheet-
    508.pdf?ACSTrackingID=USCDC_425-
    DM47349&ACSTrackingLabel=Weekly%20Summary%3A%20COVID-19%20Healthcare%20
    Quality%20and%20Worker%20Safety%20Information%20%E2%80%93%20February%201
    %2C%
    202021&deliveryName=USCDC_425-DM47349.
        \4\ https://www.federalregister.gov/documents/2020/03/18/2020-
    05794/declaring-a-national-emergency-concerning-the-novel-coronavirus-
    disease-covid-19-outbreak.
        \5\ https://www.cdc.gov/nhsn/pdfs/covid19/ltcf/cms-covid19-req-
    508.pdf.
        \6\ https://www.cdc.gov/nhsn/pdfs/NHSN-FactSheet-
    508.pd1f?ACSTrackingID=USCDC_425-
    DM47349&ACSTrackingLabel=Weekly%20Summary%3A%20COVID-19%20Healthcare%20
    Quality%20and%20Worker%20Safety%20Information%20%E2%80%93%20February%201
    %2C%
    202021&deliveryName=USCDC_425-DM47349.
    ---------------------------------------------------------------------------
        We urge you to invest $397 million in the Antibiotic Resistance
    Solutions Initiative (ARSI). Even with the accelerated development of
    new antibiotics, therapeutics, and vaccines, the growing trend in
    antibiotic resistance underscores the urgency for the U.S. to increase
    its investments in ARSI. Antibiotic resistance undermines medical
    breakthroughs in life-savings drugs by quickly making new antibiotics
    obsolete and threatening the success of cutting-edge treatments for
    cancer, organ transplants, and other medical conditions that can be
    complicated by infections. In addition, during the pandemic an alarming
    number of Candida auris outbreaks emerged. This strain of yeast is
    highly resistant to antibiotics and can target long-term care
    settings.\7\ ARSI supports 50 State health departments, four large city
    health departments, and Puerto Rico to detect, respond, and contain
    antibiotic-resistant pathogens.\8\ CDC bridges the gap in local
    laboratory capabilities and data-driven responses to antibiotic-
    resistant threats through ARSI's Antibiotic Resistance Lab Network,
    which equips the 55 States and localities with comprehensive lab
    capacity and facilitates coordination of activities through seven
    regional labs and the National Tuberculosis Molecular Surveillance
    Center.\9\ Prior to the pandemic, the aggressive strategies of ARSI
    have reduced deaths and hospitalizations from antibiotic resistance (18
    percent and 28 percent fewer since 2013, respectively).\10\ Boosting
    investments in ARSI would further strengthen the Nation's epidemiology,
    laboratory, and diagnostics capacity to combat emerging antibiotic
    resistance.
    ---------------------------------------------------------------------------
        \7\ https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2022/04/
    20/mdhhs-announces-select-specialty-hospital.
        \8\ https://www.cdc.gov/drugresistance/solutions-initiative/ar-lab-
    network.html.
        \9\ https://www.cdc.gov/drugresistance/pdf/cdc-ar-lab-network-
    final-H.pdf.
        \10\ https://www.cdc.gov/drugresistance/pdf/threats-report/
    Prevention-Works-More-Action-Needed-508.pdf.
    ---------------------------------------------------------------------------
        We urge you to invest $175 million in the Advanced Molecular
    Detection (AMD) Initiative. AMD supports the integration of genomic
    sequencing with bioinformatic and epidemiology to detect diseases
    faster, identify and respond to outbreaks sooner, and protect people
    from emerging and evolving disease threats. Through partnerships with
    State and local health departments, public health laboratories, and
    academic institutions, AMD increases access to the specialized
    technologies and expertise necessary to empower public health
    professionals at the frontlines to take action before disease-causing
    pathogens become more widespread. As the Nation responded to the to the
    COVID-19 pandemic, AMD was crucial to robustly tracking and combatting
    emerging variants of COVID-19 in real-time. An increased investment in
    AMD will better position the U.S. to respond more strategically and
    effectively to endemic COVID-19 and future pandemics.
        We urge you to invest $50 million in the CDC's new Center for
    Forecasting and Outbreak Analytics. The Center for Forecasting and
    Outbreak Analytics (CFA) is a new center established under the American
    Rescue Plan. The Center was created to improve the Nation's ability to
    prepare for and respond to infectious disease threats using data,
    modeling, and analytics. It will bring together next-generation public
    health data, disease experts, and public health emergency responders to
    meet the needs of policymakers. While a new program, CFA already had an
    impact during the COVID-19 pandemic by assembling models anticipating
    the omicron wave. Continuously investing in these types of innovative
    programs will allow policymakers to make better data-driven and timely
    decisions during the current and future public health emergencies.
        We urge you to invest $500 million for the Agency for Healthcare
    Research and Quality (AHRQ). As the lead agency for health services
    research and primary care research, AHRQ provide policymakers, health
    system leaders medical providers, and patients with evidence-based
    policies and practices to improve health care quality, safe, and value.
    AHRQ also funds research at academic medical centers and other research
    institutions, generating new knowledge and enhancing the effectiveness
    of interventions to promote patient safety, prevent HAIs, and improve
    patient outcomes. Greater investments in the evaluation of our
    healthcare delivery system are critical to closing the gaps in
    healthcare quality, spending, and outcomes.
        We urge you to invest $300 million for Broad Spectrum
    Antimicrobials and Combating Antibiotic-Resistant Bacteria
    Biopharmaceutical Accelerator (CARB-X) at the Biomedical Advanced
    Research and Development Authority (BARDA). Novel broad-spectrum
    antimicrobials are vital to ensure timely, appropriate treatment of
    infections, especially as antibiotics are becoming increasingly
    ineffective due to drug resistance. The BARDA Broad Spectrum
    Antimicrobials Program and CARB-X, programs within the office of the
    Assistant Secretary for Preparedness and Response (ASPR), have
    successfully supported the development of new FDA-approved antibiotics.
    An investment in these programs will sustain the Nation's pipeline of
    robust medical countermeasures to antimicrobial resistance.
        The ongoing COVID-19 pandemic has highlighted the importance of
    sustained investments in the Nation's infrastructure to protect combat
    emerging infectious disease threats. With the growing prevalence in AR,
    the challenges we face today will worsen without new investments.
    Preventing infections, improving antibiotic use, detecting threats, and
    implementing interventions are essential to ensuring public health. The
    societies thank you for this opportunity to submit testimony on behalf
    of clinicians and researchers who champion infection prevention and
    antibiotic resistance.
                                     ______

        Prepared Statement of the Association for Psychological Science
            aps recommendations for fiscal year 2023 appropriations
    _______________________________________________________________________

      --The Association for Psychological Science (APS) supports a funding
            level of at least $49 billion for the National Institutes of
            Health (NIH) in fiscal year (FY) 2023. Robust funding for this
            essential health-research agency is necessary to ensure that
            the country has the critical scientific research findings
            required to improve human health and well-being.
      --APS supports a funding level of at least $11 billion for the
            Centers for Disease Control and Prevention (CDC) in FY 2023. As
            COVID-19 becomes endemic and current and future disease-based
            health threats loom, CDC must receive strong and reliable
            funding to effectively carry out its programs.
      --The behavioral and social sciences are essential to improving human
            health, which is why APS recommends Congress include report
            language urging continued funding of no less than $38.9 million
            for the NIH Office of Behavioral and Social Sciences Research,
            which leads and coordinates behavioral and social sciences
            research supported by NIH. Likewise, APS asks that Congress
            fund and integrate behavioral science research at CDC as part
            of its ongoing efforts to ameliorate the negative impacts of
            social determinants of health.
    _______________________________________________________________________
                    statement of aps chief executive officer
        Chair Murray, Ranking Member Blunt, and Members of the
    subcommittee, thank you for the opportunity to provide testimony as you
    consider funding priorities for FY 2023. I am Robert Gropp, Chief
    Executive Officer of APS. APS is a nonprofit scientific organization of
    25,000 scientists and students dedicated to advancing research
    psychology for the benefit of science and society. APS recognizes and
    appreciates the subcommittee's efforts to strengthen public health and
    health research.
     funding for the national institutes of health and its behavioral and
                       social sciences research programs
        APS recommends a FY 2023 funding level of at least $49 billion for
    NIH. This level of support is also recommended by the Ad Hoc Group for
    Medical Research, a coalition of patient and voluntary health groups,
    medical and scientific societies, academic and research organizations,
    and industry that share a commitment to strengthening NIH. APS agrees
    with the hundreds of members of this coalition that NIH-funded research
    improves societal understanding of health science, prepares us to
    better combat health threats, and translates research into
    interventions and treatments that improve human health. In addition to
    funding priorities, APS is concerned about the following policy topic
    at NIH.
        Support for behavioral and social sciences research at NIH: The
    COVID-19 pandemic has provided us with many tragic examples of the ways
    in which behavioral and social factors are linked with individual and
    public health. APS members' research demonstrates that understanding
    these behavioral and social influences is as essential to preventing
    and responding to the pandemic-and other health issues-as is
    understanding their biochemical, physiological, and general medical
    underpinnings.
        Although all NIH institutes and centers support behavioral and
    social sciences research to some degree, NIH's Office of Behavioral and
    Social Sciences Research (OBSSR) plays a centrally important and unique
    role in coordinating these efforts across NIH, as well as leading
    important projects such as, most recently, accelerating COVID-19
    related testing, therapeutics, and vaccine research; understanding the
    psychosocial outcomes of the pandemic; and testing approaches for more
    effective health communication, especially as related to health equity.
    OBSSR has also played a leading role in understanding how to prevent
    injury and mortality caused by firearms and the violence related to
    them. Given the importance of strong support for OBSSR, in partnership
    with other organizations in the behavioral, brain, and population
    sciences, APS urges that the following report language be included in
    the FY 2023 Labor-HHS Report:

        Office of Behavioral and Social Sciences Research (OBSSR).--The
            Committee commends OBSSR for effectively coordinating and
            supporting essential basic, clinical, and translational
            research in the behavioral, social, and population sciences to
            advance the NIH mission. Recognizing the critical role of OBSSR
            to integrate these sciences throughout the NIH research
            enterprise via OBSSR's leadership and coordination, the
            Committee encourages NIH to continue to support OBSSR at no
            less than the FY 2022 funding level including a proportionate
            increase in its FY 2023 budget as provided to the NIH by the
            Committee. The Committee urges NIH to provide an update on
            OBSSR's activities and progress in the fiscal year 2024
            congressional justification.
    funding for the centers for disease control and prevention, and policy
                                     issues
        In support of the CDC Coalition, comprising organizations committed
    to strengthening the country's public health infrastructure and
    prevention programs, APS recommends a FY 2023 funding level of at least
    $11 billion for CDC programs in the Labor-HHS bill. The CDC is central
    to protecting the U.S. from the COVID-19 pandemic but also combatting
    chronic diseases; resolving the opioid, tobacco, e-cigarette, and
    obesity epidemics; and advancing other public health and prevention
    programs. Again, psychological science provides the understanding of
    human behavior that so often is the cause for these public health
    problems. Psychological science research also offers insights about how
    to support behavior changes that are the key to interventions that can
    contribute to improved behaviors and public health.
        APS further encourages your consideration of the following issue.
        Support for research on social determinants of health at CDC: APS
    is encouraged that Congress has made important investments in
    addressing social determinants of health (SDOH), which are defined by
    the Department of Health and Human Services as the conditions in the
    environments where people are born, live, learn, work, play, worship,
    and age that affect health, functioning, and quality of life. APS
    supports ongoing investment in CDC's efforts to address SDOH and
    stresses that fundamental and applied research in psychological science
    and other fields is crucial for defining and understanding the factors
    that affect health and developing evidence-based methods for their
    remediation. In support of the basic and applied behavioral and social
    sciences that lead to opportunities to improve well-being for all, APS
    also urges that the following language be included in the FY 2023
    Labor-HHS Report:

        Behavioral Research and Social Determinants of Health.--The
            Committee continues to support investments to better understand
            the behavioral and social determinants of health and urges the
            CDC to fund and integrate knowledge from behavioral science
            research as a part of the effort to develop new evidence-based
            interventions to ameliorate social determinants' potential
            negative effects. The Committee believes that behavioral
            science research focused on understanding the social
            determinants of health can increase uptake of and adherence to
            healthy behaviors that help prevent chronic conditions such as
            cancer, heart diseases, and diabetes.
                             summary and conclusion
        The thread shared by these two requests is that knowledge gained
    from psychological science is essential to improving human health and
    well-being. To illustrate, I respectfully direct you to the APS Global
    Collaboration on COVID-19, which has brought together psychological
    scientists and other experts to make recommendations on how our field
    can be applied for these purposes. This collaboration has identified
    that psychological and other behavioral science could have been better
    applied throughout the COVID-19 crisis, that these fields remain poised
    to contribute to COVID-19 and future health threats, and that new
    research and research funding are urgently needed to best prepare our
    country for future crises. I would be pleased to share further
    information on this effort with any interested Members of the
    subcommittee at your convenience.
        Thank you for your ongoing commitment to supporting scientific
    research, education, and training that improve health and well-being
    and reduces disease in the United States and around the world. The one
    million deaths in the U.S as a result of the COVID-19 pandemic, among
    many other things, have been a heartbreaking reminder of the links
    between human behavior and health; strong support for the important
    Department of Health and Human Services programs referenced here will
    improve our chances of ensuring that such a crisis exacerbated by human
    behavior never occurs again.

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

      Prepared Statement of the Association of American Cancer Institutes
        The Association of American Cancer Institutes (AACI), representing
    104 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) 2023 funding. AACI requests a $4.1 billion increase for the NIH
    for FY 2023, bringing the recommended funding level for the NIH to $49
    billion. This proposed level of NIH funding would ensure that academic
    cancer centers can continue to discover and deliver potentially
    lifesaving new therapies for patients with cancer. AACI also requests
    at least $7.766 billion in FY 2023 for the National Cancer Institute
    (NCI).
        As Congress moves into the FY 2023 budget planning process, 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 to patients--from prevention to
    survivorship. These centers are at the forefront of the National effort
    to eradicate cancer, yet progress in cancer research is complex. The
    pace of discovery and translation of novel basic research to new
    therapies can be accelerated by an appropriate and predictable
    investment in Federal cancer funding.
                                    payline
        Uncertainty surrounding research project grants (R01s) 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 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 in FY 2020 that R01 grants for established and new
    investigators were 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,\1\ a slight increase. However, in FY 2022, R01 grants
    flatlined at the 11th percentile for another year.\2\ We request that
    Congress build on past by making a strong investment in the NCI in FY
    2023. Steady increases from the FY 2022 11th percentile rate are
    essential to achieving the goal set by former NCI Director Dr. Ned
    Sharpless, to reach the 15th percentile by FY 2025. To continue in this
    direction, we are hopeful that Congress will adopt the NCI Director's
    Professional Judgment Budget Proposal of $7.766 billion for FY 2023.
    ---------------------------------------------------------------------------
        \1\ https://www.cancer.gov/grants-training/nci-bottom-line-blog/
    2021/funding-from-congress-allows-nci-to-raise-grants-payline.
        \2\ https://www.cancer.gov/grants-training/nci-bottom-line-blog/
    2022/budget-increase-funds-a-growing-nci-grants-portfolio.
    ---------------------------------------------------------------------------
                                   conclusion
        Now is the time for Congress to invest in biomedical research in
    general--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 2022.\3\ 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 2023
    spending package that includes $49 billion for the NIH and $7.766
    billion for the NCI.
    ---------------------------------------------------------------------------
        \3\ https://www.cancer.org/content/dam/cancer-org/research/cancer-
    facts-and-statistics/annual-cancer-facts-and-figures/2022/2022-cancer-
    facts-and-figures.pdf.
    ---------------------------------------------------------------------------
        A robust Federal investment in NCI-Designated Cancer Centers and
    academic cancer centers will allow the cancer research community to
    continue accelerating progress against cancer. We must continue to
    build on this momentum or else we stand to lose an entire generation of
    potentially lifesaving research.

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

       Prepared Statement of the Association of American Medical Colleges
        The AAMC (Association of American Medical Colleges) is a nonprofit
    association dedicated to improving the health of people everywhere
    through medical education, health care, medical research, and community
    collaborations. Its members comprise all 155 accredited U.S. and 16
    accredited Canadian medical schools; approximately 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 the millions of individuals
    employed across academic medicine, including more than 191,000 full-
    time faculty members, 95,000 medical students, 149,000 resident
    physicians, and 60,000 graduate students and postdoctoral researchers
    in the biomedical sciences. In 2022, the Association of Academic Health
    Centers and the Association of Academic Health Centers International
    merged into the AAMC, broadening the AAMC's U.S. membership and
    expanding its reach to international academic health centers.
        The COVID-19 pandemic is only one illustration of 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 2023, 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 $49.048 billion for the National Institutes of
    Health (NIH), in addition to any funding for the Advanced Research
    Projects Agency for Health (ARPA-H); $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
    $718.8 million for the Children's Hospitals Graduate Medical Education
    (CHGME) program; and at least $11 billion for the Centers for Disease
    Control and Prevention (CDC).
        The AAMC appreciates the subcommittee's longstanding, bipartisan
    efforts to strengthen these programs. 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. To this
    end, the AAMC joined nearly 400 organizations representing the
    diversity of Labor-HHS stakeholders in a May 10 letter reiterating the
    need for a robust funding allocation for the Labor-HHS-Education
    subcommittee. The AAMC also supports the president's proposal to
    supplement the annual HHS investments with mandatory funding to support
    ongoing pandemic preparedness.
        National Institutes of Health. Congress's longstanding bipartisan
    support for medical research has contributed greatly to improving the
    health and well-being of all, highlighted, for example, by the central
    role medical research has played in combatting COVID-19. As illustrated
    over the last 2 years, 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 a seventh straight year of bipartisan
    support that resulted in the inclusion of $45 billion for medical
    research conducted and supported by the NIH in the fiscal Year2022
    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 fiscal year 2022.
        In fiscal year 2023, the AAMC joins nearly 400 partners in
    supporting the Ad Hoc Group for Medical Research recommendation that
    Congress provide at least $49.048 billion in program level funding for
    the NIH, which would represent an increase of $4.1 billion over the
    comparable fiscal year 2022 funding level (an increase of $3.5 billion
    or 7.9 percent in the NIH appropriation plus funding from the 21st
    Century Cures Act for specific initiatives). Importantly, the Ad Hoc
    Group strongly urges lawmakers to ensure that any additional funding
    the subcommittee opts to provide for ARPA-H supplement our $49 billion
    recommendation for NIH's base budget, rather than supplant the
    essential foundational investment in the NIH. In addition, the
    coalition supports the president's proposal to supplement NIH's budget
    with additional mandatory funding to speed the pace of pandemic
    response and readiness.
        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,
    gender, and geographic 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 ARPA-H as it gets underway. 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.
        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 at least
    $500 million in funding for AHRQ in FY 2023.
        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 pivoted their curricula to educate our health
    workforce during this public health challenge. There were unexpected
    costs to provide personal protective equipment (PPE) for in-person
    clinical training or switching to a virtual learning experience.
        Simultaneously, the pandemic underscored the need to increase and
    continuously reshape our health workforce. These programs have proven
    successful in recruiting, training, and supporting public health
    practitioners, nurses, geriatricians, mental health providers, and
    other frontline health care workers critical to addressing COVID-19.
    Additionally, HRSA has tasked grantees with utilizing innovative models
    of care, such as training providers in telehealth, to improve patients'
    access to care during the pandemic.
        The COVID-19 pandemic pulled back the curtain on the pervasive
    health inequities facing disadvantaged and underserved 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 inequities, and attract health professionals who are more likely
    to treat underserved patients.
        Further, the HRSA health professions and nursing workforce programs
    are structured to advance new delivery systems and models of care, such
    as those promoting interprofessional teams and integrating mental
    health services with primary care. Whether developing a new curriculum
    to address emerging and ongoing public health crises, such as substance
    use disorders, or collaborating with community leaders in educating
    providers to deliver culturally competent care, the Title VII and Title
    VIII programs help ensure our health workforce is at the forefront of
    meeting all patients' health needs. The AAMC joins the Health
    Professions and Nursing Education Coalition (HPNEC) in recommending
    $1.51 billion for these critical workforce programs in fiscal year
    2023. Additionally, the AAMC supports the president's proposal for at
    least $50 million to fund the recently enacted Dr. Lorna Breen Health
    Care Provider Protection Act (Public Law 111-105). Funding from the
    American Rescue Plan allowed HRSA to support several programs to
    prevent burnout in the health care workforce and promote clinician
    well-being, but HRSA received far more high-quality applications than
    resources allowed the agency to support.
        In addition to Title VII and Title VIII, HRSA's Bureau of Health
    Workforce also supports $718.8 million in FY 2023 for 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 also encourage
    Congress to provide robust funding to HRSA's Rural Residency Programs
    to expand training opportunities in rural areas through funding to
    develop new rural residency programs or separately accredited rural
    training track programs.
        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 $11 billion for the CDC in FY
    2023. 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 that total, the AAMC joins nearly 300 national, State, and
    local medical, public health, and research organizations in supporting
    the president's proposed $35 million to increase funding for firearm
    safety research supported by CDC. The AAMC also supports the
    administration's proposal to double firearm morbidity and mortality
    prevention research funding at NIH to $25 million in FY 2023 and to
    provide $250 million to CDC for a new community violence intervention
    initiative.
        Also within the CDC total, the AAMC supports increased or new
    funding for:
      --Data Modernization Initiative (DMI): $250 million
      --Center for Forecasting and Outbreak Analysis (CFA): $50 million
      --Climate and Health Program: $110 million
      --Advanced Molecular Detection (AMD) program: $175 million
        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 emerging 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 fiscal year 2023 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 57-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 2023 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 ($109,000,000); and Susan Harwood Training
    Grants, DOL Occupational Safety and Health Administration
    ($13,787,000). Not only do these programs maximize the Federal
    Government's investment in them, but 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 farmworkers 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 available quality 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 the 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 each of DOL's
    performance goals. In 2020 alone, NFJP service organizations provided
    more than 20,000 agricultural workers with services, according to DOL.
    Extrapolating, these NFJP providers have served over 200,000
    agricultural workers and their family members over the last 10 years.
    Funding program this year at $109,000,000_the level set in the House
    Education and Labor Committee-approved WOIA reauthorization bill (H. R.
    7309)--would allow NFJP to train an even greater number of dependable,
    capable workers to take on the Nation's most challenging jobs. 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 236 trainers in 35
    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 620,000 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 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 $49
    billion in base funding in fiscal year (FY) 2023. 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 newly established Advanced Research Project Agency for Health
    (ARPA-H) can support high-risk, high-reward research to accelerate the
    pace of biomedical innovation. AIRI urges the subcommittee to ensure
    that any funding provided for ARPA-H supplements, and does not
    supplant, the NIH's base budget funding. The promise of ARPA-H rests on
    the foundational research that NIH supports through its base budget.
        AIRI is a national organization of more than 80 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 nearly 10 percent of NIH's peer-reviewed, competitively awarded
    extramural grants.
        AIRI thanks the subcommittee for providing an increase of $2.03
    billion for NIH in the FY 2022 omnibus appropriations package. 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 $49 billion for NIH in
    FY 2023.
        AIRI looks forward to working with Congress and the Biden
    Administration to examine how the establishment of ARPA-H can push the
    research enterprise to take on high-risk, high-reward research efforts.
    If successful, ARPA-H has the potential to address 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 basic research
    discovery funded by the NIH can adequately inform the transformative,
    applied research that ARPA-H has the potential to carry out.
        Not only is NIH research essential to advancing health, it also
    plays a key economic role in communities nationwide. In FY 2021, NIH
    invested $35.73 billion, over 80 percent of its budget, in the
    biomedical research community. This investment supported more than
    552,444 jobs nationwide and generated nearly $94.18 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 2022 Update on NIH's Role in Sustaining
    the U.S. Economy, https://unitedformedicalresearch.org/annual-economic-
    report/.
    ---------------------------------------------------------------------------
        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.
        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 $49 billion for the NIH's base budget in FY 2023 and
    reaffirming that any funding for ARPA-H supplements the base budget
    funding 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 2023 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
      --$49 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
        --$50 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 2 years, 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 12 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 U.S. 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).
        President Biden recently signed the John Lewis NIMHD Research
    Endowment Revitalization Act to revitalize this important initiative,
    and it is our expectation that NIMHD will act swiftly to reinvigorate
    the research endowment program so minority-serving institutions can
    participate in this competitive opportunity to build their research
    endowments in a manner consistent with the statutory goal of assisting
    them in achieving a research endowment that is comparable to the
    endowments of other schools in their health professions discipline. The
    NIMHD Research Endowment Program (REP) allows academic institutions to
    build research infrastructure and recruit, train, and maintain a
    diverse faculty and student body. Robust funding would allow active and
    former NIMHD Centers of Excellence to continue their historic focus on
    research to close the gap between the burden of illness and premature
    mortality experienced more commonly by communities of color, as well as
    other medically underserved populations. It would also help improve
    access to grants to fund research projects, as well as hire staff and
    provide scholarships for students who come from underserved
    communities. To ensure successful implementation, we are asking for the
    Committee to allocate robust funding to NIMHD for this program.
        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.
                                     ______

    Prepared Statement of the Association of Schools and Programs of Public
                                     Health
        On behalf of the Association of Schools and Programs of Public
    Health (ASPPH), thank you for the opportunity to submit outside witness
    testimony concerning Fiscal Year (FY) 2023 appropriations for agencies
    and programs impacting the academic public health community. ASPPH is
    the leading voice of academic public health and we are focused on
    growing the high-quality public health workforce of the future. We
    represent 137 schools and programs of public health accredited by the
    Council on Education for Public Health (CEPH). Our membership includes
    over 10,800 faculty and over 72,000 students. ASPPH strives to
    strengthen the capacity of members by advancing leadership, excellence,
    and collaboration in public health education, research, and practice.
        We want to thank the subcommittee for its steadfast support of
    public health programs that span the fiscal Year23 Labor, Health and
    Human Services, Education and Related Agencies (Labor-HHS-ED)
    appropriations bill. In addition to the ongoing demands of our public
    health system, the current pandemic has challenged the public health
    community's response to protect the American people and global
    populations. Your subcommittee has continued to provide the critical
    financial resources to advance those efforts. With our Nation reaching
    the 1 million death toll due to COVID-19, we underscore strong
    investments in public health initiatives at a time we need it the most.
    This pandemic is far from over.
        As you draft the Labor-HHS-ED appropriations bill, please consider
    ASPPH's funding recommendations that support the mission of our 137
    academic institutions. These agencies and programs provide the
    essential resources to advance evidence-based approaches to public
    health threats and prepare future generations of public health
    practitioners. These investments will lead to tangible public health
    outcomes that will benefit the Nation and the world.
        Our FY 2023 funding recommendations for the leading HHS public
    health agencies are aligned with many other organizations in the public
    health community:
        National Institutes of Health (NIH): We are grateful for bipartisan
    support for continuous increases to the NIH budget and join several
    organizations in supporting $49.0 billion for ongoing work of
    Institutes and Centers, an increase of $4.1 billion or 9 percent above
    the fiscal Year2022 enacted level. Public health research is a critical
    component of the NIH's research portfolio. In addition, we support $1.0
    billion for the second-year appropriation of the Advanced Research
    Projects Agency for Health (ARPA-H), which is the same as the FY 2022
    appropriation that remains available into FY 2023. Within NIH, we
    support at least $110.0 million for NIH Fogarty International Center,
    an increase of $23 million or 26 percent above the FY 2022 enacted
    level. The investment in Fogarty is an investment in the health of all
    Americans by providing support for vital global research and training
    to both prevent newly emerging infectious agents from becoming domestic
    calamities and to help us reduce the rising rate of noncommunicable
    diseases and the health impact of chronic conditions around the world.
        Health Resources and Services Administration (HRSA): Programs
    within HRSA are essential to ensuring an adequately trained public
    health workforce. We support $9.8 billion, an increase of $1.2 billion
    or 14 percent above the FY 2022 enacted level. Specifically, within
    HRSA we request:
        HRSA Public Health Workforce Loan Repayment Program: $200 million
    for a new program that provides up to $150,000 in loan repayment in
    return for service in a State, local, Tribal or territorial health
    department. In 2010 Congress authorized this critical program, but it
    has not been funded at the necessary level to make an impact.
    Therefore, student loan debt is a major obstacle to students seeking
    careers in governmental public health due to low-paying, entry-level
    jobs that are available in health departments. Loan repayment will
    allow our Nation to strengthen the capacity of the public health
    workforce, at this critical moment, with the next generation of
    professionals who have the educational training in public health and
    related disciplines. This is a vital program will help public health
    graduates make significant contributions to advance the field of public
    health practice, particularly in preparation for the next public health
    crisis
        HRSA Public Health Training Centers: at least $15.0 million, an
    increase of $5.3 million or 55 percent above the fiscal Year2022
    enacted level. The Public Health Training Center Program is the
    Nation's only comprehensive training system to ensure workers in
    healthcare, behavioral health, public health and other fields have the
    skills needed to respond to increasingly complex public health
    challenges and protect the Nation's health.
        Centers for Disease Control and Prevention (CDC): As public health
    experts predict an increase in as many as 100 million COVID-19 cases in
    the coming months, we urge stronger investments in CDC to protect the
    health of our communities. Additionally, due to years of underfunding,
    many programs at the CDC have lacked necessary resources to address the
    various health challenges our Nation continuously grapples with. Robust
    support for the CDC budget is critical to enable proper tools for the
    agency to carry out its prevention mission and ensure translation of
    research on the community level. We support $11.0 billion, an increase
    of $2.6 billion or 31 percent above the FY 2022 enacted level.
    Specifically, within the CDC we support:
        CDC Center for Forecasting and Outbreak Analytics: $50 million to
    continue this new CDC center that was initially funded through the
    American Rescue Plan Act. The center supports the President's National
    Security Memorandum-1 which called for the establishment of a national
    capability that would support the U.S. Government and our partners with
    advanced analytics, disease modeling and outbreak analytics. The center
    will bring together next-generation public health data, expert disease
    modelers, public health emergency responders, and high-quality
    communications to meet the needs of decision makers. We strongly
    encourage the Committee to facilitate the center's continuous work with
    schools of public health and other academic institutions to engage the
    Nation's expertise in disease modelling, public health data analysis,
    research, and training to build workforce capacity in this emerging
    field.
        CDC Climate and Health: $110 million, an increase of $100 million
    above the FY 2022 enacted level. CDC's Climate and Health Program
    supports state, Tribal, local, and territorial public health agencies
    as they prepare for the health impacts of a changing climate. Academic
    public health institutions are engaged in essential research and
    training to establish and support a workforce of public health
    professionals with competencies to understand and address the impacts
    of climate change on public health. ASPPH has developed a climate
    framework that will enable all of our member institutions to make an
    impact on public health climate issues in collaboration with local,
    State and the Federal Government. We urge the Committee to include
    funding to support academic public health partners to expand research,
    strengthen public health workforce education and training, and foster
    practice-based partnerships to design and implement mitigation and
    adaption strategies related to climate change.
        CDC Prevention Research Centers: $37.0 million, an increase of
    $10.0 million or 37 percent above the FY 2022 enacted level. The PRCs
    are a national network of academic research centers committed to
    conducting prevention research. They are leaders in translating
    research results into policy and public health practice. PRCs work
    closely with community members to establish health priorities and
    develop applicable research projects that address local public health
    needs. These partners collaborate with health departments, educational
    boards, and the private sector to form long-term relationships that
    make PRCs the leaders in community based participatory research. In the
    past, for every $1 the PRCs received from CDC, they were able to
    generate an average of $4.85 in research funds from other sources. As a
    result, PRCs are able to conduct hundreds of public health research
    projects every year to address issues such as cancer, smoking, obesity,
    diabetes, cardiovascular and many other conditions.
        CDC Academic Preparedness Centers: $20 million, an increase $11.8
    million or 144 percent above the FY 2022 enacted level. ASPPH endorses
    supporting not fewer than 10 centers at institutions of higher
    education, including schools of public health, and other nonprofit
    private entities, to establish a network of academic preparedness
    centers. The centers will coordinate preparedness and response
    activities with governmental health departments, healthcare providers,
    and coalitions to translate research findings into evidence-informed
    and evidence-based practices, support training needs, and provide
    technical assistance and expertise. This framework of a national
    network of centers will strengthen the connection between academic
    public health and public health departments and health care systems to
    proactively address future public health threats. In previous years,
    annual appropriations for this program exceeded $30 million and
    supported 21 academic preparedness centers at schools of public health.
        CDC Injury Control Research Centers: $15.0 million, an increase of
    $6.0 million or 67 percent above the FY 2022 enacted level. The CDC's
    Injury Control Research Centers (ICRCs) are on the scientific front
    line conducting cutting-edge, multidisciplinary research on the causes,
    outcomes, and prevention of injuries and violence. The ICRC Program
    forms a national network of nine comprehensive academic research
    centers, including some within schools of public health, that focus on
    three core functions-research, outreach, and training. ICRC research
    focuses on issues of local and national importance, including opioids,
    firearm safety, sexual violence, suicide prevention, adverse childhood
    experiences, and traumatic brain injury.
        CDC NIOSH Education & Research Centers: $34.0 million, an increase
    of $3.0 million or 10 percent above the FY 2022 enacted level. These
    centers provide state-of-the-art interdisciplinary training for the
    next generation of occupational safety and health practitioners and
    researchers. To protect American workers, safety training must
    continually evolve to keep up with technological advances,
    globalization, new and emerging risks, and occupational health
    disparities associated with the changing demographics of the U.S.
    workforce.
        CDC NIOSH Agriculture, Forestry & Fishing Centers: $30.5 million,
    an increase of $3.0 million above the 2022 enacted level. The
    Agriculture, Forestry, and Fishing sector has approximately 2.3 million
    workers, who experience the highest fatal occupational injury rate at
    21.5 deaths per 100,000 full-time workers, almost twice the rate of the
    average workforce. These centers facilitate the most important research
    to develop the most effective intervention strategies, and translate
    those findings to achieve sustained safety improvements in workplace
    practice.
        Agency for Healthcare Research and Quality (AHRQ): AHRQ is the only
    Federal agency that funds research at universities and other research
    institutions specifically on health systems. This includes research
    that takes into account the ``real-life'' patient who has complex
    comorbidities, as well as intersections with other aspects of the
    health care system. We support $500 million for AHRQ, an increase of
    $150 million or 43 percent above the FY 2022 enacted level.
        Again, ASPPH appreciates the opportunity to submit this statement
    for the record and we stand ready to assist you and your staff with
    additional information and resources from across our institutions.

        [This statement was submitted by Timothy E. Leshan, Chief External
    Relations & Advocacy Officer, Association of Schools and Programs of
    Public Health.]
                                     ______

        Prepared Statement of the Association of Science and Technology
    Centers, the Association of Children's Museums, and the Association of
                            Science Museum Directors
        Chair Murray, Ranking Member Blunt, and Members of the
    subcommittee:
        Thank you for accepting this statement submitted by the Association
    of Science and Technology Centers (ASTC), the Association of Children's
    Museums (ACM), and the Association of Science Museum Directors (ASMD).
    We are the membership organizations for science and technology centers
    and museums, for children's museums, and for science and natural
    history museum leaders. Our networks of several hundred institutions in
    all 50 States and in nearly 50 countries around the world traditionally
    engage almost 100 million people annually in the United States. Our
    members and their institutions and are increasingly serving as
    community hubs for increased understanding of--and engagement with--
    science and technology among all people and for serving the needs and
    interests of children by providing exhibits and programs that stimulate
    curiosity and motivate learning.
        Our place-based organizations are leading institutions in the
    efforts to promote education in science, technology, engineering, and
    mathematics (STEM), developing rich, innovative, and effective science-
    learning experiences. We are helping to create the future STEM
    workforce and inspiring people of all ages about the wonders and the
    meaning of science in their lives. Our members are trusted and valued
    by their communities: a recent national public opinion poll, showed
    that 95 percent of voters would approve of lawmakers who acted to
    support museums and 96 percent of voters want Federal funding for
    museums to be maintained or increased (Museums and Public Opinion,
    Wilkening, S. and AAM, 2018).
        These past 2 years have been especially challenging for our
    community as all of our members, who traditionally receive about half
    of their operating income from revenue of people coming through their
    doors, experienced prolonged closure of their facilities. Even as they
    have reopened to the public, attendance and revenue may take several
    years to recover. At the same time, our member institutions continued
    to serve their communities and their missions, engaging their regions
    with STEM and youth engagement, supporting science learning and serving
    their communities in myriad other ways. Indeed, one of the most
    inspiring aspects of the past 2 years is how our member organizations
    have shown up for their communities and worked closely with local
    residents and organizations to advance conversation and action on the
    most urgent local priorities.
        For example, a year ago ASTC and ACM joined with a coalition of
    other national organizations to launch Communities for Immunity
    (www.communitiesforimmunity.org), an initiative supported by the
    Centers for Disease Control and Prevention and the Institute of Museum
    and Library Services to activate museums, libraries, and Tribal
    organizations to boost vaccine confidence in their communities.
    Building upon the high degree of trust that the public has in these
    cultural institutions, Communities for Immunity has been able to
    effectively engage vaccine hesitant members of their communities.
        As the Nation hopefully emerges from the immediacy of the pandemic,
    this example of action by the museum and library community demonstrates
    how these trusted institutions embedded in their communities offer an
    opportunity to advance community conversation and action on national
    and international challenges in locally resonant ways.
        astc, acm, and asmd requests for fiscal year 2023 appropriations
        We appreciate the support that the subcommittee has provided for
    the Nation's science and education agencies, including support for
    programs of particular interest to ASTC, ACM, and ASMD.
        In general, we stress the need for inclusive programs that include
    support for informal education as much STEM learning--including but not
    limited to school-aged youth--happens outside of formal schooling.
    Research has consistently shown that learning experiences outside of
    the formal classroom are vitally important to youth's future interest
    and capacity in STEM (National Research Council, 2006, 2009, 2015).
    National Institutes of Health
        The Science Education Partnership Awards (SEPA) program builds
    relationships between the biomedical research community and educational
    organizations--including science centers--that improve life science
    literacy. In addition, there is growing awareness of the importance of
    public engagement as a core aspect of several major initiatives that
    intersect with societal interests and public concerns, such as the
    BRAIN Initiative and the All of Us Research Program.
        We strongly urge the subcommittee to appropriate at least $21
    million for the Science Education Partnership Awards (SEPA), based at
    the National Institute of General Medical Sciences (NIGMS).
        In addition, we would welcome language that supports incorporating
    public engagement with science as an element of NIH funding programs
    more widely, including especially for initiatives that have significant
    public impact.
    Institute of Museum and Library Services
        As the primary Federal agency supporting all types of museums, the
    Institute of Museum and Library Services (IMLS) provides critical
    funding to museums through the Office of Museum Services (OMS)--as well
    as to libraries and to Tribal and other cultural institutions. This
    includes crucial resources for informal science activities at science
    centers and museums throughout the country.
        Throughout the pandemic, OMS has provided critical leadership to
    the museum community through its CARES Act and American Rescue Plan
    grants, and 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.
        The current appropriations level has allowed OMS to fund only a
    small fraction of the grant applications received that have been rated
    highly by peer reviewers. Increased funding for OMS would allow the
    office to increase its grant capacity for museums, funds which museums
    will need to help recover from the pandemic and continue to serve their
    communities.
        We urge you to provide at least $54.5 million for the Office of
    Museum Services at the Institute of Museum and Library Services (IMLS).
        We also ask for the subcommittee to include funding for the agency
    to explore establishing 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, 20 U.S.C. Section
    9173(a)(4), in addition to the agency's current direct grants to
    museums. Unlike state library grants, IMLS does not have the ability to
    rapidly deploy resources for addressing state-defined needs and expand
    the reach of museums and enhance their ability to serve their
    communities.
    Department of Education
        The U.S. Department of Education has significant opportunity to
    complement its expanding support for schools and school systems--with
    concurrent support for out-of-school learning include summer,
    afterschool, and informal education.
        The pandemic has shown how important robust afterschool and summer
    learning programs are to working families and our most vulnerable
    students, and how vital resources are to support these programs to
    ensure they are available and effective for the children and youth who
    need them.
        Specifically, we request that you support an increase of $500
    million for the Nita M. Lowey 21st Century Community Learning Centers
    program in FY 2023, which would bring the budget to $1.789 billion.
        We continue to thank the subcommittee for all its support of a
    robust science and education budget. You have demonstrated your support
    for crucial programs that promote STEM education for our Nation's
    students. Like our organizations, you recognize these are vital
    investments in our future, and we thank you in advance for taking
    action accordingly.
        Our two organizations--along with the broader museum community--
    stand ready to be of service to your work. We are always happy to
    provide examples of the ways that museums are contributing to their
    communities and helping to advance local, regional, and national
    priorities. With our networks of hundreds of community-based
    institutions, these examples can be in or near each Congressional
    district.
        Founded in 1973, the Association of Science and Technology Centers
    (ASTC) is a network of nearly 700 science and technology centers and
    museums, and allied organizations, engaging more than 110 million
    people annually across North America and in almost 50 countries. With
    its members and partners, ASTC works towards a vision of increased
    understanding of--and engagement with--science and technology among all
    people. www.astc.org. Association of Science and Technology Centers,
    818 Connecticut Avenue, NW, Seventh Floor, Washington, DC 20006,
    info@astc.org.
        The Association of Children's Museums (ACM) champions children's
    museums worldwide. With more than 460 members in 50 States and 19
    countries, ACM leverages the collective knowledge of children's museums
    through convening, sharing, and dissemination.
    www.childrensmuseums.org. Association of Children's
    Museums, 2550 South Clark Street, Suite 600, Arlington, VA 22202,
    ACM@childrensmuseums.org.
        The Association of Science Museum Directors (ASMD) is a non-profit,
    professional association of natural history and science museum
    directors. Our community of science museum leaders gathers to share
    experiences and discuss issues related to the advancement of our
    respective organizations to benefit society and the planet. www.asmd-
    us.org. Association of Science Museum Directors, 2413 S. Whittier
    Avenue, Springfield, IL 62704-4655, asmd.styles@gmail.com.

        [This statement was submitted by Christofer Nelson, President and
    CEO,
    Association of Science and Technology Centers, Arthur G. Affleck, III,
    Executive
    Director, Association of Children's Museums, and Bonnie Styles,
    Executive Director, Association of Science Museum Directors.]
                                     ______

     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 FY23
    appropriations for the U.S. Department of Health and Human Services
    (HHS). The Association of State and Territorial Health Officials
    (ASTHO) is a national nonprofit representing State and territorial
    public health agencies. ASTHO's members--the chief public health
    officials of these agencies--are dedicated to formulating and
    influencing sound public health policy and assuring excellence in
    public health practice. ASTHO is requesting $11 billion for the Centers
    for Disease Control and Prevention (CDC), $824 million for the Public
    Health Emergency Preparedness Cooperative Agreement (PHEP), $170
    million for the Preventive Health and Health Services Block Grant
    (Prevent Block Grant), $1 billion for Public Health Infrastructure and
    Capacity, $153 million for Social Determinants of Health, and $250
    million data modernization efforts at CDC. Under the Assistant
    Secretary for Preparedness and Response (ASPR), ASTHO requests $474
    million for the Hospital Preparedness Program (HPP). Additionally, we
    ask for $9.2 billion in discretionary funding for the Health Resources
    and Services Administration (HRSA).
        Before I expand on the details of these program requests, ASTHO,
    and our members are grateful for the tireless work you and your staff
    do to support governmental public health. Despite heroic efforts to
    protect Americans' health, we have lost one million lives and 15
    million lives globally to COVID-19. These deaths weigh on us all, and
    especially on those charged with protecting the health of all
    Americans. While we are grateful for emergency supplemental
    appropriations to address the COVID-19 pandemic, Congress must provide
    long-term, sustained, and increased discretionary funding to support
    the public health workforce, modernize our data systems, and build
    laboratory capacity, among other priorities. 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. Public
    health departments are anticipating that without a change, of course,
    there will be an enormous funding cliff in two to 3 years. Federal
    resources account for nearly half of all State and territorial health
    department funding. In addition to a global pandemic, our members face
    opportunities and challenges each day in their jurisdictions, including
    data modernization, public health technology, public health worker
    burnout, mental and behavioral health crises, and rare hepatitis cases
    in children. These issues may change in urgency over the next year, but
    the same health departments will be there to prepare, prevent, and
    protect all Americans. ASTHO remains concerned that emergency public
    health funding will not make up for decades of underfunding and the
    ongoing COVID-19 response.
        America's State and territorial public health departments work in
    partnership with CDC toward this goal, and we respectfully request $11
    billion in overall funding for this agency. 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.
        An essential program that remains vital support for public health
    preparedness and response is the Public Health Emergency Preparedness
    Cooperative Agreement (PHEP) at CDC. ASTHO requests $824 million for
    the Public Health Emergency Preparedness Cooperative Agreement (PHEP)
    to sustain and improve governmental public health programs. This
    program was established after a dark day in American history: Sept. 11,
    2001. Data show that PHEP has contributed to public health preparedness
    in the Nation's 62 State, local, and territorial public health
    departments. Also, as a result of recent increases in funding for this
    program, CDC was able to provide increased funds to some city-level
    grantees, allowing them to expand their public health preparedness
    capabilities. Grantees rigorously evaluate their capacity to prepare
    for public health emergencies.
        In addition to the PHEP program, States bolster their
    infrastructure activities with the Preventive Health and Health
    Services Block Grant (Prevent Block Grant). ASTHO respectfully requests
    $170 million for this program. For more than 30 years, the Prevent
    Block Grant has served as an essential funding source for State and
    territorial health agencies. In 1999, funding peaked at $194.9 million.
    Since then, it has dropped by 17.9 percent, not including adjustments
    for inflation. Programs funded by the Prevent Block Grant cannot be
    supported or expanded through other funding mechanisms. States and
    territories use these flexible dollars to offset funding gaps in
    programs that address the leading causes of death and disability. In
    some cases, this funding serves as seed funding for innovative projects
    a State or territorial health department wishes to provide to meet
    community health goals not funded through other means.
        State and territorial public health departments have traditionally
    operated under a boom-and-bust cycle regarding how they are funded. The
    ``boom'' occurs during a public health emergency, such as the COVID-19
    pandemic, when policymakers increase public health funding to mobilize
    a response. ASTHO is grateful for the $3 billion in emergency funding,
    however, this one-time funding must be met by sustained resources in
    order to make a lasting and real improvement to our Nation's public
    health system. It is then followed by the ``bust,'' or return to
    chronic underfunding of agencies when the acute public health threat
    subsides and the crisis is deemed to be ``solved.'' ASTHO respectfully
    requests $1 billion for Public Health Infrastructure and Capacity at
    CDC. This funding will support efforts within agencies that build
    capacity to detect and respond to threats both domestically and
    globally while improving and supporting activities in core public
    health capabilities, including assessment, policy, preparedness and
    response, community partnership, communications, equity,
    accountability, and performance management. Moreover, funding will
    support agencies in their efforts to invest in a highly trained
    workforce that is ready to help emerging public health threats. It is
    also essential to ensure that funding is disease-agnostic, flexible,
    and sustainable to support the transition from sporadic influxes of
    funding that accompany the response to public health emergencies.
        State and territorial health agencies are uniquely situated to
    lead, develop, and coordinate interventions seeking to bring economic
    and community sectors together to create conditions that foster vibrant
    health. Social and economic conditions--often referred to as the Social
    Determinants of Health (SDOH) (e.g., housing, employment, food
    security, education, and transportation)--significantly influence
    individual and community health. It is also understood that these
    factors are estimated to contribute significantly to a person's health
    outcomes, while traditional healthcare only accounts for 10-20 percent.
    Therefore, knowing that investing in programs that address the root
    causes of negative health outcomes is a force multiplier; it not only
    improves Americans' health but saves the healthcare system costs and
    burden. ASTHO, therefore, supports providing $153 million in funding to
    support the implementation of a Social Determinants of Health program
    at CDC with goals to align and streamline SDOH programs across CDC,
    grow capacity to address SDOH in our communities, provide funding to
    address the SDOH of those who are most at risk and disproportionately
    affected by adverse social and economic conditions, and bolster the
    catalog and science base and disseminate these to communities. An
    increase in funding will support the expansion of activities that
    address social determinants of health in State, local, Tribal, and
    territorial jurisdictions that including expanding and implementing
    accelerator plans and building the evidence base to better understand
    health disparities.
        Along with Partner Organizations, ASTHO Supports the Data:
    Elemental to Health Campaign. We called on Congress to provide the
    first-ever dedicated funding for public health data systems and build a
    21st-century public health data superhighway. Thanks to the work of
    this subcommittee, Congress answered the call and has provided annual
    funding and necessary injections of supplemental funding through the
    CARES Act and the American Rescue Plan for CDC's public health Data
    Modernization Initiative (DMI). For FY23, we request $250 million for
    data modernization efforts at CDC. DMI is committed to building a
    world-class data workforce and data systems ready for the next public
    health emergency. We need robust, sustained, yearly funding to complete
    the foundational investment in DMI and ensure we are providing
    resources for public health systems and infrastructure, including at
    State and local health departments, to keep pace with evolving
    technology.
        Under the Assistant Secretary for Preparedness and Response (ASPR),
    ASTHO is requesting $474 million for the Hospital Preparedness Program
    (HPP) and the coalitions that serve their communities to operate and
    coordinate activities across the local, State, regional, and Federal
    levels to ready healthcare delivery systems for disasters and
    emergencies. These include developing mechanisms for effective patient
    movement, communicating situational awareness, and providing resource-
    sharing across disparate healthcare entities. HPP allows individual
    healthcare facilities and healthcare coalitions to access a truly
    national response network, enabling the system to save lives and
    protect Americans from 21st-century health security threats and is the
    only source of Federal funding for this work.
        Additionally, we request $9.2 billion in discretionary funding for
    the Health Resources and Services Administration (HRSA). We sincerely
    appreciate your support for HRSA and the significant increases provided
    in FY22. Robust funding for HRSA is critical to supporting all HRSA's
    activities and programs, which are essential to protect the health of
    our communities. Additional funding will allow HRSA to fill preventive
    and primary health care gaps, support urgent and long-term public
    health workforce needs and build upon the achievements of HRSA's more
    than 90 programs and more than 3,000 grantees.
        Thank you for considering these funding requests. We stand ready to
    work with Congress to address the countless public health challenges
    and opportunities impacting our Nation's health. If you have any
    questions or require additional information, please do not hesitate to
    contact a member of ASTHO's government affairs team: Carolyn McCoy
    (cmccoy@astho.org) or Jeffrey Ekoma (jekoma@astho.org).

        [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 Centers on
                                  Disabilities
             the association of university centers on disabilities
        The Association of University Centers on Disabilities (AUCD) is a
    membership organization that supports and promotes a national network
    of university-based interdisciplinary programs. Network members consist
    of 143 centers, including 67 University Centers for Excellence in
    Developmental Disabilities (UCEDD), 60 Leadership Education in
    Neurodevelopmental Disabilities (LEND) programs; and 16 Eunice Kennedy
    Shriver Intellectual and Developmental Disability Research Centers
    (IDDRC). AUCD's mission is to advance policies and practices that
    improve the health, education, social, and economic well-being of all
    people with developmental and other disabilities, their families, and
    their communities by supporting our members in research, education,
    health, and service activities that achieve our vision. AUCD's network
    of programs are located in every State and territory and are all part
    of universities or university medical centers. AUCD's programs excel in
    basic and applied research, training, information dissemination,
    creation of model demonstration programs, systemic reform, and policy
    analysis. Given that these programs work collaboratively, innovations
    from one program can be rapidly implemented in communities throughout
    the country. AUCD's programs serve as a bridge between the university
    and the community, bringing together the resources of both to achieve
    meaningful systemic change.
        university centers for excellence in developmental disabilities
        The University Centers for Excellence in Developmental Disabilities
    (UCEDD): UCEDDs are interdisciplinary centers authorized in the
    Developmental Disabilities Assistance and Bill of Rights Act of 2000
    (DD Act) (Section 156 of Public Law 106-402, Subtitle D). The UCEDDs
    are located in every State and territory, with some States having
    multiple UCEDDs to serve the unique needs of the state. The funding
    supports the basic infrastructure costs of operation for each UCEDD.
    Each center leverages the investment to secure additional funding to
    carry out the purpose of the DD Act. The 67 UCEDDs provide training,
    technical assistance, service, research, and information sharing to
    people with disabilities, their families, State and local government
    agencies, and providers with a focus on building the capacity of
    communities and creating improvements in the service delivery system
    for people with Intellectual and Developmental Disabilities (I/DD) and
    other disabilities. The UCEDDs have directly improved services and
    supports in the States and territories in the areas of early
    intervention, healthcare, public health, community-based services,
    education, employment, housing, assistive technology, emergency
    response and transportation.
    leadership education in neurodevelopmental disabilities (lend) programs
        The Leadership Education in Neurodevelopmental and Related
    Disabilities (LEND) Programs are authorized in The Autism
    Collaboration, Accountability, Research, Education and Support Act
    (Autism CARES Act) (Public Law 116-60). The LEND programs are located
    in 44 States, with an additional six States and three territories
    reached through program partnerships, (without additional Federal or
    State aid). LEND programs operate within universities and collaborate
    with university hospitals and/or academic health centers to provide
    advanced interdisciplinary training to enhance the clinical expertise
    and leadership skills of professionals in a broad array of professional
    disciplines in the identification, assessment, and intervention of
    children and youth with neurodevelopmental and other related
    disabilities. The training programs have an explicit focus on training
    professionals to provide culturally and linguistically relevant care
    and to recruit diverse students and professionals into the programs. In
    FY 2020, 24 percent of long-term trainees in the LEND programs were
    from underrepresented racial groups and 13 percent were Hispanic or
    Latino. LEND programs also include self-advocates and family members as
    trainees and faculty to ensure trainees interact with people with lived
    experiences and to increase the leadership skills of self-advocates and
    family members as part of an interdisciplinary care team. The LEND
    programs have pivoted in response to the COVID-19 emergency. Critical
    clinical services have transitioned to a mix of telehealth and in-
    person formats, providing access to assessment, support, and treatment.
    A real-time transition to the provision of training either remotely or
    in a hybrid model proved an added benefit of building maternal and
    child health leaders with experience in telehealth to support the
    population of people with neurodevelopmental disabilities.
       eunice kennedy shriver intellectual and developmental disability
                            research centers (iddrc)
        The Intellectual and Developmental Disabilities Research Centers
    (IDDRCs) were established in 1963. The IDDRC's represent the Nation's
    first and foremost sustained effort to prevent and treat disabilities
    through biomedical and behavioral research. The network of IDDRCs with
    AUCD membership consists of 16 Centers with current P30 core grant
    funding from the Eunice Kennedy Shriver National Institute for Child
    Health and Human Development (NICHD). Each IDDRC supports 40-100
    research projects on an annual basis that seek to advance the
    understanding of chromosomal conditions and biochemical processes as
    they relate to brain function and I/DD. IDDRCs contribute to the
    development and implementation of evidence-based practices by
    evaluating the effectiveness of biological, biochemical, and behavioral
    interventions; developing assistive technologies; and advancing
    prenatal diagnosis and newborn screening. They also provide invaluable
    research training, mentoring, and support to emerging leaders in
    clinical and research science.
           fiscal year 2023 appropriations requests and justification
        AUCD requests that Congress appropriate $47,173 million for the
    UCEDDs for FY 2023 within the Administration for Community Living (ACL)
    in the Labor-HHS-Education appropriations bill. The increased funding
    will ensure the UCEDDs meet the requirements of the DD Act and that
    people with disabilities are fully included and accounted for as States
    and territories respond to the significantly increased demand for
    assistance due to the pandemic. In FY 2020, the UCEDDs reached 13
    million people through community training and technical assistance
    activities and trained 6,242 professionals that work with people with
    disabilities. In FY 2021, the number of requests for technical
    assistance to UCEDDs increased by 44 percent and the number of
    technical assistance products developed for the UCEDDs increased by 83
    percent. These increases are a direct result of the impact of the
    pandemic on the systems supporting people with disabilities and are not
    sustainable without additional assistance. As regulatory and service
    systems continue to evolve once the public health emergency expires,
    the support needs of people with I/DD and their families will not
    decline. In addition, the increased funding will enable the UCEDDs to
    fund a new round of competitive grants focused on increasing diversity,
    equity and inclusion by partnering with minority-serving institutions
    and will also support other UCEDD activities and programs to promote
    opportunities for people with I/DD to exercise self-determination, be
    independent, and be included in all aspects of community life.
        AUCD requests that Congress appropriate $57,344,000 for Autism and
    other Developmental Disabilities for FY 2023 and of this amount
    appropriate $40,000,000 for LENDs (in report language) within Health
    Resources and Services Administration (HRSA) in the Labor-HHS-Education
    appropriations bill. The increased funding will ensure the LEND
    programs can address the significant unmet needs and disparities in
    evaluation, diagnosis, and treatment as well as supporting LENDs to
    recruit and support more autistic adults as faculty advocates and as
    trainees, with an emphasis on expanding LEND curriculum to include and
    address adult life needs and healthcare. Furthermore, while we are
    grateful the number of LEND programs were expanded from 52 to 60 in
    June of 2021, this was done with no increase in funding. All funded
    programs were subject to a 3.3 percent cut in their allocated funds to
    accommodate the expansion. We are hopeful the LEND programs will see
    their funding restored in FY 2023.
        AUCD requests that Congress appropriate $1.816 billion for the
    NICHD within the National Institutes of Health (NIH) (a 7.9 percent
    increase from FY 2021). AUCD additionally requests a proportional
    increase of 7.9 percent for IDDRCs within the NICHD in the Labor-HHS-
    Education appropriations bill.
        The increased funding for NICHD is essential to building upon the
    cutting-edge research and collaboration of the IDDRC network to better
    understand the neural and biomolecular underpinnings of I/DD to better
    inform treatments and interventions. Previous increases in NICHD
    funding have not resulted in increases to the IDDRCs. This research is
    more important given the reality that people with I/DD are experiencing
    more severe symptoms of COVID-19 and die at disproportionately higher
    rates than people without disabilities.
        other programs that support and serve children and adults with
                                  disabilities
        AUCD supports the proposed increases in the President's budget for
    programs that support and serve people with disabilities, such as
    special education, post-secondary education, and vocational
    rehabilitation programs; programs that improve the health of children
    and adults with disabilities; and programs that generate new knowledge
    and promote its effective use to strengthen opportunities for an
    inclusive life in the community. We are specifically supportive of the
    President's proposed increases for the following programs:
      --Transition Programs for Students with Intellectual Disabilities
            (TPSID) and related technical assistance centers (NCC and
            NDTAC) to promote college programs for students with
            intellectual disabilities;
      --Projects of National Significance (PNS), innovative demonstration
            projects to monitor progress on key policy priorities for
            people with I/DD;
      --The National Institute on Disability Independent Living and
            Rehabilitation Research (NIDILRR), the Federal Government's
            primary disability research organization, which funds programs
            that generate new knowledge and promote its effective use to
            strengthen individual and community capacity for inclusion; and
      --The National Center on Birth Defects and Developmental Disabilities
            (NCBDDD) strives to advance the health and well-being of people
            with disabilities by preventing birth defects, promoting better
            understanding of developmental disabilities, and improving the
            health of people with disabilities.
        AUCD and AUCD's member centers frequently secure grants from these
    programs. For example, the PNS fund three national long-term data
    collection projects that help policymakers, service providers, and
    people with I/DD and their families to make the most informed policy
    and individual decisions related to healthcare and employment. All
    three of the National longitudinal studies are conducted by AUCD's
    members. The studies include a study of the evolution of integration
    and inclusion of people ID/DD in society and more than 20 years of
    studies about community integration and employment for people with I/
    DD.
                                     ______

        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 2023 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 $3,000,000 increase over
    the FY22 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 2020, a worker died
    every 111 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 guarded roof edge; our
    farmers who may be engulfed in flowing grain, 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 they encounter at work, or heart disease from chronically
    stressful work environments. In addition to work-related deaths, we
    also have a high burden of nonfatal 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 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 these past few years, 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 wellbeing. 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 the pandemic, NIOSH
    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 eighteen 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 leads the research and outreach efforts on the Nation's most
    dangerous worksites that often impact lives in rural parts of America.
    The NIOSH AgFF Program was established by Congress in 1990 (P.L. 101-
    517) in response to evidence that agricultural, forestry, and fishing
    workers suffer substantially higher rates of occupational injury and
    illness than other workers. Agricultural workers are more than six
    times more likely to die on the job than workers in other sectors
    combined, averaging 566 fatalities per year, and nearly 5 in 100
    agricultural workers incur recordable nonfatal injuries each year. Our
    food security depends on a healthy agricultural workforce--an essential
    sector that has been hit particularly hard during the pandemic. Today,
    the NIOSH AgFF initiative includes 10 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 this vital production sector. 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, increased use of rollover
    protective structures (ROPS or roll bars) and seatbelts on tractors has
    reduced overturn-related deaths. Partnering with fishing communities,
    the AgFF Centers 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. As the majority of AgFF
    workers; self-employed farmers, ranchers, and fishermen; are exempt
    from State and Federal OSHA protections, NIOSH and the AgFF Centers
    fill a critical role in training and educating of AgFF workers.
        NIOSH also supports 10 Total Worker Health (TWH) Centers of
    Excellence that conduct multidisciplinary research and test practical
    solutions to emerging challenges that impact the safety, health,
    wellbeing, 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.
        While funding for the ERC, AgFF, and TWH Centers is crucially
    important to maintain resources, staff, and long-term capacity in
    occupational safety and health research at the State and regional
    level, we also emphasize that the overall NIOSH funding level is also
    critical. The requested increase in the NIOSH topline funding level
    supports NIOSH intramural research, including the NIOSH personal
    protective equipment program, which develops and monitors N95s and
    advanced respiratory protection systems; disaster response research;
    mental health research; Per- and Polyfluoroalkyl Substance (PFAS)
    research; and research on substance use disorders related to work.
    Increased NIOSH topline funding also enables reinstating reduced
    extramural funding levels for innovative investigator-initiated awards.
        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 Autism Speaks
        Thank you for the opportunity to submit testimony in support of
    autism funding within the National Institutes of Health (NIH), the
    Centers for Disease Control and Prevention (CDC), Health Resources and
    Services Administration (HRSA), Department of Education (DOE), and
    other agencies under your jurisdiction. For Fiscal Year 2023 we request
    that the Committee increase its investment in autism-related
    activities. Specifically, we request that you fund autism activities at
    least at $33.1 million at CDC and $64.6 million for Autism and
    Developmental Disorders activities (which includes a $7.5 million
    increase in research funding and a $2.755 million increase for the
    Leadership Education in Neurodevelopmental and Related Disabilities
    (LEND) program) at HRSA. In addition, we request that the Committee
    strongly urge the NIH to invest in autism research consistent with the
    budget recommendation included in the Interagency Autism Coordinating
    Committee's (IACC) Strategic Plan and for all agencies to invest in
    research that addresses health equity challenges and disparities that
    persist in the autism community.
        My name is Stuart Spielman, and I am the Senior Vice President for
    Advocacy at Autism Speaks. Autism Speaks is dedicated to promoting
    solutions, across the spectrum and throughout the life span, for the
    needs of individuals with autism and their families. We do this through
    advocacy and support; increasing understanding and acceptance of people
    with autism; and advancing research into causes and better
    interventions for autism spectrum disorder and related conditions.
        We are grateful for the bipartisan leadership that both the Chairs
    and Ranking Members of the full committee and subcommittee have
    provided in supporting investments in autism research, training, and
    services over many years. As you consider this year's requests, we look
    again to your leadership to build on the significant progress that has
    been made and provide investments to meet the tremendous needs that
    continue to exist.
        For Fiscal Year 2023 we request that the Committee invests in
    autism-related activities to align the Federal investment in autism-
    related activities with the budget recommendation of the 2016-2017 IACC
    Strategic Plan for Autism Spectrum Disorder. While the NIH, DOE, CDC,
    and HRSA are the largest funders of autism-related research, training,
    and services, multiple other agencies fund important autism-related
    efforts as well. We urge the subcommittee to use the recommendations
    and strategic objectives of the IACC, the congressionally created body
    responsible for advising the Federal Government on autism-related
    investments, to guide investment across all agencies.
        Much of the progress in autism research that has been made is due
    to your work and support. The research you have supported has been
    remarkably important in better understanding the biology of autism, the
    numbers of individuals across the country with an autism spectrum
    disorder diagnosis, and the types of interventions and supports that
    can benefit the autism community. In many ways, it is because of this
    progress that we know that so much more needs to be done. Here are just
    a few examples of questions that research can answer:
      --How can we develop personalized interventions and therapies to
            mitigate the co-morbid health conditions that occur in higher
            rates among autistic individuals?
      --How can we promote evidence-based supports and services to assist
            the 70,000 autistic youth who every year transition out of
            school-age services?
      --Even though autism can be diagnosed at 15 months, the average age
            of diagnosis remains at about 4 years old, and even later in
            low-income communities. What evidence-based practices can we
            use to help diagnose autism earlier across the board?
      --Research indicates that autistic individuals, women in particular,
            are at greater risk for suicide. How can we adapt existing
            suicide screening and intervention models to better reach
            individuals at risk?
      --Learning opportunities were lost during the pandemic. How can we
            ensure that educational loss during breaks in education are
            better understood and addressed for children, teenagers, and
            young adults with autism?
      --There is a dearth of research on issues affecting autistic adults.
            What can be done to not only better understand service and
            support needs, but also why autistic adults have higher
            premature death rates and poorer health outcomes than the rest
            of the population?
      --How does autism affect aging and related health conditions and how
            can we ensure that autistic adults are receiving appropriate
            mental health assessments as they age?
        Recent research has shown that while we have made progress in
    identifying all children with autism earlier, timely access to needed
    services remains a major challenge. Children with autism spectrum
    disorder have nearly 4 times higher odds of unmet health care needs
    compared to children without disabilities, and Black autistic children
    are twice as likely to have unmet healthcare needs than their non-
    Hispanic white counterparts. Black and Latinx children experience
    delays in diagnosis that result in the loss of valuable treatment time.
    It is imperative that a greater investment in research is made to help
    bridge these gaps and ensure that culturally competent interventions
    and services are available in every community.
        The scale of the challenges faced by our community require urgent,
    increased, and sustained investment. The IACC recommended in its most
    recent Strategic Plan a doubling by 2020 of 2015 levels of investment
    in autism research. Even with this investment, the IACC stated that the
    ``increases recommended by the IACC would not be sufficient to
    accomplish all of the research goals identified by the plan.'' The
    total annual cost of autism in the United States has been estimated to
    be at least $236 billion. By contrast, it has been estimated that
    combined autism research funding among Federal and private sources is
    less than 1 percent of that amount--a tiny fraction of the estimated
    annual total cost of autism. Additional research investments can
    improve outcomes and help reduce those costs through early
    identification, improved interventions, and greater availability of
    supports and services.
        Because of the Committee's previous work and the decisions made by
    the agencies funded through this bill, there are opportunities to build
    on existing investments. For example:
      --The National Institute on Deafness and Other Communication
            Disorders (NIDCD) FY 2022 Budget Justification highlighted
            research to help address communication challenges for autistic
            individuals. They note that 30 percent of autistic individuals
            over age 5 are functionally non-speaking yet are an under-
            represented group in research. Research the NIDCD is funding is
            intended to develop effective interventions and improve
            clinical practice for autistic individuals with communications
            challenges.
      --The CDC receives only enough funding to monitor the prevalence of
            children with autism spectrum disorder in 11 States. Providing
            an overall funding level of at least $33.1 million in fiscal
            Year2023 would allow more States to participate in the ADDM
            Network, giving them invaluable information to drive efforts at
            the State and local levels and providing a better national
            dataset; allow for more study of the prevalence of autism
            across the lifespan; and continue support and enhancement of
            the ``Learn the Signs. Act Early'' program on child
            development.
      --HRSA has been funding extraordinarily important research efforts to
            help address significant issues, like developing clinical
            medical standards and challenges related to the transition to
            adulthood. An overall funding level of $64.6 million for Autism
            and Developmental Disorders in FY23 (to include an increase of
            $7.5 million in research and a $2.755 million increase for
            LEND) would greatly enhance HRSA's ability to fund research to
            help bridge the gaps in these and myriad other areas.
        We hear every day from individuals and families in the autism
    community about their successes, challenges, and everything in between.
    They have shared their experiences during the pandemic, telling us
    about their struggles to receive learning supports and meet basic needs
    like food and housing. An analysis of private health insurance claims
    data has shown that a greater percentage of people with autism, alone
    or with intellectual or developmental disability, died from COVID-19
    than people with no chronic conditions. The damage done by the pandemic
    makes the need for a greater investment in the community even more
    compelling. The research that you have funded has brought a range of
    lasting changes and significant improvements. We are at a pivotal
    moment. Now is the time to address the significant gaps we know persist
    so that every person on the spectrum can achieve their full potential.

        [This statement was submitted by Stuart Spielman, Senior Vice
    President,
    Advocacy, Autism Speaks.]
                                     ______

             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 2023. Our
    key CDC programmatic priorities include those most critical to our
    members: immunization, epidemiology and laboratory capacity, public
    health data modernization, workforce, infrastructure and capacity,
    opioid overdose prevention, violence prevention, public health
    preparedness, and addressing the social determinants of health.
        BCHC is comprised of health officials leading 35 of the Nation's
    largest metropolitan health departments, who together serve more than
    61 million--or about one in five--Americans. Our members work every day
    to protect and promote the public's health. We thank you for your
    continued leadership and support for our Nation's public health
    workforce and systems.
        As the subcommittee members recognize, sustained annual funding is
    necessary to build public health capacity for the next pandemic, as
    well as the everyday work that helps keep communities as healthy and
    safe as possible.
           national center for immunization and respiratory diseases
    National Immunization Program
        We respectfully request $1.1 billion in FY 2023 for the National
    Immunization Program. The CDC Immunization Program funds 50 States, six
    large, BCHC member cities, and eight territories for vaccine purchase
    and immunization program operations. Increased and sustained investment
    is needed to modernize immunization information systems (IIS),
    establish State-to-state IIS data sharing, increase and sustain a
    network of adult immunization providers reporting data into IIS, and
    engage with communities to build vaccine confidence and minimize
    disparities among people of color and those at heightened risk for
    acute outcomes from vaccine-preventable diseases. BCHC also supports
    the creation of a Vaccines for Adults program that is essential to
    reduce vaccination coverage disparities, improve outbreak control, and
    enhance and maintain the infrastructure needed for responding to future
    pandemics, as well as routine, annual infectious disease.
          national center for emerging and zoonotic infectious disease
    Epidemiology and Lab Capacity
        We respectfully request $800 million in FY 2023 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, Puerto Rico, and the
    Republic of Palau. ELC provides critical support to and for
    epidemiologists and laboratory scientists who are instrumental in
    discovering and responding to various food, water, and vector-borne
    outbreaks, as well as funding vital improvements in health informatics.
    Despite ELC's vital role in responding to the pandemic, annual funding
    levels are not adequate to maintain public health preparedness or
    address routine challenges, particularly at the city or county level.
    An increase to ELC would enable increased support to local health
    departments to provide for their jurisdiction-specific needs, which
    should be sent directly to large, urban jurisdictions directly,
    wherever and whenever possible. Further, ELC dollars sent to the States
    should be better tracked through CDC reporting structures and shared
    publicly to contribute to Agency transparency and ensure funds are in
    fact supporting big city epidemiology activities.
                       public health scientific services
    Public Health Data Modernization Initiative (DMI)
        We respectfully request $250 million in FY 2023 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. Access to
    timely, accurate data at all jurisdictional levels is perhaps our most
    enduring public health challenge.
    Public Health Workforce
        We respectfully request $106 million in FY 2023 for CDC's public
    health workforce and career development programs, the same as the
    President's budget request. 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 and
    develop the next generation of the public health workforce, as well as
    attract and retain diverse candidates with varied 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 $1 billion in FY 2023 for a public health
    infrastructure and capacity investment. 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 prevention and response infrastructure, such as
    equity; policy development and support; communications; community
    partnership and engagement; organizational competencies; transparency
    and accountability; and emergency preparedness and response.
        Governmental public health infrastructure requires sustained
    investments over time, and we believe this is an important start.
    Building a response in real time, such as during the COVID-19 pandemic,
    is not the way to best protect our Nation's health. BCHC is grateful
    for the inclusion of funding in the FY 2022 Omnibus package and urge an
    ongoing investment to ensure that our governmental public health system
    is prepared not just for the next pandemic, but also to strengthen the
    health of our communities every day.
    Center for Forecasting Epidemics and Outbreak Analytics
        We respectfully request $50 million in FY 2023 for the Forecasting
    Center that was established with American Rescue Plan Act funding to
    facilitate the use of data, modeling, and analytics to improve pandemic
    preparedness and response. This is the same as the President's budget
    request. Local health departments do not have sufficient capacity to do
    such activities on their own and would greatly benefit from the
    information and tools developed by the Forecasting Center. Therefore,
    sustained funding is required to maintain the center's functionality
    over time. Such resources could be critical to other public health
    crises such as the dueling community epidemics of violence and opioid
    overdose.
               national center for injury prevention and control
    Opioid Overdose Prevention and Surveillance
        We respectfully request $713 million in FY 2022 for Opioid Overdose
    Prevention and Surveillance in line with the President's request.
    Overdoses are increasing in almost all of our Nation's communities,
    erasing gains of recent years. CDC's funding to health departments
    through the Overdose Data to Action (OD2A) program has been a critical
    resource for prevention of opioid and polysubstance use but must be
    expanded to include more big cities to ensure that substance use
    prevention continues to stem the tide of overdose and death. Funded
    prevention efforts include harm reduction and linkage to care
    initiatives with a focus on health equity and reducing stigma. Local
    health departments also need to be able to use these funds to purchase
    Naloxone; SAMHSA-funded purchasing is insufficient in supporting
    distribution. There is no one Federal funding stream that supports
    Naloxone purchase at the local level. Finally, we also encourage the
    committee to include directive language to ensure these dollars reach
    the local level in those communities that are not directly funded, as
    well as have CDC and HHS better track and report publicly state
    expenditures.
    Gun Violence Prevention Research
        We respectfully request $35 million in FY 2023 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 and
    continues to be an acute issue in our Nation's largest cities.
    Significant gaps remain in our knowledge about the problem and ways to
    best 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
    deadly 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 targeted programs. Additional funds in
    FY 2023 would be used to fund a new grant program to implement a menu
    of evidence-based, evidence-informed, and emerging strategies to
    prevent firearm-related injuries and deaths in high-risk urban and
    rural communities.
    Community Based Violence Intervention Initiative
        We respectfully request $250 million in FY 2023 for a 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 and believes
    it is critically important to have both funds at, and engagement of,
    the CDC's National Center for Injury Prevention, to complement efforts
    funded through the Department of Justice. 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. 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 FY 2023 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 percent 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, predictable base funding for years to rebuild
    and improve. We also encourage the committee to include directive
    language to ensure these dollars reach the local level in those
    communities that are not directly funded, as well as have CDC 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 FY 2023 for the Social
    Determinants of Health (SDOH) program in line with the President's
    request. CDC's SDOH program was initially funded in FY 2021 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 and preventable
    inequities in health outcomes. Contact: Chrissie Juliano, MPP,
    Executive Director, Big Cities Health Coalition.
                                     ______

               Prepared Statement of the Bipartisan Policy Center
        BPC is dedicated to finding bipartisan solutions to improve child
    care for children, families, educators, providers, and the broader
    economy. We know high-quality child care builds a strong foundation for
    young children and fundamentally supports the growth of their cognitive
    and social emotional development. There are more than 19 million
    children, or 27 percent of the U.S. population, under age 5 living in
    U.S. households and it is essential to both child development and a
    strong economic recovery that Congress ensure each of these children
    have access to high-quality child care.\1\ In order to achieve this, we
    urge the subcommittee to address critical areas of need in the fiscal
    year (FY) 2023 Labor, Health and Human Service, Education and Related
    Agencies appropriations bill.
    ---------------------------------------------------------------------------
        \1\ Child population by age group in the United States | KIDS COUNT
    Data Center.
    ---------------------------------------------------------------------------
        This testimony addresses two high-priority issues crucial to stable
    and thriving high-quality child care in our country. First is that the
    cost of care, which often exceeds what many parents can afford,
    freezing families out of the market without any high-quality care
    options to the most vulnerable populations. Second, the Nation is
    facing a shortage of safe and healthy child care facilities. While
    investments in facilities are critical, they are often not feasible for
    providers who are operating within a broken system and razor-thin
    profit margins. Consequently, providers do not have the capital to fund
    investments that prioritize the facility-related repairs, upgrades,
    renovations, and maintenance that meet modern safety and professional
    standards. Without the support of Congress, child care businesses will
    be unable to provide the necessary investment in facilities and
    parents, especially those in rural areas, will be denied access to the
    care they need. BPC believes it is essential to address both needs
    concurrently or the demand on child care will be overwhelmed by the
    lack of supply. For these reasons, BPC urges the subcommittee to double
    the discretionary funding for the Child Care Development Block Grant
    program (CCDBG), increase the Preschool Development Grant program (PDG)
    to $450 million, and provide $5 billion in dedicated funding to
    retrofit existing, and build new, child care facilities for FY 2023.
                         economic impact of child care
        As this subcommittee considers the FY23 allocations for child care
    programming, BPC urges it's members to weigh the impact lack of access
    to child care has on the Nation's post-pandemic economic recovery
    versus the costs of Federal support for increasing said access. While
    fundamental to the development of young children, access to child care
    as the Nation transitions away from remote work flexibilities can
    either serve as a barrier or present opportunities for employment. A
    BPC parent poll found 66 percent of parents said finding child care
    impacts the number of hours they can work, 50 percent said it affects
    whether they can search for a job, and 68 percent said it impacts
    whether they can stay in the workforce.\2\ In BPC's 2021 report ``Child
    Care in 35 States: What we know and don't know'' found that over 3.4
    million children (31.2 percent) with all available parents in the work
    force do not have access to a formal child care slot.\3\ The gap was
    higher in rural areas of the country and among women demonstrated by
    the fact that 1.3 million fewer mothers were employed in September 2021
    compared to before the pandemic began.\4\ Our survey data shows the gap
    is highest among women with children under two. If the child care gap
    is not addressed, based on lost income to parents, businesses, and
    taxpayers, BPC estimates an economic loss across 35 States over the
    next 10-years to be between $142.51 and $217.02 billion.\5\ This
    estimation is not adjusted for inflation and could be more severe.
    ---------------------------------------------------------------------------
        \2\ https://bipartisanpolicy.org/blog/child-care-poll/.
        \3\ https://bipartisanpolicy.org/report/child-care-gap/.
        \4\ https://www.washingtonpost.com/politics/2021/11/08/why-havent-
    us-mothers-returned-work-child-care-infrastructure-they-need-is-still-
    missing/.
        \5\ https://bipartisanpolicy.org/download/?file=/wp-content/
    uploads/2021/11/BPC-Economic-Impact-Report_R01-1.pdf.
    ---------------------------------------------------------------------------
                                 ccdbg and pdg
        Increases for both CCDBG and PDG would provide added stability and
    capacity to serve a greater number of qualifying families in need
    through high-quality care. Not adjusted for inflation, if Congress were
    to double the discretionary funding for CCDBG, BPC estimates that the
    U.S. Department of Health and Human Services (HHS) will likely be able
    to double the number of eligible children served. In addition to a
    greater investment for CCDBG, the increased funding for PDG will allow
    HHS to expand funding for the 28 States, Puerto Rico, and Guam which
    currently receive grants, as well as provide funding for almost all
    remaining States not currently funded.
        BPC also urges Congress to authorize HHS and the Department of
    Education to allow Large Tribes to apply for PDG funding. Large Tribes,
    including the Muscogee Creek Nation of Oklahoma, are responsible for
    overseeing access to and delivery of early learning programming for as
    many as 53,354 children aged 0-4 years--a number greater than some
    States--yet are still not eligible for PDG support. Moreover, a 2018
    report published by the Office of the Administration for Children and
    Families (ACF) found nearly one-third of American Indian and Alaska
    Native (AI/AN) young children live in households at or below the
    Federal poverty line.\6\ Additionally, only one-fifth of AI/AN young
    children were reported to have access to and attended an early care and
    learning program within a three-month period. BPC believes it is
    critical Congress address its systemic underfunding for AI/AN
    populations which begins with ensuring Large Tribes have equitable
    access to PDG funding.
    ---------------------------------------------------------------------------
        \6\ https://www.acf.hhs.gov/sites/default/files/documents/opre/
    14005_acf_opre_aian_ec_needs_brochure_v7_072418_508b.pdf.
    ---------------------------------------------------------------------------
                             child care facilities
        Approximately 129,000 center-based child care programs serve nearly
    7 million children in the United States, and 1 million in-home
    providers care for 2.7 million children.\7\ It is imperative that the
    physical spaces where kids learn, play, and grow contribute to their
    cognitive development and social, emotional, and physical well-being.
    However, many children might not have access to services that promote
    early learning. Instead, young children may be exposed to health and
    safety issues including lead, mold, dust, or other environmental
    pollutants that could cause long-term health developmental
    consequences.
    ---------------------------------------------------------------------------
        \7\ National Survey of Early Care and Education of 2012 (NSECE
    2012) | The Administration for Children and Families (hhs.gov).
    ---------------------------------------------------------------------------
        As of 2018, the Environmental Protection Agency (EPA) reported that
    approximately 500,000 child care facilities are not regulated for lead
    in drinking water.\8\ Additionally, an investigation by HHS Office of
    the Inspector General found that across 10 States, 96 percent of child
    care centers inspected during unannounced visits had one or more
    potentially hazardous conditions and noncompliance with health and
    safety requirements.\9\ This is made worse because young children have
    frequent hand-to-mouth activity, meaning that potentially toxic or
    harmful substances within the facility have a high likelihood of being
    ingested. Other safety hazards include easily accessible electrical
    outlets, lead paint, unsafe play equipment, and open windows and
    gates.\10\
    ---------------------------------------------------------------------------
        \8\ 3Ts for Reducing Lead in Drinking Water | US EPA.
        \9\ https://oig.hhs.gov/oei/reports/oei-03-16-00150.pdf.
        \10\ CIFBldgInfrastructureReport.pdf (cedac.org).
    ---------------------------------------------------------------------------
        Due to razor-thin profit margins and a broken system where child
    care services have historically been undervalued, most providers do not
    have the ability to upgrade facilities and provide a competitive wage
    and increase access to meet the National need. Absent the necessary
    fiscal supports, providers will be unable to make facility-related
    repairs, upgrades, and renovations to meet safety standards. This lack
    of capital is compounded by the fact that more than 90 percent of child
    care businesses are women-owned and over half of the industry in
    minority-owned.\11\ This lack of access to capital is further
    exacerbated by gender- and race-based discriminatory small business
    lending practices and results in parents left with no other options
    other than to place their children in a potentially dangerous setting.
    ---------------------------------------------------------------------------
        \11\ https://cdn.advocacy.sba.gov/wp-content/uploads/2016/09/
    07141514/Minority-Owned-Businesses-in-the-US.pdf.
    ---------------------------------------------------------------------------
        BPC estimates a total of $25 billion over a 5-year period is needed
    to address critical facilities needs. Beginning with $5 billion for FY
    2023, an estimated $14 billion of the $25 billion is needed to renovate
    existing facilities across the country to bring them up to professional
    standards with the remaining $11 billion contributing to increasing the
    supply of new facilities. This will result in 12,600 new center- and
    home-based child care facilities, an additional 656,000 additional
    child care slots, and has the potential to reduce the number of
    children without access to care by 12 percent.
        Increasing child care funding in FY 2023 is vital to the economic
    and social fabric of our Nation. After 2 years of living through
    endless challenges, unprecedented barriers to delivery of care, and
    exacerbated by the COVID-19 pandemic, the Nation recognizes the value
    of child care and the important role Congress plays in supporting
    families. Congress must provide a stable foundation for the child care
    system which is a pillar of a strong national recovery. We appreciate
    the subcommittee's bipartisan leadership and dedication to child care
    over the past 2 years and look forward to working together to improve
    our systems in order to better serve children and families.
                                     ______

               Prepared Statement of Blue Mountain Heart to Heart
        Chairwoman Murray, Ranking Member Blunt, and members of the
    subcommittee, my name is Everett Maroon and I serve as the Executive
    Director of Blue Mountain Heart to Heart (BMHTH), a nonprofit located
    in Walla Walla, Kennewick, and Clarkston, Washington, serving people
    living HIV/AIDS and people living with substance use disorder (SUD). I
    am pleased to submit testimony on behalf of the people I serve, my
    staff, my Board of Directors, and as a member of a large coalition of
    public health, HIV, viral hepatitis, and harm reduction organizations,
    to urge Congress to appropriate in fiscal year 2023 $150 million for
    the Infectious Diseases and the Opioid Epidemic program at the Centers
    for Disease Control and Prevention (CDC) in the Department of Health
    and Human Services (HHS). This funding would help to save lives and
    address the urgent overdose crisis by providing support and expanding
    access to effective overdose prevention and harm reduction services
    provided by syringe services programs (SSPs).
        No other public health intervention has been as thoroughly studied
    and examined in the last twenty-five years as SSPs. Notably, harm
    reduction work conducted at SSPs both satisfies classic public health
    objectives of primary, secondary, and tertiary health improvement
    (e.g., reduce the incidence of bloodborne pathogens, reduce the
    sequelae associated with needle use, and increase entry into treatment,
    respectively), and advances our understanding of real-time changes
    affecting our clients -front-line work that helps local and State
    public health jurisdictions ensure their work is relevant and useful.
    At BMHTH our strategic plan also includes reducing overdose and
    overdose death, and our hard work is showing success.
        By every metric, the environment in which SSP clients find
    themselves is collapsing. They report to my staff and me that they have
    shifted from prescribed opiates to heroin, and now to fentanyl in the
    form of counterfeit oxycontin. Synthetic opioids appear to be driving
    much higher rates of overdose and contributing more often now to
    overdose death. In Washington State, an analysis of 2020 data on
    accidental overdose showed fentanyl was present in 70 percent of the
    toxicology results on autopsy. Meanwhile the median age of overdose
    death in Washington State has dropped to 29, indicating that many young
    people probably have died from their drug use before realizing how
    serious their substance use had become.
        Earlier this month a young woman walked into a local SSP program
    and told me that she had overdosed on fentanyl the night before. I told
    her I was very glad to see her, since that was the case. She asked for
    naloxone. I gave her four kits of the reversal medication so she could
    bring some back to her friends who also use fentanyl and who live about
    90 minutes away. She mentioned that when she ``came to'' in the
    emergency department at the Walla Walla hospital, the doctor left her
    room quickly, crying. He returned shortly thereafter and explained that
    she was the first fentanyl overdose he'd been able to revive after
    losing six others--almost one person per day in his ER alone--in the
    preceding week.
        It is incredibly important for your subcommittee to understand how
    urgent the overdose crisis is right now, not just in Washington State,
    but across our Nation. Naloxone distribution is essential, and getting
    it to the communities most at risk is paramount. A 5-year SAMHSA grant
    in Washington State that concluded in August 2021, in which BMHTH
    participated, showed that 1 in 7 naloxone kits given to clients at SSPs
    was used to attempt an overdose reversal. Robust naloxone distribution
    is part of Washington State's current national drug control strategy as
    well as part of the Washington State opioid crisis response plan. SSPs
    like mine have saved lives and made a significant difference in our
    regions and we need more support now. Comprehensive services to
    increase access to drug treatment and recovery are also necessary, but
    we must save people's lives first so that they have the chance to
    benefit from these interventions.
        As a rural health provider who for the past 2 years has battled
    syndemic crises in HIV, hepatitis C, COVID-19, and the overdose crisis,
    I sincerely request that Congress provide the $150 million requested
    for the health of our communities in central and southeast Washington
    State and nationwide. We are exhausted, but steadfast in our commitment
    to keeping our community members alive and helping them on the pathway
    to health. I have met and talked to grandmothers who became addicted
    after knee replacement surgery, veterans who became addicted after
    three tours of duty in Iraq and surviving a shrapnel injury, nurses who
    started stealing medications because they'd experienced too much stress
    in the emergency department, a middle-aged man whose parents had
    injected him with heroin as a child to make him quiet down ... my list
    of stories is harrowing, and sadly, it is growing. We need real relief
    and support now.
        In Washington, our Attorney General has doggedly sued opioid
    distributors and manufacturers and won settlements. We hope that these
    gains will help fund life-saving services, but alone they won't restore
    our communities to their condition prior to the current crisis. Worse,
    COVID-19 has disrupted the ability of many community-based
    organizations to order naloxone while at the same time more fentanyl
    appeared in the drug market. There must be a robust Federal response to
    this unprecedented crisis both to save lives and build back our
    communities. Congress has the resources necessary to halt these
    dramatic losses and start needed healing.
        In the meantime, as of April 30, 2022, we have reports of more than
    230 overdose reversal attempts in southeast Washington with our
    naloxone distribution program, a trend that would bring us to 658 by
    the end of this year. In 2021 we saw 301 naloxone reversals. I cannot
    state clearly enough how quickly the environment is disintegrating with
    more than a doubling of overdoses expected based on current trends. The
    data are shown in the table below.

        As a service provider who provides harm reduction, low-barrier
    treatment, intensive case management, field-based counseling, law
    enforcement-assisted diversion, and jail-based opioid treatment, I have
    attempted to fill many of the gaps I see in my rural region of
    Washington State. I am doing everything in my power to support people
    at risk of overdose and death, but I am faced with limited Federal
    funding for SSPs and overdose prevention; work restrictions on
    providers of treatment medications that make finding local providers
    difficult; a fractured health care sector in my region; and a
    skyrocketing overdose rate.
        We know that people accessing SSPs are five times as likely to get
    into treatment and three times as likely to lower their drug use by
    frequency or quantity. A 2019 SSP survey conducted by the University of
    Washington showed that more than three quarters of SSP participants
    were somewhat or very interested in treatment. I urge you to please
    help me get them the life-saving care that they need now by fully
    funding the CDC's Infectious Diseases and Opioid Epidemic at $150
    million in FY 2023. Thank you so much for your time and consideration
    of my testimony.

        [This statement was submitted by Everett Maroon, Executive
    Director, Blue Mountain Heart to Heart, Walla Walla, WA.]
                                     ______

         Prepared Statement of the Brain Injury Association of America
        As the Nation's oldest and largest brain injury advocacy
    organization, the Brain Injury Association of America (BIAA) is
    submitting written testimony in support of increased funding for fiscal
    year 2023 appropriations for Federal programs that impact approximately
    2.87 million Americans who are treated annually in emergency
    departments and hospitals for a traumatic brain injury (TBI) and their
    families, who are generally the primary caregivers. While BIAA
    appreciates your support for additional funding for FY 2022 to the U.S.
    Department of Health and Human Services' (HHS) Administration for
    Community Living (ACL) TBI Programs, the total program amount does not
    support funding for all States and territories to participate in that
    program designed to improve access to rehabilitation and community
    services as intended by the Traumatic Brain Injury (TBI) Program
    Reauthorization Act of 2018.
        In addition, BIAA supports full funding for the National Concussion
    Surveillance System administered by the CDC's National Center for
    Injury Prevention and Control (NCIPC) in order to know the extent of
    concussions or mild TBI in this country so that we can better recognize
    and treat related symptoms. BIAA has also been a long supporter of 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, which funds research
    conducted by the TBI Model Systems. Specifically, BIAA urges:
      --$19 million additional funding for the ACL TBI State Partnership
            Program to provide funding to all States, territories and
            District of Columbia;
      --$5 million 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; and
      --$6.6 million to expand the NIDILRR TBI research capacity through
            the ACL TBI Model Systems (TBIMS) in order to increase the
            number of TBIMS from 16 to 18 ($2.5 million each; and to expand
            TBIMIS collaborative research projects for additional research
            on TBI as a chronic condition ($1 million).
        A TBI can happen to anyone at any time and can lead to physical,
    cognitive, and psychosocial or behavioral impairments ranging from
    balance and coordination problems to loss of hearing, vision or speech.
    Fatigue, memory loss, concentration difficulty, anxiety, depression,
    impulsivity and impaired judgment are also common after brain injury.
    Even ``mild'' injuries or concussions can have devastating consequences
    that require intensive treatment and long-term care. Often called the
    ``silent epidemic,'' brain injury affects people in ways that are
    invisible. The injury can lower performance at school and at work,
    interfere with personal relationships and bring financial ruin.
        The annual estimated cost to society exceeds $60 billion, and
    consumers mistakenly believe employer health plans or the government
    will pay for needed services in a health crisis. In reality, insurance
    policies are geared to wellness and routine care, strictly limiting the
    type, amount, and length of rehabilitation and post-acute brain injury
    services available to most people. Therefore, families and individuals
    living with brain injury generally look to public programs to address
    these gaps in service delivery.
        The following personal story explains all to well what can happen:
        ``I was in a really bad car accident on December 23rd, 2017. I
    still to this day have little to no memory of what happened, only from
    what I was told. It happened around 11pm, my ex-boyfriend was driving
    my car and somehow ran off the road, hit a tree, the car flipped the
    whole way around, I was immediately unconscious, he tried to drive away
    but the car was totaled. He took me out of the car and laid me on the
    side of the road while I was unconscious and bleeding internally, and
    he ran away, basically leaving me there for dead. A man in a nearby
    house heard what happened, came outside and saw me, called 911, my
    heart stopped beating 3 different times, I had to be airlifted to
    Hershey, I was immediately put into an induced coma which lasted 2
    weeks.
        I broke my spine, broke my neck, fractured my sternum and suffered
    a severe traumatic brain injury, I also had a minor stroke while I was
    in the coma which affected my whole right side. I lost my voice
    completely because I was on a ventilator for longer than your supposed
    to be, I had several skull fractures. I was then transferred to Hershey
    rehab hospital which I stayed for 3 months. Had to learn pretty much
    everything all over again. How to walk, write, spell, bath myself,
    dress myself, feed myself. I came home sometime in March of 2018,
    continued therapy. I'm still struggling with severe headaches, neck
    pain, everything that comes with a brain injury. That happened when I
    was 26, I'm 30 now. I was given very little hope of survival, but I'm
    still here, still alive, telling my story.''
        The causes vary from child abuse; motor vehicle crashes, falls,
    military-related injuries, violence, industrial injuries, and sports-
    related injuries. No one is immune from this disability. Yet, there are
    few resources to support families and caregivers with assistance in
    early recovery and through the rehabilitation process, let alone long-
    term care needs. 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, and Medicaid/
    Medicare) and payers (e.g., insurance, Workers' Comp, State and Federal
    programs). Twenty-eight States are currently funded by the ACL TBI SPP
    for 5 years. 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.
        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.
        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.
        The Brain Injury Association of America was founded in 1980 by
    individuals who wanted to improve the quality of life for individuals
    who had sustained brain injuries and their families. Today, the
    Association encompasses a nationwide network of more than 40 state
    affiliates sharing in the mission of creating a better future through
    brain injury prevention, research, education and advocacy. We urge you
    to consider increasing funding to the ACL TBI Program; the ACL NIDILRR
    program to expand TBI research; and to 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 me at:Susan H. Connors,
    President/CEO, Brain Injury Association of America, Email
    shconnors@biausa.org.

        [This statement was submitted by Susan H. Connors, President/CEO,
    Brain
    Injury Association of America.]
                                     ______

                       Prepared Statement of Bridgercare
        Dear Chairwoman Murray and Ranking Member Blunt:
        As Executive Director of Bridgercare, I appreciate the opportunity
    to submit testimony in support of expanding the budget for the Title X
    family planning program (Office of Population Affairs, funded within
    the Health Resources and Services Administration account). We recognize
    and appreciate Chairwoman Murray's strong record of advocacy and
    leadership in fighting for family planning services and urge this
    subcommittee to take necessary action to move the program forward in
    this year's bill by appropriating the full $400 million requested by
    the Biden administration.
        Bridgercare is a nonprofit Title X clinic in Bozeman, Montana that
    has served our community for 50 years. Our mission is to provide
    excellent, affordable reproductive and sexual healthcare and education
    in a safe, supportive, empowering atmosphere. We serve over 5000
    patients a year, around half of whom receive care on our sliding fee
    scale where patient fees are based on income. We provide a wide range
    of services from annual wellness exams, to STI testing and treatment,
    to cancer screenings, genetic cancer counseling, pregnancy testing,
    gender-affirming care, behavioral health counseling, and more. And as
    of April of this year, we will steward Montana's Title X program in
    place of the State health department through a new statewide nonprofit,
    Montana Family Planning.
        Title X is the only Federal program solely dedicated to providing
    family planning services to people in the United States regardless of
    income. It was enacted with broad bipartisan support in 1970: sponsored
    by then-Representative George H.W. Bush and signed into law by
    President Nixon. Prior to Trump administration changes to the program
    in 2019, Title X served more than 4,000,000 patients across the
    country, and about 18,000 in Montana (a significant number in a State
    with a population of a little over a million). Title X clinics are
    invaluable resources in communities, serving a population of patients
    who often don't otherwise interact with the health care system. In
    2016, 60 percent of women who received contraceptive services at a
    Title X-supported provider had no other interaction with the medical
    system that year.\1\
    ---------------------------------------------------------------------------
        \1\ Ruth Dawson, ``What Federal Policymakers Must Do to Restore and
    Strengthen a Title X Family Planning Program That Serves All,''
    Guttmacher Institute (March 2021)
        https://www.guttmacher.org/gpr/2021/03/what-federal-policymakers-
    must-do-restore-and-strengthen-title-x-family-planning-program.
    ---------------------------------------------------------------------------
        However, changes to the Title X program in 2019 decimated the
    National network--Montana was no exception. Between 2018 and 2020, the
    amount of patients served by Montana Title X clinics decreased by a
    staggering 53 percent.\2\ We lost four clinics out of a network of 27.
    What this means in real terms is that thousands of Montanans were left
    without access to quality, affordable reproductive health care. Our
    desire to see the Title X program made whole again, and expanded, in
    Montana was a big factor in Bridgercare competing the state for
    stewardship of the program.
    ---------------------------------------------------------------------------
        \2\ Brittni Frederiksen, Ivette Gomez, and Alina Salganicoff,
    ``Rebuilding Title X: New Regulations for the Federal Family Planning
    Program,'' Kaiser Family Foundation (November 2021)
        https://www.kff.org/womens-health-policy/issue-brief/rebuilding-
    title-x-new-regulations-for-the-federal-family-planning-program/.
    ---------------------------------------------------------------------------
        Since being awarded the Title X grant for Montana by HHS, we've
    already had five clinics reach out asking to join our network, and are
    well on our way to rebuilding Title X in Montana--we intend to grow the
    number of Montanans served by 10-15 percent each year for the next 5
    years. Further, we'll develop a stronger administrative structure to
    respond to the diverse needs of providers across the State; we'll
    allocate dollars through clear, transparent means and ensure that Title
    X funds achieve their maximum possible return on investment in Montana.
    We'll focus on bolstering Title X services in rural, frontier, and
    Tribal communities and adolescent, Indigenous, and other underserved
    populations.
        Expanding the Federal Title X program budget to $400 million will
    likely coincide in a larger disbursement to Montana's Title X program,
    helping us to increase support for our subrecipients in every part of
    our state, and bolster investments in expanding reproductive health
    care access to historically underserved communities. We hope that this
    subcommittee will seize this opportunity to invest in quality,
    affordable reproductive health care for millions of people across the
    country. For more information, please contact: Stephanie McDowell, at
    smcdowell@bridgercare.org.
        We thank you for your consideration of this request.
        Sincerely.

        [This statement was submitted by Stephanie McDowell, Executive
    Director, Bridgercare.]
                                     ______

                           Prepared Statement of CAST
        Since 1984, CAST (originally the Center for Applied Special
    Technology) has worked tirelessly to ensure that our Nation is one
    where learning has no limits for any individual. We pioneered Universal
    Design for Learning (UDL), a framework for inclusive design of learning
    and training environments that harnesses technology and instructional
    practices to remove barriers to learning in digital as well as physical
    settings. UDL is now incorporated in key Federal education, career
    training, and workforce laws.\1\ UDL provides principles and guidelines
    to support innovation and success by expanding and strengthening
    preschool to post-secondary education as well as career training
    opportunities, including access to Science, Technology, Engineering and
    Math (STEM) for all individuals across the Nation.
    ---------------------------------------------------------------------------
        \1\ See: Public Law 110-315, Public Law 113-228, Public Law 114-95,
    Public Law 115-224, National Education Technology Plan 2021, U.S.
    Department of Education.
    ---------------------------------------------------------------------------
        Our aim is to create a level playing field where all learners have
    equitable opportunities to succeed by expanding access and opportunity
    to education and employment for all individuals, including those
    historically marginalized due to race, language, income, or disability.
    UDL encourages the design of flexible learning environments that
    anticipate learner variability and provide alternative routes or paths
    to success. UDL acknowledges that variability across all learners is
    the norm rather than the exception.
        In support of its important portfolio of projects that include
    investments at the Federal level, in fiscal year 2023, CAST makes two
    recommendations for the U.S. Department of Education:
        (1)  Include funding for a pilot to comprehensively develop and
    systemically embed the UDL framework across multi-State/multi-district/
    Tribal government [K-4 classrooms] as part of in-person, hybrid, or
    virtual learning environment(s) for a minimum of 3 years. The pilot
    will utilize the evidence-based principles, flexible scaffolds, and
    supports of UDL and will be awarded to States/districts/Tribal
    governments to support the full access of students with disabilities to
    the general curriculum, and to support all learners at-risk due to
    experiencing barriers to learning because of language, literacy,
    socioeconomic factors, or disability.
        (2)  Fund education programs to sufficiently support States in
    their efforts to train personnel and educate all K-12 students. Key
    programs are:
    (A) Elementary and Secondary Education
        --Title I: $36.5 billion for students to access a quality
                education, and
        --Title II: $2.5 billion to support teacher professional learning
                and student access to literacy, evidence-based instruction
                and practices including UDL.
        --Results for the Nation (LEARN): $192 million to improve English
                Language Arts.

    Examples of UDL funded in K-12 schools (via ESSA's Title I/II and/or
    combined Federal and State funding).
    California:
      --The California Coalition for Inclusive Literacy has trained more
            than 30 County Office of Education staff to become UDL coaches
            in five counties across the State.
      --The Far North Literacy Consortium in Northern California works with
            five counties to implement UDL district-wide in rural areas of
            the state.
      --With joint funding from the National Science Foundation Co-Organize
            Your Learning (CORGI) enhances engagement and learning through
            a Google application (app) designed for students and teachers
            to use and collaboratively answer questions requiring higher
            order reasoning.
    New Hampshire:
      --The NH UDL Innovation Network brings CAST together with 70 schools
            and 500 educators across the State. Participants engage with a
            small team from their school to learn what UDL is and how to
            apply it in their K-12 learning environments. Through
            collaborative school-based instructional rounds, online
            learning, statewide workshop days, and team-supported
            reflective practice, participants work to transform their
            classrooms for greater access and to support student agency.
    (B) Individuals with Disabilities Education Act (IDEA):
        --Part B Section 611: $16.2 billion-to place the IDEA on a glide
                path to full funding (or 40 percent of the per pupil
                expenditure promised to districts when the IDEA was first
                passed in 1975).
        --Part D-National Activities: To provide the infrastructure to
                implement programs for students with disabilities through
                professional development, technical assistance, and more.
                Recommendations are:
          -- State Personnel Development: $39 million.
          -- Technical Assistance and Development: $49 million.
          -- Personnel Preparation: $300 million
          -- Parent Training and Information Centers: $45 million
          -- Media and Technology: $32 million

    Examples of UDL funded under IDEA Part D:
        --The National Center on Accessible Education Materials (AEM
                Center) provides technical assistance, coaching, and
                resources to increase the availability and use of
                accessible educational materials and technologies for
                learners with disabilities across the lifespan. The
                Center's Quality Indicators provide practitioners,
                administrators, researchers, policymakers, and parents/
                caregivers with actionable steps toward increasing the
                availability and use of accessible materials and
                technologies from early learning through postsecondary
                education and workforce development.
        --The Center on Inclusive Software for Learning has created and
                launched Clusive, a free, flexible, adaptive, and
                customizable digital learning environment. Students can use
                Clusive to read assigned or free-choice books and articles,
                build their own personal library, and take advantage of
                Clusive's growing public library. Clusive helps learners
                build self-awareness through discovering, choosing, and
                using preferences that help build learning skills.
    (C) Career and Technical Education (CTE):
        --State Grants and National Programs: $1.6 billion so States can
                develop career training pathways responsive to the needs of
                business and of learners that include a diverse population
                who may experience barriers such as poverty, low literacy,
                language and/or disability.

    Examples of UDL in CTE: CAST's work with States, school districts and
    private partners increases access to well-designed curriculum and
    career training incorporating UDL that is especially focused on diverse
    youth and young adult learners. Two recent examples are:
        --Outdoor Recreation Pathways (Tillotson Foundation): The project
                brings together outdoor recreation industry professionals,
                students, and educators to develop competencies and outline
                a CTE pathway into high-wage high-demand careers in this
                emerging field for youth in New Hampshire.
        --BioFab Explorer: BioFab Explorer is a free educational resource
                developed in partnership with industry members from the
                Advanced Regenerative Manufacturing Institute (ARMI)/Biofab
                USA, as well as in collaboration with CTE educators and
                their students in New Hampshire. This free career
                exploration resource is meant to attract high school
                students into biomanufacturing. Biofab Explorer embeds UDL
                by providing learners with several pathways through the
                content and allowing everyone to build a customized user
                experience. Information is presented through multiple
                modalities to provide users with choices that best meet
                their needs.
    (D) Vocational Rehabilitation:
        --Demonstration and Training Programs: $40.8 million for grants to
                spur innovative approaches and new partnerships that
                address long-term barriers as well as novel challenges that
                limits employment of individuals with disabilities.
        CAST appreciates the subcommittee's consideration and urges a
    continuing investment in educational innovations that incorporate
    effective implementation of UDL while prioritizing the need to include
    UDL as part of the infrastructure of workforce and CTE faculty training
    makes sense.
        As the subcommittee considers funding for career training and
    employment, CAST makes the following recommendation for the U.S.
    Department of Labor (DOL): Provide increased investments in research as
    well as career-exposure and training for eligible youth, young adults
    and adults who may experience barriers due to educational access/
    completion, literacy and/or disability. Key programs are:
        (A) Office of Disability Employment Policy:
        --Research and Demonstration: $9 million to continue to develop,
                influence and expand employment-related policies and
                practices so that every youth, young adult, and adult with
                a disability gains access to career training and STEM
                career experiences.
        (B) YouthBuild: $145 million to support grants that provide work-
    based pre-apprenticeships, in support of unemployed youth and those who
    left high school prior to graduation.
        (C) Job Corp: $1.6 billion to ensure participants receive training
    that reflects the labor market's need for in-demand skills conveyed by
    up-to-date industry standards including creating proactive and
    innovative partnerships that further modernize its training and connect
    industry leaders to a diverse student body.

    Examples of UDL funded by DOL:
        --CEE-STEM: An Online STEM Career Exploration and Readiness
                Environment for Opportunity Youth is a web-based STEM
                Career Exploration and Readiness Environment to promote
                STEM understanding and knowledge as a part of classroom and
                career training for out of school youth. CAST, UMass
                Amherst College of Education, and YouthBuild USA developed
                the CEE-STEM project and utilized the UDL framework to
                create a personalized and portable digital tool for youth
                to explore STEM careers, demonstrate STEM learning, reflect
                on STEM career interests, and take actions to move ahead
                with STEM career pathways of interest. Going beyond the
                pilot, a customized version of the tool was also developed-
                to align with alternative careers, industries, or
                educational environments, and allows use of the e-portfolio
                for other purposes and populations. The e-portfolio was
                also piloted in two high school CTE settings and a
                registered pre-apprenticeship setting.
        --The Wisconsin Regional Training Partnership supports the
                implementation of CAST's UDL e-portfolio in pre-
                apprenticeship programs in Wisconsin and Minnesota to help
                prepare and assess preparedness for the Industrial
                Maintenance Technician apprenticeship pathway. Partners are
                Jobs for the Future and SPR under the Apprenticeship
                Inclusion Models grant funded by the Office of Disability
                Employment within DOL.
        CAST urges the subcommittee to further invest in programs that
    expand the use of the UDL framework. In doing so, Congress would
    increase the capacity of States, districts, schools and career training
    programs to provide more robust professional learning and other needed
    technical assistance so that teachers have the tools and resources they
    need to teach and provide educational support to all learners. It is
    imperative that all youth and young adults, including first-time career
    seekers or those desiring new opportunities, have access to workforce
    development and career pathway strategies and programs that are
    designed from the beginning with their learning variability in mind.
        CAST appreciates the opportunity to provide testimony to the
    subcommittee for the fiscal Year2023 appropriations bill. We look
    forward to working with you as you develop a final appropriations bill
    that recognizes UDL as an integral component to K-16 education, and to
    increasing and sustaining a well-trained and vital workforce. Sherri
    Wilcauskas, swilcauskas@cast.org, www.cast.org
                    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 $11 billion for CDC's programs in FY
    2023 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 some CDC programs in FY 2022 and we urge
    Congress to continue efforts to build upon these investments and
    increase funding to strengthen all of CDC's programs.
        CDC serves as the command center for the Nation's public health
    defense system against emerging and reemerging infectious diseases as
    well as man-made and natural disasters. From playing a leading role in
    aiding in the surveillance, detection and mitigation of the COVID-19
    pandemic in the U.S. and globally, to monitoring and investigating
    other disease outbreaks, to pandemic flu preparedness, CDC is the
    Nation's--and a global--expert resource and response center,
    coordinating communications and action and serving as the laboratory
    reference center. 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.
        We thank you for your support for important public health
    infrastructure programs including the Public Health Infrastructure and
    Capacity program which will provide flexible funding to strengthen core
    public health infrastructure and capacity needs at all levels of
    government, the Public Health Workforce and Career Development program
    to ensure the Nation has a strong and well-trained workforce and Public
    Health Data Modernization Initiative is helping to build a world-class
    and modern data infrastructure system to ensure all systems can
    communicate and share data seamlessly with one another to adequately
    respond to the next public health emergency.
        Injuries are the leading causes of death for people ages 1-45.
    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. CDC reports
    that in 2019, the total economic cost of both fatal and nonfatal
    injuries totaled $4.2 trillion. In 2021, drug overdoses killed more
    than 100,000 individuals nationwide. CDC provides States with resources
    for opioid and other drug overdose prevention programs and to ensure
    that health providers to have information to improve opioid prescribing
    and prevent addiction and abuse. In 2022, there were 45,222 firearm-
    related fatalities in the U.S. We thank Congress for providing CDC with
    dedicated funding for firearm morbidity and mortality prevention
    research and strongly urge you to increase funding in FY 2023 to $35
    million at CDC. The National Center for Injury Prevention and Control
    must be adequately funded to conduct research, prevent injuries,
    address the Nation's drug overdose epidemic and help save lives.
        In 2020, 696,962 people in the U.S. died from heart disease, the
    Nation's number one cause of death. More males than females died of
    heart disease in 2020, 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 2020, 160,264 people died of stroke, accounting
    for about one of every 19 deaths. Annually, heart disease and stroke
    cost the U.S. an estimated $378 billion in health care and lost
    productivity. CDC's Heart Disease and Stroke Prevention Program;
    WISEWOMAN; Division of Nutrition, Physical Activity, and Obesity; 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 609,000 deaths from
    cancer are expected in 2022. 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 percent. 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. The National Breast and Cervical Cancer Early Detection Program
    helps millions of low-income, uninsured and medically underserved women
    access lifesaving breast and cervical cancer screenings and provides a
    gateway to treatment and the Colorectal Cancer Control Program improves
    screening rates among targeted, low-income populations aged 50-75
    years.
        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 37 million Americans living with diabetes, more
    than 8.5 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.
        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 more than 13 percent undiagnosed. Prevention of HIV
    transmission is the best defense against the AIDS epidemic. Sexually
    transmitted diseases continue to be a significant public health problem
    in the U.S. Nearly 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 investment in the Social
    Determinants of Health program and urge you to increase funding for the
    program to ensure that public health departments, academic institutions
    and nonprofit organizations are supported to address the SDOH that
    contribute to high health care costs and preventable inequities in
    health outcomes.
        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 13 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 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
    $11 billion for CDC's programs in FY 2023.

        [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
        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 2023 (FY23). 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 increase funding
    to a $2.5 million appropriation for the program in FY23 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 (Public
    Law 106-310 Title 23) and is the only such program that receives
    Federal funding for Tourette Syndrome (TS) public health education. The
    program has been flat funded since Fiscal Year 2015. The additional
    $500,000 would fund: (1) a systemic literature review to determine
    prevalence of TS and tic disorders, (2) a systematic literature review
    to document cost and impact of TS and tic disorders, (3) small grants
    to pilot innovative approaches at Centers of Excellence (CoE) in 5-7
    States to address priority needs including health equity, transition,
    and suicide prevention among families affected by TS and tic disorders
    through CoEs, and (4) two new Continuing Medical Education (CME)
    modules to serve U.S. providers to increase providers' ability to
    identify, diagnose and treat tics and tic disorders. With your support
    at the increased level of $2.5 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 50 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
    percent of parents struggle to cover the high costs of services for
    their child such as counseling, appointments and tutoring; 34 percent
    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 percent 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 percent 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 percent 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 percent) 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 percent have been diagnosed with
    at least one additional mental, behavioral, or developmental condition
    according to the CDC website. These co-occurring conditions include
    Attention Deficit-Hyperactivity Disorder (ADHD), Obsessive Compulsive
    Disorder (OCD), Autism, Oppositional Defiance Disorder, anxiety,
    depression, learning difficulties among others and can significantly
    impact the lives of those affected by TS. In fact, in TAA's 2018 Impact
    Survey, 42 percent of children felt that dealing co-occurring
    conditions was one of the biggest challenges in managing TS. In
    addition, 32 percent of children and 51 percent 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 percent of children felt that TS negatively impacted
    their school experience and education and 69 percent 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 percent 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 2023 for the Tourette Syndrome Public
    Health Education and Research Program at CDC's National Center for
    Birth Defects and Developmental Disabilities at the increased level of
    $2.5 million.
                                     ______

                   Prepared Statement of Choose Healthy Life
                  summary of fiscal year 2023 recommendations
    _______________________________________________________________________

      --Please provide the National Institutes of Health (NIH) with at
            least $49 billion to facilitate continued growth in rare
            disease research activities.
        --Please provide proportional increases for the individual NIH
                institutes and centers, and $660 million for the National
                Institute on Minority Health and Health Disparities (NIMHD)
                consistent with the administration's budget request.
        --Please provide a separate, meaningful increase to advance and
                adequately support the emerging Advanced Research Projects
                Agency for Health (ARPA-H).
      --Please provide the Centers for Disease Control and Prevention (CDC)
            with at least $11 billion to support public health efforts.
        --Please provide proportional increases for the individual CDC
                centers, please continue to support the Ending the HIV
                Epidemic Initiative, and please provide the Social
                Determinants of Health program with $150 million consistent
                with the administration's budget request.
      --Provide the Health Resources and Services Administration (HRSA)
            with a funding level of at least $9.8 billion
      --Please continue to provide meaningful funding to support ongoing
            COVID-19 response activities.
      --Please establish a faith and community-based Health Equity
            Innovation Fund of at least $100 million. The fund will provide
            resources to organizations that created a health workforce to
            address COVID-19 in underserved communities and now need
            resources to sustain that workforce as it addresses the
            underlying health inequities that led to the disproportionate
            morbidity and mortality the communities faced during the
            pandemic.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to present the
    written testimony of Choose Healthy Life. On behalf of the communities
    we serve, we deeply appreciate the FY 2022 research and public health
    funding for COVID, for infectious diseases, for health equity, and for
    chronic conditions. As you work with your colleagues on FY 2023
    appropriations, please continue to invest in public health and support
    organizations conducting innovative faith-based and community outreach.
    About Choose Healthy Life
        Choose Healthy Life (CHL) is a Black church initiative that ensures
    churches--the oldest and most trusted institutions in the Black
    community--receive the necessary resources, training, and support to
    address COVID-19 and other health inequities by making available health
    services to hard-to-reach communities.
        With funding from the Quest Diagnostics Foundation, in January
    2021, CHL established a full-time faith-based health workforce
    initially in fifty (50) Black churches in five major cities focused on
    administering COVID-19 testing and vaccination.
        Based on the early success of the program, CHL churches were
    visited by both VPOTUS and FLOTUS, and in August 2021, CHL received
    funding from HRSA and grew its workforce to 120 churches across 13
    States and the District of Columbia.
        Since launch, CHL has conducted nearly 2,500 testing/vaccination
    events and administered over 90,000 COVID-19 tests and vaccinations
    through its churches.
        Choose Healthy Life, founded by Debra Fraser-Howze, is guided by
    its 10-member National Black Clergy Health Leadership Council that is
    co-chaired by Rev. Al Sharpton (National Action Network) and Rev.
    Calvin O. Butts III (The Abyssinian Baptist Church, Harlem, NY).
        Advising the clergy is an acclaimed Medical Advisory Board that
    includes former HHS Secretary Dr. Louis Sullivan, former CDC Director
    Dr. Tom Frieden, our Nation's first female medical doctor to serve in
    congress Dr. Donna Christensen, Co-founder of the Black Coalition
    Against COVID-19 Dr. Reed Tuckson and the Nation's top obesity medicine
    expert Harvard Medical School's Dr. Fatima Cody Stanford. Choose
    Healthy Life demonstrates the power that comes from the union of
    bringing faith and science together to address health disparities.
        As the COVID-19 pandemic enters the endemic phase, CHL is pivoting
    its faith-based health workforce to focus on addressing key underlying
    health inequities--specifically obesity, diabetes, hypertension,
    maternal and mental health.
        As stated by CDC Director Dr. Rochelle Walensky, ``Your model of
    establishing in each church a full-time public health navigator ...
    trained and charged with providing access to COVID-19 testing and
    vaccinations in the immediate short-term while addressing other health
    disparities in the long term ... is a sustainable, scalable, and
    transferable approach to address public health disparities and
    inequities in the Black community ... it will serve us well far beyond
    the pandemic.''
    About Health Disparities & CHL Support
      --Healthcare outcomes in the Black community lag far behind
            healthcare outcomes in comparison to the White population:
      --Adults are 30 percent more likely to be obese
      --60 percent more likely to be diagnosed with diabetes
      --Men are 30 percent and women 60 percent more likely to have high
            blood pressure, with women twice as likely to have stroke
      --Women are 40 percent more likely to die of breast cancer
      --Twice as likely to die from COVID-19 and less likely to be
            vaccinated
    About The Black Clergy Action Plan to Eliminate COVID-19 and Address
            Health Equity
      --The Black church is the oldest and most trusted institution in the
            Black community and has the power to influence and drive change
      --Establishes a health workforce in the Black Church to deliver
            vaccinations, testing, and to provide health services through
            local partners to those most in need
      --Ensures that Churches are funded to sustain and build out its
            health services offering and effectively measure local impact
      --Raises awareness and educate the Black clergy and community about
            COVID-19 and other health disparities
      --Establish a network of trusted health navigators in the Black
            church to develop and execute a Community Solutions Action Plan
            (CSAP) to effectively measure local impact
      --Proactively engages high-risk communities through COVID-19 testing/
            vaccination campaigns with the goal of stopping the spread of
            the virus and establishing pandemic preparedness
      --Informs, educates and addresses health inequities that exist within
            the community (i.e. obesity, diabetes, and hypertension)
            through preventative health care and wellness outreach
    About the Health Equity Innovation Fund
        The Health Equity Innovation Fund will provide resources to
    organizations that created a health workforce to address COVID-19 in
    underserved communities and now need resources to sustain that
    workforce as it addresses the underlying health inequities that led to
    the disproportionate morbidity and mortality the communities faced
    during the pandemic. Many of these organizations sprung to life from
    within the community with private support to immediately address the
    pandemic. They have been results oriented, culturally competent, and
    directed by trusted leaders in the community. Too often the government
    provides resources to address challenges in underserved communities
    during a time of crisis and then abandons them after the crisis is
    over. The government needs to invest in those that are having an impact
    to ensure that they are sustainable into the future.

        [This statement was submitted by Debra Fraser-Howze, Founder &
    President, Choose Healthy Life.]
                                     ______

               Prepared Statement of the Chronic Disease Alliance
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least $49.
            Billion, a $3.5 billion increase over FY 2022.
        --Please provide proportional increases for individual NIH
                Institutes and Centers.
        --Please provide additional, distinct funding for the emerging
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH, which would facilitate implementation of this
                important program without supplanting ongoing NIH research
                activities.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $11 billion, a $2.55 billion increase over FY 2022.
        --Please provide CDC's National Center for Chronic Disease
                Prevention and Health Promotion (NCCDPHP) with systematic
                and meaningful annual increases to bring total funding up
                to $3.75 billion over the next 3 years.
        --Please provide $6 million for the Chronic Disease Education and
                Awareness (CDEA) Program at CDC and NCCDPHP.
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of the
    Chronic Disease Alliance and the National patient organization that
    support Chronic Disease Day. Chairwoman Murray, Ranking Member Blunt,
    and distinguished members of the subcommittee, we extend our thanks for
    the significant investments in HHS through the FY 20222 omnibus
    package, particularly the annual increases for NIH and CDC. As you work
    with your colleagues on appropriations for FY 2023, please continue to
    invest in programs that serve the chronic disease community, most
    notably NCCDPHP at CDC. Thank you again for your leadership on health
    funding issues and for the opportunity to present the views of the
    chronic disease community.
                           about chronic disease day
        Chronic diseases account for 7 of the top 10 causes of death in
    America and more than 90 percent of our annual healthcare spending.
    Hundreds of thousands of Americans who suffer from unpreventable
    chronic conditions need access to care. But the deadliest and costliest
    chronic diseases are also the most preventable. We promote actionable
    resources to lower the rate of preventable chronic diseases so that our
    healthcare system can better support individuals with unpreventable
    chronic conditions and invisible illnesses.
                   about chronic disease & invisible illness
        Chronic Disease Day is an opportunity for legislators to pledge to
    address issues that impact across the entire chronic disease community.
    These issues include funding needed medical research and public health
    programs and advancing legislation that supports a patient's ability to
    access the care they need. While we reflect on recent progress and
    opportunities for further advancement around July 10th, our community
    of supporters work year-round to educate policymakers about
    contemporary issues and to use our stories and collective voice to
    advocate for issues that impact across the chronic disease community.
        NIH and CDC both play key roles in preventing and addressing
    chronic illness. There is tremendous opportunity for the chronic
    disease community with increased funding, particularly innovative and
    impactful public health efforts led by CDC and NCCDPHP, such as the
    emerging CDEA program. There is also tremendous overlap between chronic
    conditions and health disparities, and we encourage robust resources
    for efforts to promote health equity, such as those led by NIH's
    National Institute on Minority Health and Health Disparities and CDC's
    Social Determinants of Health Program.

        [This statement was submitted by Clorinda Walley, President, Good
    Days,
    Chronic Disease Alliance
                                     ______

             Prepared Statement of the Coalition for Clinical and
                             Translational Science
                fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --CCTS joins the broader medical research community in asking
            Congress to provide the National Institutes of Health (NIH)
            with at least a $3.5 billion funding increase for FY22, to
            bring total agency funding up to a minimum of $49 billion
            annually.
        --Please provide the Clinical and Translational Science Awards
                (CTSA) program at the National Center for Advancing
                Translational Sciences (NCATS) with at least a $35 million
                increase in dedicated line-item funding for FY23 to bring
                annual support for the program up to a minimum of $641
                million.
        --Please provide separate, additional funding to further support
                and implement the Advanced Research Projects Agency for
                Health (ARPA-H).
        --Please provide the Cures Acceleration Network (CAN) at NCATS with
                $90 million in dedicated funding for FY23.
        --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 FY23.
      --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 $11
            billion for the Centers for Disease Control and Prevention
            (CDC).
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the strong support for the full
    spectrum of medical research demonstrated through the FY22 omnibus
    appropriations package. Particularly, thank you for maintaining line-
    item funding for the Clinical and Translational Science Awards (CTSA)
    program, for providing a meaningful annual funding increase for CTSAs,
    and for the detailed instructions regarding utilization of CTSA funds
    and the central role of CTSA hubs. The value, importance, and impact of
    the CTSA program (as well as full-spectrum research at NIH) has been
    highlighted by our ability to quickly develop treatments, vaccines,
    diagnostic tools, and health information to quickly respond to the
    ongoing COVID-19 pandemic, and through ongoing work to promote health
    equity and enhance care delivery in rural and underserved communities.
    As you work with your colleagues on FY 2023 appropriations, CCTS and
    the broader stakeholder community encourage you to continue to support
    the full spectrum of medical research and provide increased funding for
    key clinical and translational research programs, including CTSAs.
           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. While we appreciate that the administration's FY 2023 budget
    request includes line-item funding for CTSAs, we are concerned that a
    cut is recommended and more concerned by supporting Statements that
    seem to indicate a change in focus for the CTSA program from core hub
    support to more traditional project-based activities.
        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 2023.
    A Few Recent Examples of CTSA Program Efforts
                University of Wisconsin
        Within two weeks of the pandemic (March 2020) the UW-M CTSA-
    collaborated with community partners and practice-based research
    networks (PBRNs),to make available anonymous statewide electronic
    health records data on 3.5 million residents to develop and disseminate
    reports of areas at high risk of severe COVID-19 complications. Over
    150 reports were shared with State and local health departments and
    health systems throughout the state. Report requestors used information
    to gain enhanced awareness of the communities they serve and aid in
    COVID-19 response planning including preparing for potential surges,
    focusing outreach and collaborative efforts, assessing resource
    distribution, and identifying communication priorities and gaps. The
    CTSA made interactive maps and tools available at https://nhp.wisc.edu/
    covid-19/. Regional variations in vaccine acceptance and access were
    identified as an important barrier to control the pandemic. To address
    this problem, the UW-M CTSA developed an interactive COVID-19 Relative
    Mortality Risk and Barriers to Vaccination Tool. This tool aids vaccine
    intervention efforts that are appropriate for the community. The tool
    is available at the same URL: https://nhp.wisc.edu/covid-19/.
                Stanford University
        Our CTSA's Clinical and Translational Research Unit (CTRU) provided
    both clinic and laboratory services for the NIH RECOVER: A Multi-site
    Observational Study of Post-Acute Sequelae of SARS-CoV-2 Infection
    (PASC) in Adults. This study is a research initiative from the National
    Institutes of Health seeking to understand, prevent, and treat PASC,
    including Long COVID. Under PI Dr Upi Singh, Stanford in one of leading
    recruitment sites in this national consortium of USA research
    organizations, with 290 participants enrolled during the reporting
    period. The CTRU performs participant visits along side other clinics
    at Stanford and receives and processes all biospecimens collected at
    Stanford.
        As a result of CTSA infrastructure, in under 48 hours of the March
    16th, countywide shelter-in-place, CTSA bioinformatics Faulty Lead, Dr.
    Shah, led a ``data science response'' in which data related to COVID-19
    patients were made available for Stanford researchers. CTSA Faculty
    leaders also rapidly deployed protocols for the conduct of numerous,
    multi-center clinical trials for COVID-19. They formed the COVID-19
    Clinical Research Review Program (Chair: Ken Mahaffey) to adjudicate
    the complexities of conducting multiple trials at the same time. They
    reviewed 630 study requests since March 16th, 2020. This committee is
    still in place.
        CTSA Faculty leaders, rapidly deployed protocols for the conduct of
    numerous, clinical research protocols impacted by COVID-19. They formed
    the COVID-19 Clinical Human Subjects Research Committee (Chairs: Mary
    Chen and Pooneh Fouladi) to adjudicate over 250 request. This committee
    is still in place. Faculty Lead of CTSA BERD, Dr. Desai, developed an
    Adaptive Master Trial, able to add promising treatment arms in real-
    time and drop arms early for futility.
                Tufts University
        Since 2008, Tufts CTSI has provided outstanding resources and
    services to support full-spectrum translation to our community. We also
    have continually developed, demonstrated, and disseminated innovations
    to improve and accelerate clinical and translational research. Beyond
    supporting Hub research teams and incorporating these approaches into
    our internal operations and service delivery, we are a national leader
    in setting quality and efficiency standards and establishing clinical
    and translational science best practices.
        Our mature resource and service infrastructure and proclivity for
    innovation allow us to respond rapidly and effectively to emerging
    public health needs. At the start of the COVID-19 pandemic, in days, we
    redeployed our resources and services, working closely with Tufts
    Medical Center leadership. Our Clinical and Translational Research
    Center became the hospital's primary unit for COVID-19 research, with
    activation of two large Remdesivir inpatient studies in less than two
    weeks, other COVID treatment and vaccine studies, and a Tufts CTSI-
    initiated treatment trial for niclosamide, led by Dr. Selker and
    supported by a CTSA supplement. The Tufts CTSI MIT Center for Clinical
    and Translational Research helped design and produce novel personal
    protective equipment and facilitated dissemination around the world. We
    established a National COVID-19 Survivors Registry and a database
    enabling a COVID-19 biorepository. The Tufts CTSI Pilot program funded
    off-cycle COVID-19 research, and our Center for Research Process
    Improvement led a hospital-wide process to prioritize research studies
    and resource deployment. These represent a few of many examples of the
    breadth of our resources and services provided and the high degree of
    speed, flexibility, and collaboration of our teams when facing a public
    health emergency.

        [This statement was submitted by Harry P. Selker, MD, MSPH,
    Chairman,
    Clinical Research Forum and Linda B. Cottler, PhD, MPH, FACE,
    President, Association for Clinical and Translational Science.]
                                     ______

             Prepared Statement of the Coalition for Health Funding

    ------------------------------------------------------------------------
    Centers for Disease Control & Prevention..  At least $11 billion
    National Institutes of Health.............  No less than $49 billion
    Food & Drug Administration................  $3.653 billion
    Indian Health Service.....................  No less than $49.8 billion
    Health Resources & Services Administration  No less than $9.8 billion in
                                                 discretionary funds
    Agency for Health Research Quality........  No less than $500 million
    ------------------------------------------------------------------------

        The Coalition for Health Funding--an alliance of over 80 health
    organizations representing more than 100 million patients and
    consumers, health providers, professionals and researchers--welcomes
    the opportunity to submit this statement for the record about the
    importance of health funding. Together, our member organizations speak
    with one voice before Congress and the administration in support of
    federally funded health programs with the shared goal of improved
    health and well-being for all. Each member organization has individual
    funding priorities within the Department of Health and Human Services
    (HHS), but we all believe that to truly improve public health, we need
    strong, sustained, predictable funding for all Federal agencies and
    programs across the continuum. The past 2 years have taught us many
    things about the state of our public health infrastructure, which is
    why it is so critical that investments are made to ensure we strengthen
    areas such as research, prevention, and treatment programs. While we
    work to end the current pandemic, annual sustained public health
    investment will help ensure we are not only better prepared for the
    next one, but importantly also protecting the overall health and
    security of our Nation.
        HHS agencies play different yet interconnected roles in addressing
    our Nation's mounting health demands. COVID-19 has shown all Americans
    that our government works best when well-resourced agencies play
    complementary roles in defending and strengthening public health.
    Americans have seen first-hand the work that the National Institutes of
    Health did to fund certain vaccine technologies that Operation Warp
    Speed took through the development process and that the Food and Drug
    Administration (FDA) approved in record time to save American lives.
    With emergency funding, uninsured Americans have been able to access
    testing financed through the Health Resources and Services
    Administration (HRSA). The Centers for Disease Control and Prevention
    (CDC) routinely assessed available data to provide regular guidance to
    the public on COVID-19 safety protocols. And the Agency for Health
    Research Quality continues to deliver real world evidence on how we can
    better respond to the pandemic.
        We know that our response to COVID-19 was not entirely a success.
    Our public health agencies were not as prepared for the pandemic as
    they could have been. But instead of seeing that as a reason to deny
    critical funding for these essential agencies, the Committee should see
    this as an opportunity to rebuild our public health agencies through
    robust funding and ensure that public health practitioners across the
    country have what they need to combat the next pandemic while managing
    the current one. We now know that pandemics are not science fiction.
    They are not the past. They are our present, and they will be our
    future. Shortchanging public health and health research programs--or
    cutting health programs at the expense of others--leaves Americans
    vulnerable to health threats and does nothing to prevent these problems
    from arising in the first place.
        Emergency funding to combat COVID-19 does not replace consistent,
    sustained year-over appropriations. Partially this is because we must
    stay vigilant in the face of the next pandemic. But we also must combat
    other serious health and economic threats from chronic and emerging
    diseases, environmental exposures, preventable conditions, workforce
    shortages, and health disparities. Pre-existing conditions contributed
    significantly to our COVID crisis, some of which are preventable, many
    of which are manageable. We saw firsthand the impact of workforce
    shortages and are continuing to deal with the fallout. Biomedical
    research, treatment, prevention, and health promotion programs are
    critical to success moving forward. Our public health infrastructure
    must be equipped to handle the myriad challenges that it faces beyond
    the extraordinary circumstances of the pandemic. In fiscal year (FY)
    2022, discretionary health spending was only $108 billion, or 7 percent
    of all discretionary Federal spending. Of this, a little less than half
    supported medical research at the NIH, and the remainder supported all
    other public health activities--disease prevention & response, health &
    safety security, workforce development, and access to primary and
    preventive care. Having learned from the past 2 years that these areas
    of spending cannot be afterthoughts; we urge you to fund them
    accordingly. To that end, we are calling for the following levels of
    investment for specific public health agencies in FY23.

      --CDC: At least $11 billion
      --NIH: No less than $49 billion
      --FDA: $3.653 billion
      --IHS: No less than $49.8 billion
      --HRSA: No less than $9.8 billion in discretionary funds
      --AHRQ: No less than $500 million

        To achieve these necessary targets, appropriators must also raise
    the 302(b) allocation for the Labor-HHS-Education subcommittee to
    address its important needs. The era of budget sequestration hollowed
    out many of the very public health agencies we depended on to combat
    COVID-19. What the current pandemic would have looked like with
    appropriately funded agencies we will never know, but if we take our
    recent experience seriously, we will not face the same fate with the
    next pandemic. That's why the Coalition for Health Funding partnered
    with the Campaign to Invest in America's Workforce, Committee for
    Education Funding, and Coalition on Human in bringing together nearly
    370 organizations to urge appropriators to raise the subcommittee's
    allocation in FY23 to at least $239.59 billion.
        We hope in your ongoing deliberations on FY 2023 and beyond you
    will recognize that emergency funding during the acute phase of a
    pandemic does not eliminate the need for sustained long-term funding to
    the very agencies we trust explicitly with American lives. They need
    the resources to develop the next generation of tools necessary to
    protect the public's health from other health threats and to ensure the
    solvency of Medicare's Trust Fund moving forward, which is of
    particular salience given the role Medicare plays in the health care of
    those who need it most We look forward to working with the subcommittee
    in these endeavors and hope you will turn to the Coalition for Health
    Funding as a resource in the future.

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

          Prepared Statement of the Coalition on Adult Basic Education
        Chair Murray, Ranking Member Blunt, and members of the
    subcommittee:
        My name is Sharon Bonney, and I am the CEO of the Coalition on
    Adult Basic Education (COABE). COABE is the leading professional
    association for adult education, and we represent the 79,000 adult
    educators and leaders around the country. Our teachers and leaders
    provide numeracy, literacy, digital literacy, work readiness, soft
    skills, high school equivalency and numerous wraparound services to
    more than 725,000 adult learners nationwide. With over 2,200 WIOA Title
    II programs around the country, adult education serves the Nation's
    most vulnerable adults.
        COABE is appreciative of the $15.5 million increase Congress
    provided to the Adult Basic Education State Grants program under Title
    II of the Workforce Innovation and Opportunity Act (WIOA) for fiscal
    year (FY) 2022. Because of this funding, adult educators across the
    country will be able to better serve adult learners and provide them
    with the skills needed for the workplace. Our programs provide these
    skills to 725,000 adult learners throughout the country, but there are
    millions of Americans who need our services: 43 million adults are low-
    skilled in literacy and 62.7 million adults are low-skilled in numeracy
    in the United States.
        Adult education programs provide an economic boost to participants.
    According to a recent Economic Mobility Corporation study, ``unemployed
    residents with prior U.S. work experience who enrolled in an
    employment-focused English course boosted their earnings by an average
    of more than $7,100 annually 2 years after starting the program,
    compared with unemployed non-English speakers who weren't in the
    program.'' Additionally, COABE estimates that for every dollar invested
    in adult education, the surrounding community receives $60 back in
    increased income, property taxes and savings on legal system and
    welfare expenses.
        Given this clear evidence of the economic boost adult education
    programs provide to participants and communities, demand for these
    programs is high. As a result, there are waiting lists in every State
    for these programs. The pandemic has further challenged programs as
    more adults have found that they need to enhance their literacy,
    numeracy and digital skills to compete for jobs in the workplace, and
    yet these very adults might not have access to technology and broadband
    to enable them to participate in these programs.
        Adult education programs have been working hard to deliver high-
    quality education throughout the pandemic. These programs have turned
    to online and hybrid delivery services. But greater investment in
    technology, classroom space and professional development is critical.
    If funded at proper levels, adult education programs can play a
    significant role in the country's recovery from the pandemic by
    providing millions of adult learners with necessary workforce and life
    skills.
        Adult education provides learners with opportunities to which they
    may not otherwise have access. Learners often tell stories of how adult
    education changed their lives. I want to share the thoughts of two
    participants from Missouri and Washington that exemplify the power of
    adult education:

        ``I have been living in this beautiful country for 16 years. In
            2015, my life changed. I made the decision to go back to school
            and try to get my HSE credential... I'm the first Spanish
            student finishing the course and getting the HSE diploma from
            the Spanish program, which was implemented in 2015, and I'm so
            proud of my achievement.''
          -- Jose Viveros Barcenas, St. Charles Community College Adult
                Education and Literacy, Cottleville, Missouri

        ``The program was a great experience, and I learned a lot. I was
            willing to expand what I learned in high school and the classes
            were smaller, so I got more one on one with the teachers. I was
            going for my GED and ended up with my diploma and now my
            associates. I encourage anyone that wants to get their high
            school diploma to go through HS21+. It is a great learning
            experience, with great instructors.''
          -- Raymond Silva, Skagit Valley College, Mount Vernon, Washington

        We are encouraged by President Biden's FY 2023 Budget proposal,
    which included an increase of $10 million for the Adult Basic Education
    State Grants program. However, given the demand for these services and
    the opportunity they provide learners, we would urge Congress to exceed
    the President's proposed increase and provide $810 million for adult
    education in the final fiscal Year2023 appropriations bill.
        Thank you for your consideration. Please let me know if COABE can
    be of any further assistance during the appropriations process.
                                     ______

        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 continued support for a vital program addressing the health
    and safety of our Nation's firefighters. As you consider the Fiscal
    Year (FY) 2023 Labor, Health and Human Services, Education, and Related
    Agencies Appropriations bill, we urge you to provide $5.5 million for
    the National Firefighter Registry.
        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
    scarcity 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.
        During the 115th Congress, both the House and Senate unanimously
    approved the Firefighter Cancer Registry Act (Public Law 115-194). This
    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.
        Over the past several years, the registry has been able to make
    great strides, including developing an enrollment system to ensure
    information security and ease of access for users; obtaining the Office
    of Management and Budget's approval for the enrollment questionnaire;
    and compiling brochures, videos, and quarterly newsletters to maintain
    communication with the fire service regarding the status of the
    registry.
        However, the registry has also faced new challenges due to evolving
    Federal requirements for data security and storage--in addition to the
    steps that remain to continue the launch of the registry and keep its
    vital work moving forward. To ensure that the National Firefighter
    Registry does not face delays with regard to the collection and
    analysis of data pertaining to cancer in the fire and emergency
    services, we are requesting $5.5 million in FY 2023.
        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
        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 2023, COSSA urges the Committee to appropriate:
      --$49.048 billion for the National Institutes of Health;
      --$11 billion for the Centers for Disease Control and Prevention,
            including $210 million for the National Center for Health
            Statistics;
      --$500 million for the Agency for Healthcare Research and Quality;
      --$814 million for the Bureau of Labor Statistics;
      --At least $815 million for the Institute of Education Sciences; and
      --$161 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 over the past 2 years in response to the COVID-19
    pandemic.
                         national institutes of health
        COSSA joins the more than 345 organizations in support of at least
    $49.048 billion for the National Institutes of Health (NIH) base budget
    in fiscal year 2023. COSSA appreciates the subcommittee's leadership
    and its long-standing bipartisan support of NIH, especially during
    difficult budgetary times. We also appreciate the Congress's interest
    in innovating and pushing the agency forward through support for high-
    risk, high-reward endeavors. It is critical that efforts to accelerate
    discovery in new, creative ways work in tandem with-not at the expense
    of-robust, sustainable support for fundamental and curiosity-driven
    research.
        To that end, COSSA urges the subcommittee to ensure that funding
    for the new Advanced Research Projects Agency for Health (ARPA-H)
    supplement the $49.048 billion recommendation for NIH's base budget,
    rather than supplant the investments NIH makes to biomedical and
    behavioral research across its institutes and center. To be truly
    transformative, increased investment is needed on all fronts.
        In addition, as the COVID-19 pandemic has underscored, it is
    behavior change-not only medical intervention--that can help us gain
    control in the days and weeks immediately following an outbreak. From
    psychological research behind the merits of mass social distancing to
    understanding cultural variations in risk perception as we tailor
    communication about vaccine safety, the social and behavioral sciences
    have been an essential part of the response. We must learn from this
    experience and invest in our future preparedness by better committing
    to understanding the human behavior and social systems at play.
        To that end, COSSA urges the subcommittee to ``right-size'' NIH's
    Office of Behavioral and Social Sciences Research (OBSSR), housed
    within the Office of the NIH Director. This critical office 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. We are appreciative of the $10
    million increase provided to OBSSR in the final fiscal year 2022
    appropriations bill; however, behavioral and social science research at
    NIH remains grossly underfunded. For example, OBSSR's fiscal year 2022
    budget of $38.9 million represents only 1.5 percent of the total budget
    of the NIH Office of the Director; under the President's proposal, this
    would drop to 1.1 percent.
        In addition, it is estimated that NIH funds roughly $700 million in
    research related to behavioral and social science annually across its
    institutes and centers; however, about 62 percent of that is also
    classified as neuroscience research, leaving around $430 million
    annually for non-neuroscience related social and behavioral studies.
    This amounts to only 1.1 percent of the entire NIH budget annually.
    Given all we have learned from the pandemic over the last few years,
    research on the social influences of 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 direct NIH to finally support the
    office at levels commensurate with the need for these critical
    insights.
                   centers for disease control and prevention
        COSSA urges the subcommittee to appropriate $11 billion for the
    Centers for Disease Control and Prevention (CDC), including $210
    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.
        In addition, 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 of 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 $814 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 $815 million for the Institute of Education
    Sciences (IES) in fiscal year 2023. 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 $161 million ($141
    million for Title VI and $20 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, research scientists, and others involved in
    family medicine education. We urge the Committee to appropriate at
    least $59 million for the Primary Care Training and Enhancement
    program, authorized under Title VII, Section 747 of the Public Health
    Service Act HRSA. In addition, we recommend the Committee fund the AHRQ
    at a level of at least $500 million in discretionary spending and
    specifically fund $5 million dedicated to AHRQ's Center for Primary
    Care Research.
        More than 44,000 primary care physicians will be needed by 2035,
    and current primary care production rates will be unable to meet the
    demand, according to the authors of Annals of Family Medicine
    (Petterson, et al Mar/Apr 2015). The primary care training and
    enhancement programs and AHRQ research conduct research to enhance our
    Nation's workforce and health infrastructure, improving primary care to
    produce better health outcomes and reduce costs.
    Primary Care Training and Enhancement--Title VII
        The Primary Care Training and Enhancement Program (Title VII,
    Section 747 of the Public Health Service Act) has a long history of
    funding training of primary care physicians. As experimentation with
    new or different models of care continues, departments of family
    medicine and family medicine residency programs will rely further on
    Title VII, Section 747 grants to help develop curricula and research
    training methods for transforming practice delivery. Future training
    needs include: training in new clinical environments that include
    integrated care with other health professionals (e.g. behavioral
    health, care coordination, nursing, oral health); development and
    implementation of curricula to give trainees the skills necessary to
    build and work in inter-professional teams that include diverse
    professions; and development and implementation of curricula to develop
    leaders and teachers in practice transformation. Moreover, new
    competencies are required for our developing health system. This
    program has not received an increase in funding since FY2020, just at
    the time that the COVID-19 pandemic has highlighted many of the
    failings of the current health care and public health infrastructure.
    The PCTE program can help address these flaws. For example, additional
    funding is needed for both residencies and medical school departments
    to help address faculty retention, public health competencies, recruit
    and retain students into primary care, develop new curriculum related
    to the pandemic, address health equity concerns and to increase full
    scope primary care physicians.
        In this time of increasing primary care need, we urge you to
    recognize the importance of maintaining and expanding funding for
    programs that support the primary care workforce. Title VII funding for
    primary care training is an evidence-based investment in the future
    care of the Nation.
        A 2021 report by The National Academy of Sciences, Engineering and
    Medicine 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 percent
    since the 1960s.\1\ Primary care health professions training grants
    under Title VII are vital to the continued development of a workforce
    designed to care for the most vulnerable populations and meet the needs
    of the 21st century. We urge your continued down payment for this
    program and an increase in funding levels to $59 million in FY 2023 to
    allow for a robust competitive funding cycle. This funding level will
    help continue important Title VII programs who use primary care
    training funding to develop innovative programs and curricula related
    to interdisciplinary training in rising new competencies.
    ---------------------------------------------------------------------------
        \1\ National Academies of Sciences, Engineering, and Medicine 2021.
    Implementing High-Quality Primary Care: Rebuilding the Foundation of
    Health Care. Washington, DC: The National Academies Press. https://
    doi.org/10.17226/25983.
    ---------------------------------------------------------------------------
        We also ask for the following report language to accompany the
    increased funding level: The Committee includes $59 million, an
    increase of $10 million over the FY 2022 level, for Primary Care
    Training and Enhancement programs, which support training and direct
    financial assistance for future primary care clinicians, teachers, and
    researchers. This additional funding is to allow for a robust grant
    competition, to support programs within academic administrative units
    related to expanding the number of medical students choosing primary
    care careers. To stimulate this supply, it's important to reach as many
    allopathic and osteopathic primary care medical school departments as
    possible to explore innovations in training, more research into
    increasing primary care production, and dissemination of best
    practices.
    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.
        We greatly appreciate the inclusion of increased funding in the FY
    2022 omnibus package, and hope we can increase that further in FY 2023.
    With funding for FY 2022 of $350,400,000 million, including $2 million
    dedicated to the Center for Primary Care Research within it, 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 is needed
    to accomplish these goals. The President's FY 2023 budget request
    includes $10 million in funding for primary care research in general.
    We ask that $5 million be provided as a line item to the Center for
    Primary Care Research within AHRQ to help coordinate and direct primary
    care research funding at AHRQ. For this reason, we are supporting
    additional overall funding increases for FY 2023 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, and (6) how health
    extension systems serve as connectors of research institutions with
    practices and communities.
        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, one of which was 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 the $5 million
    in dedicated funds for PCR, AHRQ could prioritize and coordinate
    investments in PCR directly improving the health and wellbeing of
    Americans. The National Academy of Medicine's report on Primary Care
    concurs with RAND's assessment on the importance of targeted funding
    for PCR, demonstrating the variety of stakeholders which share common
    ground on the importance of prioritizing PCR.\2\
    ---------------------------------------------------------------------------
        \2\ National Academies of Sciences, Engineering, and Medicine 2021.
    Implementing High-Quality Primary Care: Rebuilding the Foundation of
    Health Care. Washington, DC: The National Academies Press. https://
    doi.org/10.17226/25983.
    ---------------------------------------------------------------------------
        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 in discretionary spending for FY 2023 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's Primary Care Training and Enhancement Program and AHRQ--
    both entities which enhance our Nation's primary care workforce and
    infrastructure.

        [This statement was submitted by Winston Liaw, MD, MPH, Chair,
    Academic Family Medicine Advocacy Committee, Council of Academic Family
    Medicine.]
                                     ______

          Prepared Statement of the Council of State and Territorial
                                Epidemiologists
        Chair Murray, Ranking Member Blunt, and members of the
    subcommittee, thank you for the opportunity to submit this testimony
    for the record in support of at least $250 million in Fiscal Year 2023
    funding for the Data Modernization Initiative and the Center for
    Forecasting and Outbreak Analytics at the Centers for Disease Control
    and Prevention (CDC). My name is Janet Hamilton, I am the Executive
    Director of the Council of State and Territorial Epidemiologists
    (CSTE). CSTE represents public health epidemiologists nationwide
    working on the front lines to respond to emerging public health
    threats--including, recognizing and identifying the very first
    introductions of COVID-19, and then responding daily during the COVID-
    19 pandemic.
        As you know, COVID-19 exposed deadly gaps in our Nation's public
    health data infrastructure. After years of neglect, our antiquated
    public health data systems were not prepared to handle the onslaught of
    a pandemic caused by a highly infectious virus. Instead, paper-based
    systems, phone calls, spreadsheets, and faxes requiring data entry by
    hand remain in widespread use and left us ill-equipped to combat the
    spread of the virus as it emerged and surged. Delayed detection and
    response had dire consequences. And, while COVID-19 is the most
    recent--and ongoing-threat that requires a robust public health
    response, it is not the only threat we face nor last public health
    threat we will face. As we submit this, a new emerging threat leading
    to unexplained hepatitis in children is emerging--illnesses
    (potentially due to adenovirus) can be severe, associated with
    hospitalization and liver transplants in some children. Led by the CDC,
    State and local health departments across the country need a nationwide
    public health surveillance system to detect emerging threats and
    facilitate immediate response to keep our population safe.
        Prior to the COVID-19 pandemic, CSTE initiated the call for
    improved public health surveillance systems. The pandemic only made it
    clearer that this goal cannot wait. With our partners at the Data:
    Elemental to Health Campaign we called on Congress to provide the first
    ever dedicated funding for public health data systems and to build a
    21st century public health data superhighway. Thanks to the work of
    this subcommittee, Congress answered the call and has provided annual
    funding as well as critical injections of supplemental funding through
    the CARES Act and the American Rescue Plan for CDC's public health Data
    Modernization Initiative--or DMI.
        The DMI is a commitment to building the world-class data workforce
    and data systems that support daily operations and are `response-ready'
    for the next public health emergency with capacity to surge and scale.
    We are grateful to this subcommittee for providing more than $1 billion
    to date for DMI through annual and supplemental appropriations.
    Unfortunately, it is not enough to meet our Nation's current or long-
    term public health surveillance needs, which Data: Elemental to Health
    estimates will cost at least $7.84 billion over 5 years. In the
    immediate term, we need robust, sustained, annual funding for DMI to
    ensure we are providing resources for public health systems and
    infrastructure, including at State and local health departments, to
    keep pace with evolving technology.
        DMI is an enterprise approach and there are five key interconnected
    pillars essential for public health data modernization. They are:
        1. Electronic Case Reporting,
        2. The National Notifiable Disease Surveillance System (NNDSS),
        3. The Electronic Vital Records System,
        4. Syndromic Surveillance, and
        5. Laboratory Information Systems.
        We need electronic Case Reporting (or eCR) to give health care
    providers a means to seamlessly communicate with public health. eCR
    will help guarantee that when providers see patients--in any setting--
    patient demographics, clinical information, and test results for
    reportable conditions (including, but by no means limited to COVID-19)
    are rapidly shared with State and local public health and then able to
    be seamlessly incorporated into CDC's National Notifiable Disease
    Surveillance System (NNDSS). eCR also assists with data completeness
    and rapidly understanding health inequities. DMI investments in eCR are
    already paying off. For example, race and ethnicity data received on
    case reports in pilot jurisdictions are over 90 percent complete which
    will support a more robust ability to appropriately address health
    disparities. More than 11,000 health care facilities were brought on
    board between January 2020 and February 2022. All 50 States, DC, and
    Puerto Rico, as well as 13 jurisdictions have received initial
    electronic case reports for COVID-19 ad more than 18 million COVID-19
    case reports have been sent electronically to public health agencies--
    each representing a report that a health care provider did not have to
    enter manually!
        Resources are needed to make improvements in NNDSS and rapid data
    submission from States to CDC. For example, state, territorial, local,
    and Tribal health department staff serve as disease detectives
    contacting and interviewing cases gathering detailed information to
    learn how and where they may have become infected--are they part of a
    cluster or outbreak, or what co-factors may have led to a more severe
    illness? For example, during the Zika response, case investigations
    conducted by the local health department identified persons working on
    elevators were at increased risk of infection as standing water often
    collected in the bottoms of open-air elevator shafts serving as
    breeding location for mosquitos. After case investigations and
    interviews are conducted, resources are needed to provide those details
    to the CDC through NNDSS. Numerous similar examples exist for COVID-19
    where health department staff conduct outbreak investigations or
    identify clusters from genomic sequencing but are unable to
    electronically share those data with CDC's NNDSS due to agency
    infrastructure shortages. Additionally, right now, there are multiple
    jurisdictions who have the desire to provide more detailed COVID-19
    case information to CDC, but don't have the data work force and
    resources to update file structures and data processes to submit those
    data.
        We need an electronic lab test ordering and result process that
    supports the collection of information to launch a rapid public health
    response. Seamless electronic communication is critical--a health
    department forced to sort through mailed or faxed lab reports will not
    be able to respond promptly or adequately to an emerging threat.
    Investments here have also shown early success. Electronic laboratory
    reporting (ELR), which has now been implemented across the country,
    formed the backbone of our case surveillance for COVID-19, enabling
    States, localities, territories, Tribes and the Federal Government to
    have timely information to identify cases, where those cases lived, and
    basic information about their age. Without ELR we would never have been
    able to conduct control measures and know what was happening in
    virtually every jurisdiction. In many jurisdictions this information is
    automatically uploaded and ready for analysis within a day of the
    result.
        We need improvements to our electronic vital records systems to
    ensure real-time transmission of birth and death data for statistical
    and--critically during a pandemic--surveillance purposes. We must make
    sure systems are interoperable so physicians, coroners, medical
    examiners, and funeral directors can seamlessly report deaths through
    their existing electronic records systems--eliminating delays and
    reducing errors.
        Standards-based interoperability will also help identify threats as
    they emerge. As it stands, nearly one third of all emergency department
    visits are not reported to the National Syndromic Surveillance Program,
    which helps detect, monitor, control and prevent emerging diseases.
        These five pillars are interwoven, and each plays a key role in
    moving the United States from an outdated and burdensome patchwork of
    systems to a 21st Century public health data infrastructure that
    provides complete, accurate, and instantaneous data. Again, DMI is an
    enterprise-wide approach, which will support widespread and rapid
    access to public health data for all public health programs at all
    levels of government for all diseases and conditions. Just like a
    rising tide lifts all boats, a public health data superhighway improves
    all public health programs. Public health needs a coordinated and
    integrated approach to using data to deliver on mission, serve the
    public, and steward resources while respecting privacy and
    confidentiality. Currently, CDC has many siloed public health
    surveillance systems, many of which are not interoperable, which
    results in duplicated and redundant data entry. DMI will help break
    down those siloes and ensure all systems are integrated and
    interoperable.
        Equally important is a skilled workforce that includes
    epidemiologists, public health informaticists, data scientists, and
    other experts--all of whom work together so that the public health
    surveillance system is capable of detecting and monitoring current
    threats and ready for the next pandemic. The Administration has
    committed to strengthening our Nation's public health workforce,
    including epidemiologists and data scientists and we urge the committee
    to continue to provide resources towards this goal. This is an
    important step forward to grow and build the next-generation public
    health workforce and we hope to see the committee support continued
    funding to sustain this progress.
        Working hand-in-hand with DMI, CDC's newly established Center for
    Forecasting and Outbreak Analytics (CFA) will facilitate the use of
    data, modeling, and analytics to improve pandemic preparedness and
    response. The CFA is already doing critical work, including helping to
    inform government response to the spread of the Omicron variant of
    COVID-19 in late 2021.
        We do not have a science problem; we have a resource problem. The
    core data systems for a national infrastructure already exist they must
    be modernized and maintained so they can keep pace with new technology.
        CSTE applauds President Biden for proposing an unprecedented
    investment in CDC through his discretionary budget request. The
    President requested $10.675 billion for CDC. As part of this
    significant and well-warranted funding proposed increase, the President
    seeks to ``prioritizes investments that will modernize public health
    data collection, increase capacity to forecast and analyze future
    outbreaks, and operationalize lessons learned from the COVID-19
    response.'' We also support the President's proposal to invest $81.7
    billion in mandatory funding toward pandemic preparedness efforts,
    including $28 billion for CDC to invest in critical efforts, including
    public health infrastructure and DMI. We encourage Congress to make
    this proposal a reality.
        To make our public health systems work now, and in the future, we
    need regular, sustained annual funding for our public health
    surveillance. We respectfully request the subcommittee provide funding
    of at least $250 million for DMI and $50 million for CFA at CDC in
    Fiscal Year 2023.
        Thank you.

        [This statement was submitted by Janet Hamilton, MPH, Executive
    Director, Council of State and Territorial Epidemiologists.]
                                     ______

           Prepared Statement of the Council on Social Work Education
                    department of health and human services
      --$25 million for the Minority Fellowship Program (MFP) at Substance
            Abuse and Mental Health Services Administration
      --Heath Resources and Services Administration (HRSA):
        --$225.8 million for HRSA's Behavioral Health Workforce Education
                and Training (BHWET) grant program;
        --$55.014 million for Scholarships for Disadvantaged Students;
        --$82 million for the Geriatrics Workforce Enhancement Program
                (GWEP) and the Geriatrics Academic Career Award (GACA)
        --$15 million for continued support of a demonstration program to
                strengthen the mental and substance disorders workforce;
      --$20 million for continued support of the Loan Repayment Program for
            Substance Use Disorder Treatment Workforce
      --$49.048 billion for National Institutes of Health (NIH)
        --NIH report language on Office of Behavioral and Social Sciences
                Research working groups
                            department of education
      --$13,000 for the maximum individual Pell Grant;
      --Experimental sites for paid internships for social work students
        CSWE is a nonprofit national association representing over 900
    accredited baccalaureate and master's degree social work programs, as
    well as individual social work educators, practitioners, and agencies
    dedicated to advancing quality social work education. We appreciate
    your efforts and leadership on issues that impact social work, social
    work education, and the wellbeing of individuals, families, and
    communities and social and economic justice.
        We encourage you to consider the following appropriations requests
    that will support social work programs and social work students in the
    fiscal year (FY) 2023 appropriations process. Pressing societal
    challenges and public health challenges like the twin pandemics of
    CoVID-19 and systemic racism, the opioid crisis and other substance-use
    issues, growing mental and behavioral health needs, workforce
    shortages, and rising higher education costs, are just some of the
    challenges facing social work students and practitioners. Your support
    of these appropriations requests will help meet these challenges.
        Federal funding helps strengthen the pipeline of social workers,
    addresses the needs of vulnerable and at-risk populations, and supports
    students, including those from disadvantaged backgrounds. Social work
    students go on to work in a diversity of fields including child
    advocacy, geriatrics, school social work, healthcare and other fields.
    As policymakers continue to focus on the social determinants of health,
    support for social workers, who are the workforce at the center of
    addressing these social factors, will be critical. CSWE's FY 2023
    requests (as detailed below) illustrate support for important programs
    that address vital health workforce needs, provide invaluable student
    aid, address the social determinants of health, and promote important
    health-care research. We respectfully ask for your support of these
    requests during the FY 2023 appropriations process.
        Substance Abuse and Mental Health Services Administration: $25
    million for the Minority Fellowship Program (MFP). For more than 45
    years, MFP has been increasing the number of professionals preparing
    for leadership roles in mental health and substance use fields and
    working to reduce health disparities and improve behavioral health-care
    outcomes for racial and ethnic populations. CSWE urges the committee to
    include $25 million for the MFP in FY 2023.
        CSWE requests the following report language be included in the FY
    2023 Labor-H report: The Committee believes that among the many
    consequences of COVID-19, the increasing rates of burnout facing the
    mental and behavioral health workforce has negatively impacted the
    resilience of the Nation's public health infrastructure. The pandemic
    has laid bare the need to strengthen the public health workforce
    pipeline and the need to provide educational opportunities to all who
    wish to pursue a career in mental and behavioral health care. The
    Committee urges the Minority Fellowship Program in the Substance Abuse
    and Mental Health Services Agency to explore ways in which to expand
    program eligibility, particularly for students who fall under the
    Temporary Protected Status (TPS) and Deferred Action for Childhood
    Arrival (DACA) programs. These students, the majority of whom have
    lived most of their lives in the United States, are an invaluable
    resource to bolster our public health infrastructure and mental and
    behavioral health care workforce.
        Health Resources and Services Administration: $225.8 million for
    HRSA's Behavioral Health Workforce Education and Training (BHWET)
    program. CSWE was pleased to see continuous investments for the BHWET
    program in the fiscal Year2022 Labor-HHS-ED appropriations bill. BHWET
    supports the recruitment and education of behavioral health-care
    providers, which is critical as the Nation continues to combat the
    pandemic, the opioid crisis, and substance use disorders. The number of
    training programs supported by BHWET has grown tremendously over the
    past several years, particularly amongst social workers. Social workers
    represent the most diverse health profession in the Nation and as
    efforts are taken to bolster the public health infrastructure, social
    workers represent a model for continued workforce growth and diversity.
    As the Nation's demand for well-equipped behavioral health-care
    providers continues to grow, we hope you will support $225.8 million
    for BHWET in FY 2023.
      --$55.014 million for Scholarships for Disadvantaged Students. This
            program helps ensure that the United States has the pipeline of
            health professionals to meet health needs of underserved
            individuals and communities. Furthermore, this program provides
            much needed opportunities for students from disadvantaged
            backgrounds.
      --$51 million for the Geriatrics Workforce Enhancement Program
            (GWEP). GWEP supports training and educating health
            professionals, including social workers, as well as direct care
            workers, and family caregivers in the care of older adults. It
            is the only Federal program that focuses on developing a
            health-care workforce that maximizes patient and family
            engagement while improving health outcomes for older adults.
            GWEPs are successfully integrating and equipping a primary care
            workforce and family caregivers with the knowledge and skills
            to care for older adults and build community networks to
            address gaps in health care for seniors.
      --$15 million for continued support of a demonstration program to
            strengthen the mental and substance disorders workforce.
      --$20 million for continued support of the Loan Repayment Program for
            Substance Use Disorder Treatment Workforce.
        National Institutes of Health (NIH): $49 billion in FY 2023 for the
    National Institutes of Health. CSWE appreciates the continued support
    from Congress and the increased funding for NIH. To build on the
    advances in research, CSWE hopes you will support continued investments
    in biomedical and health-related research that incorporates the social
    and behavioral science research necessary to better understand and
    address the needs of high-risk populations including children,
    minority, and geriatric populations. Social and structural determinants
    of health play a large role in the health disparities that plague
    society. Social factors play a major role in people's health and as a
    result NIH needs to fund behavioral and social science research that
    tests innovations in the design of health care and integrate social
    care into health care and health care into social services. In
    addition, research must be funded that tests the effectiveness of these
    integrated services. NIH should expand research opportunities in this
    area to provide meaningful, comprehensive, and long-lasting
    improvements in health care delivery.
        CSWE requests the following report language be included in the FY
    2023 Labor-H report: The Committee believes that a more robust and
    focused NIH commitment to behavioral and social science research and
    training would yield significant improvements to the Nation's health
    due to the important connections between social and physical conditions
    and health. Many of the leading causes of health disparities in our
    Nation are related social and structural determinants of health like
    race, income, access to care, housing, and employment. In the shadows
    of the COVID-19 pandemic, addressing these health disparities continues
    to be key challenge in our efforts to improve health across all
    populations. The 2019 Consensus Study Report from the National
    Academies of Science, Engineering, and Medicine entitled ``Integrating
    Social Care into the Delivery of Health Care'' highlighted the growing
    need to understand how social factors play a major role in people's
    health. The Committee provides $10,000,000 for the Office of Behavioral
    and Social Sciences Research for grants, Notices of Special Interest
    (NOSI), and other funding mechanisms to support this work and urges NIH
    to consider how its programs in health services, translational,
    intervention, and implementation research are inclusive of social
    determinants of health research and researchers.
        Department of Education: $13,000 in FY 2022 for the maximum
    individual Pell Grant. Pell Grants are critical to ensuring access and
    affordability in higher education. CSWE also supports increasing the
    amount of Pell funding that is supported by mandatory spending. Student
    aid programs, particularly grant programs, represent important
    investments and help students avoid crushing debt burdens when they
    graduate.
      --Support for the Public Service Loan Forgiveness (PSLF) Program.
            PSLF is an integral program to ensuring a pipeline of
            professionals in public service serving in high-needs areas.
            CSWE encourages Congress to continue support for this vital
            program and programs like the Temporary Expanded Public Service
            Loan Forgiveness (TEPSLF), which assists public service workers
            who were enrolled in ineligible loan repayment programs. In
            addition to continuing support for PSLF, CSWE asks Congress to
            continue oversight of how the Department of Education is
            implementing the program.
      --Support for Paid Internships for Social Workers. Social work
            students are required to participate in at least 400 hours of
            field experience and at the graduate level masters students are
            required to complete at least 900 hours. These experiences are
            critical to ensuring the development of a professional social
            work workforce. Yet many times these experiences are unpaid.
            CSWE requests the following report language be included in the
            FY 2023 Labor-H report: The Committee directs the Department of
            Education to consider the feasibility of using its Experimental
            Sites authority for a pilot to use Federal Work Study and other
            financial aid funding to support social work students involved
            in internships and field experiences. The Department is
            directed to provide a report to the Committees on Education and
            Labor, and on Appropriations of the House of Representatives
            and on the Committees on Health, Education, Labor, and Pensions
            and on Appropriations of the Senate on its plan for an
            Experimental Sites Initiative. Point of Contact: Otto Katt,
            otto@lewis-burke.com.
                                     ______

         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 percent 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 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 definitively diagnose human prion diseases, determine their
    origin, and determine whether the spread of CWD found in elk and deer
    in 30 States in the U.S. and in 4 Canadian provinces has become a human
    risk. A study in progress has reported 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 among its own species and the disease
    transmits by contact and through contaminated environment, including
    soil and plants, in free ranging and farmed 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 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 7 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 epidemiologic 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, what risk 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 approximately 8,000 suspected
    cases of suspected prion disease and has definitely confirmed presence
    and type of prion disease in more than 4,800 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
    approximately 8,000 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, CJD Foundation.]
                                     ______

                  Prepared Statement of 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 its ongoing
    commitment to, and support for, sustained and continued 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 $226 million in Fiscal Year 2023 above the final
    enacted amount for Fiscal Year 2022 for Alzheimer's disease research at
    the NIH.
        Additionally, Cure Alzheimer's Fund respectfully requests at least
    an additional $60 million in total appropriations for the Brain
    Research through Advancing Innovative Neurotechnologies (BRAIN)
    Initiative. Because of the past investments this subcommittee has made
    in the BRAIN Initiative, and with its interest in increasing early
    detection and diagnosis of Alzheimer's disease, the tools developed by
    the BRAIN Initiative are becoming ever more important to the search for
    a cure for 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 in 2004, Cure Alzheimer's Fund has invested more than $145
    million in research through 615 grants across the United States and
    internationally.
        In my past testimony, I have highlighted several areas of novel
    research that Cure Alzheimer's Fund has supported. Many of these are of
    interest to Congress as well as shown through the Report Language
    accompanying the Appropriations bills. Things like Diabetes, Herpes,
    and the Exposome, and their impacts on the development of Alzheimer's
    disease are some of the areas of research that were highlighted in the
    Fiscal Year 2022 Appropriations Bill Report Language.
        These are all areas in which Cure Alzheimer's Fund has long
    supported early-stage research.
        As far back as 2010, Cure Alzheimer's Fund was investing in
    research into the relationship between Alzheimer's disease and
    Diabetes.
        Research conducted by Sam Gandy at the Icahn School of Medicine at
    Mount Sinai was focused on the gene for a protein called SorSC1. SocSC1
    has been independently linked to both Alzheimer's disease and Type II
    Diabetes. Cure Alzheimer's Fund research focused on better
    understanding the potential link between Alzheimer's disease and
    Diabetes.
        https://curealz.org/research/translational/studies-of-novel-ad-
    genes/brain-structure-abeta-metabolism-and-behavior-in-mice-deficient-
    in-diabetes-and-alzheimers-associated-sorcs1/.
        Cure Alzheimer's Fund is continuing this line of investigation by,
    among other efforts, supporting research in the lab of Dr. Miranda Orr
    at Wake Forest University exploring the impact of a high-fat diet and
    consequent metabolic syndrome on the onset of cellular senescence in
    neurons containing Alzheimer's tau pathology.
        In 2015, Cure Alzheimer's Fund supported research into the
    hypothesis that beta amyloid plaques form as part of the brain's immune
    response to pathogens like Herpes Simplex Virus. This was the beginning
    of research into the theory that Beta-Amyloid is part of the innate
    immune system; research that I have highlighted often in my submitted
    testimony.
        https://curealz.org/research/translational/studies-of-tau/abeta-
    expression-protects-the-brain-from-herpes-simplex-virus/.
        This early-stage, novel theory research supported by Cure
    Alzheimer's Fund led to two journal articles published in Neuron in
    2018. These journal articles further established the link between
    pathogens like Herpes and Alzheimer's disease.
        https://curealz.org/news-and-events/evidence-of-the-link-between-
    alzheimers-and-herpes-continues-to-grow/.
        https://www.cell.com/neuron/fulltext/S0896-6273(18)30526-9.
        https://www.cell.com/neuron/fulltext/S0896-6273(18)30421-5.
        Dr. Rob Moir at Massachusetts General Hospital originally had the
    idea that Beta Amyloid was part of the innate immune system and is an
    antimicrobial.
        Although Dr. Moir passed away in 2019, the research spurred by his
    idea continues today, and is an important area of research for Cure
    Alzheimer's Fund, this subcommittee, and Alzheimer's disease research
    in general.
        In my submitted testimony last year, I highlighted the research
    supported by Cure Alzheimer's Fund that is focused on the role
    particulate matter and pollution play in the development of Alzheimer's
    disease. These exposome influences are important to not only better
    understanding Alzheimer's disease pathology, but also to understanding
    environmental justice and social determinants of health and how the air
    we breathe can influence our cognitive health.
        https://curealz.org/research/translational-research/air-pollution-
    and-app-processing/.
        The Fiscal Year 2022 Appropriations Bill Report Language also
    referenced increasing and improving diversity in clinical trials,
    improving diagnostic tools, and creating new tools for measurement of
    cognitive impairment.
        Although the early-stage research supported by Cure Alzheimer's
    Fund is not focused specifically on these areas, the work by Cure
    Alzheimer's Fund to diversify research and brain banks samples will
    inform these efforts.
        Knowing that having diversified samples available to researchers is
    vital to not only the work Cure Alzheimer's Fund is supporting, but
    also for other researchers working on other dementias and neurological
    conditions, Cure Alzheimer's Fund is working with the Brain Donor
    Project on a specific project to increase and improve outreach to
    underrepresented populations to increase brain donations. This project
    will help to create a more diversified brain bank with samples that
    will be available to all researchers working on all neurological
    conditions.
        https://curealz.org/research/foundational/biomarkers-diagnostics-
    studies-of-risk-resilience/targeted-recruitment-of-underrepresented-
    americans-for-brain-donation-registration/.
        The Fiscal Year 2022 Appropriations Bill Report Language also
    referenced the relationship between Alzheimer's disease and Down
    syndrome. These are also areas in which Cure Alzheimer's Fund has been
    supporting research. As this subcommittee is aware, individuals with
    Down syndrome are virtually certain to have Alzheimer's disease
    pathology and clinical symptoms by the time they are 50 years old
    because their genetic trisomy leads to overproduction of the amyloid
    precursor protein.
        In 2014, Cure Alzheimer's Fund hosted a webinar focused on the
    relationship between Down syndrome and Alzheimer's disease.
        https://curealz.org/news-and-events/alzstream-webinar-alzheimers-
    and-down-syndrome/.
        Recent public discussion of the anti-amyloid immunotherapy Aduhelm
    brought renewed attention to the importance of including the Down
    syndrome community in research on Alzheimer's disease. Cure Alzheimer's
    Fund recently funded work in the lab of Dr. William Mobley and the late
    Dr. Steven Wagner at the University of California San Diego testing an
    anti-amyloid oral therapeutic in a mouse model recapitulating both Down
    syndrome and amyloid pathology; this therapeutic has received
    significant funding from the NIH Blueprint program and will enter
    clinical trials in the next 9 months. It is of high potential to the
    Down syndrome community.
        Cure Alzheimer's Fund has been supporting the research of Beth
    Stevens at Boston Children's Hospital. It may seem strange for an
    Alzheimer's disease organization to be supporting research at a
    pediatric hospital, but it is important work with insights into several
    neurological conditions including Alzheimer's disease and autism.
        Dr. Stevens is researching Microglia and the role Microglia play in
    synapse development and elimination. Microglia plays an important role
    in pruning synapses in early life. During brain development,
    insufficient synapse pruning can lead to autism spectrum disorders.
    However, overaggressive synaptic pruning in older adults can lead to
    cognitive decline.
        https://curealz.org/researchers/beth-stevens/.
        https://curealz.org/research/translational/studies-of-innate-
    immune-pathology/early-role-of-microglia-in-synapse-loss-in-alzheimers-
    disease/.
        This research shows how the drivers of neurological conditions are
    interrelated and that research into one condition could provide insight
    and answers to other conditions. This research also shows the value of
    the sustained and continuing investment in, and commitment to,
    Alzheimer's disease research made by this subcommittee. The commitment
    demonstrated by this subcommittee is providing NIH with the resources
    necessary for it to be able to invest in several novel targets
    simultaneously. And as I have described in this testimony, many of
    these novel targets are the result of early-stage research supported by
    private organizations like Cure Alzheimer's Fund.
        Groups such as Cure Alzheimer's Fund can provide vital initial
    research funding allowing researchers to prove their concepts and
    compile initial data sets. With this information, researchers are then
    able to approach NIH for larger-scale and longer-term funding. It is a
    great example of public-private partnerships that are proving to be
    very important to advancing Alzheimer's disease research, as well as
    other neurological conditions.
        This is only possible because of the commitment to Alzheimer's
    disease research shown by this subcommittee. Without adequate
    resources, NIH would not be able to pursue these different avenues of
    research; which are stated areas of interest to this subcommittee and
    Congress.
        It would be disheartening, with all the advancements that have been
    made in the last 10 years, if NIH was not able to continue its broad-
    based research portfolio because of limited research funding. As
    progress is being made toward the goals of the National Alzheimer's
    Project Act, it is even more important for this subcommittee to
    continue to demonstrate its commitment to Alzheimer's disease research
    funding at NIH.
        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 $226 million above the
    final enacted level in Fiscal Year 2022 for Fiscal Year 2023 for
    Alzheimer's disease research at NIH, and at least an additional $60
    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 May 11, 2022.

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

                  Prepared Statement of Dave Purchase Project
        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 $150 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 2021, 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 $20,000 to 16 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 continues to experience a public health emergency
    related to overdose, with over 106,000 overdose deaths counted between
    November 2020 and November 2021 and deaths increasing by an alarming 45
    percent since January 2020. According to provisional CDC data, overdose
    deaths continue to accelerate in Washington, increasing by 28 percent
    in the latter half of 2021.
        Overdose deaths have increased more dramatically among Black people
    and communities of color. In 2020, Black people had the largest
    percentage increase in overdose mortality--48.8 percent. The Hispanic
    or Latino community experienced a 40.1 percent increase in overdose
    deaths as compared to white people who experienced a 26.3 percent
    increase. American Indians and Alaska Natives experienced the highest
    rate of overdose mortality of all ethnic groups in 2020, a mortality
    rate 30.8 percent higher than that of white people.
        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.
    In 2020 and 2021, in response to the housing crisis, we increased our
    outreach to individuals living houseless in encampments in Pierce
    County, WA. One of our outreach workers was able to connect to a
    disabled veteran who was experiencing active addiction and had been
    living houseless for several years. He was in rough shape as a result
    of an assault and had open, infected, wounds that required immediate
    attention. Our outreach worker cleaned and dressed the wounds and was
    subsequently able to get this individual a new tent in a safe location.
    He then referred the individual to our peer care navigator who was able
    to get the individual into medically assisted treatment for his opioid
    use disorder. The navigator was also able to secure a place to live for
    this individual in a tiny home village for veterans.
        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 2020/2021, our team distributed approximately 19,000 doses
    of naloxone and 1,722 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 percent of the reported overdose
    reversals were performed by community members--other drug users, family
    members, friends, bystanders--and not by first responders. With
    additional resources, SSPs could 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 percent. 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. NASEN's March
    2020 survey of 173 SSPs--almost 40 percent of SSPs nationwide--showed a
    43 percent decrease in SSP services as a result of COVID-19. A similar
    Drug Policy Alliance survey showed that 91 percent of respondents
    experienced an increase in clients in 2020. Funding shortfalls and
    increased need for services have persisted into 2022. As a result of
    increasing need coupled with decreased, limited resources, SSPs cannot
    reach the millions of people who could benefit from their life-saving
    services, including overdose prevention and access to critical health
    care.
        Federal funding would expand access to critical and effective SSP
    programs. NASEN's own data show that there are only approximately 400-
    600 SSPs operating nationwide. The United States could easily use as
    many as 4000 programs--7-10 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 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 FY 2021, CDC provided technical assistance
    to help ensure high-quality, comprehensive services and best practices
    for SSPs.
        If Congress were to provide $150 million in FY23 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. It is urgent that Congress 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. My brother overdosed on fentanyl, but
    thankfully survived. Because he survived, in January 2022, after many
    months of transient homelessness and estrangement from my family, my
    brother entered a residential treatment facility for his substance use
    disorder. He stated he was tired of the isolation, the homelessness,
    and the constant feeling that he was vulnerable and worthless. Mostly,
    he said, ``I miss the family.'' This is not the first time he has been
    in treatment--and likely not the last. But with the support he receives
    from his treatment team, his recovery community, and my family, we see
    improvements in his personality and his outlook on life and, in
    fleeting moments, we catch glimmers of the sweet, gullible, brother he
    is when he is not using meth.
        Thank you for your time and consideration of my testimony. Please
    do not hesitate to contact me, Jenny Collier at
    jcollier@colliercollective.org, or Bill McColl at
    bmccoll@colliercollective.org if you have questions or need additional
    information.

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

                       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, 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. 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. 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. In fiscal year (FY) 2023, Duke Health supports a program
    level of at least $49.048 billion for the NIH base budget, which would
    represent an increase of $4.1 billion over the comparable FY 2022
    funding level (an increase of $3.5 billion or 7.9 percent in the NIH
    appropriation plus funding from the 21st Century Cures Act for specific
    initiatives). Duke Health strongly urges lawmakers to ensure that any
    funding for the new Advanced Research Projects Agency for Health (ARPA-
    H) supplement our $49 billion recommendation for NIH's base budget,
    rather than supplant the essential foundational investment in the NIH.
        Duke Health appreciates the inclusion of $52 million in the FY 2022
    Consolidated Appropriations Act (Public Law 117-103) for the National
    Institute of Allergy and Infectious Disease to support Regional
    Biocontainment Laboratories (RBLs) for research, operation support, and
    training new researchers in biosafety-level (BSL) 3 practices.
    Continued Federal investment in the RBLs will strengthen the Nation's
    research on biodefense and emerging infectious disease agents and
    improve our response to future public health emergencies. For FY 2023,
    Duke Health respectfully requests $52 million to be shared among the 12
    research institutions to conduct research on developing tests for new
    antiviral compounds, vaccines, and point of care tests; support
    operations costs and purchase of equipment to keep the laboratories up
    to date and safe; and support personnel trained in biosafety level 3
    and 2 practices to ensure the highest level of expertise is brought to
    bear on these research needs that are critical for the security of the
    U.S.
        Duke Health also appreciates the Committee's support for the
    National Center for Advancing Translational Sciences (NCATS) Clinical
    and Translational Science Awards (CTSA) Program. In FY 2023, Duke
    Health urges the Committee to consider urging NCATS to make
    supplemental funding available to Minority Serving Institutions that
    partners with CTSAs to incentivize these partnerships. We also ask the
    Committee to urge NCATS to increase the cap for CTSA Program Hubs.
        Finally, Duke Health asks the subcommittee not to include language
    that would limit the use of nonhuman primates in research, which 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 $11 billion for the
    CDC in FY 2023. Within the CDC, Duke Health also requests the Committee
    consider including $10 million for the Sickle Cell Disease (SCD)
    surveillance program within the National Center for Birth Defects and
    Developmental Disabilities' Blood Disorder Division. Additional Federal
    funding for CDC's SCD Data Collection Program is also necessary to
    allow the program to be expanded to include additional States with the
    goal of covering the majority of the U.S. SCD population over the next
    5 years.
                     nih and cdc firearm violence research
        Duke Health is grateful for investments from Congress to support
    firearm violence research. As outlined in the FY 2023 NIH Budget
    Justification to Congress, violence is a widespread public health
    problem that has profound impacts on lifelong health, opportunity, and
    well-being. Duke Health asks the Committee to consider $35 million for
    the CDC and $25 million for the NIH to conduct public health research
    into firearm morbidity and mortality prevention. We also encourage
    Congress to explore opportunities for building out and further
    supporting this research at all other appropriate agencies, to ensure
    that federally funded research can explore the full scope of this
    public health issue.
              health resources and services administration (hrsa)
        Duke Health appreciates the subcommittee's continued investment in
    Title VII health professions training programs and Title VIII Nursing
    Workforce Development programs at HRSA. These programs help ensure a
    well-trained pipeline of health professionals to meet the increasing
    health needs facing the United States. These programs also increase the
    diversity and cultural competency of our Nation's health care
    workforce, which is increasingly important as the U.S. population grows
    and becomes more diverse. For FY 2023, Duke Health respectfully
    requests that the subcommittee provide $980 million to Title VII health
    professions programs, and $530 million to Title VIII Nursing Workforce
    Development 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 also supports the president's
    proposal to provide support for programs to address clinician burn-out
    and well-being, as authorized under Title VII and established in the
    recently enacted Dr. Lorna Breen Health Care Provider Protection Act.
        Duke Health urges the subcommittee to provide $23 million in FY
    2023 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. Umbilical cord blood units have the advantage of use
    without full matching which specifically meets the needs of patients of
    non-Caucasian ancestry. These patients have the lowest chance of
    finding a complete match, but can still have access to transplantation
    therapy using a partially matched banked umbilical cord blood donor
    unit.
        Duke Health respectfully requests the subcommittee provide $37
    million for the C.W. Bill Young Cell Transplantation Program through
    the NCBI at HRSA in FY 2023. 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 not less than $500
    million for the Agency for Healthcare Research and Quality in FY 2023.
    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 and primary care research, AHRQ is the bridge between
    cures and care, and ensures that Americans get the best health care at
    the best value. For example, funding from AHRQ supports patients with
    sickle cell disease, 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, particularly through the development and
    use of evidence-based decision support tools.
       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
    2023, Duke Health urges the subcommittee to provide $150 million for
    NCTSN, which matches the president's budget request.
        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,
    fully authorized funding, for the Military and Civilian Partnership for
    the Trauma Readiness Grant Program for FY 2023 within ASPR. Originally
    known as MISSION ZERO, this critical program provides 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. Building upon FY 2022's initial
    investment, 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 2023
    _______________________________________________________________________

      --Provide $49 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 $11 billion to facilitate timely public health
            efforts.
      --Please provide $6 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
        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).
        Most of the dystonia research at NIH is supported by NINDS. NINDS
    has utilized several 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 several 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
    2022. 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 support of the
    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 3 months for
    temporary relief of symptoms. This has worked well for me for over a
    decade. At the start of this year, my insurance coverage changed when
    my husband's company changed providers. As a result, I had to undergo
    an extensive review process and change methods for obtaining my
    medicine. The review lasted for four weeks. Multiple times during this
    time, my doctor and I were told that I had been denied coverage. We had
    to make numerous phone calls to encourage the company and specialty
    pharmacy to review my case again and again. These phone calls were
    extremely difficult as my voice deteriorated from the delay in
    treatment. The automated phone systems were the worst, but the
    representatives also had trouble understanding my broken voice and I
    had to repeat my information over and over. Finally, the company
    determined my treatment is medically necessary and has approved it for
    1 year. After a seven-week delay, I am scheduled for my injection and
    am looking forward to a period of spasm-free speaking.
        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 The Education Trust
        On behalf of The Education Trust, a national nonprofit that works
    to close opportunity gaps that disproportionately affect students of
    color and students from low-income families, thank you for the
    opportunity to present testimony on the Fiscal Year 2023 (FY23) Labor,
    Health and Human Services, Education, and Related Agencies (L-HHS-ED)
    Appropriations bill. We request that the L-HHS-ED bill make substantial
    investments in excess of prior, cap-limited years to ensure that
    essential education programs have the resources they need to ensure the
    greatest impact for students of color and students from low-income
    communities.
        While there are many programs under your jurisdiction that are
    critical to advancing equity, in FY23, The Education Trust is focused
    on the following:
      --Strengthening the Pell Grant program by increasing the maximum
            award to keep pace with inflation, at a minimum, and ideally,
            doubling the maximum award.
      --Supporting teachers and school leaders by including funding and
            language supporting the following:
        --ESSA (Every Student Succeeds Act) Title I-A ($18.54 billion);
        --Incentives for States and localities to evaluate their education
                funding formulas and policies and implement equitable
                reforms ($100 million);
        --ESSA Title II-A ($3 billion);
        --the Teacher and School Leader Incentive Program (TSLIP) ($200
                million);
        --the Supporting Effective Educator Development Program (SEED)
                ($140 million);
        --HEA (Higher Education Act) Title II's Teacher Quality Partnership
                (TQP) grants ($300 million); and
        --restoring funding to the School Leader Recruitment and Support
                Program (SLRSP) ($40 million).
        --Maintain FY22 omnibus report language increasing equity in
                advanced coursework.
      --Enabling enhanced preparation for teaching candidates at
            Historically Black Colleges and Universities (HBCUs) and
            Minority-Serving Institutions (MSIs) by allocating at least $40
            million in funding for the Augustus F. Hawkins Centers of
            Excellence Grant program.
      --Developing and strengthening evidence-based student success
            programs by allocating $110 million in funding for the Post
            Secondary Student Success Grant program.
      --Supporting student parents by allocating $500 million in funding
            for the Child Care Access Means Parents in School (CCAMPIS)
            program.
        We urge increased support by the Committee for these critical
    programs to help meet the needs of students of color and students from
    low-income communities.
    Strengthening the Pell Grant Program
        The Pell Grant program is the cornerstone of Federal financial aid.
    The program benefits over 7 million students annually and continues to
    serve as the primary Federal investment designed to allow students from
    low-income backgrounds to access higher education. Over one-third of
    White students, two-thirds of Black students, and half of Latino
    students rely on Pell Grants every year.\1\ Pell Grant dollars are
    well-targeted to those in need: 83 percent of Pell recipients come from
    families with annual incomes at or below $40,000, including 44 percent
    with annual family incomes at or below $15,000.\2\
    ---------------------------------------------------------------------------
        \1\ Congressional Budget Office (CBO), January 2017 baseline
    projections for the Pell Grant program, http://bit.ly/2mLy0nk, Table 2;
    and Ed Trust calculation NPSAS:12 using PowerStats.
        \2\ Analysis of Federal Pell Grant Program Annual Data Report,
    available at https://www2.ed.gov/finaid/prof/resources/data/pell-
    data.html.
    ---------------------------------------------------------------------------
    Increase the Maximum Award
        The maximum Pell Grant award has failed to keep pace with the
    rapidly rising cost of college over the past several decades. In 1980,
    the maximum Pell Grant award covered 77 percent of the cost of
    attendance at a public university. Today, it covers just over 28
    percent, the lowest portion in over 40 years. Bold action must be taken
    to halt and reverse this damaging trend.
        We are appreciative of previous increases to the maximum award in
    prior appropriations bills, including the $400 increase in the Fiscal
    Year 2022 (FY22) omnibus, and we respectfully request that you continue
    to annually increase the maximum award amount. It is also worth noting
    that nearly 1,200 organizations have gone on record supporting the
    doubling of the Pell Grant.
        In FY23, Congress should, at minimum, increase the maximum award
    upward from $6,895 to keep pace with inflation. It is also time for
    Congress to implement an ambitious plan to reverse the downward trend
    of Pell's purchasing power through doubling the maximum award,
    including expanding the mandatory funding stream, ensuring that the
    maximum Pell award covers at least half of the cost of attendance at a
    public 4-year institution.
               supporting students, teachers, and school leaders
        Increase funding for ESSA's Title I-A; ESSA's Title II-A
    (Supporting Effective Instruction); the Teacher and School Leader
    Incentive Program (TSLIP), the Supporting Effective Educator
    Development (SEED) program, HEA's Title II Teacher Quality Partnership
    (TQP) grants; incentivize States and localities to evaluate their
    education funding formulas and policies and implement equitable
    reforms; and maintain FY22 report language supporting increasing equity
    in advanced coursework.
        The Education Trust, building on the prior $1 billion funding
    increase for Title I in the FY22 omnibus, supports another $1 billion
    funding increase in FY23 budget for ESSA's Title I-A program. However,
    it is important to note that most public education funding is
    distributed via State and local formulas. Therefore, any Federal
    funding increases of this size should be accompanied by levers that
    encourage States and districts to address the inequities inherent in
    those formulas. This is a tremendous opportunity to spark systemic
    reform of the status quo that sends $23 billion more to predominantly
    White school districts than predominantly non-White school districts.
    We urge the committee to think boldly about how make the overall
    education funding system more equitable, including inserting report
    language to that effect, and to include the $100 million designated for
    this purpose within the Biden-Harris administration's FY23 budget
    request in the L-HHS-ED Appropriations bill.
        Furthermore, research and experience show the powerful impact that
    teachers and school leaders have on student learning. ESSA's Title II-A
    program provides grants to States and districts that can be used to
    invest in and develop educators. These funds can be used to, among
    other things, address inequities in access to effective teachers and
    school leaders, provide professional development, and improve teacher
    recruitment and retention. States and districts can also apply for
    additional competitive grant dollars for programs like TSLIP and SEED,
    which are targeted at specific, evidence-based strategies for improving
    teacher and school leader effectiveness and increasing educator
    diversity. Additionally, HEA's Title II TQP grants, awarded to
    partnerships between high-need districts and teacher preparation
    programs at institutions of higher education, can be used to recruit
    underrepresented populations to the teaching profession. As Ed Trust's
    work continues to demonstrate the positive impact that diverse teachers
    and school leaders of color can have on the academic achievement of
    both students of color and White students, we remain supportive of
    Federal dollars to increase and bolster the diversity of the educator
    pipeline.
        Finally, research shows that Black, Latino and Native students,
    students with disabilities, and students from low-income families are
    underrepresented in advanced programs and courses (gifted and talented,
    advanced placement, international baccalaureate, honors courses, dual
    enrollment, etc.). We the inclusion of report language included in the
    FY22 omnibus that noted that funds under ESEA (Elementary and Secondary
    Education Act) may be used to implement open enrollment, automatic
    enrollment, and/or universal screening practices; to increase course
    access and success; to provide coaching and training for educators; to
    purchase materials; and/or cover exam fees for underrepresented
    students. The language also encouraged the Department to resume
    collecting data on passing rates for all Advanced Placement subject
    areas.
        Considering the Nationwide attention to the need to invest in
    educators, especially as schools work to counteract the negative
    impacts of the COVID-19 pandemic, Congress appropriated increases for
    most of these programs in FY22: $2.17B for the Title II-A grant, $85M
    for the SEED program, and $59.09M for HEA's Title II TQP grants, but
    unfortunately cut TSLIP by $27M down from $200M in FY21.
        At a minimum, in FY23, Congress should: increase Title I-A;
    allocate $100M to incentivize States and localities to evaluate their
    education funding formulas and policies and implement equitable
    reforms; increase Title II-A, TSLIP, SEED, and TQP beyond FY22 levels:
    $18.54B, $3B, $200M, $140M, and $300M, respectively, and maintain
    report language supporting increasing equity in advanced coursework.
    Restore Funding for the School Leader Recruitment and Support Program
        Landmark research funded by the Wallace Foundation has found
    ``virtually no documented instances of troubled schools being turned
    around without intervention by a powerful leader,'' and the School
    Leader Recruitment and Support Program is the only Federal program
    specifically focused on investing in evidence-based, locally driven
    strategies to strengthen school leadership in high-need schools. A
    seven-year study, concluded in 2019, of school districts that created
    pipelines to develop school leaders saw increasing gains in student
    achievement over time, showing how a sustained initiative can
    demonstrate positive effects on student learning.
        There is still a great deal of work to do, especially when it comes
    to identifying and efficiently preparing effective turnaround leaders,
    as well as sustainably supporting them to accelerate academic
    achievement, close gaps, and maintain improvement over time for all
    students and in every community. Developing strong leaders to build
    essential relationships with students and the communities they operate
    in is a fundamental necessity to help students finish the learning
    currently unfinished due to the COVID-19 pandemic. The SLRSP is a key
    lever for seeding the next generation of effective school leader
    development programs, promoting equity, advancing ongoing innovation,
    and sharing innovative lessons on transformational leadership with the
    broader field.
        In FY23, Congress should restore funding for the School Leader
    Recruitment and Support Program to $40M, the amount included in the
    FY23 President's Budget and a moderate increase from what was included
    in FY22 Senate Labor-HHS-ED Appropriations bill.
    Increase funding for the Augustus F. Hawkins Centers of Excellence
            Grant Program
        Research has shown that students of color benefit tremendously from
    having teachers of color, particularly one of the same racial
    background: they are less likely to be chronically absent or suspended
    from school, more likely to be recommended for gifted and talented
    programs, and low-income Black students who have a Black teacher for at
    least 1 year in elementary school are less likely to drop out of high
    school and more likely to consider college. And while students of color
    make up the majority of students in public schools, the diversity gap
    for teachers of color still exists across every State. For example,
    Virginia has taken steps to address their diversity gap by using their
    ARPA (American Rescue Plan Act) funds to ``provid[e] ongoing support to
    recruit, hire, and retain a diverse school staff'' including programs
    to induct and mentor new teachers of color and targeted student loan
    assistance programs for pre-service and in-service teachers of color.
        The nationwide impact of HBCUs, MSIs, Hispanic-Serving Institutions
    (HSIs), and Tribal Colleges and Universities (TCUs) on producing
    teachers of color cannot be overstated. HBCUs, TCUs, and MSIs,
    collectively, award only 11 percent of the Nation's bachelor's degrees
    in education, yet they produce more than 50 percent of the bachelor's
    degrees earned in education by Hispanic, Native Hawaiian and Pacific
    Islander students.\3\ HBCUs graduate approximately 50 percent of the
    Nation's African American teachers with bachelor's degrees.\4\ HSIs
    prepare 90 percent of Hispanic teachers, and along with other MSIs,
    constitute a vital pipeline to maintain diversity among our Nation's
    teachers.\5\
    ---------------------------------------------------------------------------
        \3\ Branch Alliance for Educator Diversity, ``Homepage,'' available
    at https://www.educatordiversity.org/.
        \4\ Jacqueline Jordan Irvine and Leslie T. Fenwick, ``Teachers and
    Teaching for the New Millennium: The Role of HBCUs,'' The Journal of
    Negro Education 80 (3) (2011): 197-208, available at http://
    www.jstor.org/stable/41341128; National Association for Equal
    Opportunity in Higher Education: Comments to the Department of
    Education proposed rule changes for teacher preparation programs
    available at: http://nafeonation.org/wp-content/uploads/2015/01/
    NADEC_Teacher_Prep_Regulations_Discussion_Document_2-2-15----.pdf.
        \5\ Hispanic Association of Colleges and Universities, ``Teacher
    Diversity,'' https://www.hacuadvocates.net/teacherdiversity?1.
    ---------------------------------------------------------------------------
        Considering the importance of these institutions, the increased
    needs they experience as result of graduating an outsized portion of
    the Nation's teachers of color, and the exacerbated nature of the
    current shortage of teachers of color due to the COVID-19 pandemic, we
    request that Congress build on the highly appreciated $8M investment
    made in the Augustus F. Hawkins Centers of Excellence grant program in
    the FY22 omnibus. Increasing Congress' investment would provide
    critical funding to these key institutions to provide increased and
    enhanced clinical experience and increased financial aid to prospective
    teachers of color, who face higher burdens in college access and
    affordability than their White peers. Finally, the FY23 President's
    Budget proposal recommended continued and additional funding for the
    program, and a recent House Dear Colleague letter in support of
    increasing funding to the program to $40 million garnered 34 signatures
    and is circulating in the Senate.
        In FY23, Congress should fund the Augustus F. Hawkins Centers of
    Excellence Grant Program at $40M.
                          supporting college students
    Fund the Post Secondary Student Success Grant Program
        Despite the gains made in high school graduation rates over the
    past several decades, the fact remains that only six in 10 students
    earn a college degree after 6 years of undergraduate study, and Black
    and Hispanic individuals have a lower rate of degree attainment than
    their White and Asian-American peers. The COVID-19 pandemic has
    exacerbated this problem: college enrollment has declined by 5.1
    percent across the board since spring of 2020. These challenges present
    the possibility of long-term negative effects on students, their
    families, state and national economies, and the country.
        Congress, with the support of 14 organizations including Ed Trust,
    included a $5 million dollar investment in Post Secondary Student
    Success Grants in the FY22 omnibus. That is a positive development that
    we look forward to helping the Department implement, but we will need
    much more to reverse these damaging trends. Prior proposals from the
    Biden administration and both chambers of Congress understood the size
    and scope of the problem of low college completion rates, and we hope
    the committee will revisit those when deciding how much to invest
    moving forward. The FY23 President's Budget proposal included a request
    for $110M for this concept, as did a recent House Dear Colleague letter
    that garnered 26 signatures and is circulating in the Senate. We
    support that funding level for this appropriations cycle.
        In FY23, Congress should fund the Post Secondary Student Success
    Grant Program at $110M.
    Fund the Child Care Access Means Parents in School (CCAMPIS) Program
        Over 20 percent of undergraduate students are parents of dependent
    children, and within that cohort, 1.7 million are single mothers. As
    detailed further in this letter from 51 organizations in support of
    this funding ask, including Ed Trust, increasing the funding for
    CCAMPIS would provide child care support for approximately 100,000 more
    student parents, giving them access to the child care services they
    need to get to and through college. This population is increasing year
    after year, and in a recent survey of over 20,000 student parents, 70
    percent indicated their current childcare provider was unaffordable.
    Furthermore, an upcoming report from Ed Trust will show that on
    average, a student parent would need to work anywhere from 30 to 90
    hours a week to cover child care and tuition costs at a public college
    or university.
        It is essential that Congress scale up the only program
    specifically designed to deliver on-campus child care to Pell-eligible
    student parents, which would dramatically enhance their chances of
    achieving educational success and financial stability.
        In FY23, Congress should fund the Child Care Access Means Parents
    in School (CCAMPIS) Program at $500M.
        Thank you for the opportunity to submit testimony. The Education
    Trust looks forward to working with Congress to allocate Federal funds
    in a way that addresses the critical equity gaps that our Nation's
    students from low-income backgrounds and students of color continue to
    face. We are happy to respond to any questions or concerns that you may
    have on these topics.
        Sincerely.

        [This statement was submitted by Denise Forte, Interim CEO, The
    Education Trust.]
                                     ______

                  Prepared Statement of the Endocrine Society
        The Endocrine Society thanks the subcommittee for the opportunity
    to submit the following testimony regarding Fiscal Year (FY) 2023
    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
    the Centers for Disease Control and Prevention (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 $50 billion for (FY) 2023; to facilitate the translation of these
    advances to improve public health, the Endocrine Society recommends the
    CDC receive funding of at least $11 billion; and to ensure that women
    have access to appropriate health services, we recommend that the Title
    X program be funded at $512 million. This request does not include
    additional emergency supplemental funds or new programs situated in NIH
    including the Advanced Research Projects Agency for Health (ARPA-H).
                   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.
           effective progress requires consistent support across nih
        Endocrinologists often study communication between different organs
    and how this influences disease, for example how hormones produced by
    adipose tissue influence the development of cancer or susceptibility to
    infections. Our members are therefore funded by many different
    Institutes and Centers (ICs) at NIH and appreciate the need to apply
    funding increases proportionally to all ICs and offices at NIH to
    effectively advance knowledge of complex biological systems and
    signaling pathways that impact multiple organs and diseases. We are
    concerned that when funding is applied disproportionally and at the
    expense of certain ICs, payline disparities increase and gaps in our
    understanding of important biological pathways emerge. Regular,
    sustainable, and proportional increases to all NIH ICs empower
    endocrinologists to develop novel interdisciplinary approaches that
    address public health priorities. For example:
      --While the National Institute of Diabetes and Digestive and Kidney
            Diseases (NIDDK) is taking a leadership role in understanding
            the pathophysiology and clinical course of COVID-19 induced
            diabetes, NIDDK also partnered with the National Institute of
            Allergy and Infectious Diseases (NIAID) and others to develop
            community-engaged testing interventions among underserved and
            vulnerable populations.\1\
    ---------------------------------------------------------------------------
        \1\ https://www.niddk.nih.gov/research-funding/current-
    opportunities/rfa-od-22-005.
    ---------------------------------------------------------------------------
      --Endocrinologists funded by National Institute of Environmental
            Health Sciences (NIEHS) in partnership with the National
            Institute for Child Health and Human Development (NICHD) and
            others are aiming to improve our understanding of how climate
            change will impact public health, for instance via impacts on
            fertility.\2\
    ---------------------------------------------------------------------------
        \2\ Audrey J. Gaskins et al., 2021.
    ---------------------------------------------------------------------------
      --Endocrine oncologists supported by the National Cancer Institute
            (NCI) and NIEHS are contributing to our knowledge of how drugs
            and consumer products can contribute to cancer risk in
            offspring.\3,4\
    ---------------------------------------------------------------------------
        \3\ 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.
        \4\ https://endocrinenews.endocrine.org/edc-exposure-during-
    pregnancy-may-reduce-breast-cancer-protection/.
    ---------------------------------------------------------------------------
      --Endocrine researchers funded by the National Institute of Mental
            Health (NIMH) and Office of Research on Women's Health are
            helping us better address gaps in understanding of how sex
            differences contribute to mental illness in men and women.
               report language opportunities for fiscal year 2023
        Research on Transgenerational Health Effects: Diethylstilbestrol
    (DES) is an endocrine-disrupting chemical that was prescribed to women
    between 1940-1971 to prevent miscarriage, premature labor, and other
    pregnancy complications. Unfortunately, not only was DES ineffective in
    preventing these complications, but it also was linked to a rare cancer
    in women and can cause a variety of cancers and other health effects in
    the daughters and sons of exposed women. Research now suggests that the
    effects of exposures may persist and cause health effects in the
    grandchildren of exposed women and future generations. Recognizing the
    critical need for knowledge about the health effects of DES exposure,
    the NIH established the DES follow-up study, creating a coordinated
    longitudinal cohort that has made important discoveries about the
    health effects of DES exposure. We are now at a critical point in time
    to learn more about the persistence of health effects beyond the
    children of exposed women so that future generations have valuable
    information about their own health risks.
        We urge the subcommittee to therefore include report language
    asking NIH to report on plans for existing or new cohort studies that
    can address transgenerational effects of EDC exposures, including the
    continuance of the DES longitudinal cohort.
        Supporting the Physician-Scientist Workforce: Recognizing the
    challenges facing the physician-scientist biomedical research
    workforce, the NIH convened and charged a Physician-Scientist Workforce
    Working Group with analyzing the current composition and size of the
    physician-scientist biomedical workforce and making recommendations for
    NIH to take to help sustain and strengthen a robust and diverse
    physician-scientist workforce. In 2014, the NIH released a report which
    made nine recommendations to sustain and strengthen a robust and
    diverse physician-scientist workforce. We know that several Institutes
    and Centers (I/Cs) have created initiatives for their own researchers;
    however, there is a need for the NIH to comprehensively look at and
    report on outcomes, best practices, and any gaps that may remain.
        We urge the subcommittee to include report language asking NIH to
    provide an update on actions to bolster the physician-scientist
    workforce either by implementing the 2014 report's recommendations or
    otherwise, including outcomes data on the Medical Scientist Training
    Program (MSTP), and the Stimulating Access to Research in Residency
    (StARR) program.
        Special Programs Must Not Erode Support for Investigator-Initiated
    Research
        The Endocrine Society is enthusiastic about the potential for ARPA-
    H to advance transformative public health interventions and develop new
    research platforms that deliver improved care to patients quickly and
    efficiently. Likewise, we appreciate the importance of pandemic
    preparedness. However, these investments must not come at the expense
    of the important investigator-initiated research that have been chiefly
    responsible for the numerous NIH-supported success stories and public
    health achievements. We therefore urge the Committee to provide at
    least $50 billion to the NIH base budget, with increases applied
    equally across all ICs and offices. Any additional funds for pandemic
    preparedness or ARPA-H should only complement, rather than supplant,
    these necessary investments in the future of biomedical research.
     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 percent in those under 60 and by 71
    percent in those 60 and older.\5\ 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 protect the public's health.
    ---------------------------------------------------------------------------
        \5\ 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.\6\
    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.
    ---------------------------------------------------------------------------
        \6\ Frost JJ, et al., Publicly Funded Contraceptive Services at
    U.S. Clinics, 2015, New York: Guttmacher Institute, 2017.
    ---------------------------------------------------------------------------
                       fiscal year 2023 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 2023 Labor, Health and Human Services, Education, and Related
    Agencies appropriations bill:
      --$50 billion for the National Institutes of Health
      --$11 billion for the Centers for Disease Control and Prevention
      --$512 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 $49 billion in fiscal year (FY) 2023 for the National
    Institutes of Health (NIH) base program funding, including increased
    support for vector-borne disease (VBD) research at the National
    Institute of Allergy and Infectious Diseases (NIAID); $11 billion for
    the Centers for Disease Control and Prevention (CDC) base program
    funding, 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 $52 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 and arthropod carriers of
    disease, like mosquitoes and ticks, 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 resistance to pesticides.
    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 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 on understanding how to
    increase protection after exposure to arthropod disease vectors and the
    pathogens they transmit that could cause Lyme disease and other tick-
    borne infections. Using grant funding from NIAID, researchers from the
    Yale School of Medicine developed and trialed the first messenger RNA
    (mRNA) vaccine targeting ticks.\2\ Whereas previous efforts to develop
    vaccines against tick-borne disease in humans have targeted disease-
    related pathogens, this new mRNA vaccine technology induces immunity
    against a salivary protein produced by the vector ticks themselves.
    This study published in November 2021 in Science Translational
    Medicine,\3\ showed that the mRNA vaccine administered to guinea pigs
    caused blacklegged tick bites to become inflamed and ticks to fall off
    too quickly to transmit the pathogen that causes Lyme disease. This
    novel and important research demonstrates that the new mRNA vaccine
    technology holds the potential to protect individuals not only against
    the pathogen that causes Lyme disease but numerous other tick-borne
    pathogens that are carried by the blacklegged tick.
    ---------------------------------------------------------------------------
        \2\ https://www.smithsonianmag.com/smart-news/first-ever-mrna-
    vaccine-for-lyme-disease-shows-promise-in-guinea-pigs-180979090/.
        \3\ https://pubmed.ncbi.nlm.nih.gov/34788080/.
    ---------------------------------------------------------------------------
        Within the NIH, the nascent Advanced Research Projects Agency for
    Health (ARPA-H), a signature priority for the Biden Administration,
    represents an opportunity to catalyze health breakthroughs that cannot
    readily be accomplished through traditional research or commercial
    activity, which could include understanding and preventing emerging
    infectious diseases. ESA supports at least $4 billion for the ARPA-H to
    supplement, rather than supplant, the core investment of at least $49
    billion in NIH's base program level. Similarly, under NIH, the National
    Institute of Environmental Health Sciences (NIEHS) supports research
    and initiatives to address health concerns influenced by climate change
    or environmental agents, including VBD and zoonotic diseases. ESA
    supports at least $110 million for NIEHS to continue efforts to
    identify potential health effects associated with climate change and
    environmental factors and implement health adaptation plans.
        ESA requests robust support for CDC programs addressing VBD within
    the National Center for Emerging and Zoonotic Infectious Diseases
    (NCEZID) by supporting the Centers of Excellence on VBD, as authorized
    by the Kay Hagan Tick Act in 2019, and other work by the Division of
    VBD with at least $75.103 million per year, as is aligned with the FY
    2023 President's Budget Request, as well as the $20 million authorized
    by the Kay Hagan Tick Act for the Epidemiology and Laboratory Capacity
    (ELC) program to address VBD. 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 percent
    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).\4\ 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.\5\ Importantly, spotted fevers have
    non-specific symptoms, and fewer than 1 percent 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.\6\ CDC funding is crucial in the development of
    this and other educational tools that equip health care providers to
    effectively combat tick-borne diseases.
    ---------------------------------------------------------------------------
        \4\ https://www.ncbi.nlm.nih.gov/pubmed/?term=30969821.
        \5\ https://www.cdc.gov/media/releases/2019/p0513-rocky-mountain-
    spotted-fever-training.html.
        \6\ 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 for 5 years to establish
    regional Centers of Excellence (COE) to address existing and emerging
    VBD. The five centers, for which funding expired 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. Sustained funding for the COE is
    critical to continue essential efforts to help prevent and control VBD
    threats in the U.S.
        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 for VBD.
        ESA requests robust funding for IMLS, including no less than $52
    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.
        ESA, headquartered in Annapolis, Maryland, is the largest
    organization in the world serving the professional and scientific needs
    of entomologists and individuals in related disciplines. Founded in
    1889, ESA is a non-partisan professional organization over 7,000
    members affiliated with educational institutions, health agencies,
    private industry, and government. Members are researchers, teachers,
    extension service personnel, administrators, marketing representatives,
    research technicians, consultants, students, pest management
    professionals, and hobbyists. For more information about ESA, please
    see http://www.entsoc.org/.

        [This statement was submitted by Jessica Ware, PhD, President,
    Entomological Society of America.]
                                     ______

                 Prepared Statement of the Epilepsy Foundation
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Please provide $11 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 2022; and
        --$164 million for the CDC's Safe Motherhood & Infant Health
                Program in order to support and help expand the Sudden
                Unexpected Infant Death (SUID) & Sudden Death in the Young
                (SDY) Case Registry; and
        --$5 million for the CDC's National Neurological Conditions
                Surveillance System (NNCSS).
      --Please provide at least $49 billion for the National Institutes of
            Health (NIH)'s base and ensure that any funding for the new
            ARPA-H, or for other targeted programs like pandemic
            preparedness, supplement the $49 billion recommendation for
            NIH's base budget.
        --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 public
    health and research 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 2023, please continue this commitment and
    provide timely investments public health and research programs at the
    CDC and in the NIH. 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 $11 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:
      --Training for School Staff: In FY21, 6,090 school nurses and 177,120
            school personnel have been trained on seizure recognition and
            seizure first aid. On-demand training modules have been
            developed to scale up training of these key, frontline
            community members supporting students with seizures.
      --Seizure First Aid Certification: 14,690 people were certified in
            seizure first aid in FY21, in partnership with multiple
            healthcare professional groups serving minority communities.
            Continued focus is needed on rural and ethnically and racially
            diverse communities as nearly 40 percent of persons diagnosed
            with epilepsy are Black or Hispanic and many people with
            epilepsy in those communities have poorer health outcomes.
      --Professional Education in Epilepsy: To improve care in rural and
            underserved communities, Project ECHO has educated more than
            1,155 primary healthcare providers about managing epilepsy over
            3 years, though more focus is needed on management of severe,
            drug-resistant epilepsy and quality of care improvement
            methods. In addition, seven Behavioral Health Outreach webinars
            were developed as tools for ensuring access to epilepsy
            knowledge and skills for behavioral and mental health
            providers.
      --Reducing Barriers to Medication Adherence: By establishing a
            regular screening process for identifying and addressing
            barriers to medication adherence, an Epilepsy Learning
            Healthcare System (ELHS) is addressing a key health disparity
            in epilepsy. ELHS has produced 11 tools to help patients and
            families overcome common barriers to adherence.
      --Supporting Mental Health Needs: Mental health screenings have been
            implemented on the 24/7 Epilepsy & Seizures Helpline since
            people with epilepsy are at increased risk for depression,
            anxiety, and suicide. Several suicide interventions have been
            successful. In addition, people with epilepsy are being
            connected to self-management programs that prevent and decrease
            depression.
        Also as part of the $11 billion for the CDC, please provide $164
    million for the CDC's Safe Motherhood & Infant Health Program in order
    to support and help expand the SUID & SDY Case Registry.
        SUDEP is the sudden, unexpected death of someone with epilepsy, who
    was otherwise healthy. It is the leading cause of death in people with
    uncontrolled seizures. Each year, it is thought that more than 1 in
    1,000 people with epilepsy die from SUDEP and this number increases
    drastically to 1 in 150 for people whose epilepsy is not controlled by
    treatment. But there are deficiencies and inconsistencies with how
    SUDEP-related deaths are tracked. While some strides are being made,
    the exact cause(s) of SUDEP are not known.
        Building on child death review programs at the National Center for
    Fatality Review and Prevention Case's Reporting System, the SUID
    portion was initiated in 2009 and in 2015, the SDY Case Registry
    component was added to include children and adolescents. A joint
    collaboration of the CDC and NIH, the SDY Case Registry increases the
    understanding of the prevalence, causes, and risk factors for infants,
    children, and young adults up to age 20, who die suddenly and
    unexpectedly including from SUDEP-informing strategies to prevent
    future deaths. The registry is present in 22 States and jurisdictions
    but this is capturing less than half of these deaths nationwide.
    Increased investment in the CDC's Safe Motherhood/Infant Health
    Program-where the Registry is housed-would allow more States to
    participate and in turn, yield more data to improve understanding and
    prevention.
    The Foundation urges the Committee to include the following report
            language:
        Sudden Unexpected Infant Death [SUID] and Sudden Death in the Young
    [SDY] Case Registry.-The Committee is aware that SUID is the leading
    cause of death of infants 1 month to 1 year of age in the United
    States. While there is no known way to prevent SUID, there are ways to
    minimize risk by collecting and analyzing data, such as that available
    through the SUID and SDY Case Registry. The SDY component of the Case
    Registry has been critical in improving data gathered on sudden deaths
    of children and youth up to age 20. This includes the ability to study
    and better understand Sudden Unexpected Death in Epilepsy (SUDEP) and
    sudden cardiac death in the young. Each year, it is thought that more
    than 1 in 1,000 children and youth with epilepsy die from SUDEP. It the
    leading cause of death amongst people with uncontrolled seizures and
    the exact cause(s) of SUDEP are not known. Accordingly, the Committee
    includes an increase within CDC's Safe Motherhood and Infant Health
    program for the Registry to expand the number of States and
    jurisdictions participating in monitoring and surveillance.
    Furthermore, the Committee includes funding for CDC to award grants or
    cooperative agreements to States, Tribes, and Tribal organizations for
    purposes of improving data collection related to SUID and sudden
    unexpected death in childhood, including by identifying, developing,
    and implementing best practices to reduce or prevent infant death,
    including practices to improve safe sleep, as well as unexpected death
    in youth in coordination with appropriate nonprofits.
    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 2023.
    Please also provide at least $49 billion for the National Institutes of
            Health (NIH)'s base and ensure that any funding for the new
            ARPA-H, or for other targeted programs like pandemic
            preparedness, supplement the $49 billion recommendation for
            NIH's base budget 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 $154 million in FY 2017 to $198 million
    in FY 2020. Much more can be done though, particularly in the area of
    bold cross-cutting initiatives and multi-center efforts. For FY 2023,
    we ask that the subcommittee include key committee recommendations,
    like the language below, to encourage additional epilepsy research in
    emerging areas.
                         national institutes of health
            national institute of neurological disorders and stroke
        Epilepsy Care.--The Committee congratulates NINDS and its sister
    institutes in the Inter-Agency Collaborative to Advance Research on
    Epilepsy (ICARE) for supporting fundamental brain research that has
    dramatically advanced the scientific understanding of the epilepsies
    over the last two decades. The Committee encourages NIH and other ICARE
    partners to increase their investments in health services and
    implementation science to ensure that the benefits of research are
    effectively translated to epilepsy care, and to work together to
    further coordinate their activities to improve systems of epilepsy
    care.
                                     ______

                 Prepared Statement of Essential Access Health
        Dear Chairwoman Murray and Ranking Member Blunt:
        As Chief External Affairs Officer of Essential Access Health
    (Essential Access), I thank you for this opportunity to provide
    testimony in support of increased funding for the Title X Federal
    family planning program in the fiscal year (FY) 2023 appropriations
    bill. The Title X family planning program has been level-funded by
    Congress for eight straight fiscal years, as the need for family
    planning and sexual health services has increased and become more
    critical than ever. With increased need and the rising costs of
    providing care, level-funding is equivalent to a cut.
        Essential Access has been a Title X grantee since the program was
    established with strong bi-partisan support in 1970.
        For over 50 years, Essential Access has administered the Title X
    Federal family planning program in California--the largest and most
    diverse Title X system in the Nation. This year, Essential Access was
    also awarded a grant to re-introduce the Title X program in the State
    of Hawaii and address the dire need for family planning services
    statewide. On March 30, Essential Access was notified that we were
    awarded a 5-year service grant to continue serving as the sole Title X
    grantee in both States. While we are proud to continue working with a
    robust network of qualified providers, the award amounts received were
    significantly less than the requested amount of funding necessary to
    meet the needs of Title X patients and health care providers throughout
    California and the Hawaiian islands.
        The California Title X statewide program suffered a dramatic cut in
    funding. Our funding level for the next project period is $13.2
    million, a drastic reduction of $8 million. This is the largest Title X
    funding cut Essential Access has received in our 50-year history
    administering the program. The $2.1 million in funding support for the
    Title X program in Hawaii, does not meet the need for equitable,
    affordable, and high quality family planning services for the more than
    66,000 people estimated to be in need of Title X-supported services
    statewide. Hawaii did not receive any Federal resources to support
    family planning care between the summer of 2019 and January of 2022.
    This gap in Federal funding greatly reduced the capacity of the family
    planning safety-net across the State of Hawaii.
        Inadequate Title X funding is a direct consequence of the program
    receiving level-funding in the FY 2022 omnibus appropriations bill,
    despite strong support for significant increases from both chambers of
    Congress and the White House.
        Failure to increase Title X funding has had an immediate and dire
    impact. In addition to not being able to meet the need for Title X
    resources in Hawaii, some health centers in California did not receive
    any Title X funding and all remaining Title X-funded health centers in
    California's Title X provider network received a reduction.
        These unexpected cuts are compounded by increases in the cost of
    delivering care at a time when community health centers are already
    stretched thin by the pandemic and rising costs of providing care.
    Title X providers depend on these dollars to support staffing,
    infrastructure, outreach and education activities, quality improvement
    activities, and other wrap-around services.
        The impact of these cuts to Title X services will have a
    disproportionate effect on Californians and people of Hawaii with low-
    incomes, people living in rural regions and urban health care deserts,
    and communities of color.
        Additional resources are urgently needed to meet the need for
    comprehensive family planning services in Hawaii and California, and
    across the country. I urge Congress to use the FY 2023 Labor, Health
    and Human Services, Education, and Related Agencies appropriations bill
    to make a strong statement in support of high-quality, equitable, and
    patient-centered family planning care and make it right for Title X by
    increasing program funding to $737 million.
        Thank you for the opportunity to submit this testimony. Contact Amy
    Moy at AMoy@essentialaccess.org if you have questions or need
    additional information.
        Sincerely.

        [This statement was submitted by Amy Moy, Chief External Affairs
    Officer,
    Essential Access Health.]
                                     ______

               Prepared Statement of Every Hour Counts Coalition
        As the Appropriations committee finalizes its fiscal year 2023
    Labor, Health and Human Services, Education and Related Agencies (LHHS)
    appropriations bill budget request, the Every Hour Counts Coalition
    respectfully calls on Congress to preserve and strengthen Federal
    investments in education programs that help build and improve quality
    expanded learning systems across the country. The critical Federal
    investments that have been made to support students and communities
    recovering from the COVID-19 pandemic in previous years must be met by
    continued investment in annual spending to fully support the needs of
    students in all communities.
        Every Hour Counts is a coalition of citywide intermediary
    organizations that are deeply engaged in building and improving
    expanded learning systems--coordinated groups of service providers,
    public agencies, funders, and schools. These systems provide critical
    support for local education programming by offering enrichment
    opportunities, raising funds to increase access, and promoting
    continuous improvement. Since its founding in 2005, Every Hour Counts
    has grown to 28 cities, representing longstanding partnerships with
    more than 3,500 schools, districts, and community-based organizations
    that provide quality after-school and summer programming. Every Hour
    Counts' partners and learning community members support initiatives
    that reach more than 500,000 students each year.
        Strong Federal investments in education programs help to make these
    effective partnerships work. While emergency funding provided by the
    American Rescue Plan Act and previous COVID-19 relief packages were
    crucial in meeting the immediate needs of the COVID-19 pandemic
    (including summer and expanded learning), investments in the fiscal
    year 2023 budget are vital to ensure the success of continued recovery
    efforts in the years to come. Our coalition knows firsthand that out-
    of-school time instruction will continue to be a critical focus of
    long-term recovery and acceleration to address students' academic,
    social and emotional needs as the COVID-19 pandemic continues to affect
    students. Schools and districts cannot and should not be expected to
    meet every academic and non-academic need for their increasingly
    diverse student populations on their own. Therefore, we respectfully
    urge Congress to recognize the need to further invest in the following
    programs and initiatives:
         nita m. lowey 21st century community learning centers program
        The Nita M. Lowey 21st Century Community Learning Centers (21st
    CCLC) program is the only Federal funding stream dedicated to
    supporting local summer learning and after-school programs in every
    State. Today, more and more youth participate in after-school and
    summer programs across the country,\1\ and experts believe the quality
    of these programs is continually improving. These programs have been
    especially critical resources during the COVID-19 pandemic for working
    families and vulnerable student populations. Despite significant
    increases in the number of students enrolling in quality expanded
    learning programs, there continues to be substantial unmet demand for
    enrichment opportunities throughout the country, particularly for low-
    income communities. For every child in an after-school program, two are
    waiting to get in, a discrepancy further amplified in rural and low-
    income communities.\2\
        The much-needed increases to this program over recent years are
    helping serve nearly 2 million children and families in high-need
    communities across the country by increasing access to high-quality
    expanded learning programs and will continue to play a critical role in
    communities as students recover from the COVID-19 pandemic. Congress
    should push to maintain this positive momentum and continue increasing
    investments in these programs. Therefore, we respectfully ask that
    Congress support the 21st CCLC program by increasing its funding level
    to $1.39 billion, a $100 million compared to fiscal year 2022 funding
    levels.
                         full-service community schools
        Full-Service Community Schools address academic, social and health
    services for students, their families and community members in high-
    poverty areas throughout the United States. These integral services
    help students overcome barriers to learning and have become even more
    crucial to the well-being of communities in the wake of the COVID-19
    pandemic.
        Every Hour Counts urges Congress to continue its commitment to
    these services by supporting President Biden's proposal of $468 million
    for the Full-Service Community Schools program. This support will
    ensure that vulnerable communities, including high-poverty rural areas,
    receive academic, social and health services to strengthen their
    recovery from the COVID-19 pandemic.
      improving academic achievement of the disadvantaged- title i, part a
        More than 90 percent of the Nation's school districts and nearly 60
    percent of all public schools across the country rely on Title I funds
    in order to ensure that high-need students meet challenging State
    academic standards. As schools and districts work towards implementing
    school improvement strategies, particularly in partnership with
    intermediaries and other community-based organizations, it is critical
    to provide robust investments in the Title I program to ensure that
    schools have the resources needed to serve all students, including
    their most high-need students. The COVID-19 pandemic has highlighted
    the disparities among schools that were properly equipped to support
    students during times of crisis and those that were not. Our nation
    needs to make the investments necessary to provide equitable resources
    to schools so that all students may receive proper opportunities to
    learn and grow.
        The Every Hour Counts coalition asks that Congress support
    President Biden's proposal for Title I. Making strong investments in
    communities with fewer resources is critical in ensuring that the needs
    of students are addressed in the years to come.
        supporting effective instruction state grants- title ii, part a
        The Title II, Part A program provides flexible funding to States
    and districts to support high-quality professional development for
    educators, including the after-school workforce and other school
    personnel, that positively affect teacher, school leader and educator
    effectiveness. , High-quality staff are necessary for after-school,
    summer and other expanded learning programs to be successful. Despite
    the fact that the after-school workforce is one of the fastest growing
    education sectors in many cities, most citywide systems do not have
    comprehensive strategies in place to recruit, train and support a
    qualified and diverse workforce. Every Hour Counts' community partners
    have been working together with schools and districts to provide joint
    professional development with in- and out-of-school personnel to help
    increase supports for these educators and in turn increase educational
    quality. Educators must receive high-quality training and supports to
    properly address the academic, social and emotional needs of students
    during the COVID-19 pandemic recovery. Comprehensive out-of-school time
    (OST) organizations have demonstrated that they are willing and able to
    rise to post-pandemic challenges--and they are already strategizing how
    to do so, but they need consistent, reliable funding and partnerships
    to help strengthen programming, solve challenges, and fill gaps.
        We encourage Congress to continue its support for this program in
    fiscal year 2023 by requesting that it be funded at $2.295 billion, the
    authorized funding level stipulated in the Every Student Succeeds Act
    (ESSA).
    student support and academic enrichment grant program- title iv, part a
        The Student Support and Academic Enrichment (SSAE) Grant program
    provides formula grant funds to States and districts to support a host
    of activities that provide well-rounded educational opportunities,
    including those that increase student interest and engagement in
    science, technology, engineering and math (STEM) subjects, as well as
    activities to support safe and healthy students and activities to
    support the effective use of technology.
        Over the past 7 years, Every Hour Counts has been involved in
    multi-city demonstration projects that have aimed to advance and
    strengthen the connections between STEM learning in the classroom and
    expanded learning programs in order to increase access to these
    opportunities for all students, particularly those from traditionally
    underrepresented groups. Through a focus on joint professional
    development and collaborative instruction between teachers and expanded
    learning educators, we have been able to create a culture shift in
    communities to make STEM learning an expectation in quality expanded
    learning programs. Providing enrichment opportunities has been
    especially important as the Nation attempts to re-engage students
    returning from remote learning during the COVID-19 pandemic and as the
    country plans to strengthen its STEM pipeline to continue being a
    global leader in innovation and technology.
        We believe that this program will provide much needed funding to
    schools and districts to support the unique needs of their students and
    communities and therefore hope that Congress will demonstrate more
    support for it in fiscal year 2023. The Every Hour Counts coalition
    urges Congress to support this program by funding it at $1.6 billion,
    the authorized funding level stipulated by ESSA.
     the corporation of national and community service--americorps program
        AmeriCorps volunteers play a critical role in helping to increase
    student outcomes, build capacity and drive quality both in the
    classroom and in expanded learning settings. As tutors, mentors and
    role models volunteering in classrooms, after-school and summer
    learning programs across the country, AmeriCorps volunteers' days
    extend beyond the last bell. In many Every Hour Counts communities,
    AmeriCorps volunteers help us raise the bar on quality expanded
    learning programs and provide hands-on learning experiences to more
    students. During the COVID-19 pandemic, AmeriCorps volunteers have
    provided crucial supports to students and communities that will
    continue during the pandemic recovery period. For example, the
    Minnesota AmeriCorps Emergency Response Initiative, launched at the
    start of the pandemic, focused on providing tutoring support to K-12
    students during the summer of 2021 and continued funding will ensure
    such programing exists.
        We respectfully urge Congress to further support these programs by
    requesting that the Corporation for National and Community Service be
    funded at $1.767 billion and the AmeriCorps State and National program
    be funded at $970 million in fiscal year 2023.
                 the education innovation and research program
        The Education Innovation and Research (EIR) grant program provides
    funding to develop, implement and scale field-initiated innovations to
    improve achievement for underserved students. Crucially, the program
    places an emphasis on evidence-based practices and requires diligent
    evaluation of the innovations. The mission of the EIR program aligns
    closely to the mission of Every Hour Counts, and currently, Every Hour
    Counts works across sectors to build expanded learning systems across
    the country that engage students and improve academic and social-
    emotional learning outcomes. At our Expanded-Learning Systems-Building
    Institute, for example, we used cross-sector collaboration to share
    best practices, resources and lessons learned to consider how to scale
    high-quality practices, develop program quality improvement and keep
    racial equity at the center of our work. The COVID-19 pandemic has
    demonstrated the importance of social emotional learning and the needs
    of the whole child. Addressing these needs is a crucial element of the
    U.S. Department of Education's pandemic recovery efforts and requires
    robust Federal investment.
        Every Hour Counts asks that Congress support President Biden's $514
    million proposal for EIR with respective set-asides of $73.3 million
    for STEM and SEL education activities. Building upon this investment
    will expand educational opportunities that support the ``whole child''
    across a number of key programs.
        The Every Hour Counts coalition stands in strong support of the
    programs mentioned above which provide critical resources to schools
    and districts working in partnerships with us to improve educational
    outcomes for students across all communities. We urge Congress to
    support our Nation's youth through robust investments that will
    strengthen their recovery from the COVID-19 pandemic and guide them
    towards success.
        Please do not hesitate to contact me if you have any questions or
    if we can be of any further assistance.
        Sincerely.

        [This statement was submitted by Jessica Donner, Executive
    Director, Every Hour Counts.]
                                     ______

                       Prepared Statement of FASD United
        Madam Chair and subcommittee members, FASD United strongly supports
    an increase of at least $2 million for FY 2023 for this line item in
    CDC's budget, together with report language to strengthen federally
    supported initiatives to prevent, diagnose, and improve service
    delivery for FASD, the Nation's leading preventable cause of
    developmental disabilities and birth defects, and a leading cause of
    behavioral and learning problems. For many years, the line item has
    been labeled `` Fetal Alcohol Syndrome''. But the CDC typically uses
    the term ``Fetal Alcohol Spectrum Disorders'' or FASD as the umbrella
    term adopted in 2004 to describe the spectrum of developmental
    disabilities that result from prenatal alcohol exposure.
        We request the following specific report language for the CDC's
    National Center for Birth Defects and Developmental Disabilities ``to
    support expansion and strengthening of existing national community-
    based and professional fetal alcohol spectrum disorder (FASD) networks
    to disseminate best practices and technical assistance on diagnosis,
    treatment, intervention, peer mentoring, and other essential
    services.''
                                   background
        Prenatal alcohol exposure (PAE) of our children is a silent public
    health crisis within our families and communities. PAE is a major known
    cause of birth defects, brain damage causing neurodevelopmental
    impairments and learning problems--commonly known as Fetal Alcohol
    Spectrum Disorders (FASD).
        Recent CDC data show increasing use of alcohol during pregnancy
    with 14 percent (1 in 7 previously 1 in 9) pregnant people reporting
    current drinking of alcohol and about 5 percent or 1 in 20 pregnant
    people reporting binge drinking.
        How common is FASD in the U.S.? Until recently, we did not have
    reliable prevalence figures. However, a study on prevalence of FASD
    published in the February 2018 Journal of America Medical Association
    (JAMA. 2018;319(5):474-482) shows a more startling and more accurate
    picture of the problem. Researchers assessed 6,639 first graders in
    four U.S. regions and found up to 1 in 20 children with an FASD. They
    also suspected substantial under reporting of prenatal alcohol use and
    that ``we are missing kids''. So, these results are likely to be a
    conservative estimate on FASD prevalence in the U.S.
        Why was this prevalence study so important? First, researchers
    screened and did in-person assessments for FASD (other prevalence
    studies have been based on birth record reports and record reviews).
    Second, researchers learned that youth with this disability can be
    readily identified in U.S. mainstream populations. Third, neither race
    nor ethnicity and social economic status were significant factors--the
    youth with FASD mirrored the demographics of their community. Also
    important: this prevalence data is approaching two times higher than
    autism's prevalence, yet autism Federal funding is nearly 10 times
    greater. According to the National Institute on Alcohol Abuse and
    Alcoholism (NIAAA) Director Dr. George Koob, ``The findings of this
    study confirm that FASD is a significant public health problem, and
    strategies to expand screening, diagnosis, prevention, and treatment
    are needed to address it.''
        The study also confirmed that binge drinking is driving up the
    numbers of children with FASD. It provides useful data for targeted
    prevention efforts. Mothers of youth with FASD compared to a controlled
    population: (1) reported consuming significantly more drinks 3 months
    before pregnancy; (2) recognized that they were pregnant later; (3) had
    more first trimester alcohol consumption; (4) were more likely to binge
    with 5 or more drinks; (5) reported more drinking days in the past 30
    days; and (6) reported that their husbands/partners consumed
    significantly more drinks per drinking day during pregnancy.
        The above prevalence data, together with the increase in alcohol
    use during pregnancy, demands a renewed focus on the issue of binge
    drinking and other alcohol abuse and its harmful effects on our
    children.
        Insufficient Federal Investment in FASD. In 1998, Congress first
    authorized Federal FASD-related programs at $27 million annually
    (nearly $48 million in today's dollars). Since then, however, Federal
    funding for FASD-related programs has declined. Funding has flatlined
    for the Centers for Disease Control and Prevention (CDC) at $11 million
    for what is the most dedicated public health focus on FASD to support
    clinical and epidemiological research, public health initiatives and
    networks, and expansion of clinical interventions. Besides the $30
    million (FY 2022) for research through the National Institute of
    Alcohol Abuse and Alcoholism (NIAAA), the only other specific FASD
    funding is $1 million at the Health Resources and Services
    Administration (HRSA), Maternal and Child Health Block Grant, Title V
    SPRANS Set-Aside).
        There remains an alarming gap in FASD-related diagnostic and
    clinical resources. Among medical and behavioral health professionals,
    their inconsistent use or limited knowledge of diagnostic criteria and
    clinical guidelines result in many (if not most) children and adults
    living with FASD going undiagnosed or misdiagnosed. Families in every
    State, and especially in the child welfare system, struggle with FASD,
    and they cannot find systems of care that are familiar with or are
    equipped to diagnose and address FASD-related disabilities.
        Cost of FASD. Economic impact studies (J Addict Med 2018;12: 466-
    473) show that the costs of FASD are significant, totaling $205 billion
    in the United States (health care, special education, residential care,
    productivity losses, and corrections). Costs to Tribal communities over
    an individual's lifetime with FASD can range from $850,000 to $4
    million, according to the National Congress of American Indians (NCAI;
    #REN-19-037). Yet, evidence shows these risks/costs can be
    significantly reduced by FASD-informed families, communities, and
    healthcare and other providers working together to create a system of
    early identification, stable environment with enduring relationships.
        The alarming increase in prenatal alcohol consumption (41 percent)
    due to the COVID pandemic, and the already soaring rates of FASD,
    justify additional Federal investment to strengthen CDC efforts to:
    expand prevention programs to heighten awareness of FASD and the risks
    associated with prenatal alcohol exposure; and increase existing
    national community-based FASD networks to expand access to diagnostic,
    treatment, intervention, and other essential services.
        CDC's FY 2023 Congressional Justification. Last year, the House-
    passed FY 2022 Labor-HHS Appropriations bill included a $1 million
    increase (from $11 million to $12 million) for the CDC's line item for
    FASD programs, but unfortunately the conference agreement retained the
    flatlined amount of $11 million. With reference to the House-passed
    provision, the CDC included the following discussion in its FY 2023
    Congressional Justification:

          ``CDC appreciates the Committee's support of awareness and
            prevention of fetal alcohol spectrum disorders (FASDs). CDC
            uses a comprehensive approach to address FASDs and the
            prevention of alcohol use during pregnancy. CDC conducts
            activities related to assessing trends in alcohol and
            polysubstance use in pregnancy and monitoring health care
            provider behaviors related to alcohol screening and brief
            intervention (SBI). CDC currently supports a network to reach
            health care providers across the Nation to implement evidence-
            based strategies to reduce alcohol use during pregnancy and
            develop and disseminate FASD training and educational
            resources. In FY 2022, women of reproductive age within 67
            health clinics across four health care systems have received
            appropriate alcohol screening and brief intervention services.
            In 2021, CDC also partnered with the MITRE Corporation to
            develop five clinical decision support (CDS) tools on alcohol
            SBI to help screen and offer evidence-based prevention
            strategies to those at risk. In FY 2022, two of these CDS tools
            were piloted to assess their use in a clinical setting.''
        Notably, CDC's justification went on to state: ``. . . in FY 2023,
    at level funding with FY 2022, CDC will continue to monitor trends in
    alcohol and polysubstance use in pregnancy and support partnership
    activities. In the absence of additional resources, CDC lacks capacity
    to expand prevention efforts and extend the reach of its national
    partnership network.'' (Emphasis added.)
        In conclusion, the enormity of the problem of FASD and its impact
    on families and communities in the United State and the increasing use
    of alcohol during pregnancy justify an increase in investment by the
    Federal Government. Thank you so much.
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology
        Dear Chair Murray and Ranking Member Blunt:
        On behalf of the 110,000 researchers of the Federation of American
    Societies for Experimental Biology (FASEB) from its 28 member
    societies, I am writing to recommend at least $50 billion for the
    National Institutes of Health's base in FY 2023.
        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--that led to the
    development of COVID-19 vaccines and also supports pre-clinical
    research involving the use of animal studies to achieve 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, research infrastructure such as core
    facilities, 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\ https://ncses.nsf.gov/pubs/nsb20201/executive-summary.
        \2\ STEM and the American Workforce. You've heard it before: STEM
    jobs--... | by Science is US | Medium.
    ---------------------------------------------------------------------------
        The NIH is the Nation's largest public funder of biomedical
    research in the world, providing competitive grants to support the work
    of 300,000 scientists at universities, medical centers, independent
    research institutions, and companies nationwide. The biomedical
    discoveries, innovations, and treatments that NIH support are possible
    because of scientific research with animals which provide in-depth
    knowledge of entire biological systems and complex disorders affecting
    multiple organs. As required by the Food and Drug Administration,
    animal research is also essential during the preclinical stage of drug
    development to determine the safety and efficacy of potential drugs and
    therapies prior to human clinical trials.
        A recent example of NIH's effective ability to harness animal
    research and maximize its public-private partnerships, NIH collaborated
    with industry to develop a messenger RNA (mRNA) vaccine which was
    quickly adapted for COVID-19.\3\ The agency also accelerated the
    development and commercialization of COVID testing through the Radx
    initiative.\4\
    ---------------------------------------------------------------------------
        \3\ https://www.niaid.nih.gov/diseases-conditions/coronaviruses-
    therapeutics-vaccines.
        \4\ https://www.nih.gov/research-training/medical-research-
    initiatives/radx#overview.
    ---------------------------------------------------------------------------
        With these resources, NIH has accelerated progress across all areas
    of medical science, including regenerative medicine, cancer
    immunotherapy, and neurological health.\5,6,7\ The agency is also
    committed to supporting the next generation of our biomedical research
    enterprise.\8\
    ---------------------------------------------------------------------------
        \5\ NIH Regenerative Medicine Innovation Project, National
    Institutes of Health, Bethesda, MD.
        \6\ NCI's Role in Immunotherapy Research, National Cancer
    Institute, Bethesda, MD.
        \7\ The BRAIN Initiative Summary, National Institutes of Health,
    Bethesda, MD.
        \8\ 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 to
    continue pandemic preparedness efforts, not to mention the largest 12-
    month increase in inflation since June 1982 at seven percent.\9\ Our
    nation is confronting public health threats, especially given global
    climate change that is negatively impacting biodiversity and one
    health--the intersection of biological science, earth sciences, and
    ecology. More research will be needed to address infectious diseases,
    and greater exposure to environmental threats that impact national
    security, public health, and economic progress. \10\ Additionally,
    having to operate under lengthy ``continuing resolutions'' over the
    last several fiscal years has impacted NIH's ability to provide
    predictable support to the research community due to not being able to
    fund new grants or projects until the agency received a final budget,
    and NIH has not been able to make all researchers set back by the
    pandemic whole.\11\
    ---------------------------------------------------------------------------
        \9\ https://www.bls.gov/news.release/cpi.nr0.htm.
        \10\ IPCC AR5 Climate Change 2014, Chapter 11: Human Health:
    Impacts, Adaptation, and Co-Benefits.
        \11\ Ad Hoc Group Statement on RISE Act Introduction and Research
    Relief Feb. 5, 2021.
    ---------------------------------------------------------------------------
        In the U.S., we continue to address the needs of a growing aging
    population and the serious disease of obesity.\12,13\ NIH research is
    developing therapies for a whole spectrum of age- related
    disorders.\14\ Obesity impacts 42 percent of the U.S. population and
    increases the likelihood of developing costly medical conditions such
    as diabetes, cancer, and heart disease.\15\ Additionally, minority
    populations experience a higher prevalence of these diseases.\16\
    ---------------------------------------------------------------------------
        \12\ https://www.census.gov/newsroom/press-releases/2018/cb18-41-
    population-projections.html.
        \13\ NIDDK Health Information.
        \14\ Aging Well in the 21st Century: Strategic Directions for
    Research on Aging, National Institute on Aging, Bethesda, MD.
        \15\ CDC Obesity Data.
        \16\ Special issues regarding obesity in minority populations--
    PubMed (nih.gov).
    ---------------------------------------------------------------------------
        Our recommendation of at least $50 billion allows NIH to continue
    support for the Next Generation Researchers Initiative; and expand dual
    purpose research in biomedicine and agriculture among NIH and other
    Federal agencies.\17\
    ---------------------------------------------------------------------------
        \17\ BILLS-116RCP68-JES-DIVISION-H.pdf (house.gov) (pg. 63).
    ---------------------------------------------------------------------------
        Respectfully Submitted.

        [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 2023.
    FABBS represents twenty-seven scientific societies and over fifty
    university departments whose members and faculty share a commitment to
    advancing knowledge of the mind, brain, and behavior. For fiscal year
    2023, FABBS encourages your subcommittee to provide the National
    Institutes of Health (NIH) with a budget of at least $49 billion and
    the Institute of Education Sciences (IES) within the Department of
    Education a budget of $815 million.
                         national institutes of health
        FABBS thanks the subcommittee for the consistent increases to NIH
    in recent years. As a member of the Ad Hoc Group for Medical Research
    and the Coalition for Health Funding, FABBS recommends at least $49
    billion for NIH in fiscal year 2023 and suggests that any funding for
    other targeted programs supplement the base budget, rather than
    supplant the essential foundational investment in the NIH.
        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.
      --Office of Behavioral and Social Science Research (OBSSR)
        FABBS members are especially grateful for the increase of over $9
    million to OBSSR included in the joint explanatory statement for the
    fiscal year 2022 appropriations legislation. This growth to the
    Office's baseline budget provides OBSSR with consistent and reliable
    funding to provide essential support across NIH Institutes and Centers
    (ICs).
        OBSSR coordinates and promotes 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 able to leverage investments across the NIH to broadly
    improve the quality and effectiveness of federally funded research. We
    encourage the committee to once again express its strong support for
    this integral office.
      --National Institute of Mental Health (NIMH)
        FABBS members are particularly interested in NIMH, which serves as
    the premier Federal agency responsible for developing a deeper
    understanding of and effective interventions to improve mental health
    and treat mental illness. We encourage you to provide robust funding
    for NIMH in fiscal year 2023 commensurate with any increase to the
    overall NIH budget 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 all.
        In your recent hearing reviewing the President's budget request for
    the Department of Health and Human Services, we were grateful to see a
    focus on mental health and bipartisan support for increases in mental
    healthcare funding related to both the 988 national suicide prevention
    lifeline and Certified Community Behavioral Health Clinics.
        To fully capitalize on these bipartisan committee priorities and
    improve the mental health of all Americans, we recommend that the
    committee continue to prioritize investments in the NIMH.
      --Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)
        As a member of the Friends of NICHD, FABBS recommends that NICHD
    receive an increase in fiscal year 2023 commensurate with any increase
    to the overall NIH budget. NICHD has facilitated extraordinary
    achievements in brain and behavioral research with far reaching
    implications for public health, maternal, child, and family health, and
    learning and language development.
        For example, NICHD-funded researchers have recently:
        --Shown that infants of mothers in low-income households receiving
                monthly cash payments were more likely to show faster brain
                activity in a pattern associated with learning and
                development at later ages.
        --Devised a procedure for amputations below the knee that allows
                for sensory feedback from a prosthetic limb, and used
                machine learning to improve the interface of brain-
                controlled prosthetics, making them easier to use.
        --Discovered that a certain plant compound could one day be
                administered to expectant mothers as a treatment to improve
                cognitive outcomes for people with down syndrome.
        --Surveyed child forensic interviewers to develop new benchmarks to
                aid in preventing, treating, and reducing childhood abuse
                and neglect.
             advanced research projects agency for health (arpa-h)
        FABBS appreciates the funding for ARPA-H included in fiscal year
    2022 appropriations, and we are grateful that this was independent of
    the NIH budget. As ARPA-H continues to take shape, we encourage the
    subcommittee to ensure that additional appropriations for the Agency
    supplement, rather than supplant, funding for NIH.
        FABBS was grateful for the opportunity to contribute to OSTP-NIH
    listening sessions on the proposed ARPA-H. We suggest that this new
    agency will be most effective if it takes a cross-disciplinary approach
    to questions that are not adequately addressed by the current
    organizational approach of NIH. These include investing in
    implementation science to bridge the gap between the latest scientific
    advances and medical practice.
      institute of education sciences (ies), u.s. department of education
        We are grateful for the subcommittee's work to ensure a funding
    increase for IES in the fiscal year 2022 omnibus spending agreement. As
    members of the Friends of IES, FABBS encourages the subcommittee to
    appropriate at least $815 million to IES in fiscal Year2023. This
    funding level will allow the Institute to build on the fiscal year 2022
    enacted budget to maximize its capacity to advance innovative research,
    develop the methodological skills of education researchers, and
    continue to support high-quality and trustworthy statistics and
    evidence-based resources.
        We are especially grateful that the fiscal year 2022 omnibus
    provided IES with independent control over staffing. This new
    flexibility is key to capitalizing on new investments, and allows the
    Institute to be nimble, taking on high-impact approaches to research
    and implementation. For example, during the COVID-19 pandemic, IES
    launched Operation Reverse the Loss to identify specific and actionable
    interventions that can reverse learning losses for clearly identified
    populations of students. Ongoing support for dedicated staff will allow
    IES to continue its important work studying the Nation's most urgent
    education questions and facilitating the implementation of new and
    effective strategies.
        The Institute recently commissioned a report on the future of
    education research from the National Academies of Science, Engineering,
    and Medicine (NASEM). The recommendations therein provide an exciting
    path forward for the agency, outlining approaches to move the field
    forward on issues of critical importance to education policy and
    practice and improve learner outcomes for all students. However, the
    report finds that ``Given the breadth of what IES is expected to
    accomplish as mandated in ESRA [the Education Sciences Reform Act], its
    funding for both programmatic activities and staffing has historically
    been limited in comparison to other Federal science, research, and
    statistical agencies with similar objectives [and] in order to achieve
    the overarching vision presented through these recommendations, IES
    will require additional investments.''
        Thank you for considering this testimony.
    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, Flux: The Society for Developmental Cognitive Neuroscience,
    International Congress of Infant Studies, International Society for
    Developmental Psychobiology, 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 College; Boston University;
    California State University, Fullerton; Carnegie Mellon University;
    Duke University; East Tennessee State University; Florida International
    University; George Mason University; George Washington University;
    Georgetown University; Harvard University; Indiana University
    Bloomington; Johns Hopkins University; Lehigh University; Massachusetts
    Institute of Technology; Michigan State University; New York
    University; North Carolina State University; The Ohio State University,
    Center for Cognitive and Brain Sciences; Pennsylvania State University;
    Princeton University; Purdue University; Rice University; Southern
    Methodist University; Syracuse University; Temple University; Texas A&M
    University; Tulane University; University of Arizona; University of
    California, Berkeley; University of California, Irvine; University of
    California, Los Angeles; University of California, Riverside;
    University of California, San Diego; University of Chicago; University
    of Delaware; University of Illinois at Urbana-Champaign; University of
    Iowa; University of Maryland, College Park; University of Michigan;
    University of Minnesota; University of Minnesota, Institute of Child
    Development; University of North Carolina at Greensboro; University of
    Oregon; University of Pennsylvania; University of Texas at Austin;
    University of Texas at Dallas; University of Virginia; University of
    Washington; Virginia Tech; Wake Forest University; Washington
    University in St. Louis; Western Kentucky University; 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, Chairwoman 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 2023 appropriations bill. Florida A&M University (FAMU) is
    grateful for the historic support of Congress during the pandemic.
    Maintaining or enhancing funding is critical 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 significant support to the University, our students as
    well as other institutions of higher education across the Nation.
        Florida A&M University, based in the State capital of Tallahassee,
    Florida, was founded in 1887 with only 15 students and two instructors.
    Today, FAMU offers 95 degree programs to nearly 10,000 students. We are
    proud to be the highest ranked among public Historically Black Colleges
    and Universities (HBCU) for three consecutive years, according to the
    2022 U.S. News and World Report National Public Universities. The
    University is 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 undergraduate degrees and 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 enhance 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 the
    allocation of resources 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 sustain our
    academic, administrative, and fiscal capabilities.
        The President's fiscal year 2023 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.
        We support the President's fiscal year 2023 budget request of
    $102.3 million for the Strengthening Historically Black Graduate
    Institutions as well, which funds 5-year grants to provide scholarships
    for disadvantaged students, academic and counseling services to improve
    student success, and supports infrastructure and facilities
    improvements.
        FAMU, like other HBCUs, has a critical need for funding to support
    equipment upgrades and purchases, construction and renovation of our
    facilities, and the 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 the fiscal year 2022 House recommended allocation of
    $24.484 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 funding requested would be
    used to pay the loan subsidy costs in guaranteed loan authority under
    the program. We urge the subcommittee to provide increased funding for
    fiscal year 2023, which will allow HBCUs to continue to refinance
    previous capital project loans, renovate existing facilities, or build
    new facilities in alignment with our peer 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.
        Over 60 percent of our enrolled students rely on Pell grants to
    attend our institution. As Pell Grants account for less than one-third
    of the average cost of attendance at public 4-year universities, we
    join many national education associations in requesting an increase in
    the maximum individual award to $12,990. By nearly doubling the award,
    Congress will 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. 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.
    National Institutes of Health Research Centers in Minority Institutions
        FAMU supports funding at the fiscal year 2022 House recommended
    allocation of $88 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, like COVID-19, that disproportionately affect minority
    populations. Notably, the employees at the FAMU community testing site
    were selected as the Tallahassee Democrat ``Person of the Year'' and
    have provided more than 630,000 tests and 25,000 vaccines to the Big
    Bend area since April 25, 2020.
        Since program inception, the FAMU RCMI Center has greatly benefited
    from this program, which has provided critical infrastructure to enable
    the College of Pharmacy and Pharmaceutical Sciences | Institute of
    Public Health 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. With RCMI support, our College of
    Pharmacy has graduated more than 60 percent of the African A merican
    doctoral recipients in the pharmaceutical sciences nationally.
    Department of Health and Human Services, Health Resources and Services
            Administration, Health Careers Opportunity Program
        FAMU supports the fiscal year 2022 House recommended allocation of
    $20.5 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 a health or allied health professions school. 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 fiscal year 2023 budget increases funding for
    HRSA's Health Professions Training for Diversity Programs, including
    the HCOP. Continued funding is critical for these programs that help
    address the shortage 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, President, Ph.D.,
    Florida A&M University.]
                                     ______

      Prepared Statement of Florida Agricultural and Mechanical University
        Chairman Leahy, Chairwoman 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) 2023 appropriations bill. Florida A&M University (FAMU) is
    grateful for the historic support of Congress during the pandemic.
    Maintaining or enhancing funding is critical 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 significant support to the University, our students as
    well as other institutions of higher education across the Nation.
        Florida A&M University, based in the State capital of Tallahassee,
    Florida, was founded in 1887 with only 15 students and two instructors.
    Today, FAMU offers 95 degree programs to nearly 10,000 students. We are
    proud to be the highest ranked among public Historically Black Colleges
    and Universities (HBCU) for three consecutive years, according to the
    2022 U.S. News and World Report National Public Universities. The
    University is 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 undergraduate degrees and 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 enhance 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 the
    allocation of resources 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 sustain our
    academic, administrative, and fiscal capabilities.
        The President's FY 2023 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.
        We support the President's FY 2023 budget request of $102.3 million
    for the Strengthening Historically Black Graduate Institutions as well,
    which funds 5-year grants to provide scholarships for disadvantaged
    students, academic and counseling services to improve student success,
    and supports infrastructure and facilities improvements.
        FAMU, like other HBCUs, has a critical need for funding to support
    equipment upgrades and purchases, construction and renovation of our
    facilities, and the 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 the FY 2022 House recommended allocation of $24.484
    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 funding requested would be
    used to pay the loan subsidy costs in guaranteed loan authority under
    the program. We urge the subcommittee to provide increased funding for
    FY 2023, which will allow HBCUs to continue to refinance previous
    capital project loans, renovate existing facilities, or build new
    facilities in alignment with our peer 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.
        Over 60 percent of our enrolled students rely on Pell grants to
    attend our institution. As Pell Grants account for less than one-third
    of the average cost of attendance at public 4-year universities, we
    join many national education associations in requesting an increase in
    the maximum individual award to $12,990. By nearly doubling the award,
    Congress will 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. 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.
    national institutes of health research centers in minority institutions
        FAMU supports funding at the FY 2022 House recommended allocation
    of $88 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, like COVID-19, that disproportionately affect minority
    populations. Notably, the employees at the FAMU community testing site
    were selected as the Tallahassee Democrat ``Person of the Year'' and
    have provided more than 630,000 tests and 25,000 vaccines to the Big
    Bend area since April 25, 2020.
        Since program inception, the FAMU RCMI Center has greatly benefited
    from this program, which has provided critical infrastructure to enable
    the College of Pharmacy and Pharmaceutical Sciences | Institute of
    Public Health 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. With 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, health careers opportunity program
        FAMU supports the FY 2022 House recommended allocation of $20.5
    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
    a health or allied health professions school. 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 2023 budget increases funding for HRSA's Health
    Professions Training for Diversity Programs, including the HCOP.
    Continued funding is critical for these programs that help address the
    shortage 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 Focused Ultrasound Foundation
        Thank you for the opportunity to comment on the National Institutes
    of Health (NIH) budget priorities for FY 2023. We provide this
    testimony in support of the investment in innovation in health and
    medicine, particularly transformative new therapies like focused
    ultrasound.
        We offer views from the perspective as the only 501(c)(3) medical
    research, education and advocacy organization solely dedicated to
    advancing the development and clinical adoption of focused ultrasound,
    a noninvasive therapeutic medical device technology, for the treatment
    of a wide range of medical conditions. FUSF was founded in 2006 by Dr.
    Neal Kassell, a world-renowned neurosurgeon who has authored more than
    500 publications and was named to the Blue Ribbon Panel of then Vice
    President Joe Biden's Cancer Moonshot initiative. Our mission is to
    accelerate the development and adoption of evidence-based focused
    ultrasound therapy to improve the lives of countless individuals with
    serious medical disorders, including essential tremor, Parkinson's
    disease, Alzheimer's, chronic pain, various cancers, uterine fibroids,
    depression--more than 150 indications in total. We aim to bring focused
    ultrasound treatments to patients as quickly as possible, to improve
    patient outcomes and lower healthcare costs.
        FUSF encourages NIH to seriously examine Federal research
    investment in transformative cross-cutting platform technologies that
    can offer new treatments across multiple diseases and conditions. An
    example of such a technology is focused ultrasound, which offers
    unparalleled versatility due to its more than 18 different biological
    mechanisms of action, including tissue destruction, anti-cancer immune
    response, neuromodulation, localized and targeted drug delivery,
    transient opening of the blood-brain barrier, and many others. While
    this field of medicine is still emerging, various existing focused
    ultrasound applications have demonstrated its potential. With increased
    NIH investment, we can build on this knowledge and expand applications
    for many other diseases and conditions.
        To ensure that NIH delivers on its mission to foster innovative
    research for the betterment of patients, reviewers and program managers
    must truly understand a broad array of science and technology and be
    willing to invest in cross-cutting therapies. Despite extensive
    evidence of efficacy for many conditions and the immense potential to
    transform treatments for many others, as well demonstrated improvement
    to patient outcomes and reduction of healthcare costs, focused
    ultrasound is not widely accessible. One reason is the lack of funding
    needed for translational research to bring these innovations to
    patients. The current nature of funding agencies organized by organ
    system and the cross-cutting nature of research in focused ultrasound
    often means that reviewers and program officers lack the expertise or
    interest to fund these proposals, instead funding more familiar work
    deemed more mainstream and less risky. Ensuring that NIH program
    managers and reviewers have a wide array of expertise in transformative
    and innovative technologies and value high-risk, high-reward
    investments will ensure much-needed diversification in our Nation's
    publicly funded research.
        FUSF also strongly suggests that NIH place a strong focus on
    addressing health and healthcare disparities. Women's health issues
    continue to be under-represented in terms of Federal research dollar
    allocation, with dire consequences. Endometriosis is an example of one
    chronic, debilitating condition that needs to be addressed. An
    irreversible disease known to cause a wide spectrum of physical and
    psychological symptoms from chronic pain to infertility to increased
    risk of suicide, endometriosis is regularly mis-diagnosed or diagnosed
    up to seven to 9 years after the onset of painful symptoms despite it
    impacting 10-20 percent of the overall female population and 5-50
    percent among women with infertility. These symptoms are extremely
    painful and uncomfortable and range from pain during intercourse and
    bowel movements to excessive bleeding. If this chronic pelvic pain is
    detected and treated early, laparoscopy surgery may be avoided in favor
    of a non-invasive procedure like focused ultrasound, saving patients
    from unnecessary and invasive surgery and our healthcare system from
    preventable expenditures.
        A non-invasive treatment would be a significant improvement over
    surgery and would reduce resulting opioid reliance as well as related
    costs. However, these advancements can't be realized unless funding for
    women's health issues is increased exponentially, particularly for
    debilitating conditions like endometriosis. In the case of
    endometriosis specifically, this is a significant unmet need as
    evidenced by the number of physicians and providers who are asking for
    a way to better diagnose and treat these patients. We must bring
    medical innovations to all patients and ensure both diversity and
    inclusion are incorporated throughout our research, treatment, and
    coverage systems.
        In sum, investing in transformative, cross-cutting research is
    critical during a time when scientific achievements are more numerous
    than ever. We must ensure that patients are at the center of our
    healthcare system, and that the goal of improved patient outcomes
    drives funding decisions across the government landscape. It is crucial
    that we invest in innovation to ensure patients everywhere can access
    current and future life-changing and often life-saving technology.
    Thank you very much for consideration of our comments.
                                     ______

            Prepared Statement of the Fred Hutchinson Cancer Center
        Fred Hutchinson Cancer Center (Fred Hutch) appreciates the robust
    and reliable funding Congress has provided for the National Institutes
    of Health (NIH) in the past, and strongly urges continued support for
    this vital funding moving into the future. Prioritizing NIH funding as
    a key national investment helps to establish the United States as a
    world leader in health innovation, biomedical research and scientific
    advancement, and empowers the education and careers of our next
    generation of scientific and health care leaders. Critical investments
    in the NIH lead to more discoveries and increased development of
    therapies, treatments, and cures, helping patients to live longer and
    healthier lives.
        For fiscal year (FY) 2023, Fred Hutch urges the subcommittee to
    support a program level of at least $49 billion in base funding for the
    NIH.
        Strong, bipartisan support from the Appropriations subcommittee on
    Labor, Health and Human Services, Education and Related Agencies
    (Labor-HHS) over the last seven budget cycles has helped NIH to thrive,
    yielding a significant number of scientific advances to improve health
    outcomes for patients. These scientific advancements include the
    lifesaving COVID-19 vaccines that are helping our world to progress
    beyond the pandemic. As the fiscal Year2023 appropriations process
    continues, Fred Hutch is committed to working with Congress and the
    Administration to further bipartisan support for increasing this vital
    national investment and to ensure NIH funding remains a top priority.
        As with scientific discovery, and aligning with changing needs of
    our region, 2022 marks an exciting evolution for Fred Hutch. On April
    1, 2022, Fred Hutchinson Cancer Research Center and Seattle Cancer Care
    Alliance came together into one, independent entity, to form Fred
    Hutchinson Cancer Center (Fred Hutch). This opportunity to clinically
    integrate world-class research with one of the top cancer care
    hospitals in the Nation will lead to greater advances in adult
    oncology--bringing the research bench to the bedside. We anticipate
    increased numbers of clinical trials, as well as increased access to
    groundbreaking research and clinical care.
        Fred Hutch is guided by the mission to eliminate cancer and related
    diseases that cause human suffering and death and is now integrated
    with the expert clinical care to directly help patients live longer and
    healthier lives. 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. To date, performing
    more than 17,000 bone marrow transplants makes Fred Hutch one of the
    most respected and successful programs in the world.
        As the only Dedicated Cancer Center in the Pacific Northwest,
    serving patients in five northwestern States, Fred Hutch is actively
    identifying and working to fill gaps in cancer care by prioritizing an
    increasingly diverse patient population. It is our role to build caring
    relationships with all communities, and especially those experiencing
    disparities. Strategic outreach in traditionally underserved
    communities is one of the many ways Fred Hutch is developing
    relationships with our neighbors in all corners of our region.
        Mitigating Health Inequities in Clinical Trials. History
    demonstrates that racial and ethnic minorities have been
    underrepresented in clinical trials and genetic studies. People from
    racial and ethnic minorities hold a heavier burden of negative health
    and economic impacts, and studies show these same individuals have
    higher rates of cancer and are more likely to die from the disease.
    Greater inclusion helps to further sharpen precision medicine and
    ultimately brings us closer to achieving our mission to find cures for
    cancers and diseases in all people--and there is still a lot of work to
    be done to improve.
        While health inequities have had a disproportionate impact on
    racial and ethnic minorities in the United States for a long time, the
    COVID-19 pandemic brought these disparities into stark focus,
    highlighting social, political, economic, and environmental factors
    that play an important role in health disparities. In order to reduce
    these disparities and promote inclusion and participation of
    individuals from diverse groups in clinical trials, Fred Hutch
    leveraged the infrastructure already in place from coordinating the
    global vaccine trials for HIV for more than 20 years through the HIV
    Vaccine Trials Network (HVTN) to lead operations for the COVID-19
    Prevention Network (CoVPN), funded by the National Institute of Allergy
    and Infectious Diseases. The CoVPN included five large-scale COVID-19
    vaccine efficacy trials with more than 200 clinical trial sites across
    the world, which included more than 600,000 volunteers. As a result of
    this and ongoing work, the trials for CoVPN were some of the most
    diverse in history.
        Empowering Early Career Researchers and Other Health Experts. The
    focus on health equity underscores all work of Fred Hutch, which
    includes building a more diverse and innovative scientific and clinical
    workforce. Robust funding for the NIH not only bolsters important
    research programs--it secures the future of science. Increases in NIH
    funding enable initiatives to reduce barriers to academia and provide
    training and education for young scientists, as well as encourage more
    culturally inclusive research.
        Fred Hutch invests $2 million annually in science education
    programs and is currently in the process of expanding to allied health
    and other types of opportunities. Scientific internships at Fred Hutch
    range from high school and college, as well as mentorship and
    development resources for graduate students, postdoctoral fellows, and
    early-career faculty. The Science Education Partnership, which started
    in 1991, has paired researchers with more than 580 secondary school
    science teachers in Washington state through workshops and a summer
    professional development program.
        Recruitment and Retention of Exceptional Researchers. Fred Hutch
    opposes provisions such as directives to reduce salary support for
    extramural researchers, that would harm the appeal of academic
    research. Policies to cut salary support would undermine Fred Hutch's
    ability to recruit and retain the talented researchers that keep our
    U.S. institutions thriving. Emphasized in the current workforce
    climate, there are countless desirable options for researchers and
    health care experts to pursue and their retention is essential to
    maintain our Nation's innovation ecosystem.
        The partnership between the NIH and the research institutions and
    scientists across America is highly productive. The Federal Government
    has an irreplaceable role in supporting biomedical research, with no
    other entity willing or able to provide the broad and sustaining
    funding that leads to innovative breakthroughs. Fred Hutch depends on
    NIH funding to conduct basic, translational, clinical, public health,
    and infectious disease research, as well as the ability to respond
    rapidly and expertly to the needs of our Nation, such as during the
    COVID-19 pandemic. Sustained and robust funding for the NIH will
    contribute to our efforts to support future pandemics and numerous
    other global health challenges for the years ahead.
        With President Biden's announcement and reinvigoration of the
    Cancer Moonshot, Fred Hutch and the larger cancer community stand
    poised to accelerate work already underway. Increasing funding for NIH
    as well as the creation of the Advanced Research Projects Agency for
    Health (ARPA-H) will help to achieve our goals. Consistent with our
    mission and values, Fred Hutch will continue working to increase access
    to the highest quality cancer treatments and services for all patients.
    We will continue to hone scientific innovation, such as telehealth and
    data science, to increase prevention efforts across entire populations
    and also to connect with individual patients--in ways that ultimately
    improve cancer outcomes for everyone.
        Fred Hutch appreciates the Labor-HHS subcommittee for your
    continued leadership and dedication to ensuring the continued and
    robust funding for the NIH. Thank you for the opportunity to share our
    recommendation to provide at least $49 billion in fiscal Year2023 for
    the NIH base program, in addition to funding for ARPA-H. As our Nation
    continues to rebuild and looks ahead to prepare for potentially future
    pandemics, now is the time to rededicate the commitment to science and
    support for efforts to seize upon the abundance of scientific
    opportunities.

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

                   Prepared Statement of the Friends of HRSA
        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 $9.8 billion for the Health Resources
    and Services Administration in FY 2023. We are grateful for the
    increases provided for HRSA programs in FY 2022 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 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 2022 and provide at least $9.8 billion for HRSA's
    total discretionary budget authority in FY 2023. Additional funding
    will allow HRSA to pave the way for new achievements and continue
    supporting critical HRSA programs, including:
      --HRSA supports more than 13,500 community health center sites which
            provide high quality primary care services to nearly 29 million
            people and reduce barriers such as cost, lack of insurance,
            distance and language for their patients.
      --HRSA supports the health workforce across 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.
      --HRSA's maternal and child health programs support patient-centered,
            evidence-based programs that optimize health, minimize
            disparities and improve health promotion and health care access
            for medically and economically vulnerable women, infants and
            children.
      --HRSA's Ryan White HIV/AIDS Program provides medical care and
            treatment services to over half a million people living with
            HIV. Ryan White programs effectively engage clients in
            comprehensive care and treatment, including increasing access
            to HIV medication, which has resulted in 89.4 percent of
            clients achieving viral suppression, compared to just 65.5
            percent of all people living with HIV nationwide.
      --HRSA supports healthcare systems and programs that access and
            availability of lifesaving bone marrow, cord blood and donor
            organs for transplantation. Additionally, the Healthcare
            Systems Bureau supports poison control centers, which
            contribute to significantly decreasing a patient's length of
            stay and save the Federal Government $1.8 billion each year in
            medical costs and lost productivity.
      --HRSA supports community- and State-based solutions to improve rural
            community health by focusing on quality improvement, increasing
            health care access, coordination of care and integration of
            services that are uniquely designed to meet the needs of rural
            communities.
      --The Title X Family Planning program reduces unintended pregnancy
            rates, limits transmission of sexually transmitted infections
            and increases early detection of breast and cervical cancer by
            ensuring access to family planning and related preventive
            health services to millions of women, men and adolescents.
      --HRSA also supports training, technical assistance and resource
            development to assist public health and health care
            professionals to better serve individuals and communities
            impacted by intimate partner violence.
      --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 over $18 billion to providers for testing
            and treatment provided to uninsured individuals.
        The nation faces a shortage of health professionals and a growing
    and aging population which will demand more health care. Additionally,
    the COVID-19 pandemic reaffirmed the critical nature of a robust
    workforce in responding to public health emergencies. HRSA is well
    positioned to address these issues and to continue building on the
    agency's many successes, but a stronger commitment of resources is
    necessary to effectively do so. We urge you to consider HRSA's central
    role in strengthening the Nation's health and support a funding level
    of at least $9.8 billion for HRSA's discretionary budget authority in
    FY 2023.

        [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 coalition of scientific and
    professional societies, K-12 and higher education organizations,
    universities, and independent research organizations committed to
    supporting the mission of IES and the use of research and statistics.
    We recommend at least $815 million for the Institute of Education
    Sciences (IES) in the FY 2023 Labor, Health and Human Services, and
    Education Appropriations bill.
        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.
        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. Research supported
    by NCER and NCSER have been incorporated in classrooms to enhance
    instruction and support students' academic and non-academic outcomes.
    Recent examples include the Intelligent Tutoring System for the
    Structure Strategy, used by middle school students; Assessment-to-
    Instruction, which has resulted in a partnership between Learning
    Ovations and Read Memphis that is supporting the literacy development
    of young readers; and IES-supported collaborative work that resulted in
    the development of the Washoe County School District Social and
    Emotional Competency Assessments.
        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 in exacerbating
    pre-existing learning gaps.
        FY 2022 appropriations for IES represent less than one percent of
    the total discretionary funding for the Department of Education.
    Similar to the investment that the Federal Government makes in medical
    research at the National Institutes of Health to advance health
    outcomes, the investment in IES is essential to address persistent
    challenges in education. A recent report from the National Academies of
    Science, Engineering, and Medicine (NASEM) highlighted an observation
    regarding IES funding in the Federal research landscape: ``Given the
    breadth of what IES is expected to accomplish as mandated in ESRA, its
    funding for both programmatic activities and staffing has historically
    been limited in comparison to other Federal science, research, and
    statistical agencies with similar objectives.''(p. 3-3) \1\ Providing
    at least $815 million for IES in fiscal Year2023 would serve as one
    important step toward more fully supporting the education research and
    statistical infrastructure essential to education policy and practice.
    ---------------------------------------------------------------------------
        \1\ National Academies of Sciences, Engineering, and Medicine.
    2022. The Future of Education Research at IES: Advancing an Equity-
    Oriented Science. Washington, DC: The National Academies Press. https:/
    /doi.org/10.17226/26428.
    ---------------------------------------------------------------------------
        IES remains constrained in its flexibility to fully fund emerging
    research areas and scale up promising interventions and resources.
    About one of every 10 grant proposals receives funding support,
    limiting the ability of IES to tackle pressing questions in education.
    With appreciation for the boost provided in FY 2022, additional funding
    for Research, Development, and Dissemination (RD&D) is essential to
    support needed research in foundational and emerging topics, including
    measures and assessments in career and technical education; the
    development and testing of education technology products that can
    personalize instruction; and approaches to teacher recruitment,
    retention, certification, assessment, and compensation. RD&D funding is
    critical to help improve education and better support the achievement
    of our Nation's students. Additional investment in RD&D is essential to
    the support of new high-risk, high-reward research with the potential
    for transforming education, along with 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
    works with stakeholders to provide relevant data through administrative
    and longitudinal surveys, but limited funding and staff resources over
    the past decade has resulted in constraining NCES in its capacity to
    meet the real-time data needs of researchers and policymakers.
    Additional funding for NCES would provide greater flexibility to
    develop surveys such as the School Pulse Panel and more quickly release
    important educational indicators. Restoring purchasing power NCES has
    lost over the past decade would also expand the agency's capacity to
    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) program, providing
    critical investment for States to link K-12, postsecondary, and
    workforce systems to gain a better understanding of education and
    workforce outcomes. This work is particularly important for questions
    of national interest, such as interest and persistence in STEM areas to
    develop needed workforce talent. IES is also emphasizing the research
    use of SLDS to measure the effects of interventions on long-term
    student outcomes and in examining the impact of State education policy
    actions in supporting learning recovery, such as the Additional Days
    School Year initiative in Texas. 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, but currently
    has a budget that has remained relatively flat since FY 2014 and still
    below its FY 2010 funding level. Due to limited funding, NCSER did not
    run competitions in FY 2022 for its annual special education research
    and training grants.
        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.
        We also appreciate the inclusion of language in recent
    appropriations bills calling for the Department of Education to address
    how it will ensure adequate staffing levels, including in IES. We are
    particularly grateful for the inclusion of a new program administration
    line item within IES in the FY 2022 omnibus appropriations bill, which
    will provide additional flexibility for IES to hire staff to support
    the increased work that comes with added funding. A recent report from
    NASEM noted the specific staffing challenges that NCES has faced,
    seeing the attrition of more than 20 staff positions between FYs 2015
    and 2021. This has resulted in the discontinuation of 12 programs.\2\
    We look forward to your continued oversight on this issue to ensure IES
    has the resources to employ the necessary staff to effectively carry
    out its mission.
    ---------------------------------------------------------------------------
        \2\ National Academies of Sciences, Engineering, and Medicine.
    2022. A Vision and Roadmap for Education Statistics. Washington, DC:
    The National Academies Press. https://doi.org/10.17226/26392.
    ---------------------------------------------------------------------------
        To this end, we recommend that the committee provide IES at least
    $815 million in FY 2023. With continued emphasis on evidence-based
    policy and practice as our Nation continues to recover from the
    pandemic, IES plays an essential role in responding to key research
    questions, disseminating data to inform decisions, and developing
    resources to guide learning and instruction. Sustained, robust
    investment in the education research and statistical infrastructure at
    IES is necessary to support the success of our Nation's students,
    teachers, and education leaders.

        [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 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 $49 billion in fiscal year 2023 for base spending at
            NIH for current institutes and operations, which corresponds
            with the overall recommendation of the Ad Hoc Group for Medical
            Research;
      --continued efforts in establishing the Advanced Research Projects
            Agency for Health (ARPA-H) at NIH. However, investment in ARPA-
            H should not come at the cost of the existing NIH institutes
            and centers conducting and supporting research on aging. We
            support an increase of $4 billion for ARPA-H to supplement the
            core investment.
      --a minimum increase of $226 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;
      --an increase of $60 million to support the Brain Research through
            Advancing Innovative Technologies (BRAIN) Initiative.
        NIA sponsors and conducts the vast majority of Federal aging-
    related research, and this pioneering science contributes significantly
    to the improved care and quality of life for all of us as we age. 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.
        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).
        Medical and health research and development investment accounts for
    5.9 percent of overall health spending in the U.S., or just under 6
    cents of each health care dollar according to a recent report by
    Research!America.\1\ The Science & Technology Action Committee also
    recently estimated that the U.S. should double its R&D investment by
    2026 in order to remain a global competitor in science, technology,
    engineering, and math.\2\ As the world's premier public funder of
    medical research, the NIH is a critical international leadership, and
    robust annual growth in support for NIH will be key to achieving these
    objectives.
    ---------------------------------------------------------------------------
        \1\ US Investments in Medical and Health Research and Development
    2016-2020. https://www.researchamerica.org/sites/default/files/
    Publications/Research%21America-
    Investment%20Report.Final.January%202022.pdf. Accessed 5/9/2022.
        \2\ Science & Technology Action Committee. (2022 January). Briefing
    Paper: A Roadmap for Investment in Science and Technology. https://
    sciencetechaction.org/news-item/white-paper-a-roadmap-for-investment-
    in-science-and-technology/.
    ---------------------------------------------------------------------------
        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 United States,
    and acts as an economic engine and multiplier in local and regional
    communities. According to United for Medical Research, total FY21 NIH
    research spending supported more than 552,000 American jobs and
    generated nearly $94.2 billion in economic activity, in all 50
    States.\3\
    ---------------------------------------------------------------------------
        \3\ NIH's Role in Sustaining the U.S. Economy 2022 Update. https://
    unitedformedicalresearch.org/wp-content/uploads/2022/03/UMR_NIHs-Role-
    in-Sustaining-the-U.S.-Economy-FY21.pdf. Accessed 4/28/22.
    ---------------------------------------------------------------------------
        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
    pdantonio@geron.org.
        Sincerely.

        [This statement was submitted by Patricia M. D'Antonio, BSPharm,
    MS, MBA, BCGP, 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 2023 Labor, Health and Human Services
    Appropriations bill, Friends of NIDA joins with the Ad Hoc Group for
    Medical Research in recommending a program level of at least $49.048
    billion for the base budget of the National Institutes of Health (NIH),
    which would represent an increase of $4.1 billion over the comparable
    Fiscal 2022 funding level. For the National Institute on Drug Abuse
    (NIDA), Friends of NIDA encourages the Committee to provide at least
    the President's recommended funding level of $1.843 billion, which
    would represent an increase of $248 million over the comparable Fiscal
    2022 funding level for the Institute.
        Friends of NIDA also supports the proposal included in the
    President's Fiscal Year 2023 budget to change the name of the National
    Institute on Drug Abuse to the National Institute on Drugs and
    Addiction.
        We also respectfully request the inclusion of the following NIDA
    specific report language.

          Opioid Initiative. The Committee continues to be concerned about
            the high mortality rate due to the opioid 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 provisional data from the
            Centers for Disease Control and Prevention that shows opioid
            overdose fatalities were predicted to exceed 100,000 in the 12-
            month period ending in June 2021, with the primary driver being
            the increased overdose deaths involving synthetic opioids,
            primarily illicitly manufactured fentanyls. More research is
            needed to find new and better agents to prevent or reverse the
            effects caused by this class of chemicals and to provide
            improved access to treatments for those addicted to these
            drugs. To combat this crisis the Committee has provided within
            NIDA's budget no less than $405,400,000 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 provisional data released by the Centers for
            Disease Control and Prevention, over 45,000 overdose deaths
            involved drugs in the categories that include methamphetamine
            and cocaine in the 12-month period ending in June 2021, an
            increase of 25 percent in a single year. 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. No FDA-approved
            medications are available for treating 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 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, and were
            predicted to exceed 100,000 in the 12-month period ending in
            June 2021, 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 continue to support
            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.

          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 and follow them and their children up to age 10
            to characterize the influence of a variety of factors on
            neurodevelopment and long-term outcomes. The study aims to
            enroll approximately 7,500 women from 25 sites across the US,
            including regions of the country significantly affected by the
            opioid crisis. Participants will include women from the general
            population of pregnant women to assess normative development;
            those who have or are using opioids and/or other substances
            during their pregnancy; and women from comparable environments
            to the latter, but who have not used substances during their
            pregnancy. 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 illicit substance use, 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 additional NIH
            support for this important study.

          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. NIH 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.

        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 disorder -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 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 treated effectively and compassionately.
        We understand that the fiscal year 2023 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on SUDs deserves to be prioritized
    accordingly. Thank you for your support for the National Institute on
    Drug Abuse.
                                     ______

                   Prepared Statement of the Friends of NICHD
        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
    well-being 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 $1.816 billion in Fiscal Year (FY) 2023, an increase
    of $133 million over FY 2022. We also respectfully ask the subcommittee
    to maintain its commitment to increasing funding for the National
    Institutes of Health (NIH) by providing $49 billion in fiscal Year2023
    and give special attention to ensuring that overall funding increases
    for the NIH are shared evenly across the agency.
        We are pleased to support the extraordinary work of NICHD to meet
    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. By enacting our funding
    request, Congress can ensure that NICHD's base budget grows
    proportional to that of its counterpart institutes and the institute
    can build upon the initiatives detailed 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. For instance,
    NICHD is leading research to understand long COVID in children and
    pregnant women, develop evidence-based COVID-19 mitigation measures to
    allow children with special health care needs to remain in school
    safely, and identify effective strategies to improve COVID-19 vaccine
    uptake. The institute also continues to advocate for inclusion of its
    key populations in major trans-NIH COVID-19 research programs funded by
    Congress.
        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 remain unacceptably high in
    the United States and significant racial and ethnic inequities persist.
    In recent years, NICHD has led the Implementing a Maternal health and
    PRegnancy Outcomes Vision for Everyone (IMPROVE) Initiative, which
    seeks to eliminate disparities among populations with greater rates of
    maternal mortality and morbidity. With additional funding, NICHD can
    support additional research to identify ways to improve maternal and
    infant health.
        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. The BPCA NIH program has been successful in accomplishing
    its intended purpose, leading to updated pediatric labeling in 17
    drugs. However, the program has been flat funded at $25 million since
    it was originally authorized in 2002. This funding level is
    insufficient to meet needs, particularly when accounting for biomedical
    research inflation, and has prevented NIH from funding additional drug
    trials in children. Additionally, BPCA NIH has never received a direct
    appropriation from Congress as authorized by law but rather has been
    funded by contributions from NIH institutes and centers. We urge
    increased, dedicated support from Congress to ensure this program can
    fund additional studies to improve pediatric drug labeling to provide
    clinicians with needed guidance for drugs prescribed in children. 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 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 and social
    media 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, which affect 25 percent of American women, represent a major
    public health burden with high prevalence, impaired quality of life,
    and substantial economic costs. 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): In 2018, the NICHD-led PRGLAC Task Force submitted
    recommendations to Congress on opportunities to achieve broader
    inclusion of pregnant and lactating women in research and expand the
    workforce of clinicians and researchers with expertise in obstetric and
    lactation pharmacology and therapeutics. In 2020, the Task Force
    released a second report with a detailed plan to implement those
    recommendations. We encourage NICHD to continue activities to advance
    PRGLAC recommendations in the coming year.
        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 understanding and
    treating this class of disorders that affect so many. We urge resources
    and support for the IDDRCs for research infrastructure and expansion of
    cores 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. NICHD also supported a
    groundbreaking study showing that infants of mothers in low-income
    households that received monthly cash payments were more likely to show
    faster brain activity in a pattern associated with learning and
    development at later ages.
        Male Infertility: Male infertility is another relevant area of
    inquiry that would benefit from additional 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 Matthew Mariani, 2022 Chair,
    Friends of NICHD and Policy Associate, Federal Advocacy, American
    Academy of Pediatrics.]
                                     ______

                     Prepared Statement of the FSHD Society
        Honorable Chairwoman Murray, Ranking Member Blunt, and
    distinguished members of the subcommittee, thank you. We are requesting
    the FY 2023 appropriation of an amount of $25 million for the agency
    U.S. DHHS National Institutes of Health (NIH) to sustain and continue
    its research program on facioscapulohumeral muscular dystrophy
    (hereafter called FSHD). We are requesting an additional $5 million for
    specifically targeted FSHD research through the NIH as requested
    herein.
        Madam Chairman, this is my sixty-third testimony before the U.S.
    Congress' Appropriations subcommittee on this matter. I have been
    professionally engaged in FSHD research since 1987, with a focus on
    funding research on the fundamental pathophysiology, molecular biology
    and genetics of the disease. I am co-founder, past- Chairman, -
    President & CEO, and -CSO of FSHD Society, and have been involved in
    the evolution and design of FSHD research, gene mapping and genetics
    more or less from its inception to the present. My work and the FSHD
    Society's funding spans nearly every research lab working on FSHD, the
    tactical and strategic planning that have led to understanding how
    FSHD1\1\ and FSHD2,\2,3\ work, Muscular Dystrophy Community Assistance,
    Research and Education Amendments of 2001 (MD-CARE Act, Public Law 107-
    84), advocacy and policy, and the relationship of the scientific
    community to the larger societal context in which FSHD is embedded.
        I am approaching near thirty years of testifying as a patient with
    FSHD for Appropriation of funding for FSHD. I have had this disease for
    twice that time. That is a long time to live with a disease of this
    burden. I have now seen, experienced the entire effects, and borne
    almost the full brunt of what FSHD can do to you. FSHD is a heritable
    disease and one of the most common neuromuscular disorders with a
    prevalence of 1:8,000.\4\ 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 any skeletal muscle, it can bring with it
    respiratory failure and breathing issues,\5\-\7\ mild-
    profound hearing loss,\8\ eye problems and cardiac bundle blockage and
    arrhythmias.\9,10\ 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.\11,12\
        The NIH is currently the principal worldwide source of funding of
    biomedical research on FSHD. Currently annual funding specifically
    targeted for FSHD listed in NIH RCDC is $10 million. Given the
    remarkable advances and momentum in FSHD research in the past 8 years;
    it is appalling that FSHD funding has not grown according to NIH RCDC.
    This indicates a mismatch between NIH funding mechanisms and the
    external community working on FSHD.

                                      FSHD RESEARCH DOLLARS & FSHD AS A PERCENTAGE OF TOTAL NIH  MUSCULAR DYSTROPHY FUNDING
                                                                      [Dollars in millions]
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                     Fiscal Year                    2010    2011    2012    2013    2014    2015    2016    2017    2018    2019     2020    2021e    2022e
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    All MD ($ millions)..........................     $86     $75     $75     $76     $78     $77     $79     $81     $81     $83      $95      $97     $102
    FSHD ($ millions)............................      $6      $6      $5      $5      $7      $8      $9     $11     $11     $10       $9       $9      $10
    FSHD (% total MD)............................      7%      8%      7%      7%      9%     10%     11%     14%     14%     12%       9%       9%      10%
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Sources: NIH/OD Budget Office & NIH OCPL & NIH RePORT RCDC (e=estimate, a=actual)

        Currently active projects listed in NIH RePORTer as having
    application to FSHD are $17.507 million FY 2022 (actual 04May2022), a
    17.2% portion of the estimated $102 million spent on all muscular
    dystrophies. A year ago at this time in fiscal year 2021 the NIH
    portfolio of active projects was $16.554 million (actual 23June2021), a
    17.1% portion of the estimated $97 million spent on all muscular
    dystrophies. (source: NIH Research Portfolio Online Reporting Tools
    (RePORT) keyword `FSHD or facioscapulohumeral or landouzy-dejerine').
        In my role, I provide initiator and seed funding to bring new ideas
    and researchers online and am asked to evaluate and compare the various
    research projects we have funded and understand their commonalities and
    differences. I have, if I had to estimate, made a fairly extensive
    study of five to six hundred FSHD projects and proposals. My effort to
    solve FSHD has been persistent in yielding refined advances, it is
    novel and original, and is clearly driven by an overall sense of goals
    and concepts that are meaningful to patients and their families. The
    research we've started is forward-looking, as illustrated by the number
    of industry and philanthropic partners/researchers that have picked up
    on this seminal work and contributed to it.
        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 \13\-\16\. DUX4 is a
    transcription factor that kick starts the embryonic genome during the
    2- to 8-cell stage of development.\17\-\19\ 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,\20\-\26,27,28\ 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.\29\-\42\ 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.'' \43\ Add to this that FSHD was the sole disease mentioned in
    the recent tour de force Science publication 'The complete sequence of
    a human genome.' The paper is proof that scientists were able to
    sequence every base in the genome using at least one of six methods!
    FSHD was highlighted as having a bunch of newly assembled paralogs in
    the assembly; some of which showed evidence of being transcriptionally
    active. Great exposure for FSHD! This article will be read by the
    majority of genomics researchers worldwide--so should definitely
    increase awareness.\44\
        Blocking DUX4's DNA, DUX4's RNA or DUX4's protein ability to
    activate its targets has profound therapeutic
    relevance.\45\-\48\ 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. 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.
        Our FY 2022 testimony on FSHD was quite comprehensive in scope,
    complete with 82 references, with a broad call to action in research
    areas from bench-side to clinic. Rather than restating--we ask the
    Committee to urge NIH to move forward on the many priorities listed.
        In FY 2023, we request NIH to additionally make an immediate and
    targeted push to answer the following three questions. Answers to these
    questions will help remove the obstacles to measuring disease
    progression, help measure if novel therapeutics are making a difference
    in stopping the disease and elucidate if muscle can grow again and be
    restored. At present, measuring disease progression and the
    effectiveness and safety of drugs remains ambiguous and the path
    forward deep and hard-going for industry, clinical partners and
    patients.
    Three Key Research Questions
        How does DUX4 expression lead to pathophysiology? We know a lot of
    what can happen when DUX4 is expressed in a cell (mostly forced
    experimental expression), but not a lot about what happens when an FSHD
    muscle cell expresses DUX4 that leads to pathology.
        Can FSHD muscle pathology be reversed once DUX4 expression starts
    the pathogenic cascade in a particular muscle? This is a key question
    when looking to improve outcomes with either muscle building or DUX4
    halting therapies.
        Is there a systemic effect of local DUX4 expression that leads to
    amplification of muscle decline, either immune or some extracellular
    signaling? Answering this question will help delineate where along the
    travels of DUX4 from its birth and death in muscle we can intercept and
    control the disease process.
        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.
        We request for fiscal year 2023, increasing NIH FSHD research
    funding/appropriation of the standard portfolio to $25 million. The
    growth has been slow, continuous and prone to year-to-year fluctuations
    downward and upward according to NIH funding data. Additionally, we
    request a one-time boost of $5 million to solicit applications to
    answer the three questions of key import. At this moment in time, FSHD
    needs an infusion of both longstanding and immediate discovery 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). This is NIH's wheelhouse and
    forte without a doubt.
        Madam Chairman, thank you for this opportunity to update you on
    FSHD with this testimony.
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    GG, Brooks SY, Caldas GV, Chen NC, Cheng H, Chin CS, Chow W, de Lima
    LG, Dishuck PC, Durbin R, Dvorkina T, Fiddes IT, Formenti G, Fulton RS,
    Fungtammasan A, Garrison E, Grady PGS, Graves-Lindsay TA, Hall IM,
    Hansen NF, Hartley GA, Haukness M, Howe K, Hunkapiller MW, Jain C, Jain
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    Miller DE, Mullikin JC, Myers EW, Olson ND, Paten B, Peluso P, Pevzner
    PA, Porubsky D, Potapova T, Rogaev EI, Rosenfeld JA, Salzberg SL,
    Schneider VA, Sedlazeck FJ, Shafin K, Shew CJ, Shumate A, Sims Y, Smit
    AFA, Soto DC, Sovic I, Storer JM, Streets A, Sullivan BA, Thibaud-
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    Yan SM, Young AC, Zarate S, Surti U, McCoy RC, Dennis MY, Alexandrov
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        [This statement was submitted by Daniel Paul Perez, Co-Founder &
    Director Emeritus, FSHD Society.]
                                     ______

          Prepared Statement of the GBS|CIDP Foundation International
                summary of recommendations for fiscal year 2023
    _______________________________________________________________________

      --Provide $49 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 $11 billion for the Centers for Disease Control and
            Prevention (CDC) and $6 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 FY 2023 L-HHS
    Appropriations Bill.
               about gbs, cidp, variants, and related conditions
    Guillain-Barre Syndrome
        GBS is an inflammatory disorder of the peripheral nerves outside
    the brain and spinal cord. 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 6 months to 2
    years or longer. A particularly frustrating consequence of GBS is long-
    term recurrences of fatigue and/or exhaustion as well as abnormal
    sensations including pain and muscle aches.
    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 percent of CIDP patients will progress to wheelchair
    dependence. Early recognition and treatment can avoid a significant
    amount of disability. Post-treatment life depends on whether the
    disease was caught early enough to benefit from treatment options. 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.
    Multifocal Motor Neuropathy
        MMN is a rare disorder in which focal areas of multiple motor
    nerves are attacked by one's own immune system. Typically, MMN is
    slowly progressive, resulting in asymmetrical weakness of a patient's
    limbs. Patients frequently develop weakness in their hand(s), resulting
    in dropping of objects or sometimes inability to turn a key in a lock.
    The weakness associated with MMN can be recognized as fitting a
    specific nerve territory. MMN has many features similar to CIDP in that
    its onset is progressive over time, causing increased disability that
    reflects the greater number of nerve sites involved. However, unlike
    CIDP, MMN is asymmetric and affects the right and left side of the body
    differently. The clinical course of MMN is chronically progressive
    without remission.
                              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|CIDP community. During the pandemic,
    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. This however was not the size and scope of the
    original planned meeting. 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 over 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 $49
    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|CIDP Foundation International.]
                                     ______

                Prepared Statement of Helen Keller International
        Madam Chairwoman, thank you for this opportunity to provide
    testimony to the subcommittee on behalf of Helen Keller Intl's U.S.
    Vision Programs. Helen Keller Intl respectfully requests this
    subcommittee recommend that the United States Department of Education
    and Department of Health and Human Services support programs that
    provide no-cost vision care for children from low-income families in
    fiscal year 2023.
        It is Helen Keller Intl's hope that, with the renewed support of
    the Department of Education, as well as continued support of our
    private donors, we will be able to deliver free vision screenings, eye
    exams, and prescriptions eyeglasses to thousands of economically
    disadvantaged and vulnerable children who may not otherwise have access
    to them. We also request that the Department of Health and Human
    Services consider funding school-based programs that identify vision
    issues and provide prescription eyeglasses to children from
    marginalized and low-income families whose educational performance and
    future vocational success may be hindered because of uncorrected vision
    problems.
                                  our program
        Helen Keller Intl's U.S. Vision Programs exist to make clear vision
    accessible to all. Our model was first established in 1994 in the
    Washington Heights neighborhood of Manhattan. Since that time, we have
    reached more than 2 million individuals with vision screenings, eye
    exams, and free prescription eyeglasses. And yet, the need for
    accessible eye health services has not diminished. In fact, with low-
    income communities continuing to deal with economic fallout of the
    COVID-19 pandemic, we believe that this need has only grown.
        Despite the fact that routine, comprehensive vision care is a
    standard part of preventive health, as many as 12 million adults and 4
    million children in the United States suffer from impaired vision due
    to uncorrected refractive error, which can easily be corrected with a
    pair of prescription eyeglasses. According to a recent study in
    Investigative Ophthalmology and Visual Sciences, Americans of color are
    significantly more likely to have uncorrected or under-corrected
    refractive error (otherwise known as nearsightedness, farsightedness,
    and astigmatism) than white Americans. These rates are even higher when
    the populations are low-income or uninsured. In this way, a lack of
    access to clear vision exacerbates racial and economic inequality in
    this country.
        In school, students who are not able to see clearly may have
    difficulty engaging with their schoolwork and their peers. Studies have
    found that children with vision issues are three times more likely to
    fail at least one grade. They may also be misdiagnosed with learning
    disabilities and are more likely to be socially isolated.
        Although refractive error is easily addressed with a pair of
    prescription eyeglasses, many individuals across this country cannot
    afford or easily access an eye exam or glasses. In an informal survey
    our organization conducted with low-income clients nationwide, nearly 2
    in 3 reported that they could not access an annual visit to the
    optometrist. The barriers to access for this essential care included
    cost, insurance, transportation, and long wait times at local clinics.
        Our U.S. Vision Programs are prepared to help meet this need by
    providing free eye health services directly on-site at low-income
    schools and other community-based locations around the United States.
    Our three-step model is simple, flexible, and cost-effective: we bring
    trained staff and optometrists directly into school buildings or
    community partner sites to provide vision screenings and eye exams at
    no cost to students or their families. If our team determines that a
    child requires eyeglasses, they can try on and select a frame from a
    large assortment of stylish, durable options. We return to fit each
    student with their glasses and provide literature regarding the
    importance of eye health and instructions on proper eyeglass care. In
    the instance that a child has symptoms of a more complex eye disorder
    (such as strabismus or amblyopia) we will provide a referral to one of
    our partnering ophthalmologic clinics for follow-up care.
        The services we offer are comprehensive and high quality, and this
    model is time-tested. We have refined our approach so that we can
    continue to provide this critical care during the COVID-19 pandemic,
    utilizing PPE, physical distancing, and the sanitization of surfaces
    and equipment to ensure that our clients and our staff stay healthy and
    safe.
                                positive results
        The impact of a pair of eyeglasses can be transformative. For many
    of the young people we serve, our program provides their first eye exam
    and their first pair of eyeglasses. Many students don't even realize
    that they are seeing the world differently from their peers until they
    first try on their glasses.
        Researchers at the University of Minnesota have determined that the
    provision of eyeglasses to school-aged children leads to increased
    reading scores and improved education outcomes. Our own surveys have
    reflected an increase in self-esteem among students who have received
    eyeglasses. Teachers we have surveyed also report that students who
    receive eyeglasses participate in class at a higher rate. Nearly 100-
    percent of the school nurses we have surveyed state that Helen Keller
    Intl fills a glaring gap that exists between state-mandated vision
    screenings and the actual provision of exams and eyeglasses.
        This work has the capacity to change lives by removing the primary
    barriers that exist to clear vision: access and expense. Since 1994, we
    have provided more than 2 million vision screenings and delivered
    nearly 400,000 pairs of free prescription eyeglasses to children in
    need. With support from this subcommittee, we hope to see many more.
                           public/private undertaking
        Our U.S. Vision Programs are truly a public/private endeavor. In
    each of the five States in which we currently operate we bring together
    a wide range of community stakeholders, from parents and teachers to
    physicians and business people, all of whom are dedicated to restoring
    clear vision. This work is funded through a combination of public and
    private dollars--in addition to municipal contracts, we have more than
    a dozen corporate and foundation partners. They include the Lavelle
    Fund for the Blind, Alcon Laboratories, the Overdeck Family Foundation,
    the Wilf Family Foundation, Latter-day Saints Charities, the New York
    Community Trust, the Rose Hills Foundation, the Michael J. Connell
    Foundation, Healthcare Foundation of New Jersey, and Reader's Digest
    Partners for Sight Foundation, among others.
        Previously, the endorsement and support of the Department of
    Education played an integral role in our program, allowing us to reach
    larger numbers of students in more diverse locations, including rural
    communities in New Mexico, Texas, and Mississippi. With some of the
    restrictions surrounding the COVID-19 pandemic lifting, we endeavor to
    once again expand the scope of this work, and hope that we will have to
    subcommittee's support in doing so.
                                   conclusion
        Helen Keller Intl's U.S. Vision Programs provide an invaluable--and
    often life-changing service to underserved youth in a manner that is
    both comprehensive and cost-effective. Our program reaches some of the
    most vulnerable children in the country, and provides them with free
    vision screenings, free eye exams, and free eyeglasses.
        We ask this subcommittee to recommend in its fiscal year 2023
    Committee report that the United States Department of Education and the
    Department of Health and Human Services support programs that provide
    vision care for children from low-income families. These funds will
    support ongoing programs, such as ours, and will provide the eye health
    services that these young people need to succeed in the classroom and
    beyond.
        As our founder, Helen Keller, once said: Alone we can do so little;
    Together we can do so much.

        [This statement was submitted by Kathy Spahn, President and Chief
    Executive Officer, Helen Keller International.]
                                     ______

                Prepared Statement of the Hepatitis B Foundation
            hbf recommendations for fiscal year 2023 appropriations
    _______________________________________________________________________
    National Institutes of Health
      --Along with the biomedical research community, the Hepatitis B
            Foundation (HBF) supports the biomedical research community's
            request for at least $49 billion for the National Institutes of
            Health (NIH). This funding request is for the NIH's base level
            programs, any funding for the new ARPA-H, or for other targeted
            programs like pandemic preparedness, should supplement the $49
            billion recommendation for NIH's base budget.
      --HBF commends NIAID, NIDDK, NCI for the call to update the 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 $11 billion for the Centers for Disease Control and
            Prevention programs in FY 2023, and within that $140 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 and the Immunization
            Services Division (ISD) to take lead on the implementation of
            the November 2021 Advisory Committee on Immunization Practices
            (ACIP) recommendation that all adults between 19 and 59 be
            vaccinated for hepatitis B.
    HHS Office of the Secretary
      --HBF urges the Office of the Secretary and the Office of the
            Assistant Secretary for Health fully support the CDC to ensure
            the ACIP recommendation that all adults between 19 and 59 be
            vaccinated for hepatitis B is implemented as early as possible
            in FY 2023.
      --HBF urges the Public Health Service Corps to update their policies
            to align with the CDC's guidelines and allow individuals with
            chronic Hepatitis B to serve in the Public Health Service
            Corps.
    _______________________________________________________________________

        Ms. Chairwoman and Members of the subcommittee, thank you for the
    opportunity to provide testimony as you consider funding priorities for
    Fiscal Year (FY) 2023. 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.
        Ms. Chairwoman, HBF strongly supports the biomedical research
    community's request for $49 billion for the NIH base budget. 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 to eliminate the 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 $11 billion for the Centers for Disease
    Control and Prevention in the FY 2023 bill. Within that total, we join
    the Hepatitis Appropriations Partnership in urging $140 million for the
    CDC's Division of Viral Hepatitis.
        Finally, we would urge that the November 2021 ACIP recommendation
    that all adults between 19 and 59 be vaccinated for hepatitis B be
    fully implemented as early as possible in FY 2023. We urge the Office
    of the Secretary and the Office of the Assistant Secretary for Health
    to host an inter-agency Summit to discuss dissemination and
    implementation of the new recommendation.
                 recognizing the leadership of the subcommittee
        Ms. 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 community's request for $49
    billion for the NIH. While we support the President's ARPA-H
    initiative, and recognize the importance of pandemic preparedness
    funding, it is imperative that the funding for these initiatives be
    additional funding, above the $49 billion basic request for NIH. It is
    crucial 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 to fund identified
    research opportunities that would help cure and eliminate the disease
    once and for all. The Hepatitis B Foundation appreciated the NIH's call
    for an update to the Strategic Plan for Trans-NIH Research to Cure
    Hepatitis B and we look forward to the final report. Report language is
    requested in the FY 2023 Report urging the NIAID and NIDDK to issue
    targeted calls for hepatitis B research proposals in FY 2023 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 $70 million in FY 2023.
        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, 1.5
    million people worldwide are newly 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 percent.
        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 178 organizations in the CDC
    Coalition and urges a funding level of at least $11 billion for CDC's
    programs in FY 2023. This is $375 million 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 $140 million for the DVH in FY 2023.
        In November 2021, the CDC's Advisory Committee on Immunization
    Practices (ACIP) voted to recommend universal hepatitis B vaccination
    for all adults ages 19 to 59 in the U.S. This simplified, updated
    recommendation, as it is implemented, will significantly increase the
    vaccination rate of adults in the U.S. (currently only 30 percent of
    U.S. adults are vaccinated). Now, these recommendations need to be
    implemented. We urge the CDC, with support from the Office of the
    Secretary and the Office of the Assistant Secretary for Health, to
    ensure the ACIP recommendation is implemented as early as possible in
    FY 2023. As a first step, we urge the Office of the Secretary and the
    Office of the Assistant Secretary for Health to host an inter-agency
    Summit to discuss dissemination and implementation of the new
    recommendation. The CDC is further urged to promote awareness about the
    new vaccination guidelines among medical and health professionals,
    communities at high risk, and the public, and to improve collaboration
    and coordination across CDC to achieve this goal.
                            office of the secretary
        The Hepatitis B Foundation continues to be concerned that the
    Surgeon General's office maintains a hiring policy for Public Health
    Service employees that is inconsistent with the recommendation of the
    CDC by refusing to hire anyone with chronic hepatitis B. We urge the
    Surgeon General's office to change this policy to align with the
    ``Updated CDC Recommendations for the Management of Hepatitis B Virus-
    Infected Health-Care Providers and Students,'' which is based on
    science and recognizes that individuals living with chronic hepatitis B
    are not a risk to others. Compliance with the CDC policy is also
    necessary to meet the nondiscrimination obligations under the Americans
    with disabilities Act, Section 504 of the Rehabilitation Act and
    section 1557 of the Affordable care Act. The Public Health Service must
    update their guidelines.
                             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 Hispanic Association of
                           Colleges and Universities
        Chairwoman Murray, Ranking Member Blunt, and Members of the
    Committee, thank you for the opportunity to submit this testimony on
    behalf of the Hispanic Association of Colleges and Universities (HACU).
    Founded in 1986, HACU is the only national association that represents
    the 559 Hispanic-Serving Institutions (HSIs) in the country, including
    the District of Columbia and Puerto Rico. We appreciate the opportunity
    to provide our views regarding the Department of Education (DOE) Fiscal
    Year 2023 budget. Our requests for this fiscal year are:
      --$250,000,000 for Developing Hispanic-Serving Institutions (Title V,
            Part A): $67,150,000 above fiscal year 2022; and
      --$100,000,000 for Promoting Postbaccalaureate Opportunities for
            Hispanic Americans (Title V, Part B): $80,340,0000 above fiscal
            year 2022.
        HACU commends the committee for increases to Title V Part A and
    Part B in recent years, including the $34.12 million increase for Part
    A and $5.81 million increase for Part B in fiscal year 2022. These
    funds are critical to HSIs as these are their main Federal funding
    vehicles. Unfortunately, funding levels have not kept up with the
    number of HSIs. Since their codification in 1992 as part of the
    amendments to the Higher Education Act of 1965, as amended, HSIs have
    continued to grow exponentially from 311 in 2010 to 569 in 2019, for
    example. However, the pandemic saw the number of HSIs decrease, for the
    first time in 20 years, to 559, partly due to the economic and social
    impacts that disproportionately impacted Hispanic students as the entry
    requirement for HSI status is to serve 25 percent or more such students
    in their total FTE enrollment.
        HSIs educate more than 5 million students, including two-thirds of
    the estimated 3.8 million Hispanic students in American higher
    education, most of whom are first-generation college students and come
    from low-income families. HSIs also enroll twice as many African
    American students as Historically Black Colleges and Universities
    (HBCUs), 41 percent of all Asian Americans, 21 percent of all Native
    Americans, and 16 percent non-Hispanic White students in U.S. higher
    education. Additionally, while only accounting for 16 percent of higher
    education institutions, HSIs enroll 31 percent of Pell recipients.
    Despite their great diversity and need, HSIs remain at the bottom of
    the Federal funding priorities, compared to other Minority-Serving
    Institutions (MSIs) and HBCUs.
        HSIs are consistently asked to do more with less. The first
    Congressional HSI appropriation in FY1995 was a meager $12 million for
    more than 125 HSIs. As the number of HSIs has climbed rapidly, Federal
    funding has been paltry over the years and amounted to a mere $315.7
    million in FY21, including $221.6 in discretionary funds.
        Coupled with persistent Federal underfunding, COVID-19 has
    exacerbated the financial needs of HSIs: delayed deferred maintenance,
    access to broadband, classroom facilities enhancements, and much needed
    wrap-around student services, particularly health and psychological
    services. As the pandemic lingers on, the funding needs of HSIs will
    become more critical. In a report released by HACU in September
    2021,\1\ HACU surveyed HSIs and received 111 responses on their
    infrastructure needs that require capital financing. More than nine in
    every 10 HSIs need funding for construction of new buildings,
    facilities, and classrooms; eight of every 10 for deferred maintenance;
    three of every four for IT infrastructure; and more than two-thirds for
    repairs.
    ---------------------------------------------------------------------------
        \1\ https://www.hacu.net/NewsBot.asp?MODE=VIEW&ID=3424.
    ---------------------------------------------------------------------------
        Federal investments are essential to strengthen our workforce by
    enhancing educational attainment, especially in STEM and other fields
    of national priority. The U.S. Census Bureau reported that from 2010 to
    2020 Hispanics accounted for more than half the total growth of the
    National population and are now over 63 million, and it estimates that
    the Hispanic population will grow by 93.5 percent from 2016 to 2060.\2\
    ---------------------------------------------------------------------------
        \2\ https://www.census.gov/content/dam/Census/library/publications/
    2015/demo/p25-1143.pdf.
    ---------------------------------------------------------------------------
        HSIs educate and train the most diverse and underserved communities
    and do so with fewer Federal resources per student than their peer
    institutions. As the Nation looks to rebuild the economy after the
    pandemic, it is critical that Federal investments strengthen our
    workforce by enhancing the educational infrastructure of HSIs to pave
    the path of success and opportunity for Hispanic Americans for the
    fiscal year 2023.
        As the Hispanic growth-rate in K-12 enrollment continues to
    accelerate, the number of Hispanic high-school graduates is expected to
    increase by 49 percent between 2012-13 and 2028-29, compared to 23
    percent for Asian/Pacific Islanders, and to a net drop of 3 percent and
    15 percent for Blacks and Whites, respectively. In fact, NCES projected
    in the same study an increase of 14 percent in Hispanic college
    enrollment between 2017 and 2028 from 3.5 million to over 4.0 million,
    but it may be under-projecting as in 2020 there were already 3.8
    million Hispanics college students, 67 percent of them at HSIs.\3\
    ---------------------------------------------------------------------------
        \3\ https://nces.ed.gov/pubs2020/2020024abbrev.pdf.
    ---------------------------------------------------------------------------
        Investing in HSIs is an investment in the success American
    workforce. Given the preceding demographic trends and projections, it
    is evident that the Nation's labor force is also becoming increasingly
    Hispanic. The U.S. Bureau of Labor Statistics (BLS) reports that
    Hispanics have the highest participation rate in the American labor
    force, which in 2019 was 66.8 percent, compared to 63.0 percent for
    Whites and 62.4 percent for Blacks.\4\
    ---------------------------------------------------------------------------
        \4\ https://www.bls.gov/emp/tables/civilian-labor-force-
    participation-rate.htm.
    ---------------------------------------------------------------------------
        A U.S. BLS study projected that the Latino share of the workforce
    will increase dramatically from 1 in 10 in 2010 to 1 in 3 by 2050,
    while Whites will decrease from 81 percent to 75 percent, Blacks will
    remain at 12 percent, Asian Americans will increase from 5 percent to 8
    percent and all others from 2 percent to 5 percent during the same span
    of time.\5\ Currently, more than half of all the new workers joining
    the Nation's labor force is Hispanic. For America to remain competitive
    in the global economy, a much better educated and trained Hispanic
    labor force is required. As the backbone of Hispanic postsecondary
    education, HSIs must be placed at the top of Federal investment
    priorities without any further delay.
    ---------------------------------------------------------------------------
        \5\ https://www.bls.gov/opub/mlr/2012/10/art1full.pdf.
    ---------------------------------------------------------------------------
        HACU and its supporters wholeheartedly commend the U.S. Congress
    and the Administration for investing significantly in HBCUs and other
    MSIs and urge them to continue doing so. Likewise, we exhort Congress
    and the President to invest with equal commitment in HSIs and their
    underserved students; they truly are the future of the Nation.
                                   about hacu
        The Hispanic Association of Colleges and Universities, founded in
    1986, represents more than 500 colleges and universities in the United
    States, Latin America, Spain and school districts throughout the U.S.
    HACU is the only national association representing existing and
    emerging Hispanic-Serving Institutions (HSIs). The Association's
    headquarters in San Antonio, Texas, with regional offices in
    Washington, D.C and Sacramento, California.

        [This statement was submitted by Antonio Flores, PhD, President &
    CEO,
    Hispanic Association of Colleges and Universities.]
                                     ______

               Prepared Statement of the HIV Medicine Association
        Chairwoman Murray, Ranking Member Blunt and members of the
    subcommittee, my name is Marwan Haddad, MD, MPH, chair 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 Centers 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.
        For the FY 2023 appropriations process, we urge you to appropriate
    funding to support the Ending the HIV Epidemic (EHE) initiative,
    including: increased funding for the Ryan White HIV/AIDS Program
    (RWHAP) at the Health Resources and Services Administration (HRSA)
    across all parts, increased funding for the Centers for Disease Control
    and Prevention's (CDC's) HIV, hepatitis and sexually transmitted
    infections (STI) prevention programs, and increased investments in HIV
    research supported by National Institutes of Health (NIH).
        The funding requests in our testimony largely reflect the consensus
    of the Federal AIDS Policy Partnership (FAPP), a coalition of HIV
    organizations from across the country. For a chart of current and
    historical funding levels and coalition requests for each program,
    please see FAPP's FY 2023 Appropriations for Federal HIV/AIDS Programs.
    ending the hiv epidemic initiative--u.s. department of health and human
                                    services
        We urge the Senate subcommittee to build on the inroads made by the
    EHE initiative, now in its fourth year and strengthened by the Federal
    National HIV/AIDS Strategy (2022-2025). We recommend funding the EHE
    initiative at least at the President's budget request for $850 million
    across CDC, HRSA and NIH for FY 2023, to be used for expanded access to
    antiretroviral treatment and pre-exposure prophylaxis (PrEP) to prevent
    HIV transmissions as well as improved access to routine and critical
    health services.
      national prep program--u.s. department of health and human services
        The President's budget calls for the creation of a national PrEP
    program to expand PrEP use and promote racial and ethnic equity in PrEP
    access. This much needed new program would provide access to PrEP at no
    cost for uninsured and underinsured individuals, as well as support and
    expand PrEP programs across a variety of agencies.
        A national PrEP program is needed to dramatically reduce new HIV
    cases and address significant PrEP access disparities among populations
    the HIV epidemic has heavily impacted. While 1.2 million individuals
    could benefit from this prevention drug, only 25 percent have been
    prescribed PrEP. The numbers drop even further for Black and Latinx
    individuals, to 8 percent and 14 percent. HIVMA supports a program to
    scale up access to PrEP medication.
         health resources and services administration--hiv/aids bureau
        HRSA's Ryan White HIV/AIDS Program is critical to ensuring that
    individuals with HIV are linked to care, are retained in care, have
    medical adherence and achieve viral suppression. RWHAP has been
    critical to our HIV response by supporting care and treatment for
    people with HIV without another source of coverage. In 2020, the viral
    suppression among RWHAP clients reached a record high of 89.4 percent
    as compared to 65.5 percent among all people diagnosed with HIV in the
    U.S. Sustaining an undetectable viral load in people with HIV is
    important to their health and to stop HIV transmissions. This is one of
    the many reasons RWHAP is a critical component of the EHE initiative in
    decreasing racial and ethnic, age-based and regional disparities. To
    sustain current services and to ensure more people with HIV benefit
    from HIV care and treatment, we urge Congress to fund the Ryan White
    HIV/AIDS Program at $2.942 billion in FY 2023, an increase of $447.5
    million over FY 2022. In addition, we strongly recommend providing at
    least $290 million in EHE funding for the Ryan White Program, a $165
    million increase over FY 2022.
        HIVMA urges an allocation of $231 million, a $25.5 million increase
    over FY 2022, for Ryan White Part C programs. It is critical to ensure
    that clinics in all jurisdictions nationwide receive additional funding
    to increase access to HIV care and treatment to help end the domestic
    HIV epidemic. Approximately half of Part C providers serve rural
    communities, making the clinics the primary source for delivering HIV
    care to rural jurisdictions.
        Part C of the Ryan White Program directly funds approximately 350
    community health centers and HIV clinics, providing medical care to
    more than 300,000 people each year. 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 to
    prevent, intervene and treat substance use disorders as well as related
    infectious diseases, including HIV, viral hepatitis and STIs.
        CHCI's Ryan White-Funded Clinic in Connecticut Is Leading on
    Expanding Access to HIV Prevention, Care & Treatment. The Center for
    Key Populations (CKP) at Community Health Center Inc. (CHCI) has
    received funding through the Ryan White Cares Act for more than 23
    years, making us a leading source of HIV primary care in the State of
    Connecticut. Each year CHCI has increased the number of HIV patients
    served, the number of services offered and the number of HIV tests
    conducted based on the needs of the communities we serve.
        The needs of both established and newly diagnosed patients with HIV
    are growing more complex, especially as the population ages. In 2021,
    even as HIV prevention methods became more available, 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
    2021, 71 percent self-reported as racial and ethnic minorities and 56
    percent reported food and housing insecurity as major barriers to
    achieving optimal health care. Additionally, 4 percent of all Ryan
    White patients were uninsured, 87.9 percent had at least one clinical
    comorbidity and 62 percent reported unmet mental health needs at the
    time of intake. Among Ryan White Program patients at CHCI, 60 percent
    reported experiencing stigma or discrimination based on their gender
    identity, sexual orientation or HIV status in the last year. As the
    country resumed ``normal'' activities after the COVID-19 pandemic,
    individuals living with HIV reported significant symptoms of isolation
    that were difficult to overcome.
        CHCI's Ryan White Program eligible patients who are engaged in care
    are screened for substance use disorders routinely; in 2021, 59 percent
    screened positive, with 10 percent 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 in retaining
    patients in care and assisting in medication compliance. 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 health care
    outcomes for all patients.
        The support services provided by Ryan White funding were pivotal in
    maintaining stability and transitioning care efficiently during the
    COVID-19 pandemic. The infrastructure developed over 23 years of
    funding gave Ryan White patients the additional support they needed to
    sustain healthy outcomes and return to care as soon as possible after
    the pandemic. These services are integral to the success of patients in
    maintaining viral load suppression to protect themselves and their
    communities.
    health resources and services administration--bureau of primary health
                                      care
        We recommend appropriating $172.3 million in new funding for HRSA's
    Community Health Center program for the EHE initiative, a $50 million
    increase over FY 2022. As part of the EHE initiative, HRSA's community
    health center program is focused on expanding HIV prevention services,
    including outreach, care coordination and access to PrEP services. In
    2020 and 2021, EHE resources were distributed to 213 health centers
    that received Health Center/Ryan White Program funding and/or were
    located close to a Ryan White Program where no jointly funded health
    center currently existed in targeted jurisdiction sites. These health
    centers reported more than 151,000 patients receiving PrEP services in
    the first year of the EHE initiative--a significant accomplishment in
    scaling up PrEP among the most affected populations, 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 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, 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
    $731.9 million overall increase above FY 2022 levels for a total of
    $2.077 billion.
        For the Division of HIV/AIDS Prevention (DHAP), we request a total
    of $1.233 billion, which is a $246 million increase over FY 2022
    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 $310 million requested by the Administration for the EHE
    initiative, a $115 million increase above FY 2022, allowing CDC to
    scale up HIV testing to ensure early diagnosis and linkage to care, and
    PrEP programs to prevent new infections.
        Additionally, we urge the appropriation of $150 million for CDC to
    fund surveillance and programming, a $132 million increase above FY
    2022, to monitor and prevent injection-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 the National response to the opioid
    crisis, including expanding support for monitoring and data collection
    and strengthening national capacity to share information and expand
    access to effective prevention services, including syringe services
    programs.
        For the Division of Viral Hepatitis (DVH), we request a total of
    $140 million, which is a $99 million increase over FY 2022 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 eliminating hepatitis as a
    public health threat.
        For the Division of STD Prevention (DSTDP), we request a total of
    $329.2 million, which is a $164.9 million increase over FY 2022 levels.
    CDC's 2020 STD Surveillance Report shows syphilis among newborns (i.e.,
    congenital syphilis) increased, with reported cases up nearly 15
    percent from 2019 and 235 percent from 2016. Increases like these 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
        The historical response to the COVID-19 pandemic over the last 2
    years exemplifies the value of the Nation's longstanding commitment to
    NIH. Decades of medical research supported by NIH are the foundation
    for diagnostic, treatment and preventive interventions available today,
    and building on this research will be vital in finding a cure and
    vaccine for HIV. To advance these and other scientific discoveries, we
    ask that at least $3.875 billion be allocated for HIV research in FY
    2023, an increase of $681 million over FY 2022.
                                   conclusion
        Thank you for considering this request to support lifesaving
    investments in domestic HIV and infectious diseases programs in the FY
    2023 (LHHS) appropriations bill. Fully funding these programs will
    ensure progress in ending the domestic HIV epidemic and help maintain
    the gains achieved in recent years. HIVMA looks forward to working with
    Congress to ensure that the resources necessary to make significant
    progress in preventing HIV and improving the health and well-being of
    people with HIV are provided. Please contact me or HIVMA's senior
    policy and advocacy manager, Jose A. Rodriguez, 4040 Wilson Boulevard,
    Suite 300, Arlington, VA, 22203, at JRodriguez@hivma.org if you have
    any questions or need additional information.

        [This statement was submitted by Marwan Haddad, MD, MPH, Chair, HIV

    Medicine Association.]
                                     ______

            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 2023 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.
        Our nation is on a path to eliminating two infectious diseases, HIV
    and viral hepatitis, in the U.S., but we need increased funding to
    accelerate our efforts particularly in communities and populations
    disproportionately impacted. The ongoing COVID-19 pandemic has
    demonstrated the interconnectedness of communities and health
    conditions and has allowed innovative service delivery. Increased
    investment in surveillance, education, prevention, and care and
    treatment will ensure we continue to address HIV and viral hepatitis,
    including taking a syndemic approach in order to achieve maximum
    impact.
        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 3 years, Congress has appropriated 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. Unfortunately, this funding has been far less than what estimates
    used in the creation of the EHE initiative deemed necessary and were
    proposed by both Presidents Trump and Biden. The initiative, which is
    currently focused on those jurisdictions that represent about 50
    percent of diagnoses, has already shown success with the money
    appropriated to date. The Health Resources and Services
    Administration's HIV/AIDS Bureau reports that in 2020, the Ryan White
    Program served 11,139 new clients and re-engaged an additional 8,282
    clients for a total of 19,421 clients during the first year of the
    COVID-19 pandemic when services often were disrupted. Additionally,
    community health centers funded by the EHE Initiative were able to
    increase PrEP (HIV prevention medication) to 389,000 people.
        In FY 2023, we urge Congress to fund EHE activities at the level
    requested in President Biden's FY23 Budget Request. For FY 2023, we ask
    that you fully fund the fourth year of the initiative to continue to
    scale up the EHE initiative by supporting the president's budget
    request of $850 million, an increase of $377 million from FY 2021.
      --$310 million for the CDC Division of HIV/AIDS Prevention for
            testing, linkage to care, and prevention services, including
            pre-exposure prophylaxis (PrEP) (+$115 million);
      --$290 million for the HRSA Ryan White HIV/AIDS Program to expand
            comprehensive care and treatment for people living with HIV
            (+$165 million);
      --$172 million for the HRSA Community Health Centers to increase
            clinical access to prevention services, particularly PrEP (+$50
            million);
      --$52 million for the Indian Health Service (IHS) to address the
            combat the disparate impact of HIV and hepatitis C on American
            Indian/Alaska Native populations (+$47 million); and
      --$26 million for NIH Centers for AIDS Research to expand research on
            implementation science and best practices in HIV prevention and
            treatment.
                                      prep
        It is estimated that only 23.4 percent of people who could benefit
    from PrEP have received a prescription. PrEP coverage is highest among
    white people, at 63.3 percent, yet only 8.2 percent of black people and
    14 percent of Hispanic/Latino people who could benefit from PrEP in the
    U.S. have a prescription. Additionally, PrEP coverage among women is
    only at 9.7 percent. Reducing these disparities must be a priority as
    we work to expand PrEP use.
        We are thankful that there has been an increased focus on PrEP both
    in Congress and from President Biden. In his FY 2023 budget request,
    President Biden called for a new mandatory funding program to expand
    PrEP across the United States through providing medication to uninsured
    and underinsured individuals, as well as supporting and expanding PrEP
    programs across a variety of agencies. As the HIV community, relevant
    stakeholders, and Congress consider this proposal along with others, we
    urge you to support funding for new and innovative grant programs to
    expand PrEP access, ensure that those who want PrEP can easily access
    the medication without any costs or barriers, and increase demand for
    PrEP among people who could benefit from this important medication.
    This can be accomplished with increased funding for PrEP services for
    community health centers, CDC's Division of HIV Prevention, and other
    programs.
                                      hiv
        Additionally, the success of the EHE initiative and PrEP delivery
    rests upon our underlying public health prevention, care, and treatment
    programs at the CDC, HRSA, and other agencies. Congress must ensure
    that these are also 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. Nearly 61 percent
    of clients live at or below 100 percent of the Federal poverty level
    and nearly three-quarters of the clients are from racial and ethnic
    minority populations. For over 30 years, the Ryan White program has
    pioneered innovative models of care which has resulted in over 89
    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 ongoing economic impact of COVID-19. Without
    increased funding some ADAPs may be forced to institute wait lists for
    medications or other cost containment measures.
        This program is especially important in many States where there are
    large healthcare coverage gaps because of States choosing not to expand
    Medicaid. There are approximately 400,000 people living with HIV who
    are not engaged in care and treatment. The Ryan White Program can play
    a large role in bringing these people into care and treatment and
    ensuring their virus is undetectable, which makes them untransmittable.
    The Ryan White Program also needs additional support to address the
    complex challenges of the overdose crisis, mental health crisis, and
    prevention and treatment of other infectious diseases, including COVID-
    19, viral hepatitis, and STIs. We urge Congress to fund the Ryan White
    HIV/AIDS Program at a total of $2.942 billion in FY 2023, an increase
    of $447 million over FY 2022, of which $165 million is for the EHE
    initiative and $68 million is for ADAPs.
        There has been incredible progress in the fight against HIV over
    the last 40 years, but that progress has stalled with new infections
    plateauing since 2013. Increasing funding for high-impact, community-
    focused HIV prevention services through the CDC's Division of HIV
    Prevention has proven to result in a strong return on investment. HIV
    continues to disproportionately impact Black gay and bisexual men,
    Latinx gay and bisexual men, Black heterosexual women, transgender and
    gender nonconforming women, people who inject drugs, and people who
    live in the South. HIV prevention tools that meet the special
    prevention needs of these populations must be expanded.
        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. Additionally, the CDC's national surveillance
    system is a key tool in identifying people and regions most impacted by
    the epidemic and tailoring prevention efforts to meet the needs of
    those populations and prevent HIV transmission. There is no single way
    to prevent HIV, but jurisdictions use a combination of effective
    evidence-based approaches including testing, linkage to care, condoms,
    syringe service programs, and PrEP. We urge you to fund the CDC
    Division of HIV Prevention at $822.7 million in FY 2023, an increase of
    $67 million over FY 2022, in addition to the $310 million for EHE
    Initiative work at CDC.
        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
        Additionally, we respectfully request that you provide increased
    funding for viral hepatitis programs at the CDC. The CDC estimates that
    nearly 5 million people in the United States live with hepatitis B
    (HBV) or hepatitis C (HCV), and as many as 65 percent are 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 the 57,800
    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.
    CDC Division of Viral Hepatitis
        The viral hepatitis programs at the CDC are severely underfunded,
    receiving only $41 million-far short of what is needed to build and
    strengthen our public health response to hepatitis. The Viral Hepatitis
    National Strategic Plan for the United States: A Roadmap to Elimination
    (2021-2025) lays out an ambitious plan to end the hepatitis epidemic;
    however, health departments and community partners are in desperate
    need of additional resources. Increased investment would allow the CDC
    to enhance testing and screening programs, conduct additional provider
    education, enhance clinical services specific to hepatitis at sites
    serving vulnerable populations, and increase services related to
    hepatitis outbreaks and injection drug use. With the treatment of
    hepatitis D expected to be approved this year, there will be increased
    needs for testing and linkage to care programs. While we are pleased
    that the Biden administration has prioritized viral hepatitis in its
    FY23 budget with an increase of $13.5 million, we urge you to provide
    the CDC Division of Viral Hepatitis with $140 million, an increase of
    $99 million over FY 2022 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. The U.S. is experiencing an ongoing public health emergency
    crisis with the U.S. surpassing 105,000 annual overdose deaths from
    opioid overdose in 2020, a more than 45 percent increase from January
    2020. Providing full support for this program is another key step in
    preventing new cases of viral hepatitis and HIV, addressing overdose
    prevention, and putting the country on the path towards elimination. We
    urge the committee to fund this program to eliminate opioid-related
    infectious diseases at $150 million, an increase of $133 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.
                      federal hiv & hepatitis coordination
        Two important offices which coordinate the implementation of the
    NHAS and EHE activities need resources to bolster their ability to
    coordinate HIV and viral hepatitis activities across the Federal
    Government. The White House Office of National AIDS Policy and the HHS
    Office of Infectious Disease and HIV/AIDS Policy both play an important
    role in developing and implementing government-wide HIV strategies, as
    well as coordinating efforts among the wide range of Federal agencies
    working to end the HIV epidemic and the syndemics of STDs, hepatitis,
    TB, and overdoses. We urge you to provide a total of $20 million for
    the HHS Office of Infectious Disease and HIV/AIDS Policy and $3 million
    for the White House Office of National AIDS Policy in FY 2023.
        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 hepatitis epidemics. Fortunately, we
    have the tools available to end both these epidemics; however, we must
    provide the necessary resources to accelerate our efforts to achieve
    these goals.

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

                      Prepared Statement of Hope Charities
                  summary of fiscal year 2023 recommendations
    _______________________________________________________________________

      --Provide NIH with at least a $3.5 billion increase in discretionary
            funding for FY 2023 to bring overall agency funding up to a
            minimum of $49 billion annually.
        --Please provide proportional funding increases for NIH's various
                Institutes and Centers, such as the National Institute of
                Allergy and Infectious Diseases (NIAID) and the National
                Heart, Lung, and Blood Institute (NHLBI).
        --Please provide separate, additional funding to further support
                and advance implementation of the Advanced Research
                Projects Agency for Health (ARPA-H) to ensure this
                important initiative does not compete with (and ultimately
                compliments) ongoing NIH research efforts.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least a $2.55 billion increase in discretionary funding for
            FY23 to bring overall agency funding up to a minimum of $11
            billion annually.
        --Please provide established CDC Centers and Programs, such as the
                National Center for Chronic Disease Prevention and Health
                Promotion, with proportional funding increases.
        --Please provide the emerging CDC Chronic Disease Education and
                Awareness (CDEA) program with $6 million for FY 2023, an
                increase of $3 million over FY 2022.
      --Provide the Health Resources and Services Administration (HRSA)
            with a funding level of at least $9.8 billion for FY 2023, an
            increase of roughly $900 million over FY 2022.
      --Continue to support committee recommendations highlighting the
            value and importance of charitable assistance programs and
            encouraging proper access.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to present the views
    of Hope Charities and the patient communities that we serve. Primarily,
    we thank you for your continued support for medical research and public
    health programs that serve blood disorders and rare disease patients
    through the FY 2022 omnibus package. For FY 2023, Hope joins the
    broader medical research and public health community in asking that the
    investment in NIH, CDC, and HRSA be maintained and responsibly
    increased.
    About Hope Charities
        Hope Charities is a national nonprofit organization, founded in
    2009, based in Louisiana. The mission of Hope Charities is to act as a
    conduit of hope, strength, and resources to families in a crisis caused
    by a chronic illness. We accomplish our mission through several
    programs including our Resource Connection Program; direct patient
    assistance, which helps families by subsidizing the cost of utilities,
    food, housing, transportation, and medical equipment; access to care
    through health insurance premium assistance as well as educational
    programs.
    Complimenting Public Health Programs
        The Louisiana Department of Health classifies 63 percent (40 of 64)
    parishes as ``rural.'' The CDC reports that residents in rural areas
    have higher rates of poverty, less access to healthcare, and are less
    likely to have health insurance. Hope Charities works with Americans by
    increasing access to medical care for rural, underserved, and
    vulnerable populations. Our mission is to improve healthcare outcomes,
    which in turn decreases work absences, reduces the negative impact of
    chronic illness on mental health, and can lower the overall cost of
    healthcare.
        NIH conducts important research into many rare and chronic
    conditions, such as hemophilia, that incrementally improves care and
    options for affected individuals. This work is essential to advancing
    innovative research, improving outcomes, and lowering healthcare costs.
    The CDC and HRSA also support hemophilia treatment centers and have a
    variety of line-item programs that assist with public health and care
    delivery for patients affected by a variety of conditions. These
    programs, particularly at CDC's National Center for Chronic Disease
    Prevention and Health Promotion, have only seen modest increases in
    recent years, but much more can be done with an infusion of timely
    resources.
        Please note, as a safety net program, Hope Charities is pursuing a
    congressionally directed spending request to bolster efforts that
    support the work of hemophilia treatment centers and community health
    centers, in addition to requesting discretionary funding increases for
    Federal programs.
    About the Patients that We Serve
        Hope recently received a request from Van, a 31 year old male who
    lives in Louisiana and has hemophilia. He was scheduled to have surgery
    at 5:30 a.m. on his right knee as a result of hemophilia-related
    injuries. He lives two hours away from his Hemophilia Treatment Center
    and the hospital where the surgery was to occur. He is on Medicaid and
    could not afford to travel to the hospital. Hope helped him with travel
    expenses and paid for a hotel room for him to stay the night before his
    surgery.
        Anna resides in Illinois and lives 8 hours from her nearest
    Hemophilia Treatment Center. Her minor son has hemophilia B. She
    requested funding from Hope for travel to an appointment. We paid for a
    hotel room for Anna and her son the night before their appointment.
    They attended their appointment early the next day, then traveled home.

        [This statement was submitted by Jonathan James, CEO, Hope
    Charities.]
                                     ______

         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).
    HFES supports additional funding for the Advanced Research Projects
    Agency for Health (ARPA-H) through a supplement for the National
    Institute of Health (NIH) beyond the $49 billion recommended in fiscal
    year (FY) 2023.
        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 2021 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 supports the creation of Advanced Research Projects Agency for
    Health (ARPA-H) and advocates for additional funding to launch the
    agency in FY 2023. HFES advocates for $49 billion for NIH and
    additional supplemental funding to expand the ARPA-H effort ARPA-H will
    focus on high-risk, high-reward research that targets biomedical and
    health breakthroughs, while considering outcomes and the impact on
    healthcare and quality of life. These advancements will range from how
    to prevent, treat, and cure diseases that affect many Americans.
        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;
    $375.3 million for NIOSH, including $34 million for the Education and
    Research Centers (ERCs); and funding a supplement for ARPA-H through
    beyond a recommended $49 billion for NIH in FY 2023. 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 Christopher R. Reid, President,
    and Steven C. Kemp, CAE, Executive Director, Human Factors and
    Ergonomics Society.]
                                     ______

     Prepared Statement of the Infectious Diseases and the Opioid Epidemic
                                    Program
        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 addressing for Public Health-Seattle & King
    County in Seattle, WA. In this role it is my responsibility to lead the
    overdose prevention work for the community.
        I am pleased to submit testimony on behalf of King County, WA to
    urge Congress to appropriate $150 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).
        The United States is experiencing an urgent and unprecedented drug
    overdose crisis, with more than 100,000 overdose deaths from 2021-2022.
    Like the rest of the Nation, King County, WA continues to experience
    record overdose deaths each year. There have been significant increases
    in the county over the past decade, from 248 deaths in 2010 to 511
    deaths in 2020, to the biggest yearly increase yet in 2021 resulting in
    an estimated 719 deaths (some cases pending confirmation). The recent
    influx of fentanyl in the local drug supply has contributed
    significantly. Fentanyl is increasingly involved in overdose deaths,
    from 3 deaths in 2015 to 360 in 2021--a nearly 12,000 percent increase
    in just 6 years. Already marginalized demographic groups are
    disproportionately impacted. In King County, death rates (numbers per
    100,000) in 2020 were 77.2 for American Indians/Alaskan Natives, 32.7
    for Blacks, and 16.5 for Hispanics, compared to 16 for Whites.
        It is imperative that congress respond to this overdose crisis with
    the urgency it deserves and requires. We know that a public health
    approach is the most humane and effective approach to tackling this
    crisis. SSPs are an essential, evidence based public health
    intervention and a vital component of overdose prevention. The CDC has
    documented over 30 years of evidence that shows 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, but they do reduce the amount of improperly
    discarded syringes and save money.
        The King County Needle Exchange proudly serves clients by providing
    health education, naloxone training and distribution, safer sex
    supplies, and referrals for addiction treatment and other medical
    services, in addition to exchanging injection supplies. Our staff
    attempts to meet people where they are and help them address their
    needs in the safest and healthiest way possible, free of judgement and
    stigma. SSPs are among the only health care services trusted and used
    by people who use drugs, so SSP programs can effectively engage this
    highly stigmatized population.
        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 percent of respondents experienced an increase in
    clients in 2020. During this time of skyrocketing need, 42 percent of
    respondents experienced funding cuts and were forced to lay off staff
    and reduce services, limiting access to life saving interventions.
    Increased Federal funding in needed to 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.
        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.
        With additional FY23 funding, CDC could 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 $150 million for the program in FY23. Thank you also for your
    time and consideration of my testimony, and please do not hesitate to
    contact me at brad.finegood@kingcounty.gov if you have questions or
    need additional information.
        Sincerely.

        [This statement was submitted by Brad Finegood, MA, LMHC, Office of
    the
    Director, Strategic Advisor, Public Health--Seattle & King County.]
                                     ______

        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 FY2023 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 $397 million for
    the Antibiotic Resistance Solutions Initiative (ARSI) at the Centers
    for Disease Control and Prevention (CDC), $6.7 billion for the National
    Institute of Allergy and Infectious Diseases (NIAID), $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,
    high levels of antibiotic use have exacerbated existing antimicrobial
    resistance (AMR), deepening the need for antimicrobial stewardship,
    surveillance and new antimicrobial drugs. From March-September 2020,
    there was a 24 percent increase in hospital-onset, multidrug-resistant
    infections associated with COVID-19 surges. 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 $397 million in funding for the Antibiotic Resistance
    Solutions Initiative in FY2023, the cornerstone of the Nation's efforts
    to detect, prevent, and respond to AMR. The President's budget proposal
    includes $197 million in discretionary funding and $200 million each
    year in mandatory funding from FY2023-2028 (as part of the larger
    pandemic preparedness request), for a total of $397 million in FY2023.
    IDSA members see the impact that 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. Infections are a primary or associated cause of death in
    50 percent of patients with cancer, as AMR can make these infections
    difficult or impossible to treat. Tragically some patients may be cured
    of their cancer but succumb to a resistant infection which can occur as
    a result of the effects of chemotherapy. AMR has a disproportionate
    impact on certain communities due to variance in risk of exposure,
    susceptibility to infection or treatment received. Rates of several
    serious antibiotic-resistant infections, including community-associated
    methicillin-resistant Staphylococcus aureus (MRSA) infections, are
    higher incidence in Black populations. Globally, resistant infections
    directly caused 1.27 million deaths in 2019 and played a role in 4.95
    million deaths. If we do not act now, antibiotic-resistant infections
    will be the leading cause of death by 2050 and could cost the world
    $100 trillion.
        Recommended funding is needed to expand antibiotic stewardship
    across the continuum of care; double State and local grant awards;
    expand the AR 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. 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, global AMR prevention
    and surveillance, and responses to sexually transmitted infections and
    health care-associated infections. 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 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 FY2023.
    Advanced Molecular Detection (AMD)
        FY2023 funding of $175 million for the Advanced Molecular Detection
    program would ensure continued innovation in the detection and tracking
    of existing and emerging resistant pathogens. Funding would also enable
    federal, State, and local public health laboratories to expand the use
    of pathogen genomics, sustain important partnerships with academic
    research institutions, and bolster training to ensure integration of
    genomics into AMR surveillance and response. The pandemic has resulted
    in a substantial ramping up of CDC capacity for sequencing pathogens.
    CDC is in the process of establishing ``Centers of Excellence,''
    linking together public health agencies and private sector partnerships
    focused on pathogen genomics and molecular epidemiology. The $175
    million would sustain the Centers of Excellence and support ongoing AMD
    activities.
    National Healthcare Safety Network (NHSN)
        FY2023 funding of $100 million for the National Healthcare Safety
    Network (NHSN) will enable the program to meet its current and
    projected demands. Requested funding is needed to modernize and
    automate NHSN to alleviate the reporting burden and speed access to
    actionable data, which 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. In its FY2023 Inpatient
    Prospective Payment System (IPPS) rule, the Centers for Medicare and
    Medicaid Services (CMS) included a requirement that hospitals begin
    reporting antibiotic use and resistance data. IDSA has long advocated
    for this policy, which will strengthen our ability to detect and track
    emerging resistance threats and provide data to help evaluate
    stewardship interventions and inform best practices. Increased funding
    for NHSN will be essential to help hospitals that do not already report
    these data prepare to do so and to ensure the overall success of this
    initiative.
    CDC Center for Global Health
        IDSA urges the subcommittee to provide $991 million in FY2023
    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 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), 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, 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 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. Despite this progress, the pipeline of new
    antibiotics in development is insufficient to meet patient needs, and
    $300 million in funding is needed to help achieve the goals of the
    2020-2025 Action Plan to accelerate basic and applied research for
    developing new antibiotics and other products. Additional funding will
    help prevent a post-antibiotic era in which we lose many modern medical
    advances that depend upon the availability of antibiotics, such as
    cancer chemotherapy, organ transplants and other surgeries.
    Project BioShield Special Reserve Fund (SRF), Broad Spectrum
            Antimicrobials
        The Project BioShield SRF is positioned to support the response to
    public health threats, including AMR. Efforts by BARDA and NIAID have
    been successful in helping companies bring new antibiotics to market,
    but those companies 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 in which
    small biotechs that develop new antibiotics are particularly
    vulnerable. Funding is needed to expand this approach to better support
    the antibiotics market.
                         national institutes of health
    National Institute of Allergy and Infectious Diseases (NIAID)
        $6.7 billion for NIAID, including $585 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 FY2023 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.
        With regard to AMR specifically, increased funding would support
    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
    resistant infections; and support for training more physician
    scientists and clinical investigators to improve AMR research capacity,
    as outlined in the 2020-2025 National Action Plan to Combat Antibiotic-
    Resistant Bacteria.
        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. In 2021, only 70
    percent of ID physician training programs filled their slots, leaving
    us with an inadequate pipeline of ID physician-scientists necessary to
    lead clinical trials and additional research to strengthen our
    prevention and responses to ID threats. Strong NIAID support for career
    development through increased FY2023 funding and other initiatives is
    critical to improving and diversifying 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.
                                   conclusion
        Thank you for the opportunity to submit this statement. The
    nation's infectious diseases physicians and scientists rely on strong
    Federal partnerships to keep Americans healthy and urge you to support
    these efforts. Please forward any questions to Lisa Cox at
    lcox@idsociety.org.

        [This statement was submitted by Daniel P. McQuillen, MD, FIDSA,
    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 FY 2023.
        The Integrative Health Policy Consortium (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
    additional support, NCCIH 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 also supports the Center's proposed pain management research
    agenda as outlined in the President's FY 2023 budget. According to the
    President's budget, pain ``is a major public health problem and is the
    most common reason why Americans use complementary and integrative
    health practices.'' As a result, NCCIH supports a broad pain and pain
    management research portfolio that includes basic and clinical research
    and the development, evaluation, and implementation of complementary
    and integrative pain management techniques. NCCIH is a leader of the
    NIH-DoD-VA Pain Management Collaboratory, working with other Federal
    agencies to support research on nonpharmacologic approaches to pain
    management in innovative and integrative models of pain care delivery.
        IHPC joins other organizations that belong to the Ad Hoc Group for
    Medical Research in asking the subcommittee to prioritize NIH funding
    by endorsing an appropriation of at least $49 billion for the NIH, a
    $4.1 billion increase over the NIH's program level funding in FY 2022.
    In addition, we urge the Committee to ensure that any funding for the
    new Advanced Research Project Agency for Health (ARPA-H), supplements
    the $49 billion recommendation for NIH's base budget, rather than
    supplants the essential foundational investment in the NIH. Finally, we
    urge that NCCIH receive a commensurate funding increase (7.9 percent)
    in FY 2023.
                       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 $1.8 billion in discretionary funding in FY 2023.
        Thank you for considering our views. The IHPC looks forward to
    working with you to enact the FY 2023 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 the Interstitial Cystitis Association
                summary of recommendations for fiscal year 2023
    _______________________________________________________________________

      --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 $49 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
            2023 (FY 2023) 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 FY 2023.
        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 Instagram 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 $49 billion for NIH in FY 2023. 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 Jamestown S'Klallam Tribe
        Chairwoman Patty Murray, Ranking Member Roy Blunt, and
    distinguished members of this subcommittee, on behalf of the Jamestown
    S'Klallam Tribe, I would like to thank you for this opportunity to
    submit written testimony on our funding priorities and recommendations
    for the FY 2023 appropriations process for the Department of Health and
    Human Services.
    A. Tribal Specific Health Appropriation Priorities
        1. Support the President's FY 2023 Budget Request for Tribal Health
    Programs and Mandatory Funding for the Indian Health Service (IHS)
        2. 340(b) Drug Pricing Program
        3. Ensure that Medicare Reimburses Tribal Providers for Telehealth
    Services at the IHS All-Inclusive Rate or OMB rate
    B. Tribal Priorities Administration for Children and Families & the
            Administration for Community Living
        1. Child Welfare Programs Tribal Allocations Subpart 1, $350
    million; Subpart 2, $120 million $3.6 million Tribal Set Aside
        2. Promoting Safe and Stable Families $650 million for mandatory
    programs and $120 million for discretionary programs
        3. Fund Long Term Care
        4. Older American act Title VI, part A,B Native American Nutrition
    and Supportive Services- $55.5 million Title VI, $43 Million Nutrition
    and Support Services.
              a. tribal specific health appropriations priorities
        1. Support the President's FY 2023 Budget Request for Tribal Health
    Programs and Mandatory Funding for the Indian Health Service (IHS).--
    The President requested $127.3 billion in discretionary funding and
    $1.7 trillion in mandatory funding for the Department of Health and
    Human Services in FY 2023 Appropriations. This is inclusive of $9.3
    billion for the Indian Health Service. The request also seeks to
    reclassify the entire IHS budget as mandatory for FY 2023. We fully
    support the President's historical request and commitment to
    implementing long term solutions to addressing the chronic underfunding
    of Tribal health programs and delivering on the Nation's promises to
    Indian Country. To include the proposal to reclassify IHS funding and
    exempt the IHS budget from sequestration. We urge Congress to follow
    suit and adopt the President's FY 2023 budget proposal.
        2. 340(b) Drug Pricing Program.--The 340(b) program serves as a
    critical safety net drug discount program that Tribal communities rely
    on to serve their citizens and community members who comprise the most
    vulnerable, underserved and isolated populations. The program has grown
    tremendously bringing down the cost of prescription drugs by 25-50
    percent. However, the actions of several drug manufacturers have
    undermined Congressional intent and the 340(b) program resulting in
    limitations on access to discounted prescription drugs. In 2021, HRSA
    issued violation letters to manufactueres who refused to comply with
    statutory obligations unless certain conditions were met. However,
    despite HRSA acting swiftly to address this issue, the manufacturers
    refused to come into compliance with the law. We urge Congress to take
    steps to ensure drug manufacturers are compliant with the law.
        3. Ensure that Medicare Reimburses Tribal Providers for Telehealth
    Services at the IHS All.--Inclusive Rate or OMB Rate--Tribal healthcare
    systems are under unprecedented strain in the aftermath of the public
    health crisis and resulting economic crisis. The financial toll has led
    to reductions in the availability of healthcare services. During the
    public health crisis, many hospitals and clincs turned to telemedicine
    as a necessary tool for the provision of healthcare. In early 2020, the
    Centers for Medicare and Medicaid Services (CMS) waived many of the
    telehealth restrictions on providers, technology, geographic areas and
    services. As a result, use of telehealth visits increased substantially
    in the Indian Healthcare System. The telehealth flexibilities that were
    authorized by CMS increased access to primary, speciality and
    behavioral healthcare services during the pandemic and should be made
    permanent. However, while IHS and Tribal sites receive the IHS All-
    Inclusive Rate for telehealth services under Medicaid, Medicare is
    currently only reimbursing at the Part B rate which is only about $14
    dollars per unit of care. Medicare should reimburse at the full
    encounter rate to ensure providers can continue to utilize telehealth
    as a viable option for services.
       b. tribal priorities administration for children and families and
                      administration for community living
        1. Child Welfare Programs Title IV B (subpart 1)--Tribal Allocation
    $350 Million & Promoting Safe and Stable Families Social Security Act
    Title IV B (subpart 2) $120 Million Tribal Allocation $3.6 Million.--
    The pandemic amplified the existing disparities that Native children
    and families experience in child welfare systems. Limited access to
    supportive and rehabilitative services created an environment of
    enhanced risk for removal of Native children from their homes. Foster
    care is a reality that too many Native families face. Substance abuse,
    mental health challenges, economic instability, financial insecurity,
    and limited access to services continue to threaten the well-being of
    Native families, especially Native children. Tribes need the tools and
    resources to develop culturally based child centered trauma-informed
    care solutions including trained child therapists. Title IV B provides
    funding to Tribes to support community-based child welfare services.
    Tribal tradition and culture are an integral component of our child
    welfare programs because it has been proven that culturally tailored
    programs and services increase community participation and lead to
    better outcomes for American Indian and Alaska Native (AI/AN) children
    and families. Increased funding coupled with maximum flexibility to use
    these funds to provide ancillary child welfare services, including,
    parenting classes, conducting home visits, and addressing issues, such
    as, alcohol and substance abuse is essential so that AI/AN children can
    remain with their families and in their Tribal communities.
        2. Promoting Safe and Stable Families $650 million for mandatory
    programs and $120 million for discretionary programs.--Increase funding
    for the Promoting Safe and Stable Families program so that more Tribes
    are able to access this critical funding. Addressing trauma, promoting
    stronger families, and reducing the rates of foster care placements are
    all important components of this program. We appreciate the
    Administration's FY 2023 request for increased mandatory funding to
    support this program. We recommend that the programmatic increases
    include $650 million for mandatory programs and $120 million for
    discretionary programs.
        3. Fund Long Term Care.--Tribes are committed to ensuring that
    elders receive the respect, resources and care that they deserve;
    however, funding for elder programs is woefully inadequate to meet
    existing and future needs. Finding facilities to house our elders is a
    growing issue because many are cost prohibitive for both the elders and
    Tribal governments. Tribes want to keep elders on their homelands and
    in their homes so that they are close to their families and
    communities. Staying connected to their families, Tribal communities
    and cultures supports quality of life. In order to accomplish this we
    need resources to support assisted living, long term care, home and
    community based services and end of life hospice care. The Indian
    Healthcare Improvement Act (IHCIA) grants the Indian Health Service
    authorities for the provision of long term care but funding needs to be
    appropriated to provide these services.
        4. Older Americans Act Title VI, Part A, B Native American
    Nutrition and Supportive Services--$55.5 million Title VI, $43 Million
    Nutrition and Support Services.--Providing support services to our
    elders is deeply rooted in our beliefs and ensures the survival of our
    culture, traditions, and language. Title VI of the Older Americans Act
    is the primary funding source for the provision of nutrition,
    healthcare, and other holistic community-based cultural programs and
    supportive services. However, funding for elder programs is woefully
    inadequate to meet existing and growing needs. The Indian Healthcare
    Improvement Act (IHCIA) authorized the Secretary of HHS to fund these
    services but, to date, no funding has been appropriated for these
    services.
        The Jamestown S'Klallam Tribe continues to support the requests and
    recommendations of the Northwest Portland Area Indian Health Board, the
    National Indian Health Board, and the National Congress of American
    Indians. Thank you.

        [This statement was submitted by Hon. W. Ron Allen, Tribal
    Chairman/CEO, Jamestown S'Klallam Tribe.]
                                     ______

                    Prepared Statement of Johnson & Johnson
        On behalf of Johnson & Johnson's 144,000 global employees, I am
    pleased to provide written testimony to the Senate Appropriations
    subcommittee on Labor, Health and Human Services, Education and Related
    Agencies in support of increased funding for the National Institutes of
    Health (NIH) Fiscal Year (FY) 2023 budget.
        Robust funding for NIH is necessary to ensure the agency continues
    to have the ability to fuel innovation in medical research, improving
    the trajectory of healthcare in the United States and around the world.
    NIH funding also encourages the pursuit of innovative solutions
    essential in addressing the increasingly complex health threats
    confronting the United States.
        As a physician and scientist, I have dedicated much of my life to
    translating basic scientific research into medical advances. In my role
    as Executive Vice President, Chief External Innovation, Medical Safety
    and Global Public Health Officer at Johnson & Johnson and as a board
    member of the American Association for Cancer Research, I am deeply
    aware of the value of our Nation's investment in research.
        In the United States, the majority of medical research into the
    root causes of disease is publicly funded by the NIH through research
    grants to more than 2,500 institutions across the country. The
    foundational research conducted by NIH-funded investigators plays an
    important complementary role to private sector research and development
    efforts. Specifically, healthcare companies build upon this
    foundational research, and make substantial investments in R&D to
    transform this foundational research into the breakthrough healthcare
    products of tomorrow.
        At Johnson & Johnson, we make a commitment to create life-enhancing
    innovations and to produce value through partnerships that will
    profoundly change the trajectory of health for humanity. To that end,
    in 2021, Johnson & Johnson invested nearly $14.7 billion in research
    and development across our pharmaceutical, consumer, and medical
    technology companies. Our teams of scientists work tirelessly to
    accelerate the translation of scientific discoveries into meaningful
    solutions for patients and consumers. Much of our work, and that of
    scientists across the industry, is facilitated by our understanding of
    underlying disease biology--precisely the type of research funded by
    the NIH.
        In addition, Johnson & Johnson recognizes the crucial importance of
    early-stage companies, and the critical role NIH plays in supporting
    these small businesses through Small Business Innovation Research
    (SBIR) and Small Business Technology Transfer (STTR) funding. Through
    Johnson & Johnson Innovation, entrepreneurs and startups can discuss
    the innovative ideas they're working on, seek to collaborate with
    Johnson & Johnson scientists, and access our global expertise and
    resources to accelerate their work. Through Johnson & Johnson
    Innovation--Johnson & Johnson Development Corporation, they may obtain
    venture capital funding to support their innovations. At Johnson &
    Johnson Innovation--JLABS incubator sites--including a new JLABS @
    Washington DC site in collaboration with Children's National and
    BARDA--we support the life sciences ecosystem by helping entrepreneurs
    and scientists realize their dreams of creating healthcare solutions
    that improve lives. Their potentially disruptive, cutting-edge research
    may lead to novel platforms, products or technologies--advances that
    the scientific community could only imagine several years ago and that
    are becoming a reality today through the support of public-private
    partnerships like these.
        The work of the NIH is tied not only to innovation and the vitality
    of the life sciences, but also to the health of our National economy
    and to the health of our Nation. In FY 2021, NIH research funding
    directly and indirectly supported over 552,444 jobs and spurred nearly
    $94.18 billion in new economic activity. Moreover, diseases such as
    Alzheimer's, diabetes, cancer, and heart disease as well as current and
    future pandemics, threaten the lives of millions of our citizens and
    threaten to overwhelm our healthcare system in a matter of years, with
    enormous costs of care if we do not find ways to prevent, intercept,
    treat, and cure them. We must also continue to address public health
    crises and areas of pipeline need such as emerging infectious diseases
    and antimicrobial resistance. The pace of medical research must keep up
    with these challenges, and it is the NIH that must fuel that research.
        Investments in medical research over the last several decades by
    the Federal Government and private life sciences companies, combined
    with the work of industry and NIH-funded investigators across the
    country, have produced fundamental scientific advances and increasingly
    sophisticated areas of scientific inquiry. As the NIH is working on
    projects in areas like precision medicine, gene therapy, and vaccines
    to prevent infectious diseases, there has never been a more critical
    and promising time to work in medical research, nor a more critical
    time to fund the NIH.
        Johnson & Johnson believes that fully and consistently funding the
    NIH is critical to a commitment to fueling innovation in medical
    research. It is also a commitment to our communities by advancing
    science to match medical need, to our current and future generations of
    scientists by stimulating the life sciences ecosystem, and to the
    prosperity of our Nation as a worldwide leader in medical research.
    Sustainable, robust investment is needed to strengthen this research
    and to realize its benefits for improving people's lives and reducing
    the burden and associated costs of disease in the United States and
    around the world.

        [This statement was submitted by William N. Hait, MD, PhD,
    Executive Vice President, Chief External Innovation, Medical Safety and
    Global Public.]
                                     ______

                    Prepared Statement of Knowledge Alliance
        Knowledge Alliance (KA), a non-partisan, non-profit organization,
    is comprised of leading education organizations committed since 1971 to
    the greater use of high-quality and relevant data, research, evaluation
    and innovation in education policy and practice at all levels.
    Collectively, we have spent the last 50 years supporting a set of
    education programs focused on building and disseminating evidence to
    improve teaching and learning in our Nation's classrooms.
        Knowledge Alliance believes that programs at the Institute of
    Education Sciences (IES)--such as the Regional Educational Laboratories
    (RELs) and the Research, Development, and Dissemination (RD&D)
    program--coupled with the Comprehensive Centers (CCs) and the Education
    Innovation and Research (EIR) program at the U.S. Department of
    Education (ED) are the foundation of the Nation's research,
    dissemination and technical assistance infrastructure. We deeply
    appreciate the increases in funding provided in Fiscal Year (FY) 22 for
    these critical programs to better tie evidence to practice in our
    schools and improve outcomes for students. Moreover, we know these
    funds will be critical in supporting schools as districts utilize
    evidence-based practices in their responses to COVID-19 learning loss
    and the other additional educational challenges posed by this
    transitional year, especially for student populations who have been
    historically underserved and were significantly impacted by the
    pandemic. We encourage Congress to continue to provide increases in
    each of these programs for FY23 to continue leveraging critical
    research, technical assistance, evaluation and innovation to help
    States, districts and schools.
        KA priority programs require additional Federal resources to
    address the continuously growing State and local needs for education
    research and technical assistance, as these programs provide critical
    support for States, districts and schools. In response to challenges
    from COVID-19, REL West and Comprehensive Center Regions 2, 13 and 15
    provided 8 workshops to approximately 570 state, regional, district and
    school staff on selecting and measuring evidence-based strategies using
    American Rescue Plan (ARP) funds. The primary focus of each event was
    to help State educational agencies (SEAs) develop strategies to support
    local educational agencies (LEAs) in using their ARP funds to address
    high-priority needs and select evidenced-based strategies. More
    recently, the National Comprehensive Center established three
    Communities of Practice (COP) to support SEAs and their partners in
    three areas: (1) Using ARP funds to implement evidence-based
    strategies; (2) Implementing school improvement strategies through an
    equity lens; and (3) Planning for summer/extended learning drawing from
    evidence-based practices where they exist. With recognition that States
    and districts can, and should, work together to solve common
    challenges, the National Comprehensive Center provides a unique space
    for SEAs and LEAs to learn from each other as they engage around
    specific problems of practice. In the COP around school improvement,
    SEA and LEA leaders have already reported how bringing together school
    leaders, teachers and districts in their community, through an equity
    lens, is inspiring new, innovative, approaches to help low-performing
    schools. Clearly, both RELs and CCs have been first in line to provide
    technical assistance and evidence-based resources to interested SEAs
    and LEAs. An increase in funding would allow these programs to expand
    their work and better meet the ever-growing need for support.
        Despite the evident need for education research, dissemination and
    technical assistance infrastructure, evidence shows that this work
    remains underfunded. Three recently released reports by the National
    Academies of Sciences, Engineering and Medicine (NASEM) noted that IES
    is currently overburdened and underfunded, preventing efficient grant
    review cycles, adequate staffing levels and innovation within the
    agency. In the NASEM report titled ``The Future of Education Research
    at IES,'' there was consensus that ``Congress should re-examine the IES
    budget, which does not appear to be on par with that of other
    scientific funding agencies.'' The report notes that education research
    programs at the National Science Foundation (NSF) and National
    Institutes of Health (NIH) receive substantially more funds than IES
    despite working with similar constituents on comparable issues.
    Moreover, as the hub of all Federal education research work, IES is
    best situated to effectively create and disseminate evidence-based
    resources to the field. It is evident that KA's priority programs
    require increases in FY23 to better meet the needs of States,
    districts, and schools nationwide.
        To support continued education research, evaluation and innovation
    outlined above, we urge you to provide increases over FY22 levels in
    FY23 for existing Federal research and development infrastructure. KA
    proposes a critical investment of $815.0 million for the Institute of
    Education Sciences (IES); $267.9 million for the Research Development
    and Dissemination (RD&D) program at IES; $65.0 million for the Regional
    Educational Laboratories (RELs) Program; $60.0 million for the
    Comprehensive Centers (CCs); and $514.0 million for the Education
    Innovation and Research (EIR) program
        This request translates to approximately a 10 percent increase for
    IES, RELs and CCs. We have requested an approximately 30 percent
    increase for RD&D to account for how, as the hub of general education
    research, it will be relied heavily upon to support research post-
    COVID. Finally, KA's EIR request matches the President's FY23 budget,
    which recognizes the importance of education research innovation and
    proposes a significant investment in addressing the educator shortage,
    an issue KA members are actively working on.
        The below section provides greater detail on the request for each
    of the programs outlined above. Thank you for your consideration of
    these important recommendations. We believe that continued strong
    support for, and investment in, the education research and development
    infrastructure will help improve outcomes for students and effectively
    leverage scarce Federal resources. Furthermore, it will empower States
    and local school districts to develop and implement the innovative,
    evidence-based approaches that work best for the students in their
    communities.
                            fy23 appropriations asks
        The Institute of Education Sciences. IES is a major source of
    Federal funding for education research. Through its four research
    centers- the National Center for Education Research (NCER), National
    Center for Education Statistics (NCES), National Center for Education
    Evaluation and Regional Assistance (NCEE) and the National Center for
    Special Education Research (NCSER) -IES funds hundreds of grants and
    contracts annually that support a wide range of research projects.
    These centers support projects that provide vital information, often
    with an equity focus, on students with disabilities, teacher
    preparation and strategies for improving college and workforce
    readiness, among other topics. In the past year, IES has successfully
    pivoted its efforts to consider projects in the larger context of the
    COVID-19 pandemic and recovery.
        The What Works Clearinghouse produces reviews of research on
    education curriculum and practice guides with evidence-based
    recommendations to support teaching and learning. According to the
    Jefferson Education Exchange, nearly a third of educators surveyed used
    resources from the What Works Clearinghouse. In direct response to the
    COVID-19 pandemic, the What Works Clearinghouse released a Rapid
    Evidence Review of Distance Learning Programs that identifies and
    reports on what works in distance learning educational programming from
    Kindergarten onwards. Additionally, the WWC provides educational
    webinars to better disseminate research in the field, most recently
    they held a webinar on providing reading interventions for students in
    grades 4-9.
        Additional basic research could be done in areas of importance to
    educators and policymakers if more funding were available, particularly
    in the areas of postsecondary completion and workplace credentials. As
    basic research moves into the applied realm, the What Works
    Clearinghouse will continue to serve as a resource for educators
    looking for effective, research-based interventions.
        Regional Educational Laboratories. The 10 RELs nationwide, which
    operate under 5-year contracts with ED, conduct applied research,
    develop and disseminate research-based products and provide training to
    States and school district staff as well as resources for educators,
    families and caregivers. Since the RELs have a broad set of regional
    stakeholders that extend beyond the SEA, they are well-attuned to a
    wider range of student and teacher needs. In addition to forming
    research partnerships focused on problems of practice in the field that
    provide relevant and responsive research and findings that address
    local needs; RELs utilize the resources of the WWC, such as the
    practice guides, to break down the evidence into digestible chunks for
    educator use. They have also developed webinars and other resources
    based on the practice guides to aide in translating research for
    educators. RELs are continuously developing tools that districts and
    schools use to improve teaching and learning. In response to the
    pandemic, RELs have provided evidence-based resources to help address a
    host of critical challenges facing States, districts, educators and
    families as they continue to navigate the impacts of COVID-19.
        Education leaders in Michigan partnered with REL Midwest to develop
    the Midwest Alliance to Improve Teacher Preparation (MAITP). From 2017
    to 2021, MAITP conducted research with education leaders,
    practitioners, policymakers and researchers in Michigan, Illinois and
    Indiana to address teacher recruitment and retention.
        To increase the number of teachers available to Michigan public
    schools, MAITP members wanted to explore the validity of recruiting
    nonteaching certified teachers. In 2021, REL Midwest published a study
    that examined why some certified teachers no longer teach in Michigan
    public schools. The study found approximately 61,000 teachers certified
    in Michigan were not teaching in the State's public schools in 2017-18.
    The study also identified increased salary and simplification of
    certification requirements as desired incentives for teachers to
    consider returning to the classroom. REL Midwest created a companion
    infographic and documentary to communicate the study findings. The
    Michigan Department of Education drew on the findings and launched the
    ``Welcome Back Proud Michigan Educator Campaign,'' an initiative that
    seeks to recruit individuals with expired teacher certificates into the
    teacher workforce by reducing-and in some cases, eliminating-
    professional learning requirements for recertification.
        Education Innovation and Research. The EIR Program, authorized by
    Every Student Succeeds Act (ESSA), helps drive substantial and lasting
    improvements in student achievement by supporting the development and
    scale-up of successful innovations at the State and local levels. EIR
    uses a tiered evidence approach that has two important design
    principles: it provides more funds to programs with higher levels of
    evidence, and it requires rigorous and independent evaluations so that
    programs continue to improve, and future competitions can be geared
    towards more promising areas of investment.
        KA supports the Administration's FY23 EIR proposal which recommends
    a historic, and needed, increase in funding for the program. EIR would
    allow for the creation of more innovative evidence-based resources to
    address the myriad of educational challenges facing the Nation. Of this
    historic increase, $350 million would target projects that identify and
    scale up evidence-based strategies to elevate and strengthen a teacher
    workforce hit hard by COVID-19. Given the educator workforce shortage,
    KA supports the use of these funds to support efforts to stabilize the
    profession through improved support for educators and expanded
    professional growth opportunities, including access to leadership
    opportunities that can lead to increased pay and improved retention for
    fully certified, experienced, and effective teachers.
        Future Forward is a literacy intervention for students struggling
    with reading from kindergarten through third grade that combines
    intensive one-on-one tutoring during the school day with family
    engagement support embedded in all aspects of the program. Ongoing
    support from the U.S. Department of Education through the Education
    Innovation and Research (EIR) grant program has allowed Future Forward
    to rigorously evaluate their program with randomized controlled trials
    and multi-site regression discontinuity analysis. The external
    evaluation found the program yielded positive, statistically
    significant impacts on reading achievement, literacy, and regular
    school attendance. The EIR program has enabled Future Forward to
    subsequently sustain, replicate and scale those practices. In December
    of 2021, Future Forward was awarded an expansion-phase EIR grant and
    will work over the next 5 years to expand to several dozen new schools
    in rural communities across the country; prepare schools to take full
    ownership over long-term program implementation to ensure
    sustainability; and rebuild the online program management platform to
    become a first of its kind integrated reporting system for supplemental
    education programs. Future Forward was the recipient of a mid-phase EIR
    grant in 2017 (the program was known as ``SPARK'') as well as an
    Investing in Education (i3) grant in 2010.
        Comprehensive Centers. The Comprehensive Centers (CCs) provide
    technical assistance that builds the capacity of SEAs to help districts
    and schools improve educational outcomes for all students, close
    achievement gaps and increase the quality of instruction. The CCs
    include 19 Regional Centers that work closely with States in their
    regions on implementation of critical reforms in elementary and
    secondary education, as well as one national center providing technical
    assistance to the regional centers and SEAs. The CCs operate under a
    Memorandum of Understanding with each SEA in the region, and the SEA
    sets the scope of work to be conducted through the 5-year agreement.
        In 2021, the National Comprehensive Center and national partners
    launched the Summer Learning & Enrichment Collaborative (``the
    Collaborative'') to support States, school districts and community
    partners in using ARP funds to implement and expand evidence-based
    summer learning and enrichment experiences for students, especially
    those most impacted by the pandemic. Throughout the summer of 2021, the
    Collaborative invited States, school districts, community partners, and
    other stakeholders to participate in a series of eight virtual learning
    opportunities to discuss and share promising practices in planning and
    implementing summer experiences for all students and student groups.
        The Collaborative hosted over 50 topical sessions for over 1,300
    participants across 49 States. Sessions addressed a wide range of
    topics from staff recruitment to student attendance, STEM partnerships,
    developing community-school agreements and many more.
                                     ______

           Prepared Statement of the Learning and Education Academic
                                Research Network
        We are writing on behalf of the LEARN Coalition to express our
    support for increased funding for several key education research
    programs that the LHHS subcommittee will debate as part of the Fiscal
    Year (FY) 2023 appropriations process. LEARN, a coalition of 41 leading
    research colleges of education across the country, supports critical
    investments in research aimed at advancing the scientific understanding
    of learning and development. We advocate for greater funding for these
    priorities across all Federal agencies, including the Institute of
    Education Sciences (IES), the National Institute of Child Health and
    Human Development (NICHD), and the National Institute of Mental Health
    (NIMH). Specifically, LEARN is requesting no less than $815 million for
    IES overall with $225 million dedicated to the Research, Development
    and Dissemination (RD&D) line item and $70 million for the National
    Center for Special Education Research (NCSER). Within the National
    Institutes of Health (NIH), LEARN requests that $2.02 billion go
    towards NICHD and $2.57 billion go towards NIMH. While advocating for
    these increased resources for fiscal year 2023, we want to express our
    appreciation for the increases for IES and NIH that were made in fiscal
    year 2022.
                        institute of education sciences
        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 this evidence base. While 12-15
    percent of NCER and NCSER's grant awards have been funded over the last
    several years, the number of grant competitions offered by IES are
    currently severely limited due to chronic understaffing within the
    agency. Furthermore, NCSER was unable to fund all the grant
    applications rated outstanding or excellent in fiscal year 2021 due to
    a lack of sufficient funds. Such evidence displays how IES is currently
    too understaffed and underfunded to support the Nation's education
    infrastructure to its best potential.
        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. The
    increases provided to IES will support the continued examination of
    what works and what does not work to further our education system's
    curricula, instructional techniques and assessments. This additional
    funding will bolster IES' work in relation to education research
    overall as well as provide support as the Nation works towards COVID-19
    recovery. Given the importance of developing reliable evidence during
    this critical time, LEARN is requesting $815 million for IES overall
    and $225 million for the RD&D line item within IES.
        In addition, we recommend that funding for research in special
    education, through NCSER, 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 evidence-
    based resources that improve academic outcomes for children with or at
    risk of disabilities. Special education students were dramatically
    impacted by the change in schooling due to COVID-19; additional funding
    to NCSER is necessary to support data and evidence-based resources that
    will ensure a strong recovery for these students.
        Of note, prominent experts have expressed concern over the
    relatively small amount of funding being provided to IES compared to
    other Federal research agencies. In a 2022 National Academy of
    Sciences, Engineering and Medicine (NASEM) report titled ``The Future
    of Education Research at IES,'' a diverse panel of 17 experts in the
    field came to consensus that Congress should re-examine the IES budget
    as it is currently severely underfunded despite the continuously
    expanding work of IES. After hours of research and discussion, the
    panel recognized that IES funding ``does not appear to be on par with
    that of other scientific funding agencies,'' such as NIH or NSF,
    despite being charged to lead the Nation's education research agenda,
    collect and evaluate education research and disseminate evidence-based
    resources to classrooms nationwide. In alignment with this trusted
    outside evaluation, LEARN urges Congress to provide much needed fiscal
    support to IES by appropriating no less than $815 million to the agency
    overall, $225 million to the RD&D line time and $70 million to NCSER.
                         national institutes of health
        There are critical education research programs within the 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 $2.02 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 long-term 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 $2.57
    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. At a time when the
    mental health impact to children and adolescents remains dire following
    the COVID-19 pandemic, this research is needed more now than ever.
        The LEARN Coalition believes that collectively these key
    investments in education research will drive improvements in school,
    teacher and student performance in the coming years, strengthen the
    Nation's education infrastructure and ensure a strong, educated
    workforce in the long run. Thank you for considering these requests and
    please contact Alex Nock at anock@pennhillgroup.com with any questions,
    comments or concerns.

        Sincerely,

        Camilla P. Benbow, Ed.D., Co-Chair, Learning and Education Academic
    Research Network (LEARN)
    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 (LEARN), Dean of the School of Education, University of Kansas

        Glenn E. Good, Ph.D., Co-Chair, Learning and Education Academic
    Research
    Network (LEARN), Dean of the College of Education, University of
    Florida
                                     ______

      Prepared Statement of the Low Income Home Energy Assistance Program
        The Low Income Home Energy Assistance Program authorized by 42
    U.S.C. Sec. Sec. 8621 et seq. (LIHEAP) is the cornerstone of government
    efforts to help needy seniors and families stay warm and avoid
    hypothermia in the winter, as well as stay cool and avoid heat stress
    (even death) in the summer. LIHEAP is an important safety net program
    for low-income unemployed and underemployed families struggling in this
    economy. LIHEAP helped approximately 6 million households afford their
    energy bills in FY 2019.\1\ This crucial safety net program protects
    the health and well-being of low-income seniors, consumers with
    disabilities, and families with very young children., We respectfully
    request that LIHEAP be funded at no less than $5.1 billion \2\ for FY
    2023 and an additional $500 million in emergency contingency
    funding.\3\
    ---------------------------------------------------------------------------
        \1\ Testimony of the National Energy Assistance Directors'
    Association, House subcommittee on Labor, Health and Human Services and
    Education and Related Agencies (April 8, 2019).
        \2\ 42 U.S.C. Sec. 8621(b).
        \3\ 42 U.S.C. Sec. 8621(e).
    ---------------------------------------------------------------------------
    The Urgent Need for Adequate LIHEAP Appropriations
        Funding LIHEAP at no less than $5.1 billion for the regular program
    in FY 2023 and an additional $500 million in emergency contingency
    funding is imperative to address the record increases in energy prices
    \4\ coupled with the record increases in the cost of other essential
    necessities such as food and shelter \5\--price increases that hit the
    lower wealth households the hardest. The U.S. Bureau of Labor
    Statistics Consumer Price Index for April 2022 shows an 80.5 percent
    12-month increase in the cost of fuel oil, an 11 percent increase for
    electricity service and an 22.7 percent increase for natural gas. These
    12-month increases in energy costs have been amongst the highest
    increases in decades.\6\ Similarly the 12-month increase in the cost of
    food and shelter are also the highest increases in decades. Low-income
    households cannot escape these price increases. They are driving
    untenable choices between basic necessities.\7\
    ---------------------------------------------------------------------------
        \4\ See U.S. Bureau of Labor Statistics, News Release, Consumer
    Price Index--April 2022 (May 11. 2022), available at https://
    www.bls.gov/news.release/cpi.nr0.htm (hereafter, ``May 11, 2002 CPI
    Release''); Ivan Penn, ``Get Ready for Another Energy Price Spike: High
    Electric Bills"(rates have jumped because of a surge in natural gas
    prices and could rise rapidly for years) (May 3, 2022), available at
    https://www.nytimes.com/2022/05/03/business/energy-environment/high-
    electric-bills-summer.html.
        \5\ Fn. 5, May 11. 2022 CPI Release.
        \6\ Fn. 5, May 11, 2022 CPI Release; NEADA, ``Energy Inflation Hits
    Lowest Income Families Hardest'' (April 12, 2022), available at https:/
    /neada.org/energyinflationpr/.
        \7\ See e.g., Christine Stephenson, ``Duke Energy, CenterPoint
    bills are spiking in Bloomington. ,'' The Herald Times (Feb.22, 2022),
    available at https://www.heraldtimesonline.com/story/news/local/2022/
    02/22/duke-energy-bills-spiking-bloomington-monroe-county/6882306001/.
    ---------------------------------------------------------------------------
        Moreover, as moratoriums on disconnections of utility service
    during COVID have ended, utility disconnections are at record high
    levels in many parts of the country. The need for substantial LIHEAP
    funding is greater than ever. One market analysis conservatively
    estimates that while utility sector bad debt had declined to an average
    annual rate of 2.9 percent ($2.5 billion total) between 2000--2019, in
    2020 utility bad debt jumped to $5.2 billion.\8\ LIHEAP helps
    households at risk of energy disconnections due to non-payment remain
    connected to essential home energy and avoid choosing between energy
    bills and rent or food.\9\ For very poor, struggling households, LIHEAP
    helps bring the cost of these essential heating and cooling services
    within reach for an estimated 6 million low-income households and helps
    them stay connected.
    ---------------------------------------------------------------------------
        \8\ Kaulkin Ginsburg, ``The Kaulkin Report 2022 Ed.'' Kaulkin
    Ginsburg Co. at page 36; NEADA Press Release, ``Families are Drowning
    in Utility Debt: NEADA Calls for Additional Funding for Energy
    Assistance'' (April 26, 2022)(estimated utility arrearages increased to
    $23 billion at the end of 2019; 20.1 million households had utility
    debt), available at https://neada.org/wp-content/uploads/2022/04/
    utilitydebtpr4-26.pdf.
        \9\ See e.g., Tami Luhby, ``Utility Shutoffs loom as energy prices
    soar and moratoriums end. But help is available'' (April 24, 2022),
    available at https://www.abc12.com/news/national/utility-shutoffs-loom-
    as-energy-prices-soar-and-moratoriums-end-but-help-is-available/
    article_85b1942f-1f6d-5799-8278-cbf8bf303f79.html; Mark Wolfe,
    ``Opinion: Struggling US Families face a wave of power shutoffs if
    Congress doesn't act'' (updated April 28, 2022), available at https://
    www.cnn.com/2022/04/28/perspectives/utility-bills-power-shutoffs/
    index.html.
    ---------------------------------------------------------------------------
        Energy bills are not affordable for struggling, low-income
    households. The average LIHEAP household in 2015 devoted over 8 percent
    of total household income just for home energy services, compared to an
    average of under 4 percent for all U.S. households. Home energy is also
    more expensive during prolonged periods of extreme temperatures because
    households use more fuel to keep the home at safe temperatures.
    Prolonged colder than normal temperatures, such as the sharp cold wave
    that resulted in 22 deaths and affected a wide swath of the country
    January to March 2019,\10\ can result in an unexpected, increased use
    of heating fuels. Likewise, prolonged hot temperatures, which are
    becoming more common, can result in an increased need for air
    conditioning, particularly for consumers with certain medical
    conditions.\11\
    ---------------------------------------------------------------------------
        \10\ See e.g., ``Extreme cold in the Midwest led to high power
    demand and record natural gas demand,'' US Energy Information
    Administration, Today in Energy (Feb. 26, 2019) available at https://
    www.eia.gov/todayinenergy/detail.php?id=38472.
        \11\ Lynne Page Snyder and Christopher Baker, Affordable Home
    Energy and Health: Making the Connections, AARP Public Policy Institute
    (June 2010) at pp.10-11, available at https://www.aarp.org/money/low-
    income-assistance/info-06-2010/2010-05-consumer.html.
    ---------------------------------------------------------------------------
        Yet, struggling low-income households are at risk of disconnection
    from essential utilities because they do not have the savings or income
    on hand to afford their energy bills. The Federal Reserve finds that 4
    in 10 households report that they would have difficulty with an
    unexpected expense of $400 and that 3 in 10 households are either
    unable to pay their bills or are a modest financial setback from
    hardship.\12\ A growing body of research is documenting the rise in
    household income volatility (the dramatic fluctuation of income over
    time) and the impacts on household well-being.\13\ Approximately one-
    third of households experience income volatility \14\ and irregular
    work schedules were the leading cause of volatility.\15\ When income is
    hard to predict, paying for necessities such as utility service can be
    difficult, if not impossible, without help from programs like LIHEAP.
    Households experiencing income volatility tend to turn to more
    expensive alternative financial services products such as payday
    loans.\16\ Low and moderate income consumers who experience income
    volatility have much higher rates of skipped bills, skipped medical
    care, skipped housing payments and food insecurity.\17\
    ---------------------------------------------------------------------------
        \12\ Board of Governors of the Federal Reserve, Report on the
    Economic Well-Being of U.S. Households in 2018 (May 2019) at p.21,
    available at https://www.federalreserve.gov/consumerscommunities/files/
    2018-report-economic-well-being-us-households-201905.pdf.
        \13\ See e.g., Federal Reserve Survey of Household Economics and
    Decisionmaking reports available at https://www.federalreserve.gov/
    consumerscommunities/shed.htm; The Aspen Institute Expanding Prosperity
    Impact Collaborative (EPIC) series on the issue of income volatility
    available at http://www.aspenepic.org/epic-issues/income-volatility/;
    Pew Charitable Trusts, How Income Volatility Interacts with American
    Families; Financial Security (March 9, 2017) available at https://
    www.pewtrusts.org/en/research-and-analysis/issue-briefs/2017/03/how-
    income-volatility-interacts-with-american-families-financial-security.
        \14\ Daniel Schneider and Kristen Harknett, Income Volatility in
    the Service Sector: Contours, Causes, and Consequences (July 2017) at
    p.3, available at http://www.aspenepic.org/epic-issues/income-
    volatility/issue-briefs-what-we-know/issue-brief-income-volatility-
    service-sector/; Board of Governors of the Federal Reserve, Report on
    the Economic Well-Being of U.S. Households in 2018 (May 2019) at p.2,
    available at https://www.federalreserve.gov/consumerscommunities/files/
    2018-report-economic-well-being-us-households-201905.pdf.
        \15\ Income Volatility: A Primer (May 1, 2016) The Aspin Institute
    Financial Security Program and EPIC at p.5, available at https://
    www.aspeninstitute.org/publications/income-volatility-a-primer/; Daniel
    Schneider and Kristen Harknett, Income Volatility in the Service
    Sector: Contours, Causes and Consequences (July 2017) at p.3, available
    at http://www.aspenepic.org/epic-issues/income-volatility/issue-briefs-
    what-we-know/issue-brief-income-volatility-service-sector/.
        \16\ Daniel Schneider and Kristen Harknett, supra, fn. 15, at p. 9,
    available at http://www.aspenepic.org/epic-issues/income-volatility/
    issue-briefs-what-we-know/issue-brief-income-volatility-service-sector/
    (almost a quarter of consumers reporting week-to-week volatility report
    using payday lenders).
        \17\ Stephen Roll, David S. Mitchell, Krista Holub et al.,
    Responses to and Repercussions from Income Volatility in Low- and
    Moderate-Income Households: Results from a National Survey, Aspen
    Institute EPIC, Center for Social Development, Intuit Tax & Financial
    Center (Dec. 2-17) at pp 6-7, available at https://
    www.aspeninstitute.org/publications/responses-repercussions-income-
    volatility-low-moderate-income-households-results-national-survey/.
    ---------------------------------------------------------------------------
        LIHEAP protects the health of the frail elderly, the very young and
    those with chronic health conditions, all of whom are highly
    susceptible to temperature extremes. LIHEAP also helps keep families
    together by keeping homes habitable during cold winters and sweltering
    summers.
    LIHEAP Is a Critical Safety Net Program for the Elderly, the Disabled
            and Households with Young Children
        Recent national studies have documented the dire choices low-income
    households face when energy bills are unaffordable. Because adequate
    heating and cooling are tied to the habitability of the home, low-
    income families will go to great lengths to pay their energy bills.
    According to the US Energy Information Agency (EIA), one in three
    households face challenges meeting energy needs, with over 20 percent
    forgoing basic necessities to pay their energy bills, over 10 percent
    report keeping their home at unsafe temperatures and almost 15 percent
    received a disconnection notice.\18\ EIA's analysis is consistent with
    other studies showing that low-income households faced with
    unaffordable energy bills cut back on necessities such as food,
    medicine and medical care.\19\ The U.S. Department of Agriculture has
    documented the connection between low-income households, especially
    those with elderly persons, experiencing very low food security and
    heating and cooling seasons when energy bills are high.\20\ A pediatric
    study in Boston documented an increase in the number of extremely low
    weight children, age 6 to 24 months, in the 3 months following the
    coldest months, when compared to the rest of the year.\21\ It is
    shocking that in this wealthy nation, so many face heat-or-eat choices
    where families go without food during the winter to pay their heating
    bills, and their children fail to thrive and grow. A 2007 Colorado
    study found that the second leading cause of homelessness for families
    with children is the inability to pay for home energy.\22\
    ---------------------------------------------------------------------------
        \18\ ``One in three U.S. households faces a challenge in meeting
    energy needs,'' US Energy Information Administration, Today in Energy
    (Sept. 19, 2018) available at https://www.eia.gov/todayinenergy/
    detail.php?id=37072.
        \19\ See e.g., National Energy Assistance Directors' Association,
    2018 National Energy Assistance Survey, Tables in section IV, F and G
    (Dec. 2018) (to pay their energy bills, 32 percent of LIHEAP recipients
    went without food, 41 percent went without medical or dental care, 31
    percent did not fill or took less than the full dose of a prescribed
    medicine, 13 percent got a payday loan). Available at http://neada.org/
    wp-content/uploads/2015/03/liheapsurvey2018.pdf.
        \20\ Mark Nord and Linda S. Kantor, Seasonal Variation in Food
    Insecurity Is Associated with Heating and Cooling Costs Among Low-
    Income Elderly Americans, The Journal of Nutrition, 136 (Nov. 2006)
    2939-2944.
        \21\ Deborah A. Frank, MD et al., Heat or Eat: The Low Income Home
    Energy Assistance Program and Nutritional and Health Risks Among
    Children Less Than 3 years of Age, AAP Pediatrics v.118, no. 5 (Nov.
    2006) e1293-e1302. See also, Child Health Impact Working Group,
    Unhealthy Consequences: Energy Costs and Child Health: A Child Health
    Impact Assessment of Energy Costs And The Low Income Home Energy
    Assistance Program (Boston: Nov. 20060.
        \22\ Colorado Interagency Council on Homelessness, Colorado
    Statewide Homeless Count Summer, 2006, research conducted by University
    of Colorado at Denver and Health Sciences Center (Feb. 2007).
    ---------------------------------------------------------------------------
        When people are unable to afford paying their home energy bills,
    dangerous and even fatal results occur. In the winter, families resort
    to using unsafe heating sources such as space heaters, ovens and
    burners, all of which are fire hazards. Space heaters pose 3 to 4 times
    more risk for fire and 18 to 25 times more risk for death than central
    heating. In 2007, space heaters accounted for 17 percent of home fires
    and 20 percent of home fire deaths.\23\ In the summer, the inability to
    keep the home cool can be lethal, especially to seniors. According to
    the CDC, older adults, young children and persons with chronic medical
    conditions are particularly susceptible to heat-related illness and are
    at a high risk of heat-related death. The CDC reports that 3,442 deaths
    resulted from exposure to extreme heat during 1999-2003.\24\ The CDC
    also notes that air-conditioning is the number one protective factor
    against heat-related illness and death.\25\ LIHEAP assistance helps
    these vulnerable seniors, young children and medically vulnerable
    persons keep their homes at safe temperatures during the winter and
    summer and also funds low-income weatherization work to make homes more
    energy efficient.
    ---------------------------------------------------------------------------
        \23\ John R. Hall, Jr., Home Fires Involving Heating Equipment
    (Jan. 2010) at ix and 33.
        \24\ CDC, ``Heat-Related Deaths--United States, 1999-2003'' MMWR
    Weekly, July 28, 2006.
        \25\ CDC, ``Extreme Heat: A Prevention Guide to Promote Your
    Personal Health and Safety'' available at http://emergency.cdc.gov/
    disasters/extremeheat/heat_guide.asp.
    ---------------------------------------------------------------------------
        LIHEAP is an efficient and effective targeted health and safety
    program that works to bring fuel costs within a manageable range for
    vulnerable low-income seniors, the disabled and families with young
    children. We respectfully request that LIHEAP be funded at no less than
    $5.1 billion in FY 2023 and an additional $500 million in emergency
    contingency funding.

        [This statement was submitted by Olivia Wein, Staff Attorney,
    National
    Consumer Law Center.]
                                     ______

        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 $49 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
            $11 billion for FY 2022 and enable $6 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
    2023 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 through education, research, and advocacy.
    These include lymphedema, lipedema, lymphatic anomalies, and the
    continuum of lymphatic diseases. 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 2023 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 and other
    lymphatic diseases truly treatable. 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 $49 billion for NIH in FY 2023.
        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. We
    appreciate some steps that NIH is taking to address the subcommittee's
    and our concerns about the National Commission, but we still are not at
    the point where the Commission is set to begin key work. While we
    remain hopeful that our continued work with NIH will continue to pay
    off, strong support from Congress remains essential for our success.
        LE&RN also joins the public health community in asking Congress to
    provide the Centers for Disease Control and Prevention (CDC) with $11
    billion through FY 2023 and to increase funding to increase awareness,
    education, and surveillance of lymphatic diseases. We encourage the
    subcommittee to support $6 million for the Chronic Disease Education
    and Awareness Program in FY 2023 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 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) 2023
    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 ongoing and
    demonstrated commitment to maternal health in his HHS budget proposal
    for FY 2023, 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 $1.816 billion for NICHD's groundbreaking biomedical research
    activities in FY 2023. 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
    (Public Law 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 28 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 a specific funding level be set-aside
    under the $164 million Safe Motherhood Initiative request to fully
    scale these programs in all States.
        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 a
    specific funding level be set-aside under the $164 million Safe
    Motherhood Initiative request 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 $29 million
    for NSQAP and $29.883 million for the Heritable Disorders program for
    FY23.
        In addition, we request $15 million under the CDC to support full
    implementation of the Recommended Uniform Screening Panel (RUSP) in all
    50 States. These additional resources for timely implementation of
    newborn screening conditions with a goal of complete RUSP
    implementation nationwide by 2025.
        Lastly, we request $2 million under HRSA to support a newborn
    screening study. It would direct HHS to commission a study with the
    National Academy of Medicine (NAM) on uniform screening panel review
    and recommendation processes to identify factors that impact decisions
    to add new conditions to the uniform screening panel, to describe
    challenges posed by newly nominated conditions, including low-incidence
    diseases, late onset variants, and new treatments without long-term
    efficacy data.
        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 $11.5 million in fiscal Year2023 to add five
    programs and provide technical assistance to non-grantee States.
        Maternal Mental Health Hotline: We thank the Committee for funding
    $4 million in FY22 to the new maternal mental health hotline launched
    by HRSA. 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 support President Biden's request of $7 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 2023 (FY23) 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 longstanding leadership and support for the program.
    For 50 years, these programs have served as daily lifelines, providing
    hundreds of millions of meals and vital social connection to a growing
    number of older adults who rely on the OAA Nutrition Program to meet
    their basic needs. The critical role and significance of this
    bipartisan legislation have been made even more evident throughout the
    COVID-19 pandemic, in which local home-delivered and congregate
    programs continue to experience dramatic and sustained increases in the
    number of older adults who require nutrition and social support.
        To sustain these proven and effective nutrition programs that
    reduce senior hunger and loneliness, improve health and well-being, and
    enable independence, appropriations increases are urgently needed in FY
    2023. Accordingly, we are calling for a minimum of $1,933,506,000 for
    the OAA Nutrition Program to be included in the final FY 2023 Labor,
    Health and Human Services, Education and Related Agencies (Labor-HHS-
    Ed) Appropriations bill. The specific line-item requests are:
      --Congregate Nutrition Services (Title III-C-1)--$965,342,000
      --Home-Delivered Nutrition Services (Title III-C-2)--$791,342,000
      --Nutrition Services Incentive Program (NSIP) (Title III)--
            $176,822,000
        This FY23 request 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 COVID-19 health and economic crises, these nutrition
    programs are a lifeline for millions of older adults and the services
    they provide must flex to meet the need. We must not go backwards and
    instead invest more significantly in these cost-effective programs that
    allow individuals to age at home, with better health and independence,
    outside of costly healthcare facilities.
        Overseen by ACL's Administration on Aging and implemented at the
    local level through thousands of community-based providers, the OAA
    Nutrition Program delivers nutritious meals, 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 five decades.
        Nutrition is a crucial part of overall health, development, and
    quality of life and is fundamental to healthy aging. Older adults who
    are food insecure and lack consistent access to nutritious meals
    experience worse health outcomes and are at increased risk for heart
    disease, depression, diabetes and declines in cognitive function and
    mobility than those who are food secure.\1\ Most older Americans
    possess at least one factor that puts them at greater risk of food
    insecurity, malnutrition, social isolation and/or loneliness, thereby
    increasing the likelihood of experiencing negative health effects.
    Despite the wide recognition of the relationship between healthy aging
    and access to nutritious food and regular socialization, millions of
    older adults were struggling to meet these basic needs even prior to
    the COVID-19 pandemic.
    ---------------------------------------------------------------------------
        \1\ Ziliak and Gunderson, 2021, The Health Consequences of Senior
    Hunger in the United States: Evidence from the 1999-2016 NHANES, report
    prepared for Feeding America, available at www.feedingamerica.org/
    research/senior-hunger-research/senior.
    ---------------------------------------------------------------------------
        The reality of senior hunger today is sobering, and there are
    millions more older adults who need our help, but who we are not
    reaching today. We know in 2020, during the pandemic, over 9 million
    (12 percent) older adults 60+ were threatened by hunger--nearly 5.2
    million (7 percent) of whom experienced low food security or very low
    food security. Nationwide, that is one in eight older adults struggling
    with hunger--and the fraction of seniors experiencing very low food
    security has increased almost 90 percent since 2001.\2\ It has also
    been estimated that up to almost half of all older adults may be at
    risk of becoming or is already malnourished.\3\ Today, millions of
    seniors experience some degree of food insecurity and are forced to
    make choices about the foods they eat due to financial strain, and/or
    forgo eating properly to pay for utilities, rent and/or medication.
    ---------------------------------------------------------------------------
        \2\ U.S. Census Bureau, 2020, Current Population Survey (CPS)
    December Food Security Supplement, dataset available at https://
    www.census.gov/data/datasets/time-series/demo/cps/cps-supp_cps-repwgt/
    cps-food-security.html.
        \3\ Kaiser et al., 2010, ``Frequency of malnutrition in older
    adults: a multinational perspective using the mini nutritional
    assessment'', Journal of the American Geriatrics Society 58(9):1734-8,
    abstract available at https://pubmed.ncbi.nlm.nih.gov/20863332/.
    ---------------------------------------------------------------------------
        As greater awareness of food insecurity, social isolation and
    loneliness and their negative effects on physical and mental health
    have emerged since the COVID-19 pandemic, it is important to note that
    older adults in particular--especially those who were already homebound
    and/or living in rural areas--have long been at higher risk of these
    threats to healthy aging. Older adults have unique challenges
    maintaining community connections and accessing healthcare, which can
    be further compounded if one has physical limitations, lack of
    transportation, inadequate financial resources, and/or other obstacles
    to accessing resources.
        Certain segments of the population experience a range of different
    challenges at disproportionately higher rates. As examples, older
    adults who are racial or ethnic minorities; lesbian, gay, bisexual,
    transgender, and queer (LGBTQ+); living with disabilities or limited
    mobility; living in or near poverty; and in rural areas face systemic
    inequities that too often result in a lack of adequate resources and/or
    access to services they need to remain well in later life.
        The OAA Nutrition Program is designed to reduce hunger, food
    insecurity and malnutrition, and promote socialization and the overall
    health and well-being of older adults. OAA services, including
    congregate and home-delivered meals, 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 institutional
    care.
        The impact of these services on seniors' lives is powerful, and
    older adults who receive them have better health because of
    participating. Most seniors receiving OAA nutrition services
    consistently report that participating in the program helps them feel
    more secure, prevents falls or fear of falling, and allows them to stay
    in their own home.\4,5\ In turn, this helps avoid preventable emergency
    room visits, hospital admissions and readmissions, extended stays in
    rehab, and premature institutionalization--ultimately reducing our
    Nation's health care costs.
    ---------------------------------------------------------------------------
        \4\ Administration for Community Living (ACL), 2019, National
    Survey of OAA Participants, available on ACL's AGID Custom Tables,
    available at https://agid.acl.gov/.
        \5\ Meals on Wheels America, 2015, More Than a Meal Pilot Research
    Study, report prepared by Thomas & Dosa, available at
    www.mealsonwheelsamerica.org/learn-more/research/more-than-a-meal/
    pilot-research-study.
    ---------------------------------------------------------------------------
        A rigorously designed study from 2015 found that older adults
    receiving home-delivered meals experienced statistically significant
    improvements in health than their counterparts who did not receive
    services. The group who received home-delivered meals and safety checks
    were more likely to have improved physical and mental health, including
    reduced feelings of anxiety and loneliness, and fewer hospital
    admissions and falls.\6\ On the ground, senior nutrition program staff
    and volunteers delivering meals can help identify and promptly notify
    caregivers and healthcare providers of a change in an older adult's
    condition so that necessary steps can be taken to address urgent and/or
    developing health conditions and medical needs, both physical and
    mental.
    ---------------------------------------------------------------------------
        \6\ See footnote 5.
    ---------------------------------------------------------------------------
        It is often through an older adult's need for nutrition services
    that they become aware of and connected to other services available in
    their communities. For many Meals on Wheels participants, staff and
    volunteers may be the only individual(s) she or he sees that day.
    Social connection is part of the Meals on Wheels model and can include
    intentional and additional face-to-face conversation during delivery or
    enhanced programming, like friendly visiting or telephone reassurance
    calls. Further, in-home safety services include a regular environmental
    safety check and established approach for addressing identified
    hazards, fall risks, and home modification needs. For example, Meals on
    Wheels programs helped refer and/or serve an estimated 18,000 older
    adults who needed home repairs in 2018, and 34 percent of programs
    report directly offering home repair and modification services.\7\
    ---------------------------------------------------------------------------
        \7\ Meals on Wheels America, 2021, Membership Perspectives and
    Practices Survey, research conducted by Trailblazer Research (report in
    publication).
    ---------------------------------------------------------------------------
        The power and importance of the OAA Nutrition Program was never
    more clear than during the COVID-19 pandemic. Practically overnight,
    the thousands of programs across the country faced an unprecedented
    surge in demand as the number of older adults sheltering in place
    increased and congregate centers shifted ways of operating. Programs
    quickly adapted traditionally their high-touch service model to
    continue safely offering senior clients critical, person-centered
    supports that go well beyond the meal itself.
        Programs like Meals on Wheels were and continue to be pivotal to
    our Nation's pandemic response and recovery, and senior nutrition
    programs have been highly sought out for the trusted nutrition and
    social connections they offer. Despite the incredible response from the
    senior nutrition network to quickly scale services, challenges remain
    in addressing the demand. A survey of Meals on Wheels America
    membership last year found 97 percent of programs believe that there
    continues to be substantial unmet need in their communities and about
    60 percent of programs reported that the major limitation to serving
    meals to all the seniors in their community who need them is funding to
    pay for the meals.\8\ The gap between those struggling with hunger and
    those receiving nutritious meals through the OAA will continue to widen
    across the country if not adequately addressed with the necessary
    support and investment from both public and private sources.
    ---------------------------------------------------------------------------
        \8\ Meals on Wheels America, July 2021, 2021 Mid-year COVID-19
    Pulse Survey, available at www.mealsonwheelsamerica.org/learn-more/
    research/covid-19-research-portfolio.
    ---------------------------------------------------------------------------
        Even prior to the pandemic, Federal funding for aging services was
    not keeping pace with increasing demand, rising costs and inflation.
    Now, more than 2 years into this public health emergency, programs are
    continuing to deliver life-saving services at sustained high rates with
    ongoing and emerging challenges and uncertainties. Currently, 8 in 10
    Meals on Wheels programs are still serving more home-delivered meals
    and clients than they were before COVID-19, and many of them are taking
    drastic steps to sustain their programs due to funding challenges. Some
    of these measures include but are not limited to adding seniors to
    waiting lists, discontinuing, or cutting back services. As of April
    2022, 20 percent of Meals on Wheels programs reported adding clients to
    a waiting list. Most senior nutrition programs are currently facing at
    least one significant barrier, such as rising costs of inflation, food,
    and gas (necessities like beef and gas have been up 16 percent and 38
    percent, respectively) or sustaining funding, and a third have reported
    that increased operating costs are requiring them to tap into reserve
    funding.\9\
    ---------------------------------------------------------------------------
        \9\ Meals on Wheels America, April 2022, Spring Member Pulse
    Survey, available at www.mealsonwheelsamerica.org/learn-more/research/
    covid-19-research-portfolio.
    ---------------------------------------------------------------------------
        Thanks to your leadership, ACL received emergency funding necessary
    to help address the significant needs presented by the pandemic. ACL
    and its programs have subsequently been able to reach new communities
    and people who have long needed services, such as meals, but were not
    receiving them. Senior nutrition programs nationwide have expanded
    capacity, innovated operations, and shown that their services can
    literally be a matter of life and death. Now we are at a crossroads.
    Pandemic-level funding for these programs must be sustained. We must
    not go backwards.
        We understand the difficult decisions you face with respect to
    annual appropriations bills and other budgetary challenges. However,
    the risks and benefits of healthy aging cannot be underestimated, both
    in social and economic costs. The requested appropriations increase
    will help provide the funding levels necessary for community-based
    nutrition programs to serve more older adults and sufficiently address
    the increased demand for services and help offset the higher operating
    costs they are experiencing.
        In closing, as the subcommittee develops its FY23 Labor-HHS-
    Education appropriations bill, we urge you to fund programs that are
    critical to healthy aging, including $1.934 billion for the OAA
    Nutrition Program, so that local community-based senior nutrition
    programs can ensure the health, safety and social connectedness of our
    Nation's older adults, build the capacity of ACL's 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
    older adult in America is left hungry and isolated.

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

                        Prepared Statement of METAvivor
                fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Please provide the National Institutes of Health (NIH) with an
            increase of at least a $3.5 billion for FY 2023 to bring total
            agency funding up to a minimum of $49 billion annually.
        --Please provide separate and distinct funding for the emerging
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH, which would further support this promising effort
                without disrupting ongoing NIH efforts.
      --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 $5 million for a pilot program at CDC to modernize
            the Surveillance, Epidemiology, and End Results Research
            Program (SEER) Registry to better capture the experience of
            metastatic cancer patients.
    _______________________________________________________________________

        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 2023 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 this commitment for FY 2023 by supporting
    innovative medical research, including the reinvigoration of the
    ``moonshot'' and by providing adequate resources for public health
    programs, including new funds to modernize the SEER registry (building
    on prior committee recommendations).
                                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.
                        about seer modernization funding
        As the saying goes, what gets measured, gets done. Currently,
    cancer registries do not capture data on metastatic recurrence or
    metastatic progression. There are many opportunities though to properly
    incorporate critical metastatic cancer information into cancer
    registries moving forward, including squeezing more out of current
    registry data, linking registries to data resources that can inform
    about recurrence or progression, and build the infrastructure necessary
    to systematically incorporate recurrence information into registries.
    For example, NCI is working to enhance reporting through pathology,
    radiology, and hospitals while several research teams are exploring
    algorithms that use administrative data to identify recurrence events.
    Currently these efforts are concentrated in areas in which information
    infrastructure exists to support them and are not yet nationally
    scalable. A key emerging conclusion is that there would be a tremendous
    value in ``A Big Count'' of breast cancer metastases on an ongoing
    basis. This would be achievable if States would develop scalable
    processes and invest the time and resources to do the counting and
    gather the data. This could incorporate the utilization of innovative
    tools developed by NCI or could be complementary to those efforts.
        The community asks Congress to establish a $5 million pilot program
    administered by CDC that can provide grants to a few meritorious States
    to develop and test local solutions to directly incorporate metastatic
    breast cancer recurrence and progression into current cancer
    surveillance activities. This would provide a handful of multi-year
    cooperative agreements to stakeholders at approximately $250,000
    annually. This modest investment would facilitate:
      --The development of local information infrastructures to routinely
            count metastatic events at and after a cancer diagnosis;
      --The creation of possibly the best MBC database in existence that
            researchers will want to access and will likely cite for
            decades to come;
      --The ability to generate survival curves capturing the time to
            recurrence or metastasis after diagnosis overall and within
            different population subgroups;
      --Key collaborations with NIH and CDC, including recommendations and
            best practices to advance systematic incorporation of this data
            moving forward.

        [This statement was submitted by Jamil Rivers, Board Chair,
    METAvivor.]
                                     ______

            Prepared Statement of 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.
        In year two of the COVID-19 pandemic, not only do lives continue to
    be lost but the U.S. economy continues to suffer as well. It is
    estimated that the COVID-19 pandemic will cost the U.S. economy more
    than $16 trillion.\1\ The NIH's fiscal year (FY) 2022 budget was less
    than 0.3 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 NIH
    with $100 billion in base funding in FY 2023.
    ---------------------------------------------------------------------------
        \1\ https://news.harvard.edu/gazette/story/2020/11/what-might-
    covid-cost-the-u-s-experts-eye-16-trillion/.
    ---------------------------------------------------------------------------
        The Michelson Center for Public Policy (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. MCPP 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 Patty Murray and Ranking Member Roy
    Blunt, have shown in providing the NIH with its seventh consecutive
    funding increase 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 $49
    billion in FY 2023, which includes $4 billion for the Advanced Research
    Projects Agency for Health (ARPA-H). This is a good start, but it is
    not nearly enough. This is precisely the right time to be bold and go
    bigger. 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 NIH's base funding, 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.
        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 2021, NIH
    invested $35.73 billion, over 80 percent of its budget, in the
    biomedical research industry across the country. This investment
    supported more than 552,444 jobs nationwide and generated nearly $94.18
    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 U.S. economy-a 178-fold return on
    investment--and has paid for itself many times over in industry tax
    revenues returned to the government.\3\
    ---------------------------------------------------------------------------
        \2\ NIH's Role in Sustaining the U.S. Economy--2022 Update, https:/
    /unitedformedicalresearch.org/wp-content/uploads/2022/03/UMR_NIHs-Role-
    in-Sustaining-the-U.S.-Economy-FY21.pdf.
        \3\ https://www.nih.gov/about-nih/what-we-do/impact-nih-research/
    our-society.
    ---------------------------------------------------------------------------
        MCPP is enthusiastic about the newly established Advanced Research
    Projects Agency for Health (ARPA-H) and the potential it has to 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. The research at ARPA-H must complement the
    work at the NIH, and not duplicate current research efforts at the
    NIH's Institutes and Centers. To have the largest impact on biomedical
    research, medicine, and healthcare, ARPA-H should focus on breakthrough
    technologies that are multi-disciplinary and operate across disease
    groups as well as focus on questions and topics that do not fit well
    within the confines of traditional biomedical research but may have
    clinical or commercial applications, something the NIH has historically
    been unable to do.
        In addition, funding for ARPA-H should supplement, not supplant
    NIH's base budget funding. For ARPA-H to yield successful results with
    the most promise for transformative advances, NIH must receive adequate
    base funding to ensure breakthroughs in the same basic research that
    makes these transformative advances possible.
        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 FY
    2021, only one out of every five applicants was ultimately awarded NIH
    funding,\4\ 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.\5\
    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 10 percent of the
    agency's overall budget invested in the most promising young
    investigators conducting highly innovative research with truly
    transformative potential.
    ---------------------------------------------------------------------------
        \4\ https://report.nih.gov/nihdatabook/report/20.
        \5\ https://nexus.od.nih.gov/all/2018/05/04/the-issue-that-keeps-
    us-awake-at-night/.
    ---------------------------------------------------------------------------
        MCPP thanks the subcommittee for its important work dedicated to
    ensuring the health and security of the Nation, and we appreciate this
    opportunity to urge the subcommittee to continue the success of NIH by
    providing $100 billion in FY 2023. 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 Morehouse School of Medicine
                  summary of fiscal year 2023 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
      --$49 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
        --$50 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.
    Community Project Funding/Congressional Directed Spending Request
            (HRSA)
      --$950,000 request to continue the development of a Research and
            Academic Building on MSM's main campus ($10 million total cost)
    _______________________________________________________________________

        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. Valerie Montgomery Rice, President, and Dean of
    Morehouse School of Medicine (MSM).
        Morehouse School of Medicine was founded to address the disparities
    in health status and health care among vulnerable populations. Central
    to our mission is increasing the diversity and cultural competence of
    the health professional scientific workforce, addressing the primary
    health care, mental health and public health needs of underserved
    populations, as well as engaging in innovative research and developing
    patient-centered programs aimed at advancing health equity in Georgia
    and across the Nation. This is a mission that we, and our Historically
    Black Colleges and Universities (HBCU) medical school colleagues, take
    seriously.
        We are proud to be a one of the four institutions that comprise our
    Nation's HBCU medical schools. While each of our esteemed institutions
    brings something slightly different to the table, we all share one
    common goal: helping Americans achieve their optimal level of health.
    HBCU medical schools are distinguishable from our other institutional
    colleagues because health equity is at the core of everything we do.
    From the research opportunities that we engage in, to our
    prioritization of clinical continuity for underserved communities, to
    our commitment to providing access to trusted medical services for
    those who need it most, we have always existed to protect the most
    vulnerable amongst us.
        We have learned valuable lessons over the past 2 years, and
    continue to respond the best we can to the pandemic, but we know that
    there is more work to be done. The country has now seen what MSM and
    other Historically Black Graduate Institutions (HBGIs) and HBCUs know
    and work towards everyday: the pitfalls and shortcomings of minority
    health. Our funding recommendations are robust and necessary given the
    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.
        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 U.S. are
    disproportionately suffering and dying from 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 MSM and other HBGI 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).
        President Biden recently signed the John Lewis NIMHD Research
    Endowment Revitalization Act to revitalize this important initiative,
    and it is our expectation that NIMHD will act swiftly to reinvigorate
    the research endowment program so minority-serving institutions can
    participate in this competitive opportunity to build their research
    endowments in a manner consistent with the statutory goal of assisting
    them in achieving a research endowment that is comparable to the
    endowments of other schools in their health professions discipline. The
    NIMHD Research Endowment Program (REP) allows academic institutions to
    build research infrastructure and recruit, train, and maintain a
    diverse faculty and student body. Robust funding would allow active and
    former NIMHD Centers of Excellence to continue their historic focus on
    research to close the gap between the burden of illness and premature
    mortality experienced more commonly by communities of color, as well as
    other medically underserved populations. It would also help improve
    access to grants to fund research projects, as well as hire staff and
    provide scholarships for students who come from underserved
    communities. To ensure successful implementation, we are asking for the
    Committee to allocate robust funding to NIMHD for this program.
        In addition to the recommendations referenced above, MSM has
    submitted a community project funding/congressionally directed spending
    request for continuing to develop a new academic and research facility
    that will provide critical support in the Institution's mission to
    improve and diversify the healthcare workforce. The recent growth in
    the size and diversity of the student body has not only made it
    necessary to train more healthcare professionals committed to
    underserved communities, but it also requires expanded space and
    resources on campus. More classrooms, lecture spaces, learning
    communities, research laboratories, and common spaces for knowledge
    sharing are all needed to meet the needs of a growing student body.
        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 Morehouse
    School of Medicine.

        [This statement was submitted by Valerie Montgomery Rice, M.D.,
    President and Dean, Morehouse School of Medicine.]
                                     ______

                           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 2023 report language for paid work-based
    learning 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 120,000 high
    school students in 35 States and territories. NAF is focused on helping
    to eliminate systemic, educational, and professional barriers,
    especially those faced by students of color.
        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 teens 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.
        Research shows that participation in work-based learning during
    high school has a positive impact on students, including completing
    high school, securing higher-quality jobs, and boosting equity and
    economic opportunity.\1\ Work-based learning is the continuum of
    activities both in classroom learning and the workplace setting that
    leads students to gain real world experience. Work-based learning has
    proven impacts on earnings, job quality and stability and is a critical
    lever in addressing systemic racial and economic inequities.
    ---------------------------------------------------------------------------
        \1\ Sun, J., & Spinney, S. (2017). Transforming the American High
    School Experience: NAF's Cohort Graduation Rates from 2011-2015. ICF
    International.
    ---------------------------------------------------------------------------
        Students in NAF academies are more likely to graduate on-time than
    their peers who are not involved with career academies. NAF has an
    overall positive effect on all students but is particularly impactful
    for those at-risk of not graduating-with full, 4-year program
    participation in a high-quality career academy, these students were 10
    percentage points more likely to graduate on-time than their non-NAF
    counterparts. Black and Hispanic students attending NAF academies also
    are shown to have higher high school graduation rates.ii
        Students who graduated from a career academy amassed 11 percent
    more total earnings each year, over the 8 years following high school
    than those who did not attend a career academy. Youth who drop out of
    high school can expect to earn $10,000 less annually compared to high
    school graduates.\2,3\ In 2020, NAF academies reported 99 percent of
    the seniors graduated with 87 percent of graduates planning to go to
    college.
    ---------------------------------------------------------------------------
        \2\ Kemple, J. J., & Willner, C. J. (2008). Career Academies Long-
    Term Impacts on Labor Market Outcomes,. mdrc.
        \3\ ICF. (2017). Transforming the American High School Experience:
    NAF's Cohort's Graduation Rates from 2011-2015, 2017.
    ---------------------------------------------------------------------------
        Work-based learning helps students to build relationships, sharpen
    essential skills 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. Eighty percent of jobs are
    filled through personal and professional connections.\4\ Young people
    deserve an education that builds workforce essential skills, helps them
    create social capital, and connects them to opportunity.
    ---------------------------------------------------------------------------
        \4\ Fisher, J. F. (2020, February 14). How to get a job often comes
    down to one elite personal asset, and many people still don't realize
    it. Retrieved from CNBC: https://www.cnbc.com/2019/12/27/how-to-get-a-
    job-often-comes-down-to-one-elite-personal-asset.html.
    ---------------------------------------------------------------------------
        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 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.
        While funding to schools for career and technical education is
    provided through the Perkins Career and Technical Education Act, this
    funding cannot be used to pay students for their work. However, paid
    internships are vital to closing the equity gap. Moreover,
    opportunities to intern in the nonprofit and government sectors can
    foster interest in public service careers among financially
    disadvantaged students. This potential for increased awareness of civic
    affairs would represent an important step toward a more engaged and
    inclusive democracy.
        To build upon Congress' previous support for work-based learning
    coordinators at the secondary education level, NAF urges the
    subcommittee to support and advocate for the inclusion of the following
    report language in the fiscal year 2023 Appropriations bill, ``The
    Committee includes $5,000,000 to provide grants to no more than three
    national, non-profit education organizations, which work
    collaboratively with Title I public high schools to facilitate paid
    internships for enrolled high school students completing secondary
    career and technical education in information technology, finance,
    health sciences, hospitality, and engineering. Ninety percent of funds
    shall be used by grantees to support paid internships with local
    employers, which shall include, but not be limited to, non-profit and
    government agencies. Preference shall be given to organizations with
    existing internship preparation programming and internship assessment
    tools in order to provide an evaluation of outcomes to the
    Department.''
                                   conclusion
        Work-based learning is advantageous for employers and communities.
    It is a proven way to grow the talent pipeline and help students be
    ready for the workforce.\5\ By partnering with high schools to provide
    work-based learning opportunities to students, employers help develop a
    talent pipeline aligned with their workforce needs. Employers also gain
    the opportunity to observe prospective employees in action before
    making the investment to hire them.\6\ The nation must invest in work-
    based learning, so workers have the skills they need to succeed; and
    employers have the diverse talent they need to thrive. NAF appreciates
    the opportunity to share its expertise; and thanks you for your
    consideration of this important request.
    ---------------------------------------------------------------------------
        \5\ Ross, M., Moore, K. A., Murphy, K., Bateman, N., DeMand, A., &
    Sacks, V. (2018, October). Pathways to high-quality jobs for young
    adults. Retrieved from Brookings: https://www.brookings.edu/research/
    pathways-to-high-quality-jobs-for-young-adults/.
        \6\ Benefits of Work-Based Learning. (n.d.). Retrieved from JFF:
    https://www.jff.org/what-we-do/impact-stories/center-for-
    apprenticeship-and-work-based-learning/benefits-work-basedlearning/
    #::text=Jobseekers%20also%20see%20work%2Dbased,of%20%20a%20skilled%regi
    onal%20 workforce.
    ---------------------------------------------------------------------------
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
        Serving as ``Friends of the National Eye Institute,'' the National
    Alliance for Eye and Vision Research (NAEVR) is a 501(c)4 non-profit
    advocacy coalition comprised of over 55 organizations, research
    institutions, and companies involved in and supportive of eye and
    vision research. NAEVR is grateful to Congress, especially the House
    and Senate Labor, Health, and Human Services (LHHS) Appropriations
    subcommittees, for the strong bipartisan support for NIH funding
    increases over the past 7 years. The $14.88 billion increase during
    that timeframe has helped the agency, and researchers, regain lost
    ground after a decade of effectively flat budgets.
                support nih base funding of at least $49 billion
        The past increased investments in NIH have continued to improve our
    understanding of fundamental life and health sciences, advance research
    across conditions, and prepare the Nation to combat existing and future
    health threats, including COVID-19. To maintain and build on this
    momentum, NAEVR strongly supports a funding level of at least $49
    billion for the NIH's base program level, a $4 billion increase over
    the comparable FY22 enacted level, with an emphasis that any additional
    funds for the Advanced Research Projects Agency for Health (ARPA-H)
    supplement, rather than supplant, this core investment in NIH. This
    increase would help keep NIH's base budget ahead of the biomedical
    research and development price index (BRDPI) and provide for inflation
    plus growth to support promising science across the Institutes and
    Centers.
        NAEVR continues to support ARPA-H funding and supports any funding
    above the $1 billion allocated in FY22 to be supplemental to the NIH
    base budget as referenced above. NAEVR is further interested in
    identifying and supporting ways that vision researchers can engage in
    advanced research projects through ARPA-H given how vital vision
    researchers have proven to be across advancements in multiple
    conditions.
        NAEVR is also supportive of the proposed use of mandatory funding
    to supplement NIH's base funding to improve pandemic response and
    readiness. COVID-19 has continued to impact research and our society
    and focusing research to address these issues is vital.
                      support nei funding of $950 million
        NAEVR also urges Congress to fund the National Eye Institute at
    $950 million, an $86.1 million increase over the comparable FY22
    enacted level. Vision researchers continue to perform extremely well in
    cross NIH initiatives because of how central the eye is to not only
    vision, but it provides one of the best windows into the brain and
    brain function. While funding for NEI has increased along with other
    NIH institutes, the FY22 funding level continues to remain below 2012
    inflation-adjusted dollars.
        NEI will play an even greater role in research that can stem the
    tide of the looming vision epidemic in the United States. The Centers
    for Disease Control (CDC) estimates that three-in-five Americans over
    40 have eye and vision problems (90 million Americans). By 2050, CDC
    estimates a 72 percent increase in diabetic retinopathy, an 87 percent
    increase in cataracts, a 100 percent increase in glaucoma, a 100
    percent increase in macular degeneration, and a 150 percent increase in
    vision impairment and blindness. Americans are facing an increasing
    burden of vision impairment and eye disease due to an aging population,
    the disproportionate impact risk and incidence of eye disease in fast-
    growing minority populations, and comorbidities impacting vision from
    numerous chronic conditions such as diabetes. With an ever-increasing
    reliance on electronic communication and screen time for children and
    adults, increased rates of myopia, dry eye, and eye strain are all
    expected to impact future generations.
        Maintaining the momentum of vision research and increasing the
    investment in vision research is vital to not only vision health but
    also to Americans' independence and quality of life. In a 2014
    Research!America and Alliance for Vision Research (AEVR) survey of over
    2,000 adults, vision loss was rated as potentially having the greatest
    effect on their day-to-day life, greater than the loss of limb, memory,
    hearing, and speech. Maintaining the momentum of vision research is
    vital to vision health, as well as to overall health and quality of
    life. Since the United States 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 aged 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) 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.
                  economic burden of eye and vision conditions
        Vision disorders represent the fifth-highest direct medical cost in
    the United States. In a 2014 Prevent Blindness study, it was reported
    that vision disorders will cost an estimated $182.5 billion in 2022--
    only less than heart disease, cancers, emotional disorders, and
    pulmonary conditions. Left unaddressed, and with the looming vision
    epidemic, this is projected to grow to an inflation-adjusted $717
    billion by 2050. The U.S. is spending over $545 per American on the
    treatment of vision disorders every year while only spending $2.50 per
    American on research that can improve outcomes. [http://
    costofvision.preventblindness.org/]
        NEI's breakthrough research is a cost-effective investment that has
    led to treatments and therapies that may delay, save, and prevent
    health expenditures. It can also increase productivity, help
    individuals maintain their independence, and improve their quality of
    life as vision loss is associated with increased depression and
    accelerated mortality.
                                    summary
        NAEVR supports the efforts of Congress to provide an eighth
    consecutive year of increases in the base funding for NIH. This funding
    is vital to building on the momentum of existing research and NAEVR is
    confident a funding level of at least $49 billion will provide the
    necessary increase in FY23 to continue this growth. Inflation plus
    growth investment for the National Institutes of Health (NIH) and
    specifically the National Eye Institute (NEI), is vital to ensure we do
    not fall short of the Institute's ability to respond to the research
    needs of today to improve the outcomes of patients in the future.
        NAEVR supports the NEI and believes that a funding level of $950
    million would reflect the urgent need to address eye and vision
    research in the United States. This funding would allow NEI to support
    researchers to identify new treatments, therapies, and interventions
    and address the future crisis in vision care as Americans age and more
    Americans rely on increased screen time to remain productive.
        NAEVR thanks the LHHS Appropriations subcommittee for the
    opportunity to submit this written testimony, especially as it
    continues to grapple with the multitude of short and long-term
    challenges exacerbated by the COVID-19 pandemic.
        For more information, or if the subcommittee has additional
    questions, please contact Dan Ignaszewski, Executive Director of NAEVR
    at Dan@eyeresearch.org. Additional information can also be found on
    NAEVR's website at www.eyeresearch.org. Thank you again for your time
    and consideration,
        Sincerely.

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

       Prepared Statement of the National Alliance for PANS/PANDAS Action
        Madam Chairwoman,
        It is an honor to provide testimony to the subcommittee on behalf
    of thousands of children and young adults across the country who have
    had their lives turned upside down by Pediatric Acute-Onset
    Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune
    Neuropsychiatric Disorders Associated with Streptococcus (PANDAS),
    which are Childhood Post-Infectious Neuroimmune Disorders (CPINDs). We
    are requesting support of report language and $5,000,000 in program
    funding for PANS and PANDAS in the fiscal year 2023 Labor, Health And
    Human Services, Education and Related Agencies bill.
        First, I would like to thank the Committee for the strong language
    included in past Committee reports. It has been effective and has
    brought attention to PANS and PANDAS. However, it is now time to take
    decisive action to direct NIH and other Federal agencies to increase
    funding for investigations into these conditions.
        I am the parent of three children with PANDAS, a founding member of
    the National Alliance for PANS/PANDAS Action (NAPPA), and co-founder of
    the Mending Minds Foundation. I helped start these organizations to
    drive much-needed research and awareness.
        PANS and PANDAS are neuroimmune disorders caused by a misdirected
    immune response following an infection. In short, antibodies and immune
    cells that would normally fight infection ``go rogue'' and attack the
    brain. The resulting inflammatory process leads to debilitating
    neurological and behavioral changes in young people.
        PANS and PANDAS cause life-altering and horrific symptoms. The
    first sign is dramatic deterioration in one or more areas of
    functioning including cognitive, motor, sensory, executive, social, and
    emotional. These disorders have an alarming impact on mood and
    personality, rendering an adolescent who thrived in school suddenly
    unable to leave the house, or an exuberant healthy child intensely
    phobic and anorexic. Restrictive eating, severely impulsive, self-
    harming behavior, and suicidal ideation may necessitate
    hospitalization. Children's lives are in danger.
        My family's story illustrates the devastating reality posed by
    these diagnoses. My two older children presented with primary mental
    health and neurological symptoms and, as a result, the underlying
    immune dysfunction was missed. Psychotropic medications did not
    alleviate these symptoms, and my children continued to deteriorate. We
    finally arrived at the true cause of their illness: undiagnosed,
    untreated strep infection, the same bacteria that causes a sore throat.
    When they received medication to address this underlying infection,
    they began to respond and improve in ways that had not been possible
    with mental health treatment alone.
        Like many children with PANS and PANDAS, their identification and
    treatment was delayed due to ?limited awareness and clinical
    understanding. Unfortunately, lack of medical care to address the
    underlying infectious, inflammatory, and/or immune process resulted in
    symptom escalation and prolonged illness. The risk of misdiagnosis is
    greater in communities already facing barriers due to income and racial
    disparities in health care.
        My children also exemplify the contrast between delayed and early
    identification. My oldest two 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. My youngest was treated successfully when her
    symptoms began, and she recovered quickly. Catching this illness early
    is the best path to full and complete recovery. When left undiagnosed
    and untreated, the condition may worsen and lead to chronic illness in
    young adulthood and beyond.
        Caring for youth in a sustained crisis places a heavy financial
    burden on families, health care systems, and schools. Parents endure
    lost wages and out-of-pocket medical costs. Insurers incur immense
    costs due to repeated emergency room visits, inpatient medical and
    psychiatric stays, and years of pharmacological and behavioral
    therapies for symptom management.
        Educational systems face an enormous financial burden when
    providing special education services for children who need increased
    academic support, one-to-one aides, home tutoring, or out-of-district
    placements. Shortening the time to identification and appropriate
    medical treatment would significantly minimize these societal costs.
        In the past 2 years, COVID-19 has brought increased recognition of
    the irrefutable link between infections and delayed, but highly
    disruptive, immune and inflammatory reactions in the body and brain,
    including post-infectious psychosis, depression, and anxiety. Medical
    illness triggering psychiatric symptoms is not a new phenomenon and
    holds the key to understanding the connection between the body's
    response to infection and mental illness.
        The youth mental health crisis, which arose out of the global
    pandemic, is staggering. Suicide is a leading cause of death in young
    people beginning at age 10. Children and adolescents with PANS and
    PANDAS have a high degree of impulsivity and often have intrusive
    thoughts of self-harm and of killing themselves. Tragically, many young
    people have lost their lives from PANS and PANDAS as a result of
    impulsive acts causing self-injury or persistent thoughts of death,
    including Louisa, the 13-year-old daughter of one of NAPPA's founding
    members.
        Prior to the onset of PANDAS, Louisa flourished socially and
    academically-a straight A student with much promise who aspired to
    become a doctor. The day that Louisa became ill was her last day at
    school. She was never able to return and suffered terribly for two and
    a half years until her untimely death. Her parents donated Louisa's
    brain to Georgetown University's brain bank dedicated to PANS/PANDAS
    research. Growing this critical research and ensuring that all children
    are routinely screened for PANS and PANDAS will save lives.
        Researchers can develop better screening tools and biomarkers to
    identify youth with underlying medical illnesses. Larger and longer-
    term studies can lead to more effective individualized treatment.
    Across the U.S., dedicated scientists and clinicians are doing
    groundbreaking work that cannot continue without funding.
        They cannot achieve the breakthroughs our children so desperately
    need alone. A $5 million commitment from Congress and NIH to dedicate
    funding to PANS and PANDAS will promote the development and application
    of diagnostic tools and effective interventions early in the course of
    illness, when affected youth can recover quickly and return to thriving
    in their homes, schools, and communities.
        The ability of children suffering from PANS and PANDAS to regain
    their quality of life with appropriate intervention is exemplified by
    the story of Tim:

          Tim was a happy, healthy 10-year-old, thriving in school and
            engaged in many extracurricular activities. He was an avid
            reader and a valued contributor on his chess, soccer, and
            tennis teams. He was honored as an exemplary school community
            member. Shortly after an infection, he became so riddled with
            OCD that he was unable to leave his bedroom to attend school or
            medical appointments, and some days he refused to eat.
          He lost his reading, writing, and math skills. He was in physical
            pain and could not sleep at night. When Tim suddenly began
            attempting to jump off the balconies of his house and running
            into traffic, his parents had to provide round the clock
            supervision. This continued despite repeated trips to numerous
            doctors and therapists. His family said it was as if an alien
            had invaded his brain and his body. The stress took an enormous
            toll on their family, including their other children. Medical
            providers were baffled, had a 10-year-old somehow become
            bipolar overnight? Thanks to the family's persistence and a
            dedicated medical team familiar with PANDAS, the root cause was
            finally identified. All of this mayhem stemmed from a simple
            strep infection. With treatment for his underlying infection
            and immune dysfunction, Tim returned to school and resumed his
            activities. The crippling OCD is gone, the dark thoughts are
            gone, the arthritis is gone, and the headaches are gone. He has
            his life back.

        We are living in complicated times when our vulnerability to
    infectious diseases has never been so glaring. We turn to medicine and
    science for the rapid development of tests, treatments, and vaccines to
    harness the immune system in the fight against COVID-19. We must now
    use those tools to improve the lives of children with PANS and PANDAS.
    Funding research will be a vital next step for the health of our
    country and the future of our children.
        I would like to conclude by emphasizing the following points:
      --Early intervention lowers the risk of chronic illness and
            alleviates the heavy financial burden on families, school
            systems, health care systems, and insurers.
      --When left untreated, PANS and PANDAS can result in unintentional
            loss of life. Directing resources to screening young people
            will save lives.
      --The association between neuropsychiatric illness and infections has
            become even more evident because of SARS CoV-2 and provides
            increasing opportunities for breakthroughs in research and
            treatment.
      --25 years after NIH began researching PANDAS, program funding
            remains insufficient to develop diagnostic tests and to
            identify more effective treatments.
      --NIH research funding for PANS/PANDAS would bring much-needed
            attention to these diagnoses in the medical community, thereby
            aiding in early identification and treatment.
        Advancing our understanding of PANS and PANDAS through a $5 million
    commitment will contribute to a paradigm shift in research, medicine,
    and mental health care. Such a Federal investment in scientific
    research will dramatically change the lives of many young people
    affected by these neuroimmune disorders.
        America's youth deserve the best that our healthcare system has to
    offer-not a lifetime of pain and symptom management. Your support will
    help PANS and PANDAS families achieve their dream of solving this
    nationwide health crisis.

        [This statement was submitted by Amanda Peel Crowley, Founding
    Member,
    National Alliance for PANS/PANDAS Action.]
                                     ______

     Prepared Statement of the National Alliance of 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
    (the National Alliance) on the Fiscal Year (FY) 2023 appropriation for
    the Charter Schools Program (CSP) and other programs administered by
    the U.S. Department of Education. The National Alliance is the leading
    national nonprofit advocacy organization committed to advancing the
    public charter schools movement.
        I would like to thank the subcommittee for maintaining support for
    the CSP at a funding level of $440 million in FY 2022, as the program
    helps expand educational opportunities for children and families and
    drives improvements in educational outcomes nationwide. Indeed, the
    importance of charter schools (supported by the CSP) in offering
    choices to needy families has been demonstrated by the continued growth
    in charter school enrollments during the ongoing COVID-19 pandemic. As
    the subcommittee considers the budget for FY 2023, we ask that you
    increase the CSP appropriation to at least $500 million.
        The National Alliance also strongly supports the provision of
    additional resources for Federal K-12 education programs that fund
    schools more generally, including Title I Grants to Local Educational
    Agencies (LEAs) and the State Grants under the Individuals with
    Disabilities Education Act. We endorse the Administration's request for
    increased funding for these programs, which will help public schools,
    including charter schools, address the challenges they now face in
    enabling students to recover from learning losses attributable to the
    pandemic and to reach the outcomes we want all students to achieve.
    The Operation of Charter Schools During the Pandemic
        In the wake of the pandemic, charter schools acted more quickly
    than district-managed schools to provide real- time virtual
    instruction, made more regular contact with students and families, and
    were more likely to track online attendance.\1\ Charter schools may
    have also been faster to deliver remote learning tools and technology
    to students, to a student population that was more likely to lack
    access to internet connectivity and devices than their traditional
    public school counterparts.\2\ When asked if they felt they had the
    resources and support they needed to teach effectively during the
    pandemic in spring 2020, 66 percent of charter school teachers said yes
    compared to 61 percent of district school teachers.
    ---------------------------------------------------------------------------
        \1\ Linda Jacobson, ``Charters Were Quicker to Provide Instruction,
    Regular Contact During Closures, Reports Say.'' The 74 Million, April,
    2020, https://www.the74million.org/article/charters-were-quicker-to-
    provide- instruction-regular-contact-during-closures-reports-say-but-
    thats-also-how-they-keep-the-kids-one-expert- explains/; CREDO,
    ``Charter Schools' Response to the Pandemic in California, New York and
    Washington State,'' Stanford University, February, 2022, https://
    credo.stanford.edu/wp-content/uploads/2022/02/Charter-School-COVID-
    Final.pdf (pg. 17-18).
        \2\ National Center for Education Statistics, ``Impact of the
    Coronavirus (COVID-19) Pandemic on Public and Private Elementary and
    Secondary Education in the United States (Preliminary Data)'', U.S.
    Department of Education, February, 2022, https://nces.ed.gov/pubs2022/
    2022019.pdf.
    ---------------------------------------------------------------------------
        A 2020 report that we produced in partnership with the organization
    Public Impact found that small charter school 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.
        And what was the impact of these efforts? Charter school
    enrollments grew by 7 percent in school year 2020-2021, the largest
    increase in half a decade. Preliminary data for 2021-22 show that
    charter enrollment continues to increase nationally. Moreover, charter
    schools continue to be the only sector within the public school
    universe that grew during this period. Parents clearly appreciated the
    options offered by charter schools and took advantage of those options
    by enrolling their children.
    Charter School Enrollments, Operations, and Accomplishments
        In school year 2020-2021 more than 3.6 million students enrolled in
    some 7,700 charter schools, representing about 7.2 percent of total
    public school enrollment. As the charter school sector has grown, it
    has continued to serve students and families whose needs were not being
    met by district schools and who desired additional options. The most
    recent data indicate that some 60 percent of charter school students
    are eligible for free or reduced-price school meals and over two-thirds
    are students of color. Both of these percentages exceed those of
    district schools. To reiterate, charter school enrollments have grown
    in large measure because of what the schools offer to families of
    historically underserved students.
        Notwithstanding charter schools' growth and achievements, recent
    years have seen the proliferation of a number of misconceptions about
    these schools. One is that they are not public schools and represent an
    attempt to ``privatize'' public education. Let's be clear: charter
    schools are public schools, and open to all students. A second
    misconception is that charter schools are unaccountable. To the
    contrary, they are subject to public accountability requirements as set
    forth in State authorizing legislation and in their individual
    charters. Unlike schools in general, if they do not produce results
    they will close. Further, while charter schools typically have more
    flexibility than district schools (in such areas as determining
    curriculum and employing staff), they are held to the same testing and
    accountability requirements as other schools under the Elementary and
    Secondary Education Act (ESEA).
        And charter schools are delivering results. 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 attended 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.
        Most recently, a 2021 meta-analysis of research on charter school
    effects and competitive influence by the National Bureau of Economic
    Research (NBER) highlighted trends from three decades of research. It
    found that charter schools located in urban areas boost student test
    scores, particularly for Black, Latinx, and low-income students; that
    attending some urban charter schools increases college enrollment and
    voting; and that the competitive impact of charter schools on
    traditional public schools suggests a small beneficial influence on
    neighboring schools' student achievement.\3\
    ---------------------------------------------------------------------------
        \3\ Cordes, Sarah A. 2018. ``In Pursuit of the Common Good: The
    Spillover Effects of Charter Schools on Public School Students in New
    York City.'' Education Finance and Policy 484-512. https://
    www.mitpressjournals.org/doi/abs/10.1162/edfp_a_00240.
    ---------------------------------------------------------------------------
        A 2020 study from the Program on Education Policy and Governance at
    Harvard University, using results from National Assessment of
    Educational Progress fourth- and eighth-grade reading and math
    assessments, found greater academic gains between 2015 and 2017 for
    students in charter schools than for students in traditional public
    schools The study found particularly significant gains for African
    American and low-income students attending charter schools, they 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
        Since its creation in 1994 during the Clinton Administration, the
    CSP has received bipartisan support. The program was originally
    authorized to provide start-up funding for new charter schools, but it
    has evolved to address additional objectives, including meeting the
    needs of charter schools for adequate facilities and supporting the
    expansion and replication of high-quality charter schools operated or
    managed by charter management organizations.
        Since the program's inception, the Congress has appropriated some
    $6.8 billion for the CSP. To put that number in context, it is
    equivalent to less than 2 percent of the appropriations for Title I LEA
    Grants over that time. This modest investment has enabled the number of
    charter schools to grow from only a handful in the early 1990s to the
    7,700 or so operating today. Because States have not typically financed
    the planning and initial start-up costs of their new charter schools,
    it is inconceivable that the charter sector would have grown as rapidly
    and successfully without this Federal investment. Nor have States and
    localities provided charter schools the same facilities and facilities
    funding that are available to district-operated schools; Federal
    funding for the two CSP facilities programs, while not adequate, has
    thus addressed a gaping unmet need.
        Charter school enrollment has grown rapidly, but it has not kept up
    with family demand. Surveys indicate that some 3.3 to 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.
    Regulation of the Charter Schools Program
        As you may know, on March 14 of this year the Administration
    published for public comment a Notice of Proposed Priorities,
    Requirements, Definitions, and Selection Criteria (NPP) for the CSP.
    This notice came out late in the fiscal year, jeopardizing the ability
    of the Department of Education to review and respond to comments,
    decide on final rules, conduct CSP competitions, and make awards before
    the end of the fiscal year. It also was issued in violation of Section
    4307of the ESEA, which requires stakeholder engagement prior to
    rulemaking that impacts charter schools and the CSP. Because of this
    poor timing and the fact that the NPP included provisions that raised
    grave concerns within the charter school community, the National
    Alliance has called on the Administration to put the proposed rules on
    hold, conduct the FY 2022 competitions under the current rules, and use
    the next year to engage with the community about what improvements are
    needed in the program and how those improvements can best be
    accomplished through regulation. The National Alliance is grateful that
    many thousands of individuals and organizations expressed the same
    concerns in their comments on the rule.
        To be clear: we are not opposed to greater transparency in the
    operation of the program, although we note that the transparency-
    related provisions of the NPP were vague and would have led to
    confusion and inconsistent implementation. Nor do we dispute the
    Administration's contention that the statute requires that grantees and
    subgrantees retain administrative control over their grants and
    subgrants. However, the administration has put forward appropriations
    language on the charter school management issue that is unclear and was
    developed, like the NPP, without consultation or stakeholder input. We
    believe it should be possible to work out an acceptable regulatory
    solution on this issue without additional appropriations language, such
    as including current guidance on contracting with for-profit entities
    as in program regulations. Therefore, we do not support the proposed
    language.
        Further, in response to concerns about charter schools that receive
    start-up support but never open, we can endorse the proposed regulation
    prohibiting schools from receiving implementation funding until they
    have obtained a charter and a facility, so long as such a school may
    receive support for such planning and program design activities as
    curriculum development, hiring and training staff, carrying out
    community engagement activities, and purchasing books, other materials,
    supplies, and equipment.
        On the other hand, we will never support regulations that limit
    charter schools to operating in communities with overcrowded schools,
    give district school officials the ability to veto the opening of
    charter schools, or demand that charter schools have demographically
    diverse enrollments and staff even when the communities they serve are
    not diverse. Again, we thank the many commenters who expressed their
    opposition to these and other provisions of the NPP.
                                fy 2023 request
        Our request for fiscal Year2023 is $500 million, a $60 million
    increase. We also recommend that the appropriations act give the
    Department of Education sufficient flexibility to allocate funds across
    CSP programs in response to current needs of the field. $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 enable the expansion of high-quality schools and
    reduce wait lists in order to 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. We also
    request report language that would ensure that State entity grantees
    have access, at the beginning of the grant period, to the full seven
    percent reservation for technical assistance as provided for in the
    statute.
        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. 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.

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

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

      --At least $49 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 $11 billion for the Centers for Disease Control and
            Prevention (CDC).
        --Please provide $6 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 FY 2023 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. 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 Nicole Friedland, President & CEO,
    National Alopecia Areata Foundation.]
                                     ______

       Prepared Statement of the National Area Health Education Centers
                                  Organization
        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to submit testimony
    on behalf of the National AHEC Organization (NAO). I serve as the chief
    executive officer of NAO with over 14 years of experience as an AHEC
    Center Director from Kentucky. The NAO is the professional organization
    that represents Area Health Education Centers (AHECs) across the
    country. We support advances in the AHEC network to improve health by
    leading the Nation in recruiting, training, and retaining members of a
    diverse health workforce in rural and underserved communities. As a
    member of the Health Professions and Nursing Education Coalition
    (HPNEC), NAO is pleased to recommend $790 million for the health
    professions training programs under Title VII and VIII of the Public
    Health Service Act that are administered by the Health Resources and
    Services Administration (HRSA). Of this amount, the NAO recommends
    $67.00 million in fiscal year (FY) 2023 for the Area Health Education
    Center program.
        The national AHEC network consists of more than 300 AHEC program
    offices and centers, serving over 85 percent of the counties in the
    United States. With 50 years of operation, AHECs meet the current and
    emerging needs of the communities they serve through robust community-
    academic partnerships, with a focus on exposure, education, and
    training of the current and future health care workforce.
                    highlighted ahec programmatic activities
      --AHEC Scholars Program: This 2-year program initiative recruits,
            trains, and supports interdisciplinary groups of health
            professions students committed to increase health care quality
            through community-based service and health care transformation.
            Every AHEC Scholars program includes 40 hours of didactic and
            40 hours of community-based or clinical activities each year.
            Through these experiences, Scholars develop new skills and
            knowledge designed to expand their understanding of the social
            determinants of health and health equity (or lack of), for
            populations living in rural and underserved communities. This
            curriculum is a critical tool to prepare a diverse, equitable,
            compassionate, qualified health care workforce.
      --Continuing Education: The NAO and member AHECs provide accredited
            continuing education programs and professional support for
            healthcare professionals who seek licensure and certification
            credits with an emphasis on rural health and health care in
            underserved areas.
      --Health Professions Pipeline: AHECs expose students in grades 9-12
            to health careers through job shadowing, health career
            presentations, and summer programming. Undergraduates
            participate in AHEC networking/enrichment programs to enhance
            their knowledge, experience, and forward the pathway to health
            professions school admission.
      --Clinical Rotations: Clinical training rotations are available
            throughout most of the AHEC network to enhance clinical
            expertise for medical students, residents, pharmacy, PA, APRN
            and other health professions students in rural and underserved
            communities.
        The AHEC program is reauthorized through FY 2025. The AHEC
    authorization language recommends a funding level of $250,000 annually
    for each AHEC Center. A FY 2023 funding level of $67 million would
    facilitate that recommendation.
                 justification for nao's funding recommendation
        Funding the AHEC program at $67 million provides critical
    opportunities to support AHECs as they:
      --Foster strategic community-based partnerships within the
            communities they serve to address the health workforce needs
            related to the emerging health issues such as COVID-19
            pandemic;
      --Strengthen linkages between academic health science centers and
            community health service delivery systems to provide additional
            training opportunities for students, faculty, and
            practitioners;
      --Increase the return on Federal investment by leveraging State and
            local resources to meet the required 1:1 funding match in
            support of health workforce development;
      --Expedite the transformation of the health care system by training
            the current and future workforce for a value-based, patient-
            centered, team-based practice environment for innovative models
            of care.
        The AHEC network is a part of a critical pipeline that fuels the
    recruitment, training, distribution, and retention of a national health
    workforce. At a time where the AAMC projects our Nation will have a
    shortage of nearly 120,000 physicians by 2030, AHEC stands as a central
    access point in meeting this demanding shortage area. Primary care
    practitioners are the front-line in prevention of disease and providing
    cost savings in the United States healthcare system. In recognizing
    this, the AHEC program engages in pre-pipeline, pipeline, and post-
    pipeline activities that guide individuals through health careers
    pathways and beyond, with a special emphasis on primary care providers.
    In the 2020-2021 academic year, AHECs introduced more than 178,000
    students, ranging from high school to collegiate status, to careers in
    the health professions and health workforce. AHECs facilitated 24,766
    student clinical rotations, many of which were in rural and
    underserved. Additionally, AHECs were responsible for training 416,862
    professionals through continuing education, and more than 7,000
    students were enrolled in the AHEC Scholars program. Madam Chair, these
    facts make AHECs integral in the recruitment, interdisciplinary
    training, and retention of the healthcare workforce.
        AHECs have a continual focus on improving the health care system by
    working with 120 medical schools, 600 nursing and allied health
    schools, healthcare settings like CHCs, behavioral health practices,
    and community-based organizations across the Nation. Through these
    longstanding partnerships, the AHECs employ traditional and innovative
    approaches to develop and train a diverse health care workforce
    prepared to deliver culturally appropriate, high-quality, team-based
    care for rural and underserved communities. AHECs are embedded in the
    communities they serve, positioning them to respond rapidly to emergent
    training needs of health professionals, health professions students,
    and inter-professional teams on issues associated with natural
    disasters, disease outbreaks, and substance use disorders.
        Madam Chair, thank you and the committee for the opportunity to
    present the views of the National AHEC Organization. Allow me to re-
    emphasize the funding request of $67.00 million for the Area Health
    Education Centers program. As you begin the FY 2023 process, we look
    forward to working with the subcommittee to continue prioritizing
    health workforce initiatives that improve training opportunities, the
    quality of our healthcare workforce, and alleviate patient care,
    research in health disparities, and health professionals going into the
    health workforce.

        [This statement was submitted by Dwain Harris, Chief Executive
    Officer,
    National Area Health Education Centers Organization.]
                                     ______

         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 $88.48 million
    for the DD Councils within the Administration for Community Living
    (ACL) in the Fiscal Year (FY) 2023 Labor-HHS-Education Appropriations
    Bill, the same level included in the President's FY23 budget.
        We also respectfully request that the following report language be
    included in the Fiscal Year 2023 Labor, Health and Human Services,
    Education Appropriations bill:

          Technical Assistance.--The Committee instructs the Department to
            provide not less than $700,000 for technical assistance and
            training for the State Councils on Developmental Disabilities.
            In addition, the Committee encourages ACL to consult with
            Developmental Disabilities Act stakeholders prior to announcing
            opportunities for new technical assistance projects and to
            notify the Committee prior to releasing new funding opportunity
            announcements, grants, or contract awards with technical
            assistance funding.

        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. 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 intellectual and developmental
    disabilities (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.
        The request for an increase in funding for FY 2023 is supported by
    the steadily and rapidly increasing numbers of people with
    developmental disabilities who continue to lack comprehensive and
    coordinated support systems to meet specific needs for full community
    inclusion. During the COVID-19 pandemic many people with developmental
    disabilities lost the assistance provided by families and other
    informal supports and people with disabilities disproportionately
    experienced loss of employment. Demand for services even after the
    pandemic has remained significantly higher than before 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.
        During the COVID-19 pandemic, DD Councils provided life-saving
    access to information, resources, and support to people with I/DD and
    their families. The past 2 years underscored the critical role of the
    DD Councils to meet the needs of people with I/DD so they can live
    safely in the community and free from discrimination. States have
    called on DD Councils to create life-saving solutions to problems faced
    by people with I/DD during the pandemic. Federal agencies and States
    have looked to DD Councils to bridge public health communication gaps
    with the I/DD community; advocate for non-discrimination in health
    care; promote immunization; distribute personal protective equipment;
    support access telehealth; and more. This funding request reflects the
    increased need for direct resources through partnerships with local
    non-profits, businesses and State and local governments, to provide
    innovative and cost-effective strategies so more people with I/DD can
    become independent, self-sufficient, and integrated into the community.
        Thank you for consideration of our request. For more information,
    please contact Erin Prangley at eprangley@nacdd.org, National
    Association of Councils on Developmental Disabilities, 1825 K Street,
    N.W., Suite 600, Washington, D.C.
                                     ______

       Prepared Statement of the National Association of County and City
                                Health Officials
        The National Association of County and City Health Officials
    (NACCHO) is the voice of the nearly 3,000 local health departments
    across the Nation. Local health departments continue to lead the
    Nationwide response to COVID-19, while also working to protect the
    health and safety of their communities from a myriad of public health
    challenges, many of which have worsened during the multi-year pandemic
    response.
        COVID-19 has brought to the fore the critical role of governmental
    public health, especially local health departments, in all aspects of
    daily life and exposed the consequences of years of underinvestment in
    our public health system. Congress has the opportunity now to rebuild
    the public health system to face current and future challenges. To
    enable local health departments to support Federal public health
    priorities and effectively lead in their communities, NACCHO requests
    Congress provide robust investments to the public health workforce and
    infrastructure, and exercise oversight to ensure Federal funds are
    efficiently and equitably allocated to the local level.
                          public health loan repayment
        The public health workforce is the backbone of our Nation's
    governmental public health system, but was understaffed and overworked
    even before the pandemic. Local health departments have lost over 20
    percent of workforce capacity since 2008,\1\ and over a third of the
    local public health workers were projected to leave the field in the
    next 5 years due to retirement or to pursue opportunities in the
    private sector.\2\ Furthermore, at least 500 local and State health
    officials have reportedly left their positions during the pandemic due
    to politicization, harassment, termination, and burnout.\3\ Combined,
    these forces create an urgency to addressing our public health
    workforce crisis.
    ---------------------------------------------------------------------------
        \1\ NACCHO, 2019 National Profile of Local Health Departments,
    https://www.naccho.org/uploads/downloadable-resources/Programs/Public-
    Health-Infrastructure/NACCHO_2019_Profile_final.pdf.
        \2\ Leider JP, Coronado F, Beck AJ, Harper E. Reconciling Supply
    and Demand for State and Local Public Health Staff in an Era of
    Retiring Baby Boomers. Am J Prev Med. 2018;54(3):334-340.
        \3\ Baker M. and Ivory D. (2021, October 18). Why Public Health
    Faces a Crisis Across the U.S. The New York Times. https://
    www.nytimes.com/2021/10/18/us/coronavirus-public-health.html.
    ---------------------------------------------------------------------------
        A bipartisan group of Senators have recognized this need and
    introduced legislation, the Strengthening the Public Health Workforce
    Act (S. 3506), that would authorize a public health workforce loan
    repayment program and give local, State, and Tribal health departments
    a vital tool to recruit and retain top talent. Additionally, Senators
    Murray and Burr have incorporated the proposal into the PREVENT
    Pandemics Act recently approved by the Senate Health, Education, Labor,
    and Pensions Committee. In conjunction with this legislation, NACCHO
    urges Congress to provide $200 million for the establishment of a
    public health loan repayment program at the Health Resources and
    Services Administration so that health departments can immediately
    bolster their efforts to strengthen the public health workforce.
                   public health infrastructure and capacity
        Local health departments operate on limited and unpredictable
    budgets that do not allow for long-term investments in needed
    infrastructure and cross-cutting needs. Federal public health funding
    has traditionally followed a boom-and-bust cycle in response to
    crises?. Additionally, funds are often limiting, for example tied to a
    specific disease state or programmatic function, which makes it
    difficult to invest in or sustain critical health department functions
    not tied to a specific disease state. Local health departments need
    sustainable, disease-agnostic, predictable funding to support local
    public health infrastructure, including data modernization and
    workforce development. Such funding would allow local health
    departments to focus on certain skillsets that are critically
    necessary--like communication, outreach, data analysis, and
    digitalization--but that they largely lack due to current funding
    constraints. The lack of this ability at the local level hinders
    efforts to support Federal public health objectives.
        NACCHO is grateful that Congress recognized this need and
    established a new Public Health Infrastructure and Capacity line within
    the CDC in fiscal year 2022, and NACCHO requests $1 billion for this
    crucial program in fiscal year 2023. Importantly, funding to support
    cross-cutting core public health functions should supplement, not
    supplant the disease-specific funding that currently supports many
    critical health department activities. Indeed, new capabilities
    supported by disease-agnostic funding will ultimately enhance the
    functionality of existing programs. NACCHO also requests Congress
    require CDC to ensure at least 35 percent of a State's allocation be
    directed toward local health departments with clear expectations
    regarding the timing of such suballocations.
                   centers for disease control and prevention
        The CDC has unmatched expertise and experience in tackling a broad
    array of public health issues including the ongoing COVID-19 pandemic
    and other pre-existing challenges that have been exacerbated by the
    pandemic like mental health, substance use, sexually transmitted
    infections, and chronic disease. CDC serves as the command center for
    the Nation's public health defense system against emerging and
    reemerging infectious diseases, man-made and natural disasters, and
    other public health emergencies. Strong funding is critical to
    supporting all of CDC's activities and programs, which are essential to
    protect the health of our communities, and NACCHO requests $11 billion
    for CDC in FY 2023. Due to years of underfunding, many CDC programs
    have not received the resources that are needed to address the many
    health challenges we face as a nation, resulting in many of CDC's most
    effective prevention programs not reaching all communities.
        Additionally, Federal funding from the CDC intended for both State
    and local health departments continues to have variable reach to local
    public health agencies. Ensuring these resources reach the local health
    department level in a timely way is critical to enabling communities to
    address public health needs. NACCHO requests that Congress include
    report language similar to that included in the explanatory statement
    accompanying Division H (L-HHS) of the fiscal year 2022 Consolidated
    Appropriations Act (H.R. 2471) encouraging CDC to require States to
    fund local health departments when programmatically appropriate, and
    further urging CDC to publicly track and report to the Committee how
    funds provided to State health departments are passed through to local
    health departments, including amount, per grant award, by local
    jurisdiction, and date funds are made available to each local health
    department.
           public health emergency preparedness cooperative agreement
        The PHEP Cooperative Agreement provides funding to 50 States, 4
    large cities (Chicago, Los Angeles County, New York City, and
    Washington, D.C.), and eight territorial health departments to
    strengthen public health departments' capacity and capability to
    effectively plan for, respond to, and recover from public health
    emergencies.
        NACCHO urges $1 billion for PHEP in fiscal year 2023, the level at
    which the program was originally funded when it was created after the
    9/11 terrorist attacks. Public health emergencies have increased in
    number and scope since the establishment of the PHEP program, and PHEP
    funding has not kept pace. Restoring funding to $1 billion is necessary
    to allow the program to comprehensively support local communities and
    States in their ability to prepare to respond to terrorist threats,
    infectious disease outbreaks, natural disasters, and biological,
    chemical, nuclear, and radiological emergencies, and other threats.
        More than 55 percent of local health departments rely solely on
    Federal funding for emergency preparedness. However, funding from State
    health departments to local health departments can have a varied
    approach and have reduced over time as overall Federal appropriations
    fell. To ensure all communities have the resources they need to prepare
    for and respond to public health emergencies, NACCHO requests report
    language to provide increased transparency around suballocations of
    PHEP funding from States to local health departments, similar to
    language included in both the House (H. Rept. 117-96) and Senate
    Committee Reports for the FY22 Labor, Health and Human Services, and
    Education, and Related Agencies Appropriations Bill requesting a State
    distribution table in the fiscal year 2024 Congressional Budget
    Justification, showing how funding is being allocated to local health
    departments, how States are determining these allocations, and date
    funds are made available to each local health department.
                         data modernization initiative
        The local health department COVID-19 response was hampered by a
    historical lack of resources, outdated systems, and an overall
    underfunding of public health infrastructure. Public health needs a
    robust, modern, and secure public health information ecosystem capable
    of sustainment and surge that delivers real-time, accurate, and useful
    data to public health and policymakers at the local, State, and Federal
    levels. Across the country, local and State public health departments
    operate a mismatched network of siloed public health information
    systems, most of which do not talk to each other nor to the health care
    delivery sector, and all of which are in urgent need of upgrade to
    prepare for and respond to public health challenges. To meet these
    challenges, NACCHO requests $250 million for the CDC's Data
    Modernization Initiative and asks Congress to urge CDC to consider
    local health department access and needs at all stages of data
    development.
                  epidemiology and laboratory capacity awards
        The ELC program provides annual funding, strategic direction, and
    technical assistance to domestic jurisdictions for core capacities in
    epidemiology, laboratory, and health information technology activities.
    In addition to strengthening core infectious disease capacities
    nationwide, this cooperative agreement also supports a myriad of
    specific infectious disease programs. Like other Federal streams,
    funding through ELC grants has variable reach to the local level.
    NACCHO requests Congress urge CDC to work with States to prioritize
    funding to local health departments based on factors such as population
    size, disease burden, and other public health metrics to promote
    equitable funding distribution, and to publicly track and report how
    funds are passed through to local entities.
                             medical reserve corps
        The Medical Reserve Corps (MRC) is a national network of local-
    organized volunteers committed to improving the public health and
    resiliency of their communities. Two-thirds of the Nation's 800 MRC
    units are housed within local health departments. MRCs are deployed to
    address public health emergencies and have stepped up to serve their
    communities during the COVID-19 response--in FY2021, MRC units provided
    2.7 million hours of service, compared to about 300,000 hours in FY2019
    prior to the pandemic. Additionally, the number of volunteers across
    the MRC network has grown from roughly 175,000 at the beginning of 2020
    to over 300,000. The total economic value of MRC volunteer
    contributions is estimated at over $91 million.
        NACCHO advocates for $12 million for MRC so that capacity built
    during COVID-19 can be sustained and at the ready for future public
    health emergency responses. NACCHO also requests Congress urge ASPR to
    continue the historical funding approach that provides funds directly
    to local MRC units and ensures efficient release and delivery of funds.
        NACCHO appreciates the consideration of these requests and looks
    forward to working with Congress to strengthen and support local public
    health.

        [This statement was submitted by Lori Tremmel Freeman, MBA, Chief
    Executive Officer, National Association of County and City Health
    Officials.]
                                     ______

               Prepared Statement of the National Association of
                           Federally Impacted Schools
        Dear Chairwoman Murray and Ranking Member Blunt:
        The National Association of Federally Impacted Schools (NAFIS)
    strongly urges the Senate Labor-Health and Human Services-Education
    Appropriations subcommittee to continue recognizing the Federal
    Government's obligation to federally impacted communities as you set
    funding priorities for the U.S. Department of Education.
        Based on our analysis, we urge you to provide at least a $2 million
    increase for Federal Property and a $55 million increase for Basic
    Support for FY 2023.
        NAFIS represents the 1,100-plus Impact Aid-recipient school
    districts that together educate 10 million students across the Nation.
    Impact Aid is the oldest elementary and secondary education program and
    is a partnership between local communities and the Federal Government
    where there is significant non-taxable property, such as military
    installations, Indian treaty or trust land, Alaska Native Claims
    Settlement Act land, Federal low-rent housing facilities, national
    parks and national laboratories. Congress recognized in 1950 that the
    Federal Government had an obligation to help meet the local
    responsibility of financing public education in areas impacted by a
    Federal presence. That same recognition holds true today.
        While the Administration has indicated it does not intend to
    support funding cuts to education programs, the President's FY 2023
    budget request includes many--including a $16 million cut to Impact
    Aid--because Congress finalized FY 2022 appropriations after the
    Administration finalized its FY 2023 request. It is particularly
    disappointing that the Impact Aid funding request is notably below the
    levels included in both the House and Senate FY 2022 appropriations
    bills, which were in conference at the time the FY 2023 budget was
    developed.
        NAFIS is grateful for the subcommittee's past support of the Impact
    Aid program, and we hope to see that support continue in FY 2023.
    Federally impacted school districts cannot afford stagnant
    appropriations or a loss of funding. FY 2023 will require additional
    funds to build on the important funding progress made in the last few
    years.
        Section 7003 Basic Support: Although appropriations have increased
    in recent years, Basic Support remains significantly underfunded. The
    Basic Support payment formula is based on several factors, including
    the actual cost of education. That cost is measured by the Local
    Contribution Rate (LCR), which is based on per pupil expenditures (PPE)
    from 3 years prior.
        Basic Support is currently funded at about 60 percent of the
    payment formula. Because the program is so underfunded, the Impact Aid
    law includes a proration factor called the Learning Opportunity
    Threshold (LOT), which measures the need a school district has for
    Impact Aid funds. The higher a school district's LOT, the more reliant
    it is on Impact Aid.
        In 2020, for the first time in more than a decade, LOT paid out at
    over 100 percent. That means the highest need Impact Aid districts got
    their full payment. However, hundreds of other school districts still
    received far less than they would have if the program were fully
    funded.
        For FY 2021, the LOT Payout is estimated to be 98 percent. Whenever
    the LOT Payout is below 100 percent, all federally impacted school
    districts--including those with the most need that rely most heavily on
    Impact Aid funds to operate--receive payments below those calculated by
    the formula in the Impact Aid law.

    ------------------------------------------------------------------------
                Fiscal Year                    LOT Payout         LCR Rates
    ------------------------------------------------------------------------
    FY 2011...........................    97.066 percent of LOT    $5,215.00
    FY 2012...........................    96.109 percent of LOT    $5,330.00
    FY 2013...........................    87.061 percent of LOT    $5,404.50
    FY 2014...........................    91.730 percent of LOT    $5,406.00
    FY 2015...........................    93.074 percent of LOT    $5,386.00
    FY 2016...........................    93.690 percent of LOT    $5,468.00
    FY 2017...........................    92.332 percent of LOT    $5,635.50
    FY 2018...........................    96.187 percent of LOT    $5,840.50
    FY 2019...........................    98.138 percent of LOT    $6,036.00
    FY 2020...........................    101.15 percent of LOT    $6,268.50
    FY 2021...........................        98 percent of LOT    $6,495.00
    FY 2022\*\........................      100+ percent of LOT    $6,794.00
    ------------------------------------------------------------------------
    \*\Estimated final rates

        We expect that the LCR in the Impact Aid formula could increase by
    3.5-4 percent in FY 2023 based on projected increases in per pupil
    expenditures (NCES data will be available in September on which the FY
    2023 LCR will be based). Without a corresponding increase in
    appropriations, the LOT Payout could drop substantially.
        The increases in appropriations and LOT Payout have been critical
    for federally impacted school districts, especially given increased
    costs stemming from the COVID-19 pandemic. A $55 million increase for
    FY 2023 would build on these increases and help the program keep pace
    with the rising costs of education. With that increase, the 7003 Basic
    Support formula will still be approximately $850 million below fully
    funding its formula. We encourage Congress to make up this gap and set
    a glide path to fully fund the formula.
        Section 7003(d) Children with Disabilities: Another important
    element of Impact Aid is the Children with Disabilities (CWD) section,
    which provides funding for military-connected or Indian lands students
    with an active Individualized Education Program (IEP). It has been
    funded at $48 million since 2008, despite rising costs of providing
    special education services. This currently means a school district
    receives approximately $1,200 per eligible student living on Federal
    property (or $600 for military-connected students who do not live on a
    military installation). As the cost of special education rises, this
    $48 million appropriation is stretched too thin, especially given the
    chronic underfunding of IDEA. Payments per CWD dropped from $1,215.65
    in FY 2018 to $1,205.00 in FY20. School districts are continuing to
    educate their students with disabilities, spending significant general
    funds to do so.
        Section 7002 Federal Property: We thank you for the $4 million
    increase in 7002 payments in FYs 2019 through 2022. For FY 2023, we
    request an additional $2 million to build on these increases. These
    funds will partially offset new costs as the Federal Government
    continues to take property off local tax rolls and as the value of
    taxable land on which the funding formula is based increases.
        Section 7007 Construction: Finally, the Construction section of
    Impact Aid receives very little support, languishing at a $17 million
    level for the past several years. For comparison purposes, in FY 2005
    Section 7007 received just over $45 million. We recommend that FY 2023
    Impact Aid Section 7007 funds be distributed under Section 7007(b)
    competitive grants, since FY 2022 funds will be dispersed through
    Section 7007(a) formula grants.
    School superintendents are saying...
        Impact Aid provides the necessary funding to ensure that all
            students in our district have access to a Free Appropriate
            Public Education and high levels of learning every day for
            every student to ensure that all students are prepared to
            graduate Life, College, and Career ready!--Washington

        We would not be able to operate without Impact Aid; our Impact Aid
            funds pay for all support staff, consultants, utilities, daily
            operations, professional development, curriculum, materials,
            and technology needs.--Montana

        Impact Aid money has helped improve our relations with the Southern
            Ute Tribe. Over the last 10 years, we have developed a
            meaningful MOU, included a representative from the Tribe on our
            administrative team, added a Ute Language Class, and had
            regular and meaningful community meetings with Tribal leaders
            to get important feedback.--Colorado

        Because of Impact Aid, we have truly leveled the playing field and
            dramatically improved the working relationship with the Seneca
            Nation. Instead of the conversation being framed ``you are not
            doing enough'' the conversation is now ``how can we partner to
            do more for all children''. Because we have been able to use IA
            funding to improve program, graduation rates, drop out rates,
            Advanced Placement rates our enrollment has dramatically
            increased in the past 5 years (+300 students). Simply put IA
            has made our ``product'' better, much better.--New York

        Additional investments in Impact Aid are critical to help school
    districts close achievement gaps, update technology, expand access to
    early childhood and afterschool programs, integrate culturally relevant
    curriculum, replace failing infrastructure, offer competitive salaries
    to recruit and retain school leaders, and more. These investments help
    school districts provide supportive and nourishing learning
    environments for all students. Through increased funding, we ask you to
    continue to view the program as a critical Federal investment and a tax
    replacement program for federally impacted communities.
        Sincerely.

        [This statement was submitted by Nicole Russell, Executive
    Director, National
    Association of Federally Impacted Schools.]
                                     ______

         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 1.5 million graduates of treatment court
    programs and the 150,000 people treatment court programs will connect
    to lifesaving substance use and mental health treatment this year
    alone. Given the ongoing substance use crisis, 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 2023.
        I am writing to you today as a husband, employee, taxpayer, and
    grateful drug court graduate. Before coming to the Lewis County Drug
    Court program, I spent much of my life cycling in and out of the
    justice system for crimes fueled by addiction. I went to jail seven
    times--and that doesn't encompass the many times I wasn't caught
    breaking and entering, stealing, and causing general harm to my
    community doing anything to support my addiction. I had also been to
    treatment multiple times, but without accountability, I'd never truly
    had the chance to heal from the trauma of my past, and I was never able
    to sustain my recovery. I often wonder what might have happened if
    there were no drug court available to me.
        The multidisciplinary treatment court team, which includes case
    managers, treatment providers, and counselors, not only looked at the
    facts of my case, but they also looked at my entire criminal history,
    my addiction history, and my life experiences up to that point. They
    created a plan to ensure I received the treatment and social services I
    needed, while still holding me accountable for my actions and the
    requirements of the program. Receiving treatment for my addiction was
    only part of the process. Because sustained, long-term recovery is the
    goal, drug court helped me work on myself from the inside out,
    addressing issues that had been impacting my behavior since I was a
    child.
        I completed the program in 2016, and I have dedicated myself to
    repairing the damage I caused by giving to others what was given to me.
    I first worked for an organization that conducts outreach to vulnerable
    populations with substance use disorders and helps them get their lives
    back on track. I also became 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.
        In February of this year, I had to step down as president of that
    organization, but for good reason--I became the community outreach
    worker at the very same drug court that changed my life. The treatment
    court team is like a family, and I work every day alongside my fellow
    team members to ensure our participants are connected to the services
    and treatment they need to turn their lives around the way I did. And
    while I'm no longer president, I'm still a proud and active member of
    the nonprofit organization full of graduates like me. And taking
    ``family'' one step further, I recently married my wife.
        I am proof that 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.
        But don't just take my word for it; there is overwhelming empirical
    evidence showing the effectiveness of these programs. The Government
    Accountability Office has concluded the drug court model reduces crime
    by up to 58 percent. 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, and financial
    stability, as well as reduced foster care placements.
        I am not alone in my success. This year, treatment courts will
    connect 150,000 people who have 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. 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 as our country continues to battle the ongoing opioid crisis,
    we know there are many more people 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 2023, so treatment
    courts in Washington and beyond can continue providing substance use
    treatment that allows people to heal from the inside out.

        [This statement was submitted by Brant Byrd, graduate of Lewis
    County,
    Washington, Drug Court Chehalis, Washington.]
                                     ______

     Prepared Statement of the National Association of Free and Charitable
                                    Clinics
        On behalf of the National Association of Free and Charitable
    Clinics (NAFC) Board of Directors, our patients, and the 1,400 Free and
    Charitable Clinics in the United States, thank you for the opportunity
    to submit this written testimony to the Labor, Health, and Human
    Services, Education, and Related Agencies subcommittee. The National
    Association of Free and Charitable Clinics is respectfully asking for
    funding for the following HHS programs, the Federal Tort Claims Act
    (FTCA) for Free Clinics, the Nurse Loan Repayment Program, the National
    Health Service Corps, The Breast and Cervical Cancer Screening Program
    under Title X, and the Corporation for National and Community Service.
                                   background
        Annually, 2 million patients through 6.9 patient visits receive
    health care at America's Free and Charitable Clinics. This care is
    provided by a volunteer and staff workforce of over 200,000 individuals
    from medical and non-medical fields. Unfortunately, 96% of our patients
    are uninsured and living at 100 to 300% of the poverty level. In
    addition, 4% of our patient population is eligible for Medicaid in
    their States; however, they do not have access to dental care or
    affordable medications through their state Medicare Medicaid programs.
    In addition, 58% of our patients are women, 37% of patients are
    Hispanic (Hispanic individuals make up 18% of the US population), 36%
    of patients are Caucasian (Caucasian individuals make up 60% of the US
    population, and 17% of patients are Black (Black individuals make up
    13% of the US population).
        Racial, societal, and economic factors directly impact people's
    health and ability to access health care and other resources needed to
    have a healthy life. Free and Charitable Clinics and Pharmacies are on
    the frontlines of natural disasters and the coronavirus pandemic, but
    they are on the frontlines of injustice in health care. We are
    committed to working toward health equity and addressing the racial,
    societal, and economic factors that influence people's health.
        Free and Charitable Clinics and Charitable Pharmacies are safety-
    net health care organizations that utilize a volunteer/staff model to
    provide a range of medical, dental, pharmacy, vision, and behavioral
    health services to economically disadvantaged individuals. Such
    clinics/pharmacies are 501(c)(3) tax-exempt organizations or operate as
    a program component or affiliate of a 501(c)(3) organization. Entities
    that otherwise meet the above definition, but charge a nominal/sliding
    fee to patients, may still be considered Free or Charitable Clinics or
    Pharmacies provide essential services are delivered regardless of the
    patient's ability to pay. Free or Charitable Clinics and Charitable
    Pharmacies restrict eligibility for their services to individuals who
    are uninsured, underinsured, and have limited or no access to primary,
    specialty, or prescription health care.
                             appropriations request
        Our clinics receive little to no State or Federal funding, we do
    not receive HRSA 330 funds, and we are not Federally Qualified Health
    Centers or Rural Health Centers. Therefore, our clinics rely heavily on
    the generosity of individual donors, foundations, and grants as funding
    sources.
        Free and Charitable Clinics are a supreme example of private-public
    partnerships. We are excellent partners to the Federal Government
    because we provide access to health care to individuals who typically
    utilize the emergency department for routine care. Therefore, it is
    imperative to our operations that the Free Clinic Medical Malpractice
    (FTCA), the National Health Service Corps, the Nurse Corps Loan
    Repayment Program, The Breast and Cervical Cancer Screening Program
    under Title X, and the Corporation for National and Community Service
    programs continue to be adequately funded.
    FTCA
        The Federal Torts Claims Act Program allows volunteer medical
    providers to provide health care to our patient populations and receive
    malpractice protection from the Federal Government. In addition to
    saving the clinics money, this program allows providers to understand
    that their expertise is valued and essential to the health of our
    patients. Therefore, we request that this program be funded in FY23 at
    the FY22 level of $1 million.
    Nurse Corps Loan Repayment Program
        The Nurse Corps Loan Repayment Program allows registered nurses
    (including advanced practice registered nurses and nursing faculty) to
    help to create healthy communities in poor urban and rural areas as
    they build their careers by paying off 60% of their unpaid nursing
    student loans in just 2 years- plus an additional 25% of the original
    balance for an optional third year. In return, NURSE Corps members
    fulfill a service obligation at one of the eligible entities located in
    designated mental health or primary medical care Health Professional
    Shortage Areas across the United States. This program allows free and
    charitable clinics to recruit talented nurses by assisting them with
    their nursing school loans. Therefore, we request that this program be
    fully funded in FY23 at the FY22 levels.
    National Health Service Corps
        The National Health Service Corps allows the next generation of
    medical providers to receive loan repayment for providing their time
    and expertise in a clinic that is in a health professional shortage
    area. Over 52% of clinics are in a health professional shortage area.
    The loan repayment program also allows for more medical students or
    nursing students to understand that the need for primary care doctors
    is at an all-time high in this country. Therefore, we ask that this
    program be funded at the FY23 budget request level of $210 million.
    Breast and Cervical Screenings
        The Breast and Cervical Cancer Screening Program funded under Title
    X is how they receive routine cancer screenings for many uninsured
    women. According to a study conducted by the American Cancer Society,
    Emory University, and Dana Farber Institute: Differences in health
    insurance explained about 35% of the excess risk of death in black
    women compared with white women. Almost three times as many black women
    were uninsured or had Medicaid insurance (22.7%) compared to white
    women (8.4%). The study authors wrote, ``Lack of insurance is a barrier
    to receiving timely and high-quality treatment and screening
    services.'' Free and Charitable Clinics utilize this program to ensure
    that our patients have access to screening, testing, and life-saving
    treatment. Therefore, we request that this program be fully funded in
    FY23 at the FY22 levels.
    Corporation for National and Community Service
        In addition to private donations, Free and Charitable Clinics need
    volunteers to increase our capacity at our locations across the
    country. The AmeriCorps Vista program allows clinics to enhance their
    operations, procedures, policies, and educational materials. The
    AmeriCorps Vista program is essential for expanding care and allowing
    volunteers to receive work experience in a non-profit setting.
    Therefore, we ask that this program be fully funded in FY23 at the FY22
    levels.
                                    closing
        Our patients face various complex challenges and barriers to health
    care access. Therefore, Free & Charitable Clinics have been deeply
    committed to providing whole-person health care and addressing social
    determinants of health and health disparities.
        Please ensure that these programs continue to be fully funded, so
    we can continue to partner to ensure that every person has access to
    affordable quality health care. We thank you for the opportunity to
    share this written testimony.

        [This statement was submitted by Nicole Lamoureux, CEO and
    President,
    National Association of Free and Charitable Clinics.]
                                     ______

        Prepared Statement of 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 FY 2023 appropriations for Federal programs that
    impact approximately 2.87 million Americans who are treated annually in
    emergency departments and hospitals for a traumatic brain injury (CDC,
    2014). We appreciate your support for additional funding for FY 2022 to
    the U.S. Department of Health and Human Services' (HHS) Administration
    for Community Living (ACL) TBI State Partnership Program that helps
    States expand services to address the cognitive, behavioral and
    physical rehabilitative and long-term needs of Americans living with
    brain injury in accordance with the Traumatic Brain Injury (TBI)
    Program Reauthorization Act of 2018.
        However, as not all States or territories are currently
    participating in the grant program, NASHIA is requesting increased
    funding for the ACL TBI State Partnership Program (TBI SPP) so that
    individuals living with brain injury and their families have resources
    and assistance to return to home and community, school and employment
    regardless of where they live in this country. In addition, we support
    full funding for the National Concussion Surveillance System
    administered by the CDC's National Center for Injury Prevention and
    Control (NCIPC). And, 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, which authorizes
    research, including research conducted by the TBI Model Systems.
    Specifically, NASHIA is requesting:
      --$19 million additional funding for the ACL TBI State Partnership
            Program to provide funding to all States, territories and
            District of Columbia;
      --$5 million 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 ($2.5 million each;
            and
      --$1 million to expand TBIMIS collaborative research projects for
            additional research on TBI as a chronic condition.
        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 past 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 related to the pandemic.
    Thus, the Federal funding requested is critical to assist States with
    issues that emanated from the pandemic as programs and services are
    brought back to pre-pandemic status.
             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, and Medicaid/
    Medicare) and payers (e.g., insurance, Workers' Comp, State and Federal
    programs). Twenty-eight States are currently funded by the ACL TBI SPP
    for 5 years. 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.
     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.
    We are joined in this support by:
        AANS/CNS Joint Section on Neurotrauma & Critical Care; Advancing
    States; Alzheimer's Association; American Academy of Physical Medicine
    and Rehabilitation (AAPMR); American Association of Neurological
    Surgeons; American Physical Therapy Association; Brain Injury
    Association of America; Concussion Legacy Foundation; Congress of
    Neurological Surgeons; Friends of TBI Model Systems; Injury Prevention
    Research Center at Emory; Matthew Gfeller Center, University of North
    Carolina at Chapel Hill; National Association of State Directors of
    Developmental Disabilities Services; National Association of State
    Mental Health Program Directors; National Athletic Trainers'
    Association; National Disability Rights Network; North American Brain
    Injury Society; Safe Kids Worldwide; SCORE Program, Children's National
    Hospital; The Center on Brain Injury Research & Training at the
    University of Oregon; The National Concussion Management Center; United
    States Brain Injury Alliance (USBIA); USA Field Hockey; USA Lacrosse;
    and USA Football.
        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 is a nonprofit organization that 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
    to the ACL TBI State Partnership Program; the ACL NIDILRR program to
    expand TBI research; and to 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, svaughn@nashia.org or Zaida Ricker, NASHIA
    Government Relations, zricker@ridgepolicygroup.com.
                                     ______

       Prepared Statement of the National Coalition for Homeless Veterans
        Dear Chair Murray and Ranking Member Blunt, Chairman Heinrich and
    Ranking Member Boozman, and Chairman Schatz and Ranking Member Collins:
        As you begin work on the fiscal year 2023 Appropriations bills, the
    National Coalition for Homeless Veterans (NCHV) submits this letter as
    testimony, requesting your respective subcommittees to fully fund the
    programs that directly impact homeless veterans to perpetuate the
    successes in reduction of homeless veterans. Multiple Federal
    departments and agencies play vital roles in combatting, preventing,
    and ending veteran homelessness in America including the Department of
    Labor (DOL), the Department of Veterans' Affairs (VA) and the
    Department of Housing and Urban Development (HUD).
        COVID-19 has continually impacted the economy in unprecedented
    ways, and as the VA's own Secretary testified, we have yet to reach
    peak requests for care. The Committee's diligence in providing
    emergency appropriations for these programs shows great foresight, yet
    now we must work toward permanent housing for those veterans housed
    with those funds, in regular program appropriations so we do not return
    veterans to pre-emergency levels of veteran homelessness. Every veteran
    deserves safe and permanent housing, whether they are currently
    experiencing homelessness or are facing housing-cost burdens that put
    them at risk of homelessness. We therefore ask that you fully fund the
    listed programs at the following levels:
                              department of labor
        The Homeless Veterans' Reintegration Program (HVRP) provides
    services to assist in reintegrating homeless veterans into meaningful
    employment within the labor force and to stimulate the development of
    service delivery systems that will address the employment challenges
    facing homeless veterans. ($107.5 Million)
                         department of veterans affairs
        1. The Healthcare for Homeless Veterans Program (HCHV) performs
    outreach to identify veterans experiencing homelessness who are
    eligible for VA services and assist these veterans in accessing
    appropriate health care and benefits. ($275 Million)
        The Homeless Providers Grant and Per Diem (GPD) promotes the
    development and provision of transitional housing and services with the
    goal of helping homeless veterans achieve residential stability,
    increase their skill levels and/or income, and obtain greater self-
    determination. Includes $180 million for post-covid per diem
    adjustments and $50 million for the next round of Capital Grants. ($500
    Million)
        The Healthcare for Reentry Veterans and Veteran's Justice Outreach
    program helps justice-involved veterans avoid the unnecessary
    criminalization of mental illness and extended incarceration by
    ensuring that eligible veterans have timely access to Veterans Health
    Administration. ($75 Million)
        The Supportive Services for Veteran Families (SSVF) program
    provides funding for very low-income veteran families in or
    transitioning to permanent housing. The Secretary has expressed a
    departmental goal of permanently housing an additional 38,000 homeless
    veterans by the end of the year and the funding should reflect that
    aim. NCHV is requesting continued report or bill language to ensure
    sufficient rapid rehousing and homelessness prevention capacity
    monitoring the expansion of the shallow subsidy initiative of the SSVF
    program until outcomes are tangible. ($795 Million)
        Case Managers working Case Management for the HUD-VASH Program work
    with homeless veterans can use this resource to address the
    multifaceted needs they have. Veterans must agree to participate in
    case management in order to receive a HUD-VASH voucher. The President's
    Fiscal Year 2023 Budget and the VA secretary have requested larger base
    increases to continue to hire full-time equivalent (FTE) case managers.
    ($594 Million)
        The Medical Support and Compliance (0152) accounts under VA Medical
    Services for homeless veteran programs requires additional funding to
    support the use of administrative fees for the hiring and retention of
    staff. (Highest Funding Possible)
                  department of housing and urban development
        Additional funding for new HUD-VASH Vouchers provides a much-needed
    yearly increase in program funding to allow for continued referrals.
    Many factors contribute to underutilization like housing stock, case
    manager hiring and retention, and VA has been working to alleviate what
    it can and has made some progress on hiring FTEs. Additional vouchers
    will allow developers to operationalize additional supportive housing
    for veterans. Includes $40 million for project-based vouchers. ($90
    Million)
        Tribal HUD-VASH--Tribes have been working to actively increase
    capacity within HUD-VASH to meet community needs. ($5 Million)
                                   reporting
        We request that each Secretary produce continuing reports on racial
    equity and access to programs providing services to homeless veterans.
    The reports track departmental expenditures within Homeless Veteran
    Programs specifically with regard for minority, female and LGBTQ
    populations. This report would be provided annually to the
    Appropriations and Veterans' Affairs subcommittees of jurisdiction. The
    information should be disaggregated by ethnicity, age, gender identity,
    and discharge status. The data collected to produce the report will be
    crucial in determining how to continue future homeless veteran
    population reductions and should be accessible to the general public.
        We request report language in the VA appropriations bill to
    continue the implementation of a housing first oriented approach to
    addressing veteran homelessness. Given the research on its outcomes and
    cost effectiveness NCHV requests Congress direct the Department to
    continue implementation of housing-first oriented systems and efforts
    to meaningfully incorporate appropriate levels of transitional housing
    capacity into systems across the country to meet the needs of veterans
    who choose recovery services or transitional housing programs.
        We request the VA Secretary produce a report regarding increased
    effectiveness and efficiency of VA's Grant and Per Diem. The report
    would include historical rate data (3-5 years) disaggregated by
    location & zip code and not solely by grantee name, in addition to
    ethnicity, age, gender identity, and discharge status. The report would
    include the number of beds indicated by geographic location and
    disaggregated by type of bed and their level of congregate setting. The
    report would also include a proposal and ramifications for decoupling
    GPD rates from the state home domiciliary rate in favor of more
    regional calculation based on area fair market rents. When the National
    Health Emergency sunsets the GPD rate will revert to 115 percent of the
    state home rate. NCHV has testified repeatedly that this rate is
    nowhere near sufficient to shelter veterans in major urban areas like
    California where the cost is over 400 percent of the state home rates.
        We thank you for your past and continued support of veteran
    homelessness programs and your consideration of these important
    requests.

        Sincerely.

        [This statement was submitted by Kathryn Monet, Chief Executive
    Officer,
    National Coalition for Homeless Veterans.]
                                     ______

         Prepared Statement of the National College Attainment Network
        On behalf of the National College Attainment Network (NCAN), we
    write to respectfully request that investments in education programs,
    such as funding for Federal student aid, remain a high priority for the
    Labor-HHS-Education subcommittee in Fiscal Year 2023. NCAN hopes that
    discretionary funding will rise in FY23 for programs that are critical
    to our Nation's students and future workforce. Thank you for your
    continued leadership on investing in the Federal programs that support
    students in their pursuit of postsecondary education,
        For FY23, NCAN requests these funding levels for the U.S.
    Department of Education programs:
      --NCAN recommends the requisite funding in FY23 so that the maximum
            Pell Grant award can be increased to $12,990, double the
            maximum Pell Grant award (award year 2021-22).
      --Supplementary Educational Opportunity Grant funding of $1.09
            billion.
      --Federal Work-Study funding of $1.52 billion.
      --TRIO program funding of $1.307 billion.
      --GEAR UP funding of $435 million.
      --$620 million increase in administrative funding for Federal student
            aid management.
        Additionally, we request that the Corporation for National and
    Community Service receive $1.34 billion in funding for FY23--and that
    the AmeriCorps program, that allows some college access programs to
    provide near-peer mentors for their students, receive $557 million in
    funding.
        Founded in 1995, NCAN represents more than 500 members across the
    country that all work toward a shared 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
    percent less likely to enroll in postsecondary education directly after
    high school than a high-income student. Ultimately, only 35 percent of
    low-income high school students obtain a postsecondary credential by
    age 26, compared to 72 percent of high-income students.
        To help close equity gaps in attainment, NCAN requests the
    following in Federal investments:
    Pell Grant Investments
        NCAN recommends that the maximum Pell Grant award be increased to
    $12,990, double the maximum award (award year 2021-22).
        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, far less
    students from low-income backgrounds would be able to access higher
    education. NCAN appreciates investments Congress has made to raise the
    maximum Pell Grant award in recent years.
        Given that the previously required automatic inflationary increases
    have expired, annual investments by Congress are essential for our
    Nation's students who are least likely to have the means to pay for
    education after high school. Even with recent investments, the maximum
    Pell Grant award's purchasing power at a 4-year public institution only
    covers 30 percent of the cost of attendance. At its high in the 1970s,
    the maximum Pell Grant award could have covered more than three-fourths
    of the average cost of attendance--tuition, fees, and living expenses--
    at a 4-year public institution.
        To address its long-term purchasing power, and so that the maximum
    award cover at least half of the cost of attendance at a 4-year public
    institution, the maximum Pell Grant award should be doubled. In the
    president's FY23 budget request, the administration requests Congress
    consider a Pell Grant increase of $1,775, through discretionary and
    mandatory funding, to bring the maximum award to $8,670 for the 2023-24
    award year. If Congress adopted this increase, the maximum award's
    purchasing power would increase to 36 percent. Further, this historic
    investment is necessary to reach the goal outlined in the president's
    budget of doubling the Pell grant by 2029.
    FAFSA Simplification
        In the president's FY23 budget request, the administration requests
    a $620 million increase in administrative funding for the management of
    Federal student aid. This funding is 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 1 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 FY23 so that institutions
    of higher education to support a greater percentage of our Nation's
    lowest-income students. For FY22, NCAN respectfully requests that
    Congress fund the SEOG program at a total of $1.09 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 FY23, NCAN
    respectfully requests that Congress increase the FWS program budget for
    a total of $1.52 billion.
    Federally Funded College Access Programs--TRIO and GEAR UP
        High school seniors, and especially students from low-income
    backgrounds, require a variety of programs to help assist as they
    strive to pursue education beyond high school. NCAN's members serve
    roughly two million students annually in their path towards attainment.
    To reach the students who need crucial assistance services, our members
    build important partnerships 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: $1.307 billion for TRIO and $435 million for GEAR
    UP.
    Corporation for National and Community Service (CNCS)
        For every dollar spent on national service, our Nation sees a major
    return on investment. Service plays an important role in the college
    access movement. Many of NCAN's largest members can maximize their
    impact for 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 $1.34 billion and $557 million,
    respectively, for FY23.
        Thank you for this opportunity to provide our funding priorities
    for fiscal year 2023. 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.
    NCAN appreciates your leadership in Congress to support these important
    Federal programs.
        Sincerely.

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

        Prepared Statement of the National Congress of American Indians
        On behalf of the National Congress of American Indians (NCAI),
    thank you for this opportunity to provide testimony on fiscal year 2023
    funding for the Department of Labor (DOL), Department of Health and
    Human Services (HHS), Department of Education (Ed.), and the
    Corporation for Public Broadcasting (CPB).
        Indian Country is socially, economically, and geographically
    diverse. Most Tribal lands are held in trust by the United States or
    have been completely taken from our Nations through the long history of
    Federal Indian policies of removal, assimilation, reorganization, and
    termination. As a result, we do not have the same asset base or tax
    base as other governments and our government revenue structure is
    different; Tribal Nations rely on Federal Government funding and on
    economic development. Policies failing to consider that we do not have
    the same capital equity as other American governments cause Federal
    programs and initiatives to be less successful than intended. Federal
    spending policy for programs that benefit Native Americans must be
    considered holistically across appropriations subcommittee
    jurisdictions and recognize the unique historical and political
    position forced upon Tribal Nations. The United States must be bold and
    look at new and unrealized solutions to Federal taxing and spending
    related to its trust and treaty obligations to Tribal Nations.
        After the COVID-19 pandemic struck, the Federal Government listened
    to Tribal Nations' collective voice and provided the largest single
    infusion of Federal funding for Native Americans in U.S. history.\1\
    Funding from the American Rescue Plan Act embodied a simple and
    effective strategy to maximize the investment: empowering Tribal
    Nations to design their own solutions. This funding was not a panacea,
    particularly given that Tribal Nations began the pandemic on unequal
    footing compared to State and local governments, but it was historic,
    necessary, and essential. This historic inclusion in Federal spending
    for Indian Country must be the norm, and not the exception.
    ---------------------------------------------------------------------------
        \1\ Eric C. Henso et. al, ``Assessing the U.S. Treasury
    Department's Allocations of Funding for Tribal Governments under the
    American Rescue Plan act of 2021'', Harvard Project on American Indian
    Economic Development & Native Nations Institute, Policy Brief No. 7
    (November 3, 2021), available at: https://ash.harvard.edu/files/ash/
    files/assessing_the_u.s.--treasury_
    departments_allocations_of_funding_for_tribal_governments.pdf?m=16359725
    21.
    ---------------------------------------------------------------------------
                              department of labor
        Beginning in February 2022, the Bureau of Labor Statistics
    published monthly data on American Indian and Alaska Native (AI/AN)
    employment, using data that was previously available through the Census
    Bureau's Current Population Survey. The newly published data reveals a
    labor market that would be considered catastrophic if it were
    representative of the full U.S. economy, with an unemployment rate more
    than double that of the Nation's topline unemployment rate.\2\ Indian
    Country is still recovering from the effects of the pandemic on the
    labor market, with unemployment rates reaching 28.6 percent during the
    peak of the pandemic fallout-an amount comparable to the National
    unemployment rate during the Great Depression.\3\ As of January 2022,
    the unemployment rate for Native Americans was still greater than the
    peak unemployment rate for white workers during the pandemic.\4\
    ---------------------------------------------------------------------------
        \2\ Robert Maxim, Randall Akee, and Gabriel R. Sanchez, For the
    first time, the government published monthly unemployment data on
    Native Americans, and the picture is stark, available at: https://
    www.brookings.edu/blog/the-avenue/2022/02/09/despite-an-optimistic-
    jobs-report-new-data-shows-native-american-unemployment-remains-
    staggeringly-high/#:\:text=Prior%20to%20
    the%20pandemic%2C%20Native,unemployment%20during%20the%20Great%20Depress
    ion, Accessed: May 4, 2022.
        \3\ Id.
        \4\ Id.
    ---------------------------------------------------------------------------
        Even when controlling for a host of factors, the Brookings
    Institute posits that structural racism in the U.S. economy affects AI/
    AN access to education and attainment as well as employment
    opportunities.\5\ As traditionally place-based peoples with strong
    cultural and historical ties to the land, AI/ANs tend to not move away
    even when the economy goes bad. This means that the structural
    impediments to economic growth are focused and exacerbated on Tribal
    lands, underscoring the importance of DOL employment and training
    programs for AI/ANs. Unfortunately, spending for Native American
    programs within DOL represents 0.5 percent of total regular DOL budget
    authority in the fiscal year 2022 Omnibus, with an increase of less
    than 4.8 percent over 5 years-an amount that drastically fails to keep
    pace with inflation for that same period according to the Bureau of
    Labor Statistics' own inflation calculator. With Federal investment
    metrics such as these, it is no surprise that the labor market in
    Indian Country remains in a State of catastrophe by national standards,
    which dampens local, regional, and national U.S. economic productivity.
    ---------------------------------------------------------------------------
        \5\ Id.
    ---------------------------------------------------------------------------
        This subcommittee can correct this investment deficiency by
    providing at least $61.5 million for DOL Native American Programs,
    $15.5 million for Tribal grants within YouthBuild Activities, and not
    less than $250 thousand to DOL Department Management for the
    Secretary's Native American Employment and Training Council, holding
    Native American Program resources harmless. Additionally, DOL has
    failed to make meaningful headway on the American Indian Population and
    Labor Force Report, required by Congress to be submitted every 2 years,
    despite several Tribal consultations on the need for it and meaningful/
    useful data. Instead, in February 2022, the DOL Employment and Training
    Administration issued a 96-page report on the difficulty of compiling
    the report and opted to further pass the buck on to the Bureau of Labor
    Statistics--wasting time and taxpayer resources while simultaneously
    failing to meet Congress' mandate. DOL must be directed to execute this
    long overdue and meaningful report in consultation and collaboration
    with Tribal Nations, and DOL resources must be conditioned on the
    completion of this unfulfilled obligation. Executive Branch agencies
    should be held accountable to fulfill Congressional and U.S. Code
    requirements--not waste Federal resources meant to support Indian
    Country to issue reports on why projects are difficult. DOL must work
    with Tribal Nations and across Federal agencies to develop the report
    Indian Country needs and deserves to support Tribal solutions.
                    department of health and human services
        As Congress declared in the Indian Health Care Improvement Act (25
    U.S.C. Sec. 1602), in order to fulfill its trust responsibility and
    treaty obligations, the U.S. must achieve the highest health care
    levels for AI/ANs and provide the requisite resources. While the Indian
    Health Service (IHS) is the primary source of Federal funds for
    healthcare for AI/ANs, annual appropriations for the IHS have never
    exceeded 50 percent of the demonstrated patient need. By cross-
    referencing Office of Management and Budget data with Appropriations
    Committee reports, regular appropriations for HHS in fiscal year 2022
    for the benefit of Native Americans represents 0.68 percent of the
    total budget authority provided by Appropriations Committees. When this
    amount is controlled to remove IHS (funded within the jurisdiction of
    the Interior, Environment, and Related Agencies subcommittee), this
    subcommittee's investment in Indian Country is an appalling 0.15
    percent of its regular budget authority appropriated for fiscal year
    2022.
        This (lack of) investment tells a vivid story of health and
    wellbeing in Indian Country and of Congress' priorities for health and
    wellbeing when controlling for all competing interests within this
    subcommittee's jurisdiction. It tells a story of how Congress values
    (or fails to value) its treaty and trust obligations and the human
    lives that it obligated itself to protect in exchange for the wealth
    and bounty that created the most economically prosperous and powerful
    country in world history. The ongoing Coronavirus pandemic uniquely
    impacted and exacerbated the health conditions of Indian Country, but
    AI/ANs began this pandemic already in a health crisis caused by the
    United States' chronic underinvestment in its own obligations; by the
    promises to its citizens that it broke-that remain broken. Even as we
    recover globally from the pandemic, additional emerging issues are
    disproportionately impacting Tribal communities. The loss of our loved
    ones, our economies, and the devastating effects of isolation with
    inadequate infrastructure are causing a mental health crisis across
    Indian Country. The rising costs of goods and lingering labor fallout
    are affecting early childhood development outcomes. The lack of
    adequate communications infrastructure is affecting our educational
    attainment. This crisis is not over for our people, even as we face new
    crises on practically every front.
        The United States' trust and treaty obligations to Tribal Nations
    and their citizens cannot be singularly siloed into one bureau or
    agency. IHS services are largely limited to direct patient care,
    leaving little, if any, funding available for public health initiatives
    such as disease research and prevention, early childhood development
    and welling education, injury prevention, and promotion of healthy
    lifestyles. HHS administers a wide array of health and wellbeing
    programs for Indian Country, including child and family welfare, mental
    health services, education, and cultural preservation. This
    subcommittee can address these compounded crises by providing not less
    than $505.98 million for Tribal grants within Children and Families
    Services Programs-including $349.98 million for Programs for Children,
    Youth and Families and not less than $156 million for Native American
    Programs (Administration for Native Americans); $203.52 million for
    Tribal grants within the Substance Abuse and Mental Health Services
    Administration; $111.23 million for Tribal grants within the
    Administration for Community Living; $17.41 million for Tribal grants
    within Promoting Safe and Stable Families; and $14.01 million for the
    Tribal Home Visiting Program.
                            department of education
        The U.S. Department of Education funds promote the success of
    Native students in public schools, as well as Bureau of Indian
    Education-funded and tribally controlled schools and Tribal Colleges
    and Universities. An educated citizenry serves as a catalyst to boost
    prosperity and growth through a more competitive workforce, which can
    attract new businesses, stimulate Tribal economies, and foster
    entrepreneurial endeavors in the community. Tribal education is
    uniquely reliant on the Federal appropriations process because
    disparities in tax jurisdictions limit Tribal governments' ability to
    raise revenue in ways other governments take for granted. A growing
    body of research finds important positive connections between the
    linguistic and cultural environments in which Native American children
    grow and their outcomes. Congress must provide the resources to fulfill
    its trust and treaty obligations to Native Americans through culturally
    appropriate education.
        In order to fulfill these obligations and improve on AI/AN
    education and attainment, this subcommittee should provide not less
    than $2.095 billion for Indian Education programs--including $2 billion
    for Tribal Local Education Agencies (LEAs); $2 billion for Impact Aid
    for the benefit of Native students; $20 million for Bureau of Indian
    Education school assessment maintenance; $94.2 for Higher Education
    Tribal programs--including $45 million for Tribal Colleges and
    Universities and $15 million for Tribally Controlled Postsecondary
    Vocational/Tech Institutions; and $76 million for the American Indian
    Vocational Rehabilitation Services Program.
                      corporation for public broadcasting
        Native radio stations are critical to the communities they serve
    because they are often the first source of emergency reporting and
    information for Tribal citizens. Public broadcasters use datacast
    technology for public alert and warning systems, homeland security, and
    other public safety purposes. In addition to providing emergency
    information, Native radio stations provide vital access to healthcare
    information and other services specific to the Tribal communities they
    serve. Often, the only forum where Native stories and issues are
    broadly heard are on Native radio stations.
        Since 1976, the Corporation for Public Broadcasting's (CPB) 2-year
    advance appropriations have served as a Congressional strategy to
    protect public media from any immediate political pressure. Community
    Service Grants (CSGs) account for approximately 70 percent of CPB's
    appropriation, which directly funds 1,300 local public television and
    radio stations--including 36 Native radio stations. CPB also funds the
    essential system-wide station support services provided by Native
    Public Media, Inc., and the content production and satellite
    programming distribution by Koahnic Broadcast Corporation. This funding
    ensures that Native radio stations stay on-air and provide broadcast
    services to some of the most rural and remote locations in the United
    States.
        Congress should provide at least $7 million (advance appropriation
    for fiscal year 2025) to fund American Indian and Alaska Native radio
    stations, at least $500,000 (advance appropriation for fiscal year
    2025) for Native Public Media, and at least $500,000 (advance
    appropriation for fiscal year 2025) for the Koahnic Broadcast
    Corporation.
                                   conclusion
        Tribal Nations are uniquely reliant on the Federal Government to
    fulfill its promises made in exchange for the land that created the
    foundation of the bounty and wealth of the United States. Our people
    have paid for every penny obligated to Indian Country hundreds of times
    over by providing this Nation with our land. In order to uphold this
    Nation's promises to its people, it must first uphold its promises to
    this land's First Peoples. We expect to continue to be treated as
    sovereign nations with governmental parity. We must continue down that
    path of Nation-to-Nation growth, and only then will all of our people
    be able to fully flourish.

        [This statement was submitted by Dante Desiderio, CEO, National
    Congress of American Indians.]
                                     ______

    Prepared Statement of the National Council for Community and Education
                                  Partnerships
        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 Mark
    Figueroa, 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 2023 to support an additional 80,000 students across our country
    so that they, too, can have the support I received in GEAR UP.
        As you know, 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 knowledgeable about the steps necessary to prepare 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 percent higher than low-income students
    nationally.\1\ Considering that GEAR UP achieves this critical goal at
    a cost of approximately $645 per student, per year, I strongly believe
    that the investment in GEAR UP pays significant dividends. GEAR UP is a
    powerful catalyst for sustained community improvement.
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Education (2016). fiscal Year2017 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.
    ---------------------------------------------------------------------------
        I grew up in a place in Eastern Washington State in a region known
    as the Tri-Cities. This part of the country is fueled by passionate
    Latinx immigrant migrant families working in produce fields across the
    State of Washington. With long days and hard work, preparing for a
    higher education can be challenging for many. As a first-generation
    migrant student and the eldest of six in my family, post-secondary
    education seemed like a very distant, unknown land with no clear path
    toward it.
        However, participating in the GEAR UP program helped me actualize
    my dreams of a post-secondary education through mentors, college &
    career fairs, FAFSA nights, and college admissions workshops. Being the
    first in my family to pursue a higher education, my parents and I had
    many questions. It is a daunting process, especially if done alone.
    Nevertheless, GEAR UP was there to support us, and walk with us all the
    way. Because of GEAR UP, I was admitted and graduated from Washington
    State University. With these experiences, and the confidence that GEAR
    UP gave me, I was able to develop strong leadership skills, community
    connections, and discovered all the ways to give back to my community.
    During my time at Washington State University, I connected with other
    first-generation migrant students and encouraged them to follow their
    dreams. I joined the only Aztec-based brotherhood in the Pacific
    Northwest, I served in student government, and helped lead a student
    ministry at the intersection of faith and culture. Having led the way,
    with the support of GEAR UP, I am now there for my parents and my five
    sisters as they navigate the college-going process.
        Additionally, I was inspired by my experiences and the experiences
    of others with stories similar to mine, and I was able to bring
    awareness to various issues affecting college students from all walks
    of life. I currently volunteer with local civic engagement
    organizations to encourage members of my community to elevate their
    voices. I am a secondary education teacher, I coach soccer at the same
    high school where GEAR UP supported me, and I am working towards a
    master's degree in theology. I can attest to the truth that GEAR UP
    does work.
        For me, none of this would have been possible without the guidance
    of the GEAR UP program. Through my own achievements in attending
    postsecondary education, I can see that generational barriers in my
    family have been removed for future generations and they may find the
    same successes that I have through education. While the support that
    GEAR UP provided me was truly priceless, the only way that other
    students will be able to access the educational experiences I had
    because of GEAR UP, will be to continue to increase funding.
    Acknowledging that I am just one of the thousands of families GEAR UP
    has positively impacted highlights the impact of the GEAR UP program.
        As you take on the work of preparing for the fiscal year 2023
    appropriations, I urge you to consider increasing the investment in the
    GEAR UP program to $435,000,000 so that 80,000 more students just like
    me can benefit from the program as I did. Thank you to the committee
    for taking the time to read my testimony.
                                     ______

      Prepared Statement of the National Council for Diversity in 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 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) 2023 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
            2023.
         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.
    NCDHP recommends $47.95 million for the HCOP program in Fiscal Year
            2023.
     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 1-year programs, with 90% being accepted to
                medical school, of which >95% will graduate as physicians.
        As you begin the FY 2023 process, NCDHP asks that you further
    prioritize Title VII health professions training programs. Chairwoman
    Murray and Ranking Member Blunt, 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 2023 and the future.

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

       Prepared Statement of the National Council of Urban Indian Health
        My name is Francys Crevier, I am Algonquin and the Chief Executive
    Officer of the National Council of Urban Indian Health (NCUIH). On
    behalf of NCUIH, the National advocate for health care for the over 70
    percent of American Indians and Alaska Natives (AI/ANs) living off-
    reservation and the 41 Urban Indian Organizations (UIOs) that serve
    these populations, I would like to thank Chairwoman Murray, Ranking
    Member Blunt, and Members of the subcommittee for the opportunity to
    submit public witness testimony regarding Fiscal Year (FY) 2023
    appropriations. We respectfully request the following:
      --Fully fund the Indian Health Service (IHS) at $49.8 billion and
            Urban Indian Health at $949.9 million for FY23 (as requested by
            the Tribal Budget Formulation Workgroup)
      --Advance appropriations for IHS until mandatory funding is enacted
      --Increase funding for Electronic Health Record Modernization
      --Increase funding to $30 million for Good Health and Wellness in
            Indian Country (GHWIC)
      --Permanently reauthorize Native Connections (Tribal Behavioral
            Health Grant)
      --Include urban Indians in language for all health programs
      --Include UIOs in critical opioid grants
    Fully fund the Indian Health Service at $49.8 billion and Urban Indian
            Health at $949.9 million for FY23 (as requested by the Tribal
            Budget Formulation Workgroup)
        While your leadership was instrumental in providing the greatest
    investments ever for Indian health and urban Indian health, it is
    important that we continue in this direction to build on our successes.
    The average health care spending is around $12,000 per person, however,
    Tribal and IHS facilities receive only around $4,000 per patient. UIOs
    receive just $672 per IHS patient--that is only 6 percent of the per
    capita amount of the National average. That's what our organizations
    must work with to provide health care for urban Indian patients.
        The Federal trust obligation to provide health care to Natives is
    not optional, and we thus request Congress honor the Tribal Budget
    Formulation Workgroup (TBFWG) FY23 recommendations of $49.8 billion for
    IHS and $949.9 million for urban Indian health. That number is much
    greater than the FY21 enacted amount of $63.7 million, which truly
    demonstrates how far we have to go to reach the level of need for urban
    Indian health. At an IHS Area Report meeting where Tribal leaders
    presented their budget requests, one Oklahoma Tribal leader stated that
    ``There are inadequate levels of funding to address the rising urban
    Indian population.'' Congress must do more to fully fund the IHS in
    order to improve health outcomes for all Native populations at the
    amount requested.
        In 2018 the Government Accountability Office (GAO-19-74R) reported
    that from 2013 to 2017, IHS annual spending increased by roughly 18
    percent overall, and roughly 12 percent per capita. In comparison,
    annual spending at the Veterans Health Administration (VHA), which has
    a similar charge to IHS, increased by 32 percent overall, with a 25
    percent per capita increase during the same period. Similarly, spending
    under Medicare and Medicaid increased by 22 percent and 31 percent
    respectively. In fact, even though the VHA service population is only
    three times that of IHS, their annual appropriations are roughly 13
    times higher.
        Currently, the entire Eastern seaboard is without any full-
    ambulatory UIOs due to lack of funding. The IHS has deemed the two
    remaining UIOs on the East Coast to be outreach and referral only, with
    a combined less than two-million-dollar budget. Unfortunately, the
    pandemic has shown that two outreach and referral UIOs to serve all
    urban Indians on the entire East Coast of the country is a failure to
    uphold the Federal trust obligation. It is evident the UIO line item is
    insufficient to allow IHS to authorize our East Coast UIOs to open
    fully operational clinics. Native American Lifelines is actually two
    programs run in both Boston and Baltimore with an annual budget for
    both cities of $1.6 million. During the height of the pandemic, that
    meant Native people living in urban areas on the East Coast had to go
    back to reservations to get their vaccine to take advantage of the IHS
    authority that would give them the vaccine early and hopefully not
    become a mortality statistic.
        The Federal Government owes a trust responsibility to Tribes and
    AI/ANs that is not restricted to the borders of reservations. Funding
    for Indian health must be significantly increased if the Federal
    Government is, to finally, and faithfully, fulfill its trust
    responsibility.
    Advance Appropriations for IHS Until Mandatory Funding is Enacted
        The Indian health system, including IHS, Tribal facilities and
    UIOs, is the only major Federal provider of health care that is funded
    through annual appropriations. If IHS were to receive mandatory funding
    or, at the least, advance appropriations, it would not be subject to
    the harmful effects of government shutdowns, automatic sequestration
    cuts, and continuing resolutions (CRs). When IHS is funded through a
    CR, the IHS can only expend funds for the duration of a CR, which
    prohibits longer term purchases, disrupts the contracts that allow UIOs
    to provide health care, and quite literally puts lives at risk. Because
    UIOs must rely on every dollar of limited Federal funding they receive
    to provide critical patient services, any disruption has significant
    and immediate consequences.
        NCUIH supports the President's proposal in the FY 2023 Budget to
    fund the IHS through mandatory appropriations and to exempt IHS from
    proposed law sequestration. The 10 years of appropriated mandatory
    funding in the FY 2023 Budget will ensure predictability that will
    allow the I/T/U system to engage in long-term and strategic planning.
    The lack of consistent and clear funding creates significant barriers
    on the already underfunded IHS system. Until authorizers act to move
    IHS to mandatory funding, we request that Congress provide advance
    appropriations to the Indian health system to improve certainty and
    stability.
    Increase funding for Electronic Health Record Modernization
        We request your support for the Indian Health Service's (IHS)
    transition to a new electronic health record (EHR) system for IHS and
    UIOs. As EHR modernization moves from planning to fruition, it is
    vitally important that appropriations continue to increase as
    appropriate to provide for its success. NCUIH Requests the committee to
    support this transition with $355.8 million in FY23 appropriations.
    NCUIH is also supportive of the inclusion of report language suggested
    by members of Congress in a letter to the House appropriations
    committee.\1\
    ---------------------------------------------------------------------------
        \1\ https://files.constantcontact.com/a3c45cb9201/562eb81b-dee4-
    48b8-8519-69bcbebb0ff2.pdf?rdr
    =true.
    ---------------------------------------------------------------------------
    CDC: Good Health and Wellness in Indian Country--$30 Million Good
            Health and Wellness in Indian Country (GHWIC)
        The GHWIC program is CDC's single largest investment in Indian
    Country. The program funds a total of 27 Tribes, Tribal organizations,
    and UIOs to improve chronic disease prevention efforts, expand physical
    activity, and reduce commercial tobacco use. The FY 2023 President's
    Budget proposes maintaining at current levels of $22 million. NCUIH
    requests the Committee support the GHWIC program by increasing funding
    to $30 million for FY 2023.
    SAMHSA: Tribal Behavioral Health Grant (Native Connections)--$23.2
            Million
        The Tribal Behavioral Health Grant (known as Native Connections) is
    a 5-year grant program that helps American Indian and Alaska Native
    communities identify and address the behavioral health needs of Native
    youth. The program supports grantees in reducing suicidal behavior and
    substance use among Native youth up to age 24, easing the impacts of
    substance use, mental illness, and trauma in Tribal communities, and
    supporting youth as they transition into adulthood.
        As of June 2021, SAMHSA had awarded 242 5-year grants to eligible
    AI/AN entities including UIOs. The program is up for reauthorization in
    2022 and the FY23 President's budget has a request of $23.2 million for
    the program, an increase of $2.5 million from the FY 2022 Annualized
    Continuing Resolution. NCUIH requests the committee support addressing
    the behavioral health needs of our Native communities by reauthorizing
    this critical program.
    Include Urban Indians in Language for All Health Programs
        The Declaration of National Indian Health Policy in the Indian
    Health Care Improvement Act States that: ``Congress declares that it is
    the policy of this Nation, in fulfillment of its special trust
    responsibilities and legal obligations to Indians to ensure the highest
    possible health status for Indians and urban Indians and to provide all
    resources necessary to effect that policy.'' In fulfillment of the
    National Indian Health Policy, the Indian Health Service funds three
    health programs to provide health care to AI/ANs: IHS sites, tribally
    operated health programs, and Urban Indian Organizations (referred to
    as the I/T/U). Unfortunately, this system has been hampered by decades
    of chronic underfunding. Additionally, while the majority of the Native
    population resides in urban areas, only 1 percent of the entire Indian
    health budget is provided for urban Indian health.
        When urban Indians are not specifically mentioned in programmatic
    language they are most often excluded from participating in such
    programs. Many programs in the Health and Human Services appropriations
    bills include language for Indian Tribes and Tribal organizations, but
    not for urban Indian organizations. Urban Indian Organizations are not
    considered Tribal organizations, which is a common misconception.
    Therefore, UIOs must be explicitly included to receive funding. UIOs
    also do not have access to other IHS line items like IHS and Tribal
    facilities and do not receive hospitals and health clinics money,
    purchase and referred care dollars, or IHS dental services dollars, and
    are not eligible for the IHS facilities fund.
        As one advocate stated, ``The language everywhere has to include
    the word 'urban'--urban Indian or urban Native. They have to say it,
    they have to write it and then it'll reach a critical mass, eventually.
    Because they don't get it, you know. We're just invisible.'' \2\
    ---------------------------------------------------------------------------
        \2\ https://www.usatoday.com/story/news/politics/2022/03/07/
    opioids-native-americans-funding/9380063002/?gnt-cfr=1.
    ---------------------------------------------------------------------------
    Include UIOs in Critical Opioid Grants
        UIOs have repeatedly been left out of funding designed to help AI/
    AN communities address the opioid crisis. To address the opioid
    overdose epidemic in Indian Country by increasing access to culturally
    appropriate and evidence-based treatment, Congress provided funding for
    Tribal Opioid Response grants. NCUIH has long advocated for UIOs to be
    added to the Substance Abuse and Mental Health Services
    Administration's (SAMHSA) State Opioid Response (SOR) grants given the
    extent of the impact of the opioid epidemic on all AI/ANs regardless of
    residence. Since FY 2018, Congress has enacted set asides in opioid
    response grants to help Native communities address this crisis.
    However, it was only available for Tribes and Tribal organizations,
    meaning UIOs working against the same problem are left without the
    resources necessary to reach the highest health status for all AI/ANs
    as required of the Federal Government. This is a failure of equity.
    Without the necessary funding to address health crises in Indian
    Country, urban AI/AN people will again be left out of the equation.
        Last Spring, Congress introduced the State Opioid Response Grant
    Authorization Act of 2021 (H.R. 2379), which included a 5 percent set-
    aside of the funds made available for each fiscal year for Indian
    Tribes, Tribal organizations, and UIOs to address substance abuse
    disorders through public health-related activities such as implementing
    prevention activities, establishing or improving prescription drug
    monitoring programs, training for health care practitioners, supporting
    access to health care services, recovery support services, and other
    activities related to addressing substance use disorders. NCUIH worked
    closely with Congressional leaders to ensure the inclusion of urban
    Indians in the funding set-aside outlined in this bill, which
    eventually passed the House on October 20, 2021. Despite this effort,
    UIOs were removed from the SOR Grant reauthorization, which saw a $5
    million increase (9 percent increase from FY 2021), included in the
    recently passed FY 2022 Omnibus (H.R. 2471). The final language in the
    Omnibus only listed ``Indian Tribes or Tribal organizations'' as
    eligible and did not use the language from H.R. 2379. When UIOs are not
    explicitly stated as eligible entities, we are excluded from critical
    resources and grants, which is a violation of the trust obligation.
        We were disappointed to yet again be left out of this key resource
    as our communities are plagued by the opioid crisis. Inclusion in this
    program could have enabled UIOs to expand services or workforce or to
    help address the catastrophic impacts of the opioid epidemic in Indian
    Country. We urge you to work to ensure funding designated to help AI/AN
    communities have the proper language to prevent UIOs from lacking
    access to these critical funds.
    Conclusion
        These requests are essential to ensure that urban Indians are
    properly cared for, both during this crisis and in the critical times
    following. It is the obligation of the United States government to
    provide these resources for AI/AN people residing in urban areas. This
    obligation does not disappear in the midst of a pandemic, instead it
    should be strengthened, as the need in Indian Country is greater than
    ever. We urge Congress to take this obligation seriously and provide
    UIOs with all the resources necessary to protect the lives of the
    entirety of the AI/AN population, regardless of where they live.
                                     ______

             Prepared Statement of the National Eczema Association
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least $49
            billion in funding, a $3.5 billion increase over FY 2022.
        --Provide proportional funding increases for the individual NIH
                institutes and centers that manage the eczema portfolio,
                most notably the National Institute of Allergy and
                Infectious Diseases (NIAID) and the National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS).
        --Provide additional, distinct funding for the emerging Advanced
                Research Projects Agency for Health (ARPA-H) at NIH, which
                would facilitate implementation of this important program
                without supplanting ongoing NIH research activities.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            $11 billion in funding, an increase of $2.55 billion over FY
            2022.
        --Provide $6 million in funding for the Chronic Disease Education
                and Awareness Program at CDC, an increase of $3 million
                over FY 2022.
    _______________________________________________________________________

        Thank you for the opportunity to present testimony on behalf of the
    National Eczema Association (NEA) and to share the experiences of the
    eczema community. Chairwoman Murray, Ranking Member Blunt, and
    distinguished members of the subcommittee, thank you for continuing to
    invest in medical research and public health programs through the FY
    2022 omnibus appropriations package. Recent years of funding increases
    have led to notable advances in eczema research and new opportunities
    for meaningful public health collaborations. As you work with your
    colleagues on FY 2023 appropriations, please maintain the commitment to
    increase funding for medical research and public health programs that
    serve eczema patients and raise awareness of the wide-ranging impacts
    on affected individuals and their families.
                     about the national eczema association
        The National Eczema Association is the largest patient advocacy
    organization dedicated solely to all forms of eczema, including atopic
    dermatitis (AD), the most common and chronic form of eczema. NEA
    represents the voice of over 31 million affected American adults,
    children, and their families, and is the driving force for an eczema
    community fueled by knowledge, strengthened through collective action
    and propelled by the promise for a better future.
                       about eczema and atopic dermatitis
        Eczema is the name for a group of conditions that cause the skin to
    become itchy, inflamed, and have a rash-like appearance. Atopic
    dermatitis (AD) is the most common type of eczema, affecting more than
    9.6 million children \1\ and about 16.5 million adults \2\ of all races
    and ethnicities \3\ in the United States. We are entering a new era of
    care for eczema patients with several n FDA-approved groundbreaking
    therapies for AD that have the potential to be transformative in their
    ability to ease the numerous physical, psychological, and quality of
    life burdens of eczema.\4,5,6\
    ---------------------------------------------------------------------------
        \1\ Shaw TE, Currie GP, Koudelka CW, Simpson EL. Eczema prevalence
    in the United States: data from the 2003 National Survey of Children's
    Health. J Invest Dermatol. 2011;131(1):67-73.
        \2\ Chiesa Fuxench ZC, Block JK, Boguniewicz M, et al. Atopic
    Dermatitis in America Study: A Cross-Sectional Study Examining the
    Prevalence and Disease Burden of Atopic Dermatitis in the US Adult
    Population. J Invest Dermatol. 2019;139(3):583-590.
        \3\ Hanifin JM, Reed ML, Eczema Prevalence and Impact Working
    Group. A population-based survey of eczema prevalence in the United
    States. Dermatitis. 2007;18(2):82-91.
        \4\ Drucker AM, Wang AR, Li WQ et al. The burden of Atopic
    Dermatitis: Summary of a report for the National Eczema Association. J
    Invest Dermatol. 2017;137(1):26-30.
        \5\ Chiesa Fuxench ZC, Block, JK, Boguniewicz M, et al. Atopic
    dermatitis in America study: A cross-sectional study examining the
    prevalence and disease burden of atopic dermatitis in the US adult
    population. J Invest Dermatol.2019;139(3):583-590.
        \6\ Silverberg J, Gelfand J, Margolis D et al. Patient burden and
    quality of life in atopic dermatitis in US adults. Ann Allergy Asthma
    Immunol. 2018;121(3):340-347.
    ---------------------------------------------------------------------------
        Research in this area is largely led by the National Institutes of
    Health (NIH) through the National Institute on Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS) and the National Institute of
    Allergy and Infectious Diseases (NIAID). Much more basic,
    translational, and clinical research is needed to further the
    scientific understanding of all forms of eczema, as recent
    breakthroughs have led to the advent of potential drug and biologic
    therapies for atopic dermatitis. However, despite life-changing
    therapeutic advances, these novel treatment options are presenting
    emerging coverage, access, and out-of-pocket cost barriers for the
    diverse community. Public health activities are also relatively modest
    with meaningful opportunities for enhanced surveillance, public
    awareness, and healthcare provider education.
                                  quick facts
      --31 million people in America are living with eczema.\7,8\
    ---------------------------------------------------------------------------
        \7\ Hanifin JM, Reed ML, Eczema Prevalence and Impact Working
    Group. A population-based survey of eczema prevalence in the United
    States. Dermatitis. 2007;18(2):82-91.
        \8\ Silverberg JI, Hanifin JM. Adult eczema prevalence and
    associations with asthma and other health and demographic factors: a US
    population-based study. J Allergy Clin Immunol. 203;132(5)1132-1138.
    ---------------------------------------------------------------------------
      --The annual economic burden of AD (AD) is estimated to be over $5
            billion.\9\
    ---------------------------------------------------------------------------
        \9\ Drucker AM, Wang AR, Li WQ, Sevetson E, Block JK, Qureshi AA.
    The Burden of Atopic Dermatitis: Summary of a Report for the National
    Eczema Association. J Invest Dermatol. 2017;137(1)26-30.
    ---------------------------------------------------------------------------
      --55 percent of affected adults with AD currently report inadequate
            disease control.\10,11\
    ---------------------------------------------------------------------------
        \10\ Simpson EL, Guttman-Yassky E, Margolis DJ, et al. Association
    of Inadequately Controlled Disease and Disease Severity With Patient-
    Reported Disease Burden in Adults with Atopic Dermatitis. JAMA
    Dermatol. 2018;154(8):903-912..
        \11\ Wei W, Anderson P, Gadkari A, et al. Extent and consequences
    of inadequate disease control among adults with a history of moderate
    to severe atopic dermatitis. J Dermatol. 2018;45(2):150-157.
    ---------------------------------------------------------------------------
                                  nih research
        Ongoing congressional support for NIH has allowed for growth of the
    NIH annual budget to $42.9 billion in FY 2021 from $34.1 billion in
    FY2017. As a result of additional resources and high-quality
    investigator-initiated research proposals, the eczema research
    portfolio has grown from $32 million in FY 2017 to $46 million in FY
    2021. While the eczema portfolio is increasing, so are research costs,
    and this current funding translates to approximately $1.42 in annual
    research funding per American affected by eczema. More can be done as
    gaps in our basic understanding of eczema remain and patients continue
    to have limited treatment options. With additional NIH support, more
    ambitious projects can be initiated, including timely translational
    research and larger clinical studies.
                           cdc public health efforts
        The CDC budget's growth has been modest in recent years and as such
    the National Center for Chronic Disease Prevention and Health Promotion
    has been working in several priority areas with limited resources.
    Presently, and despite a significant U.S. disease prevalence, there are
    few public health efforts taking place in eczema. Additional public
    awareness, professional education, and related efforts would be of
    tremendous benefit to the eczema patient, caregiver and health care
    provider communities. The Chronic Disease Education and Awareness
    (CDEA) program provides an opportunity to infuse identified disease
    areas with additional needed resources and is currently supporting four
    novel projects through its first round of funding. Increasing CDEA
    funding to $6 million for FY 2023 will facilitate growth in the program
    while providing another opportunity to submit for projects in disease
    areas, such as eczema, not yet supported by the CDEA program or broader
    CDC efforts.
                                patient stories
    Akilah from Pennsylvania: NEA Ambassador and parent of a teenager
            living with eczema
        Akilah is one of NEA's Ambassadors and she is the parent of a
    teenager living with eczema. Her son has severe eczema and was
    diagnosed at a young age. As a parent, Akilah worked closely with her
    son's doctor to try and find a treatment that would work for him. This
    resulted in trying and failing a variety of treatments. Finally, they
    learned that a biologic was available but due to step therapy Akilah's
    son would have to try and fail methotrexate, which has a plethora of
    severe side effects and could damage internal organs. Akilah made the
    tough decision to say no to this treatment option and had a frank
    conversation with the doctor. Would you put your own child on this drug
    when there is a safer treatment available? She feels strongly that
    parents shouldn't have to have this conversation and they shouldn't
    have to battle with insurance companies to get the right treatment at
    the right time for their child. Her doctor helped her find a clinical
    trial for her son--and he has since been prescribed the biologic. She
    is a strong believer in research and that more treatment options need
    to be approved in the eczema space, especially in patients of color.
    Christy from Utah: NEA Ambassador and a patient with atopic dermatitis
        Christy is one of NEA's Ambassadors and she has atopic dermatitis.
    She feels lucky to have had a great relationship with her dermatologist
    for the past 10 years. During this time, she has tried and failed a
    variety of treatments--until she finally found a treatment that worked
    for her. Unfortunately, when she switched jobs, she had a new insurance
    company that mandated step therapy. She was then forced to fail on
    medications that she's tried before. This made zero sense, both to her
    health and to her pocketbook, to have to try medications that were
    already documented as failure. Ultimately, she was able to get back on
    the right medication, but it took perseverance from her dermatologist
    as well as being her own advocate.

        [This statement was submitted by Julie Block, President & CEO,
    National
    Eczema Association.]
                                     ______

       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) 2023 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, including
    proposing a historic $500 million for Title X in the FY 2022 bill, and
    urge you to take at least this substantial step forward in this year's
    bill.
        NFPRHA is a non-partisan, non-profit membership association that
    supports the work of family planning providers and administrators,
    especially in the safety net. NFPRHA membership includes more than
    1,000 entities 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. As a leading expert
    in publicly funded family planning, NFPRHA conducts and participates in
    research; provides subject matter expertise to policymakers, health
    care providers, and the public; and offers its members capacity-
    building support aimed at maximizing their effectiveness and financial
    sustainability as providers of essential health care. Currently, more
    than 80 percent of all Title X grantees are NFPRHA members.
        Title X is the only Federal program dedicated to providing family
    planning services for people with low incomes. Title X-funded health
    centers are lifelines in their communities, providing high-quality
    reproductive and sexual health care, including cancer screenings,
    testing and treatment for sexually transmitted infections,
    contraceptive services and supplies, pregnancy testing, and other
    essential health care services. These centers offer care to people who
    often face severe structural barriers to accessing quality health care,
    such as people with low incomes, people who are un- or under-insured,
    people of color, people who live and work in rural areas, and LGBTQ
    people. Prior to the implementation of the Trump administration's
    devastating program rules in 2019, nearly 4,000 health centers in the
    Title X network served close to 4 million patients annually.\1\ In
    addition, six in 10 women who used Title X-funded health centers in
    2016 said that provider was their only source of health care for the
    entire year.\2\
    ---------------------------------------------------------------------------
        \1\ Christina Fowler et al, ``Family Planning Annual Report: 2018
    National Summary,'' RTI International (August 2019). https://
    opa.hhs.gov/sites/default/files/2020-07/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).
    ---------------------------------------------------------------------------
        For FY 2022, Title X is funded at $286.5 million, well below the
    $500 million proposed in the Senate bill and the $737 million 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.\3\ We
    respectfully request that the Senate match that federally recommended
    level of funding, $737 million, for the Title X program in FY23. That
    funding level would allow the program to rebuild from crises
    experienced in recent years and expand to reach millions more
    Americans. We also note that this recommendation, based on the number
    of women in need, is a significant under-estimate of the true need, as
    the program now serves more than 100,000 men and nonbinary individuals
    each year.
    ---------------------------------------------------------------------------
        \3\ 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.
    ---------------------------------------------------------------------------
        An influx of funds is particularly important given the continued
    impacts that recovery from the Trump administration's 2019 program rule
    and the COVID-19 pandemic are having on the program, the providers
    funded by it, and most importantly the patients for whom Title X sites
    serve as critical, and sometimes their only, points of access to care.
    On July 15, 2019, the Trump administration's new 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, including all of the health centers in six States.
    Then, in March 2020, family planning providers, like all frontline
    health care workers, needed to adapt overnight to the realities of
    serving under-resourced communities during a global pandemic.
        In September 2021, OPA released the first Federal data showing the
    impact of the rule and COVID-19, and the results were devastating:
    relative to 2018, Title X-funded health centers provided family
    planning services to 2.4 million fewer patients in 2020, a staggering
    61 percent decrease over just 2 years. This drastic decrease translated
    to millions of fewer contraceptive services provided, more than 4.3
    million fewer STI and HIV tests administered, and more than 800,000
    fewer lifesaving breast and cervical cancer screenings performed with
    Title X funds. OPA attributed 63 percent of the decrease in patients
    served to the 2019 rule and 37 percent to the pandemic.\4\ Compounding
    these challenges in accessing Title X-funded services, a 2020 study
    showed the COVID-19 pandemic 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.\5\ Women of color and women with low incomes were more
    likely to report both findings.
    ---------------------------------------------------------------------------
        \4\ Christina Fowler, Julia Gable, and Beth Lasater, ``Family
    Planning Annual Report: 2020 National Summary,'' RTI International
    (September 2021). https://opa.hhs.gov/sites/default/files/2021-09/
    title-x-fpar-2020-national-summary-sep-2021.pdf.
        \5\ 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/earlyimpacts-covid-19-pandemic-findings-2020-
    guttmacher-survey-reproductive-health.
    ---------------------------------------------------------------------------
        The Biden-Harris administration has made significant progress
    toward restoring the Title X program, including finalizing a new rule
    in October 2021,\6\ distributing $6.6 million in Title X funds to
    communities with a dire need for family planning services in January
    2022,\7\ and distributing $256.6 million for Title X projects across
    the country just last month.\8\ However, the administration was unable
    to fund many qualified applicants, and under-funded dozens more, due to
    insufficient funds. While a small number of past grantees received
    additional funds in May 2022, it is clear that current funding of
    $286.5 million annually is simply insufficient to meet the needs of
    providers and patients across the country. Without additional funds,
    grantees and subrecipients are at significant risk of reducing service
    availability, laying off frontline health care workers, and even
    closing health centers.
    ---------------------------------------------------------------------------
        \6\ HHS Press Office, ``HHS Issues Final Regulation Aimed at
    Ensuring Access to Equitable, Affordable, Client-Centered, Quality
    Family Planning Services,'' US Department of Health and Human Services
    (October 4, 2021). https://www.hhs.gov/about/news/2021/10/04/hhs-
    issues-final-regulation-aimed-at-ensuring-access-to-equitable-
    affordable-client-centered-quality-family-planning-services.html.
        \7\ ASH Media, ``HHS Awards $6.6 Million to Address Increased Need
    for Title X Family Planning Services,'' US Department of Health and
    Human Services (January 21, 2022). https://www.hhs.gov/about/news/2022/
    01/21/hhs-awards-6.6-million-address-increased-need-for-title-x-family-
    planning-services.html.
        \8\ ASH Media, ``HHS Awards $256.6 Million to Expand and Restore
    Access to Equitable and Affordable Title X Family Planning Services
    Nationwide,'' US Department of Health and Human Services (March 30,
    2022). https://www.hhs.gov/about/news/2022/03/30/hhs-awards-256-
    million-to-expand-restore-access-to-equitable-affordable-title-x-
    family-planning-services-nationwide.html.
    ---------------------------------------------------------------------------
        With a significant increase in funds in FY23, OPA can make real
    progress toward rebuilding the Title X program and serving more people
    in need of these critical services. We thank you for your consideration
    of this request and look forward to working with you throughout the
    FY23 appropriations process. If you have questions about this request,
    please contact Lauren Weiss, Director, Policy & Communications, at
    lweiss@nfphra.org.
        Sincerely,
        Clare Coleman
                                     ______

    Prepared Statement of the National Institute of Diabetes and Digestive
                              and Kidney Diseases
        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 $49 billion for
    the National Institutes of Health base budget in Fiscal Year (FY) 2023,
    an increase of 7.9% that will provide real growth above biomedical
    research inflation, 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. As Congress considers authorizing
    and providing additional appropriations for the Advanced Research
    Projects Agency for Health (ARPA-H), our request will ensure that
    funding for the new entity will supplement, not supplant, those funds
    provided to NIH to support much needed basic research and training
    programs in kidney disease.
        In addition, our organizations request that the committee include
    report language in the Labor, Health and Human Services, and Related
    Agencies (LHHS) appropriations bill to support achieving kidney health
    equity and a strong kidney health workforce. We request that Congress
    address kidney health equity by allocating resources at NIDDK to study
    improved methods for diagnosing kidney diseases that do not rely on
    race-based variables. Further, we request that Congress ensure there is
    a physician-scientist workforce ready to meet the current and future
    needs of people with kidney diseases by making certain new training
    programs, such as the Division of Kidney, Urologic, and Hematologic
    Diseases (KUH) U2C grant mechanism, increase the number of training
    slots for adult and pediatric physician-scientists. Greater investment
    in kidney research is needed to advance the 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 these conditions.
        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
    and has a survival rate worse than most cancers (and comparable with
    brain cancers). While a kidney transplant is the optimal therapy for
    most patients, it is often inaccessible due to a shortage of organs and
    inequities in our Nation's transplant health system. Both dialysis and
    transplant patients are immune compromised, which puts them at
    increased risk of communicable diseases--especially COVID-19.
    Devastatingly, COVID-19 has caused a 20% increase in mortality among
    people receiving dialysis, the first-ever decrease of people enrolled
    in the Medicare ESRD program. 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.
        Almost 50 years ago, Congress made a commitment to treat all
    Americans with irreversible kidney failure, regardless of age, through
    the Medicare End-Stage Renal Disease (ESRD) Program. Medicare annually
    spends approximately $125 billion on the care of people with kidney
    diseases, or 24% of all Medicare fee-for-service spending. Of this
    amount, $37 billion, or 7% of Medicare fee-for-service spending, is
    spent managing kidney failure. These costs do not include expenditures
    from Medicare Advantage or non-Medicare plans, which together cover 62%
    of people with kidney failure. 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.
        Even as Congress has provided steady increases for the NIH over the
    past decade, NIH funding for kidney disease research has lagged far
    behind that of NIH overall; between fiscal years 2015 and 2020, funding
    for NIH rose 37%, compared to just 19% for kidney research.
    Additionally, no dedicated funding has been provided to NIDDK to study
    the impact of COVID-19 on kidney health despite the severe impact of
    COVID-19 on people with kidney diseases. As a result, research of this
    critical topic has come at the expense of existing, and underfunded,
    research opportunities. Increased investment in kidney health research
    will improve outcomes for people living with kidney diseases and reduce
    costs to the US health care system. As Congress considers establishing
    new programs to fund science and innovation such as ARPA-H, our
    organizations request that the committee maintain and increase
    investment in kidney disease research by providing a $49 billion
    increase for NIH in FY 2023 with an at least proportional increase for
    NIDDK.
              improving equity in the diagnosis of kidney diseases
        People with kidney diseases face stark racial and socioeconomic
    disparities in disease burden and access to care. For instance, Black
    Americans and Hispanic Americans are more than four and two times as
    likely than White Americans respectively to have kidney failure.
    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.
        One factor contributing to disparities in access to care--
    especially transplantation--is the inclusion of race as a variable in
    the diagnosis of kidney diseases. Kidney function is commonly assessed
    using an equation to estimate glomerular filtration rate (GFR). In
    2021, ASN and NKF finalized a recommendation to remove a patient's race
    as a variable in equations to estimate GFR. Our organizations request
    the committee consider including report language in the FY 2023 LHHS
    appropriations bill directing NIDDK to prioritize research on new
    approaches for estimating GFR that do not include race as a modifier,
    such as the below:

          ``Improving the Diagnosis of Kidney Diseases.--The Committee
            understands that current equations for assessing glomerular
            filtration rate (GFR), a key measure of kidney function,
            include the patient's race, and that this practice may lead to
            disparities for African Americans in terms of access to care
            and kidney transplantation. NIDDK should prioritize research on
            new approaches for estimating GFR that do not include race as a
            modifier.''
                   enabling a strong kidney health workforce
        Most people with kidney diseases experience comorbidities such as
    cardiovascular disease (including heart attack and stroke), anemia,
    bone disease, hypertension, and diabetes, and face increased risk from
    communicable diseases, including COVID-19 which has increased
    hospitalization and mortality among this vulnerable population.
    Pediatric kidney disease patients are often more complex than adult
    patients, many are living with rare medical conditions with unique
    needs which must be better understood. A strong, demographically
    representative, and culturally competent workforce of physician-
    scientists is needed to meet the needs of adults and children living
    with kidney diseases, especially while they face deadly consequences of
    the COVID-19 pandemic in their daily lives. Our organizations request
    that the committee ensure NIDDK is providing adequate support for
    training the next generation of kidney health scientists by requesting
    NIDDK to report the number of adult and pediatric training positions
    funded by the newly established U2C grant mechanism compared to prior
    mechanisms. Draft report language to support this request is provided
    below:

          Kidney, Urologic, and Hematologic Research Training Awards.--The
            Committee understands that NIDDK's Division of Kidney,
            Urologic, and Hematologic Diseases replaced its T32 training
            grant mechanism, which provided grant support to institutions
            whose programs promote diversity and offer doctoral degrees in
            the health professions or health-related sciences in these
            three disciplines, with a new U2C grant mechanism, which
            requires institutions to submit a single application to receive
            training slots in all three research areas. The T32 program
            maintained a strong record of success in training new members
            of the biomedical research workforce in nephrology, urology,
            and hematology, including future pediatric researchers. With
            this in mind, the Committee is concerned that the new U2C
            mechanism may lead to a reduction in training slots for adult
            and pediatric researchers in these three disciplines. The
            Committee requests the Institute provide a comparison of
            training positions, adult and pediatric, funded by discipline
            under the T32 mechanism in 2018-19 to the number of slots
            currently funded and projected to be funded in the next 3 years
            under the U2C mechanism within 120 days of enactment.
        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 kidney
    diseases and its progression in adults and children, combined with
    improved methods for detecting kidney diseases and a highly skilled
    workforce of physician-scientists, may even prevent irreversible kidney
    failure in the future.
        Thank you again for your leadership, and for your consideration of
    our request. Should you have any questions or wish to discuss kidney
    disease research in more detail, please contact Erika Miller with the
    American Society of Pediatric Nephrology at emiller@dc-crd.com; Zach
    Kribs with the American Society of Nephrology at zkribs@asn-online.org;
    or Lauren Drew with the National Kidney Foundation (NKF) at
    lauren.drew@kidney.org.
                    about the american society of nephrology
        Since 1966, ASN has been leading the fight to prevent, treat, and
    cure kidney diseases throughout the world by educating health
    professionals and scientists, advancing research and innovation,
    communicating new knowledge, and advocating for the highest quality
    care for patients. ASN has more than 20,000 members representing 132
    countries. For more information, visit www.asn-online.org and follow us
    on Facebook, Twitter, LinkedIn, and Instagram.
               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 Zach Kribs, Senior Government
    Affairs
    Specialist, American Society of Nephrology.]
                                     ______

     Prepared Statement of the National Institute of Environmental Health
                                    Sciences
        The Friends of the NIEHS are pleased to submit the following
    testimony regarding Fiscal Year (FY) 2023 Federal appropriations for
    the Labor, Health and Human Services, Education, and Related Agencies
    in support of the vital work being carried out by the NIH/NIEHS as a
    result of the annual appropriation provided for this work in the
    subcommittee's bill. We ask you to provide at least $909 million for
    NIEHS in FY 2023 as part of an overall appropriation for NIH of $49.048
    billion not inclusive of other funds for the Advanced Research Projects
    Agency for Health (ARPA-H) or pandemic preparedness. We further request
    additional funding of at least $100 million for NIEHS to lead research
    efforts on climate change and health, in partnership with other
    Institutes and Centers at NIH, to a total funding level of at least
    $1.01 billion.
        Our coalition of organizations represents a variety of interests,
    including medical and scientific professional societies, environment
    and public health focused organizations, children's health advocates,
    women's health advocates, and many others. Collectively, our community
    supports and calls attention to the vital work being done by the
    National Institute of Environmental Health Sciences. NIEHS, one of the
    component institutes and centers of the National Institutes of Health
    (NIH), focuses on the prevention of health problems and diseases with
    special emphasis on the intimate interactions between our bodies and
    the environments where we live, work, and play over our lifetimes.
        niehs plays a unique role in advancing public health priorities
        The NIEHS plays a unique role within the NIH; it 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, Parkinson's disease, autoimmune diseases, chemical intolerance
    or toxicant-induced loss of tolerance, and chemical sensitivities.
    Expert research funded by NIEHS addresses diseases across all the NIH
    Institutes and Centers and identifies environmental contributors to
    health disparities. Specific research areas with projects that address
    national priorities include:
        Climate Change and Health: NIEHS-funded scientists are poised to
    make major discoveries that will help us appreciate and address the
    ongoing impacts of climate change on public health. However, additional
    funds are needed for NIEHS to maximize the potential for biomedical
    research to meet the public health needs driven by climate change.
    Additional research is necessary to design and tailor interventions
    that will reduce the impact of climate change on the incidence and
    severity of disease, in particular for disadvantaged communities that
    may not have resources to mitigate the effects of climate change. We
    strongly support additional appropriated funds for NIEHS so that NIEHS
    can work with all the Institutes and Centers at NIH to develop
    solutions that build on existing knowledge and promote
    transdisciplinary collaborations to meet the needs of communities
    affected by climate change.
        Breast Cancer and Health Disparities: NIEHS-funded studies have
    been instrumental in advancing our new knowledge about the causes of
    cancer, including the discovery of the first breast cancer
    susceptibility gene. In 2019, the NIEHS Sister Study, a national cohort
    of over 50,000 women, found that women who use chemical hair dye and
    chemical hair straighteners have an increased risk of breast cancer,
    particularly black women. The study results suggest that chemicals in
    hair products may play a role in breast carcinogensis.
        Maternal and Children's Health and Environmental Exposures: NIEHS-
    funded research also helps us understand how and why pregnant women and
    children are uniquely vulnerable to harmful substances in their
    environment. Today's pediatric health challenges include chronic
    conditions such as obesity, asthma and neurodevelopmental disorders
    including learning disabilities and the impacts of COVID-19.
    Increasingly, in utero and early childhood exposures are correlated
    with life-long consequences including whether such exposures increase
    child and adolescent susceptibility to future illness and learning
    challenges. NIEHS research is critical, since children have unique
    susceptibility to toxicants due to their ongoing development and face
    higher rates of exposure to contaminants than adults by virtue of their
    size and developmentally-appropriate behaviors. Importantly, NIEHS
    helps us identify and act on risks to children's health. A recent
    NIEHS-funded study found fewer new asthma cases and an up to 20 percent
    lower rate of asthma after air quality improvements, including
    reductions in nitrogen dioxide and PM2.5, were made.
        Pandemic and Disaster Preparedness: Researchers funded by NIEHS
    have highly relevant expertise that has enhanced our response to COVID-
    19 and prepared us for future pandemics, for example by identifying
    interventions to protect health care workers facing occupational
    exposure to SARS-CoV-2 and how environmental exposures such as air
    pollution impact individual susceptibility to infection and severity of
    disease. NIEHS can also positively impact our response to and recovery
    from natural disasters and climate change. For example, the Disaster
    Research Response Resources Portal (DR2) and Climate Change and Human
    Health Literature Portal provide researchers and the public with
    resources and tools to design studies in partnership with communities
    and rapidly translate research results into actionable interventions.
        Endocrine Disrupting Chemicals: NIEHS-funded research teams have
    led the way in advancing our understanding of how chemicals that
    interfere with the normal function of hormones and endocrine systems,
    also known as endocrine-disrupting chemicals (EDCs) can cause adverse
    health effects. New scientific knowledge on EDCs has established that
    these chemicals may have nontraditional dose response curves,
    developmental effects with long-term consequences, and unique effects
    at low doses due to the sensitive nature of the endocrine system. The
    decades of scientific contributions of NIEHS to this field resulted in
    a 2019 paper identifying key characteristics of EDCs.
          increased funding for nih and niehs is necessary in fy 2023
        In conclusion, to ensure that NIEHS-funded researchers are able to
    continue to advance research in support of the Nation's public health
    priorities, the Friends of NIEHS recommend that the subcommittee
    provide at least $909 million for NIEHS in FY 2023 as part of an
    overall appropriation for NIH of $49.048 billion in the FY 2023 Labor,
    Health and Human Services, Education, and Related Agencies
    appropriations bill. Further, the subcommittee should provide an
    additional $100 million for NIEHS to support necessary research on
    climate change and public health to a total level of $1.01 billion.
    Finally, we request that any funding for the new Advanced Research
    Projects Agency for Health (ARPA-H) agency complement this funding
    recommendation for NIH's base budget, rather than supplant the
    essential investment in the NIH, to ensure that NIH can continue to
    support and grow the investigator-initiated research programs that have
    provided the foundation for our collective successes in biomedical
    research.

        [This statement was submitted by Joseph Laakso, Director of Science
    Policy,
    Endocrine Society.]
                                     ______

           Prepared Statement 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 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 (SUDs). 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 SUD field.
        In the Fiscal Year 2023 Labor, Health and Human Services
    Appropriations bill, CPDD joins with the Ad Hoc Group for Medical
    Research in recommending a program level of at least $49.048 billion
    for the base budget of the National Institutes of Health (NIH), which
    would represent an increase of $4.1 billion over the comparable Fiscal
    2022 funding level. For the National Institute on Drug Abuse (NIDA),
    CPDD encourages the Committee to provide at least the President's
    recommended funding level of $1.843 billion for NIDA, which would
    represent an increase of $248 million over the comparable Fiscal 2022
    funding level for the Institute.
        CPDD also supports the proposal included in the President's Fiscal
    Year 2023 budget to change the name of the National Institute on Drug
    Abuse to the National Institute on Drugs and Addiction.
        We also respectfully request the inclusion of the following NIDA
    specific report language.

        Opioid Initiative. The Committee continues to be concerned about
            the high mortality rate due to the opioid 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 provisional data from the
            Centers for Disease Control and Prevention that shows opioid
            overdose fatalities were predicted to exceed 100,000 in the 12-
            month period ending in June 2021, with the primary driver being
            the increased overdose deaths involving synthetic opioids,
            primarily illicitly manufactured fentanyls. More research is
            needed to find new and better agents to prevent or reverse the
            effects caused by this class of chemicals and to provide
            improved access to treatments for those addicted to these
            drugs. To combat this crisis the Committee has provided within
            NIDA's budget no less than $405,400,000 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 provisional data released by the Centers for
            Disease Control and Prevention, over 45,000 overdose deaths
            involved drugs in the categories that include methamphetamine
            and cocaine in the 12-month period ending in June 2021, an
            increase of 25 percent in a single year. 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. No FDA-approved
            medications are available for treating 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
            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, and were
            predicted to exceed 100,000 in the 12-month period ending in
            June 2021, 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 continue to support
            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.

        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 and follow them and their children up to age 10
            to characterize the influence of a variety of factors on
            neurodevelopment and long-term outcomes. The study aims to
            enroll approximately 7,500 women from 25 sites across the US,
            including regions of the country significantly affected by the
            opioid crisis. Participants will include women from the general
            population of pregnant women to assess normative development;
            those who have or are using opioids and/or other substances
            during their pregnancy; and women from comparable environments
            to the latter, but who have not used substances during their
            pregnancy. 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 illicit substance use, 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 additional NIH
            support for this important study.

        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. NIH 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.

        Substance use disorders 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 disorder -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 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 treated effectively and compassionately.
        We understand that the FY 2023 budget cycle will involve setting
    priorities and accepting compromise, however, in the current climate we
    believe a focus on SUDs deserves to be prioritized accordingly. Thank
    you for your support for the National Institute on Drug Abuse.
                                     ______

              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,
    society, 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 an increase for kidney
    research activities under the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) that is at least proportional to
    the funding increase for NIH overall. We also request that
    appropriations for the Advanced Research Projects Agency for Health
    (ARPA-H) be in addition to a robust increase for NIH. Lastly, we urge
    greater collaboration between NIDDK and other Institutes studying
    related comorbidities and conditions that occur in kidney patients,
    such as hypertension, cardiovascular disease, immunology, disparities,
    and genomics.
                                   about ckd
        Chronic kidney disease impacts an estimated 37 million American
    adults and is the Nation's 10th leading cause of death, and 1 in 3
    Americans are at risk of developing it. Although it is detectable
    through simple blood and urine tests, an estimated 90 percent of
    patients are undiagnosed, often until advanced stages when it is too
    late for interventions to slow disease progression (up to 40 percent of
    people with advanced kidney disease have not seen a nephrologist prior
    to progressing to kidney failure). Alarmingly, some patients are not
    diagnosed until they have progressed to irreversible kidney failure
    (end stage kidney failure, or ESKD) and must undergo urgent start
    dialysis. Nearly 800,000 Americans have ESKD, requiring kidney dialysis
    at least 3 times per week at a dialysis center, daily home dialysis, or
    a kidney transplant to survive. The 5-year survival rate for a dialysis
    patient is only 35 percent. The mortality rate for dialysis patients
    aged 66-74 is twice that of heart failure and 2.5 times that of cancer.
        Medicare spends an estimated $153 billion annually (fee-for-service
    and Medicare Advantage combined), nearly 25 percent of Medicare
    expenditures, on the care of people with a kidney disease diagnosis.
    Individuals with ESKD represent 1 percent of Medicare beneficiaries but
    comprise 7 percent of Medicare fee-for-service expenditures. The need
    for an increased Federal commitment to address the societal and
    economic burdens of CKD is undeniable.
        CKD is a disease multiplier, with patients often experiencing
    cardiovascular disease, bone disease, anemia and fatigue, and increased
    hospitalization. Quality of life is impacted by cognitive challenges,
    depression, infection, dietary restrictions, and other factors. 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 stark racial, ethnic, and socioeconomic
    disparities. Blacks/African Americans, Hispanics/Latinos, Asian
    Americans and Pacific Islanders, and Native Americans and Alaska
    Natives are at higher risk for CKD and ESKD. Blacks/African Americans
    make up 13 percent of the U.S. population, but account for 35 percent
    of Americans with kidney failure. Kidney failure among Blacks/African
    Americans and Hispanics/Latinos are 4 times and 1.3 times more likely
    compared to Whites, respectively. Blacks/African Americans and
    Hispanics/Latinos 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. Blacks/African Americans and Hispanic/
    Latinos have less access to the kidney wait list, experience a longer
    wait once listed, and are less likely to receive a transplant from a
    living donor compared to Whites. The prevalent kidney transplant
    population with a functioning graft is 52 percent White, 20 percent
    Blacks/African Americans, and 16 percent Hispanics/Latinos. Among
    patients waitlisted in 2014, the median wait time for a transplant was
    37 months for Whites, 64 months for Blacks/African Americans, and 57
    months for Hispanics/Latinos.
                                    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. This 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. COVID-19
    hospitalizations in April 2021 were 8,617 per 100,000 Medicare ESKD
    beneficiaries, compared to 1,932 per 100,000 Medicare beneficiaries
    overall. Transplant recipients in particular face higher COVID-19
    mortality risk. In addition, patients with 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.
                     cdc chronic kidney disease initiative
        The CDC Chronic Kidney Disease Initiative comprehensive public
    health strategy was created at the urging of Congress and NKF more than
    15 years ago. Annual funding fluctuated between $1.6 million and $2.6
    million until Congress provided $3.5 million for FY 2022, for which we
    are most appreciative. The CKD Initiative supports a web site,
    surveillance and epidemiology activities, and assistance to the
    National Center for Health Statistics for CKD data collection. However,
    in order to address the roughly 90 percent of patients who are unaware
    they have CKD, and the 40 percent who receive no kidney-specific care
    before crashing into dialysis in full kidney failure, we must improve
    awareness of CKD among the public and health care practitioners to
    improve early detection, provide early intervention and improve
    outcomes. Early intervention can slow CKD progression and, in some
    instances, prevent kidney failure, reduce the impact of comorbidities,
    and reduce hospitalizations and readmissions. A sustained 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. Especially in light
    of the connection between surviving COVID-19 and increased risk of
    developing kidney disease, the time is right for a major nationwide
    program to improve awareness and early detection of kidney disease.
        To expedite activities to improve early detection and intervention
    measures, NKF requests $15 million for the CKD Initiative to increase
    public awareness, educate clinical professionals and expand health
    system capacity to diagnose and manage CKD, implement systemic changes
    to reduce disparities, and spur innovation by entities that serve the
    kidney disease community. Additional funding also would 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.
                                     niddk
        Despite CKD's impact on patients and Medicare, NIH funding for
    kidney disease research is only about $700 million annually, or about
    $19 per CKD patient, a fraction of what is provided on other major
    diseases. Fiscal Year 2021 funding for NIDDK increased by less than 1
    percent, the smallest percentage increase of any disease Institute, and
    the FY 2022 increase was 3.4 percent. From FY 2015-2020, NIH monetary
    support for kidney research increased at half the rate of NIH funding
    increases overall. As a result, innovation in kidney research and
    treatment has lagged that of other diseases. Scientists however are at
    the cusp of potential breakthroughs in improving our understanding of
    CKD. 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 given its unique
    Medicare coverage.
        In October 2021, NKF released a Research Roadmap containing
    recommendations for opportunities in pre-clinical and clinical research
    in which additional funding could help bridge existing deficits in
    kidney disease detection and management, reduce incidence and
    disparities, improve outcomes, and lower healthcare costs. Key
    recommendations include increasing the number of and access to clinical
    trials related to kidney disease (including increased participation by
    under-represented populations) and identifying and implementing
    strategies to improve the delivery of evidenced-base care in under-
    represented populations. Our roadmap was the culmination of input from
    nephrology leaders and from kidney patients, family members and care
    givers, and living kidney donors. NKF leadership and staff presented
    the final recommendations to NIDDK staff and to representatives from
    other Institutes and participated in a briefing that was available to
    congressional staff and the public.
        As the first step towards expanding kidney research opportunities,
    NKF requests a substantial funding increase for NIDDK that is
    commensurate with the percentage increase to NIH as a whole. Within
    that increase, we respectfully request a percentage increase for kidney
    research proportional to if not greater than that of NIH overall. NKF
    applauds recent clinical practice changes in the diagnosis of kidney
    disease and requests priority consideration of new markers to estimate
    kidney function. NIDDK should prioritize research into the adoption of
    new equations for estimating the Glomerular Filtration Rate (eGFR) that
    do not include race as a modifier. We also request NIDDK give priority
    consideration to additional investments in CKD clinical trials,
    including diversity of participants, and initiatives to improve
    evidence-based care in under-represented populations.
        Lastly, we request Congress encourage related Institutes to
    consider additional funding of 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 2023.

        [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 2023, we respectfully request that the
    subcommittee increase funding for the Program to the amount of
    $38,000,000 to eliminate financial and socioeconomic barriers that
    reduce access to cellular therapies for thousands of primarily
    traditionally underserved patients.
        With our Program being founded under the direction and guidance of
    our initial Congressional champion, the late Congressman C.W. Bill
    Young, NMDP/Be The Match has facilitated over 111,000 bone marrow,
    blood stem cell, and cord blood transplants. Each of these transplants
    represents a person and a family hoping above all else that cellular
    therapy would be the cure to save themselves or a loved one. As the
    home of the Nation's Registry, we are forever grateful to Mr. Young for
    his legacy of caring for blood cancer and blood disease patients. And,
    we are equally honored that Senator Roy Blunt has taken up the charge
    with his steadfast determination to ensure that NMDP/Be The Match has
    the support of Congress to continue and expand upon how we deliver
    cures to patients every single day. Through his commitment to seeing
    our patients as people he can help, Senator Blunt's longstanding
    promise of expanding the reach and resources of the Nation's Registry
    has saved thousands of lives. We know our patients are thankful beyond
    measure for his support and we feel that Congressman Young would be
    quite proud of Senator Blunt's wholehearted dedication to furthering
    the mission of saving lives through cellular therapy.
        By establishing a national bone marrow donor registry in the mid-
    1980s, Congress promised patients with blood cancers, like leukemia and
    lymphoma and other life-threatening diseases, 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
    75 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 10 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 2 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 2 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, 115,000 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 we are
    seeking in Fiscal Year 2023, 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 $38,000,000 to immediately provide access to
    therapy at the point of diagnosis for all patients.
        Our request this year builds upon past funding to clear a pathway
    for more patients, especially those from minority and rural
    communities, to be able to access transplant services. It would enable
    targeted donor recruitment efforts, expand early intervention with
    community referring physicians upon patient diagnosis to accelerate the
    path to transplant, and propel innovation to improve outcomes and
    establish new treatment options to ensure a matched donor for all
    searching patients, regardless of their racial/ethnic background or the
    complexity of their DNA, ensuring access to transplant and equal and
    successful outcomes for all.
        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 Pancreas Foundation
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --The Foundation joins the broader research community in requesting
            that the National Institutes of Health (NIH) receive a funding
            increase of at least $3.5 billion for FY 2023 to bring total
            agency funding up to a minimum of $49 billion annually.
        --Please provide proportional increases for the various NIH
                Institutes and Centers, including the National Institute of
                Diabetes and Digestive and Kidney Diseases (NIDDK) and the
                National Cancer Institute (NCI).
        --Please provide separate and distinct funding to further support
                the emerging Advanced Research Projects Agency for Health
                (ARPA-H) initiatives, which would ensure this important new
                effort does not supplant any ongoing NIH activities.
      --The Foundation joins the broader public health community in
            requesting that the Centers for Disease Control and Prevention
            (CDC) receive a funding increase of at least $2.55 billion in
            discretionary resources to bring total agency funding up to a
            minimum of $11 billion annually.
        --Please provide $6 million in dedicated, line-item funding for the
                Chronic Disease Education and Awareness (CDEA) Program
                within the National Center for Chronic Disease Prevention
                and Health Promotion to facilitate support for meritorious
                and timely public health campaigns.
    _______________________________________________________________________

        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 treatment progress for
    pancreatitis. We also thank you for the ongoing support for the CDEA
    program at CDC. The Foundation has developed a strong proposal and
    additional resources will allow us (along with many other patient
    groups) to apply and compete for a CDC cooperative agreement. For FY
    2023, we urge you to maintain this commitment to medical research and
    to similarly increase support public health programs. 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 like insulin. 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.
        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.
        Over recent years, key Committee Recommendations have been included
    that have moved key pancreas research projects forward and it is our
    hope that the subcommittee will continue to demonstrate an interest in
    this area during the FY 2021 process as treatment development
    activities reach a critical phase.
                        cdc public health opportunities
        The National Center for Chronic Disease Prevention and Health
    Promotion coordinates line-item public health programs on a variety of
    conditions. Recently, CDC has limited their public health activities
    almost exclusively to these named efforts. While these programs have
    been highly successful for the conditions they represent, there is a
    tremendous public health need to launch a similar program for
    pancreatitis.
        A lack of adequate professional and public information about
    pancreatitis leads to a suboptimal situation where patients are not
    effectively managing the condition and as it progresses inappropriate
    interventions occur, most notably unnecessary surgery to remove the
    pancreas. The CDC can fill key knowledge gaps with a pancreatitis
    program to disseminate best practices to the professional community and
    make sure public health messages reach at-risk individuals.
    Pancreatitis can often be managed if the proper information is
    available, which can prevent the progression of disease, including the
    onset of pancreatic cancer.
        Increasing funding for the CDEA program to $6 million will provide
    CDC with the resources and flexibility it needs to hold another
    competition and award a third cohort of 3-year cooperative agreements
    through this mechanism. The collaborative public health efforts already
    underway with CDC have been meaningful for their communities and we
    look forward to pursuing a similar program and impact for pancreatitis.
                          african american initiative
        The incidence of pancreatitis is higher in African Americans than
    any other racial group in the U.S. Many studies suggest that
    environmental and socioeconomic factors have contributed to the
    increased risk of pancreatitis among African Americans. Other
    preventable risk factors that are more common among African Americans
    that increase the risk of pancreatitis include type 2 diabetes, and
    obesity. Although smoking is not a cause of pancreatitis, it can
    accelerate the progression of the disease.
        To promote health equity and address health disparities within the
    community, the Foundation worked with a diverse team of leading medical
    experts to develop and advance a pancreatitis and pancreatic cancer
    awareness campaign with the African American community. We welcome
    Federal collaborations to support further awareness and bolster
    critical public health activities.
    Diane Tonelli's Story
        I am a resident of Massachusetts and I have chronic pancreatitis. I
    was first diagnosed in 2002 w acute pancreatitis-idiopathic just shy of
    2 years after my dad had died from pancreatic cancer. I was
    hospitalized 2 times, managed for pain and treated with TPN.
        I struggled intensely the first few years. I lost 28 pounds, down
    to 92 pounds by mid-summer of 2002.
        During the first few years I had genetic testing which was positive
    for genetic mutation CFTR R117H-cystic fibrosis and negative for BRCA1
    and 2, SPINK1 and PRSS1.
        Over the years since initial diagnosis I have had yearly screening.
    The disease had progressed to chronic pancreatitis with imaging
    revealing moderate to severe disease. I've had a sweat test which
    revealed probable Cystic fibrosis and bone density testing has revealed
    osteoporosis (density of an 80-year-old) due to decreased nutrition
    related to pancreas insufficiency.
        Currently I take pancreatic enzymes and continue to follow with GI
    for pancreas severity and have screening for pancreatic cancer.
    Lee Zeidman's Story
        My name is Lee Zeidman. I am a Strategic Communications Consultant
    and pancreatic cancer survivor. I'm a native Washingtonian. I was part
    of the team that launched CNN in 1980. I also was a local sportscaster
    early in my career in Washington, D.C. and New York City.
        I came down with an acute case of pancreatitis while on a business
    trip on the west coast. It was the worst pain I've ever felt--and I've
    broken bones playing sports. I went to the emergency room. I flew home
    to New York City the next day and was admitted into Weill-Cornell
    Medical Center where I spent 10 days in the hospital.
        The doctors at Weill-Cornell diagnosed acute pancreatitis and told
    me it was manageable. My wife was concerned that it was cancer. She
    insisted they do a biopsy to rule out cancer. The doctor insisted there
    was no relationship between pancreatitis and pancreatic cancer (this
    was back in 2013, now doctors routinely look for cancer when treating
    pancreatitis). Grudgingly, the doctor agreed to do a biopsy after my
    wife repeatedly insisted. I was put on a liquid diet and sent home. Two
    days later the doctor called and told us to come back to the hospital,
    they needed to have an urgent conversation about my health. At that
    moment I knew the doctors had been wrong--I knew it was pancreatic
    cancer. The doctor refused to acknowledge the diagnosis and the news
    had to be delivered face-to-face. I quickly realized that had my wife
    not insisted on the biopsy, I might have died from pancreatic cancer
    within months.
        My surgery was 9 years ago. It gave me a new lease on life. I still
    go to Sloan Kettering for annual check-ups, but I remain cancer-free. I
    am diabetic and wear an insulin pump, but that's a small price to pay
    for surviving pancreatic cancer.

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

           Prepared Statement of the National Scleroderma Foundation
     the foundation's fiscal year 2023 l-hhs appropriations recommendations
    _______________________________________________________________________

      --$11 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).
        --$6 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 $49 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 FY
    2023 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 National Scleroderma Foundation is a 501(c)(3) charitable
    organization founded in 1998 to advance medical research, promote
    disease awareness, and provide support and education to people with
    scleroderma. Supported by a network of thousands of individuals across
    the United States, the Foundation is a leader in funding peer-reviewed,
    innovative research to discover the cause, understand the mechanism,
    and overcome scleroderma forever.
        One of the most challenging things about scleroderma is that it
    shows up differently in each person. Scleroderma is complicated to
    manage, since it does not follow one clear path. At the National
    Scleroderma Foundation, we know that no two scleroderma journeys are
    the same. We help people find the resources that are right for them so
    they can live better with scleroderma.
                   centers for disease control and prevention
        Early recognition and 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 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. Because of this, it is important
    to promote cross-cutting research across such Institutes as NIAMS and
    NHLBI.
        Please provide NIH with a significant funding increase so the
    scleroderma research portfolio can continue to expand and facilitate
    key breakthroughs. Continued support in the following areas is critical
    to improving the health of people with scleroderma:
      --The Trans-NIH Working Group on Fibrosis, which is working to
            promote cross-cutting research across Institutes.
      --The Scleroderma Lung Study II, being led by NNHLBI, which is
            comparing the effectiveness of two drugs in treating pulmonary
            fibrosis in scleroderma.
      --Leading efforts to discover whether three gene expression
            signatures in skin can serve as accurate biomarkers predicting
            scleroderma as well as 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 being led by NIAMS.
        Every story we hear from someone living with scleroderma reminds us
    how disruptive and life-altering this disease is. Now more than ever,
    it is important it is for us to understand scleroderma and find a cure.
    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 must 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.''

        [This statement was submitted by Mary J. Wheatley, IOM, CAE, Chief
    Executive Officer, National Scleroderma Foundation.]
                                     ______

      Prepared Statement of the National Technical Institute for the Deaf
        Chairwoman Murray, Ranking Member Blunt and Members of the
    Committee:
        I respectfully submit the FY 2023 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 also prepares professionals to
    work in fields related to deafness. 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.
                                 budget request
        On behalf of NTID, for FY 2023 I would like to request $95,200,000
    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 25 percent of NTID's Operations
    budget coming from non-federal funds, up from 9 percent in 1970. Since
    FY 2013, NTID raised more than $11 million in support from individuals
    and organizations.
        Like all college campuses, NTID is seeing a greater demand for
    mental health and counseling services, a phenomenon that has been
    exacerbated by the COVID-19 pandemic. With 45 percent of NTID students
    being eligible for Pell Grants, many of these students do not have
    access to external resources and rely on what they receive at RIT/NTID.
    This FY 23 request includes funding to hire three additional counselors
    to provide students with and connect students to the mental health and
    case management services they need. It also includes funding to hire 13
    additional captionists, a crucial service for deaf and hard-of-hearing
    students to access content inside and outside of class and another area
    where NTID has seen a dramatic increase in student requests.
        NTID's FY 23 request also includes funding to establish a new
    Bachelor's of Science in Applied Internet of Things (IoT). This
    interdisciplinary field involves the application of interconnected
    devices embedded with electronics that communicate and share
    information across the Internet. The new degree will address the four
    major areas of IoT--hardware, software, communication and
    cybersecurity--and will be applied across the many employment sectors
    of IoT, including agriculture, manufacturing, healthcare, and
    government.
        NTID's secondary mission includes preparing professionals to work
    in fields related to deafness, such as sign language interpreting,
    teaching deaf students, and audiology. NTID's FY 23 request would
    provide significant scholarships to support students in NTID's American
    Sign Language and Interpreting Education program and Master of Science
    in Secondary Education of Students who are Deaf or Hard of Hearing
    program, as well as provide externships to audiologists. The
    scholarships would aim to address the shortage of students going into
    these fields, as well as increase underrepresented students in these
    occupations.
        For FY 23, NTID hopes to increase outreach funding for the NTID
    Regional STEM Center (NRSC) partnership by $1,000,000 to expand NRSC
    programs. The NRSC partnership serves deaf and hard-of-hearing students
    primarily 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.
                                   enrollment
        Truly a national program, NTID has enrolled students from all 50
    States. In Fall 2021 (FY 2022), NTID's enrollment was 1,166 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 2022, 245 deaf and hard-of-hearing high school
    students enrolled in dual-credit courses at partner high schools.
                             ntid academic programs
        NTID offers 21 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. NTID
    also offers two bachelor's degree programs (ASL-English Interpretation
    and Community Development & Inclusive Leadership) as well as an MS in
    Secondary Education of Students who are Deaf and Hard of Hearing.
        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, 219
    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 2-year and 4-year colleges. For NTID deaf and
    hard-of-hearing graduates, over the past 5 years, an average of 95
    percent have found jobs commensurate with their education level. Of our
        FY 2020 graduates (the most recent class for which numbers are
    available), 95 percent were employed 1 year later, with 72 percent
    employed in business and industry, 21 percent in education and non-
    profits, and 7 percent in government.
        Graduation from NTID has a demonstrably positive effect on
    students' earnings over a lifetime, and results in a notable reduction
    in dependence on Supplemental Security Income (SSI) and Social Security
    Disability Insurance (SSDI). In 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 percent of NTID deaf and hard-of-
    hearing graduates with bachelor degrees and 73 percent with associate
    degrees report earnings, compared to 58 percent of NTID deaf and hard-
    of-hearing students who withdrew from NTID and 69 percent of deaf and
    hard-of-hearing graduates from other universities. Equally important is
    the demonstrated impact of an NTID education on graduates' earnings. At
    age 50, $58,000 is the median salary for NTID deaf and hard-of-hearing
    graduates with bachelor degrees and $41,000 for those with associate
    degrees, compared to $34,000 for deaf and hard-of-hearing students who
    withdrew from NTID and $21,000 for deaf and hard-of-hearing graduates
    from other universities.
        An NTID education also translates into reduced dependency on
    Federal transfer programs, such as SSI and SSDI. At age 40, less than 2
    percent of NTID deaf and hard-of-hearing associate and bachelor degree
    graduates participated in the SSI program compared to 8 percent of deaf
    and hard-of-hearing students who withdrew from NTID. Similarly, at age
    50, only 18 percent of NTID deaf and hard-of-hearing bachelor degree
    graduates and 28 percent of associate degree graduates participated in
    the SSDI program, compared to 35 percent of deaf and hard-of-hearing
    students who withdrew from NTID.
                                access services
        Access services include sign language interpreting, real-time
    captioning, classroom notetaking services, captioned classroom video
    materials, and assistive listening services. NTID provides an access
    services system to meet the needs of a large number of deaf and hard-
    of-hearing students enrolled in baccalaureate and graduate degree
    programs in RIT's other colleges as well as students enrolled in NTID
    programs who take courses in the other colleges of RIT. Access services
    also are provided for events and activities throughout the RIT
    community. Historically, NTID has followed a direct instruction model
    for its associate-level classes, with limited need for sign language
    interpreters, captionists, or other access services. However, the
    demand for access services has grown recently as associate-level
    students request communication based on their preferences.
        During FY 2021, 117,831 hours of interpreting and 27,744 hours of
    real-time captioning were provided to students.
                                    summary
        NTID's FY 2023 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 percent over the
    past 5 years. Therefore, I ask that you please consider funding our
    FY2023 request of $95,200,000 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, Vice President and Dean,
    Rochester Institute of Technology.]
                                     ______

                  Prepared Statement of The Nature Conservancy
        Chair Murray, Ranking Member Blunt and members of the subcommittee,
    thank you for the opportunity to submit recommendations for fiscal year
    2023 (FY23) appropriations for programs under the Department of Labor
    (DOL). The Nature Conservancy (TNC) is a nonprofit conservation
    organization working around the world to protect ecologically important
    lands and waters for people and nature. Our mission is to conserve the
    lands and waters upon which all life depends.
        TNC appreciates Congress's work last year to pass the bipartisan
    Infrastructure Investment and Jobs Act (IIJA), which included
    significant investments in developing employee training and an
    equitable workforce. This will help strengthen our communities, create
    jobs and build a more prosperous future for all. These investments
    complement but do not supplant the need for ongoing program funding
    through the appropriations process. We ask the subcommittee to advance
    a robust appropriations package that will serve as the foundation for
    implementing the IIJA and ensuring long-term success for critical
    programs under the panel's jurisdiction.
        The pandemic made evident the economic disparities that exist due
    to low-wage jobs. We appreciate concerns about the country's current
    economic scenario where the Congress must balance job growth while also
    addressing inflation. We see investments in employment training and on-
    the-job training experiences as a tremendous opportunity to contribute
    to the Nation's economy. By supporting workforce development programs
    like the Job Corps and AmeriCorps, we can provide career development
    opportunities for youth and the unemployed through conservation and
    restoration projects on lands across the country.
        An example of the significant impacts investments in corps programs
    have on communities, their economies, and the environment is the work
    being done by the GulfCorps program. Over the last 5 years, TNC has
    worked extensively to develop, design and implement a region-wide,
    GulfCorps program, a five-state (Alabama, Florida, Mississippi,
    Louisiana and Texas) conservation corps program in the Gulf of Mexico
    region. This program was carried out under a contract with National
    Oceanic and Atmospheric Administration (NOAA) with funding from the
    Deepwater Horizon oil spill settlement. TNC has operated GulfCorps in
    partnership with NOAA, the RESTORE Council, the Student Conservation
    Association, The Corps Network and local conservation corps and
    community development organizations.
        In 2021, the RESTORE council voted to renew the program for
    additional 4 years and awarded $11.9 million to GulfCorps. The program
    will use the additional funding to create more than 400 conservation
    jobs over 4 years in the Gulf of Mexico. As of July 2021, this program
    has restored, conserved, and monitored 10,000 acres of TNC and partner
    lands. Additionally, 60 percent of the National AmeriCorps program
    alumni have taken their experience and skills and applied them to full-
    time positions in the conservation field (both within TNC and with
    partners).
        The DOL budget levels detailed below represent a significant
    investment in our Nation's future. TNC asks your support for the
    following requests:
                              department of labor
        AmeriCorps: TNC supports no less than $1,340,000,000, which is
    consistent with the president's FY23 budget request. This amount
    represents a $140 million increase from FY22 funding. The AmeriCorps
    program (officially known as the Corporation for National and Community
    Service) supports approximately 77,500 members providing service to
    communities across the country through local organizations and
    Governors' State Service Commissions. The AmeriCorps' state and
    national programs accomplish critical projects like disaster response
    and recovery, infrastructure, wildfire remediation, public lands
    access, and disconnected youth and veteran engagement. AmeriCorps and
    the country's network of conservation corps aim to develop a service
    ethic in young people; build and support diverse, inclusive and
    equitable American communities; provide education and vocational
    training; complete significant amounts of high-quality work in
    communities and on our public lands and waters; and prepare
    participants to advance to a career in conservation.
        Conservation and restoration work that AmeriCorps supports has been
    shown to yield a high return on investment. For example, when
    performing coastal restoration work, on average 15 jobs are created per
    million dollars invested and this increases to up to 30 jobs per
    million dollars invested for the more complex, labor-intensive
    restoration projects, according to data collected by National Oceanic
    and Atmospheric Administration. Similarly, every $1 invested by the
    U.S. Forest Service (USFS) in resource management generates $1.43 in
    GDP and, on average, 19 jobs are created per million dollars invested.
    Additionally, projects completed by AmeriCorps and the network of
    conservation corps will help improve and support the local economies of
    the communities they are located in. We appreciate the increased
    funding provided in FY22 for AmeriCorps and TNC urges the subcommittee
    to continue strong funding for this program in FY23.
        Job Corps: TNC supports funding no less than $1,778,964,000, which
    is consistent with the president's FY23 budget request. This amount
    represents a $30 million increase from FY22 funding. DOL co-leads Job
    Corps with USFS. For almost 100 years, USFS has combined land
    stewardship with education and training, beginning with the development
    of the Civilian Conservation Corps in the 1930s. The agency manages 20
    percent of the DOL Job Corps through their Civilian Conservation
    Centers. We would like to see USFS participation continue to be
    supported by DOL at least at this level. The mission of the Forest
    Service Job Corps Civilian Conservation Centers is to train eligible
    youth ages 16 to 24 with educational, social and vocational skills,
    while offering an integrated approach to address the Nation's
    conservation challenges. As first responders during local, State and
    national disasters, USFS Job Corps students also are trained by local
    agency units to assist during national emergencies, including those
    caused by wildfires, floods, hurricanes and tornados. Each year,
    Civilian Conservation Centers serve about 3,800 students and about 85
    percent of the graduates start new careers, enroll in higher education
    programs or join the military, according to USFS. As mentioned in the
    previous section, projects supported by corps programs produce a high
    return on investment and aid in the economic recovery of local
    communities. TNC supports continued robust funding for the Job Corps
    program and its Civilian Conservation Centers.
        Thank you for the opportunity to submit TNC's recommendations for
    the FY23 subcommittee on Labor, Health and Human Services, Education
    and Related Agencies Appropriations Bill. Please contact me if you have
    any additional questions or would like additional information.

        [This statement was submitted by Sarah Murdock, Director, U.S.
    Climate
    Resilience and Water Policy, The Nature Conservancy.]
                                     ______

              Prepared Statement of NephCure Kidney International
                summary of recommendations for fiscal year 2023
    _______________________________________________________________________

      --Provide $49 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 $11 billion for the Centers for Disease Control and
            Prevention (CDC) and $6 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 because 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 that 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 percent 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 percent of its entire budget, on ESRD. In 2005, FSGS
    accounted for 12 percent of ESRD cases in the U.S., at an annual cost
    of $3 billion. It is estimated that there are currently approximately
    20,000 Americans living with ESRD due to FSGS.
        Research on FSGS 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, 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 5-year cohort study of
    glomerular disease patients. Participants will be followed
    longitudinally to better understand the causes of disease, response to
    therapy, and disease progression, with the ultimate objective to cure
    glomerulonephropathy. NephCure recommends that the subcommittee
    continues to support the work that the 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
    trials leading to more trials than ever before. This has led to the
    creation of the Kidney Health Gateway Clinical which will connect
    patients with breakthrough clinical trials and access to 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 FY 2022 and encourage continued
    support by providing $6 million for this critical program in FY 2023.
    Patient Perspective
        Meet 16-year-old Macy! She was diagnosed with Nephrotic Syndrome
    and later FSGS when she was three. Her 13-year journey with kidney
    disease has been long and hard. Macy did not respond to treatments for
    her kidney disease and within 2 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 areis just the beads she earned in 2018!
    Those black beads are for pokes (lab draws, IVs, 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 Josh M. Tarnoff, CEO, 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 2023 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, 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
    have a higher chance of developing 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. NF1 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 percent of all human cancers. Some of these tumor
    types are benign and some are malignant, hard to treat and often fatal.
    Previous studies have found a high incidence of intracranial
    glioblastomas and malignant peripheral nerve sheath tumors (MPNSTs), as
    well as a six-fold incidents of breast cancer compared to the general
    population. One of these tumor types, malignant peripheral nerve sheath
    tumor (MPNST), is a very aggressive, hard to treat and often fatal
    cancer. MPNSTs are fast growing, and because the cells change as the
    tumor grows, they often become resistant to individual drugs. Clinical
    trials are underway to identify a drug treatment that can be widely
    used in MPNSTs and other hard-to-treat tumors.
        The enormous promise of NF research, and its potential to benefit
    millions of 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 $28 million in FY 2022. Given the
    potential offered by NF research for progress against a range of
    diseases, we are hopeful that the NIH will continue to build on the
    successes of this program by funding this promising research and
    thereby continuing the enormous return on the taxpayers' investment.
        We appreciate the subcommittee's strong support for the National
    Institutes of Health and will continue to work with you to ensure that
    opportunities for major advances in NF research at the NIH are
    aggressively pursued. Thank you.
                                     ______

                       Prepared Statement of New Leaders
        Thank you for the opportunity to provide testimony regarding the
    fiscal year 2023 Labor, Health and Human Services, Education, and
    Related Agencies Appropriations bill.
        New Leaders is a national nonprofit organization dedicated to
    ensuring high academic achievement for all children, especially
    students in poverty and students of color, by developing
    transformational school leaders and advancing the policies and
    practices that allow great leaders to succeed. Together with our school
    system partners, we build the capacity of equity-minded school leaders
    who are committed to the success of every child. Our leaders remove
    barriers to success for underestimated and underserved students,
    supporting students in fully realizing their futures as the next
    generation of great thinkers, innovators, and leaders for our society.
    Over the past 20 years, we have trained more than 8,000 equity-focused
    leaders-sixty percent of whom identify as leaders of color. Our leaders
    impact more than 2 million students in our K-12 school system annually
    and serve as powerful and positive forces for change in their
    communities. In addition, our programs are evidence-based. Multiple
    independent studies have found that students who attend New Leader
    schools outperform their peers by statistically significant margins
    specifically because of the strong leadership of their New Leader
    principal.\1\ And a recent review of school leadership interventions
    cited New Leaders as the principal preparation program with the
    strongest evidence of positive impact on student achievement.\2\
    ---------------------------------------------------------------------------
        \1\ Gates, S.M., Baird, M.D., Doss, C.J., Hamilton, L.S., Opper,
    I.M., Master, B.K., Tuma, A.P., Vuollo, M., Zaber, M.A., (2019).
    Preparing School Leaders for Success Evaluation of New Leaders'
    Aspiring Principals Program, 2012-2017. RAND Corporation RR-2812-NL.
        Gates, S., Hamilton, L., Martorell, P., et. al. (2014). Preparing
    Principals to Raise Student Achievement: Implementation and Effects of
    the New Leaders Program in Ten Districts. The RAND Corporation.
    Retrieved from http://www.rand.org/pubs/research_reports/RR507.html.
        \2\ Herman, R., Gates, S. M., Chavez-Herrerias, E. R., and Harris,
    M. (2016). School Leadership Interventions Under the Every Student
    Succeeds Act (Volume I). The RAND Corporation. Retrieved from http://
    www.rand.org/content/dam/rand/pubs/research_reports/RR1500/RR1550/
    RAND_RR1550.pdf.
    ---------------------------------------------------------------------------
        New Leaders is committed to getting a well-prepared, well-supported
    principal in every school so that our Nation's teachers and students
    can thrive. More than a decade of research shows that well-prepared,
    well-supported principals have a huge influence on teacher practice and
    student success. School leaders account for 25 percent of a school's
    impact on student learning,\3\ and an above-average principal can
    improve student achievement by 20 percentage points.\4\ And school
    leaders transform the lowest-performing schools, where the positive
    effects of strong leadership on student achievement are most
    pronounced.\5\ In fact, a landmark study found ``virtually no
    documented instances of troubled schools being turned around without
    intervention by a powerful leader.'' \6\
    ---------------------------------------------------------------------------
        \3\ Leithwood, K., Seashore Louis, K., Anderson, S., & Wahlstrom,
    K. (2004). How leadership influences student learning: A review of
    research for the Learning from Leadership Project. New York, NY: The
    Wallace Foundation. Retrieved from http://www.wallacefoundation.org/
    knowledge-center/Pages/How-Leadership-Influences-Student-Learning.aspx.
        \4\ Marzano, R. J., Waters, T., & McNulty, B. A. (2005). School
    leadership that works: From research to results. Alexandria, VA:
    Association for Supervision and Curriculum Development.
        \5\ Seashore Louis, K., Leithwood, K., Wahlstrom, K., & Anderson,
    S. (2010). Investigating the links to improved student learning.
    Washington, DC: Wallace Foundation. Retrieved from http://
    www.wallacefoundation.org/knowledge-center/Pages/Investigating-the-
    Links-to-Improved-Student-Learning.aspx.
        \6\ Leithwood, K., Seashore Louis, K., Anderson, S., & Wahlstrom,
    K. (2004).
    ---------------------------------------------------------------------------
        We were pleased that the Biden Administration has proposed funding
    the School Leader Recruitment and Support Program (SLRSP) at $40
    million in FY23, and we strongly encourage Congress to fund the program
    at this level.
        The School Leader Recruitment and Support Program (SLRSP) was
    authorized under ESSA with bipartisan support and is the only Federal
    program with an exclusive focus on evidence-based school leadership
    interventions for high-need schools. SLRSP updates the School
    Leadership Program (SLP), the program included in the previous version
    of the Elementary and Secondary Education Act, and provides districts
    with resources to develop and support dynamic leaders who have a
    measurable, positive impact on student achievement. The program
    empowers eligible entities-including State or local educational
    agencies-to pursue a range of activities in support of school
    leadership for high-need schools, such as the development and
    implementation of leadership training programs, the provision of
    ongoing professional development for school leaders, and the
    dissemination of best practices regarding the recruitment and retention
    of highly effective school leaders. In addition, eligible entities may
    carry out projects in partnership with nonprofit organizations and
    institutions of higher education. Finally, under priorities set forth
    in the reauthorized statute, SLRSP incentivizes eligible entities to
    focus on principal preparation and professional development practices
    for which there is evidence of effectiveness, as demonstrated through
    rigorous research.
        Of critical importance right now, SLRSP can help combat the
    deleterious effects of the COVID pandemic on our educator workforce.
    According to a recent poll conducted by the National Association of
    Secondary School Principals (NASSP), 45 percent of principals report
    that pandemic working conditions are accelerating their plans to leave
    the profession, and nearly four out of 10 principals plan to leave the
    profession in the next 3 years.\7\ Leadership transitions are
    disruptive and negatively impact students' learning experiences.
    Through high-quality professional development and support, we can
    support the steady, determined leadership of experienced principals
    even as we invest in preparing the next generation of school leaders.
    Further, many teachers are burned out and suffering from low morale,
    with more than half of teachers reporting they plan to quit due to
    COVID-related workplace stressors.\8\ Yet we know that effective school
    leaders can make all the difference: 97 percent of teachers list
    principal quality as critical to their retention and career decisions-
    more than any other factor.\9\ And we know that strategies to address
    principal burnout, which disproportionately affects high-need
    schools,\10\ can yield huge cost savings for school systems,\11\ which
    can be reinvested in pandemic recovery efforts.
    ---------------------------------------------------------------------------
        \7\ National Association of Secondary Principals. (2020). NASSP
    Survey Signals a Looming Mass Exodus of Principals From Schools.
    Retrieved from https://www.nassp.org/news/nassp-survey-signals-a-
    looming-mass-exodus-of-principals-from-schools/.
        \8\ National Education Association. (2022). Poll Results: Stress
    And Burnout Pose Threat Of Educator Shortages. Retrieved from https://
    www.nea.org/sites/default/files/2022-02/NEA percent20
    Member percent20COVID-19 percent20Survey percent20Summary.pdf.
        \9\ Scholastic Inc. (2012). Primary Sources: America's Teachers on
    the Teaching Profession. New York, NY: Scholastic and the Bill and
    Melinda Gates Foundation. Retrieved from http://www.scholastic.com/
    primarysources/pdfs/Gates2012_full.pdf.
        \10\ According to 2014 data from the National Center for Education
    Statistics, high-need schools must also grapple with an overall
    principal turnover rate of 28 percent, significantly higher than
    schools in more affluent communities.
        \11\ According to School Leaders Network (2014), up to $330K
    annually for a typical urban district.
        School Leaders Network. (2014). Churn: The High Cost of Principal
    Turnover. Retrieved from http://connectleadsucceed.org/sites/default/
    files/principal_turnover_cost.pdf#page=1&zoom=
    auto,-15,792.
    ---------------------------------------------------------------------------
        The Federal Government has a crucial role to play in advancing
    innovation and sharing best practices with the field so that State and
    local leadership strategies, especially for high-need schools, can be
    strengthened, now and in the future, by a strong and growing evidence
    base. The SLP helped launch and expand some of the country's most
    innovative and effective leadership development programs, including New
    Leaders, New Teacher Center, NYC Leadership Academy, and TNTP. Since
    receiving SLP grants, these organizations have grown exponentially to
    reach many more schools, teachers, and students in high-need
    communities--greatly expanding the impact of the Federal Government's
    initial investment. Further, SLP grantees, including those affiliated
    with the University Council of Educational Administrators (UCEA), have
    demonstrated a remarkable commitment to programmatic evaluation,
    continuous improvement, and transparency. By proactively sharing their
    lessons and resources open-source with the field, these organizations
    have helped to galvanize dramatic changes to the principal preparation
    sector as a whole \12\--inspiring necessary changes to the way
    principals are trained to lead our Nation's schools in States and
    districts across the country.
    ---------------------------------------------------------------------------
        \12\ University Council for Educational Administration and New
    Leaders. (2016). State Evaluation of Principal Preparation Programs
    Toolkit. Retrieved from www.sepkit.org.
    ---------------------------------------------------------------------------
        We urge Congress to restore funding for SLRSP at $40 million to
    support innovative, evidence-based school leadership programs that
    promise a return for students and schools that far exceeds this
    targeted investment.
        Thank you for the opportunity to provide the views of New Leaders
    on the FY 2023 appropriations. If you would like to discuss our
    recommendations, please do not hesitate to contact
    policyteam@newleaders.org.

        [This statement was submitted by Jean Desravines, CEO, New
    Leaders.]
                                     ______

     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 2023. 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
    2023 HHS appropriations.
        The NPAIHB is a Tribal organization, established in 1972, under the
    Indian Self-Determination and Education Assistance Act (ISDEAA), Public
    Law 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.
        These past 2 years, COVID-19 has dramatically impacted Northwest
    Tribes and carries long-term effects physically, mentally, emotionally
    and physically. We are grateful for the diligent service of our
    Congressional representatives in ensuring that Tribal Nations were
    provided with resources, including vaccines and medical supplies, to
    battle this pandemic. We know that working together improved our
    ability to 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 subcommittee must honor Tribal sovereignty and trust and
    treaty obligations as to HHS funding to Tribal Nations. For FY 2023, we
    ask this subcommittee 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 subcommittee consider the important role
    that Tribal Epidemiology Centers (TECs) 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
    2023, 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
    2022. For FY 2023, 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 2023, 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 hecpatitis C (HCV) prevention, treatment,
    outreach and education. Tribes in the Portland Area appreciated the
    $1.5 million MHAF Tribal set-aside in FY 2022. For FY 2023, 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 and continuing. the important
    program work that is already in place. We thank OASH for the
    relationship it has created with IHS and Tribes over the past 15 years.
        Climate Change. Climate change has been significantly impacting our
    Northwest Tribes. Tribal communities are facing increased flooding that
    impacts our health care operations and continually threatened by
    increased forest fires year after year. We request that this
    subcommittee provides additional funding to support Tribal capacity
    building and training for Tribal communities. This would allow Tribes
    to be in charge of collecting and monitoring their own scientific data.
    We also request a 5 percent set aside of all climate change funding for
    Tribes.
                   centers for disease control and prevention
        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 2023, 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.
    Through the Tribal Public Health Emergency Fund, disease intervention
    services--which played such a vital role in COVID-19--could be used to
    respond to the syphilis outbreaks across Tribal communities.
        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 2023, we recommend that the
    subcommittee 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 healthy,
    culturally appropriate and locally-produced foods and the nutritional
    and healing qualities of these food in a time of crisis. Likewise, the
    importance of protecting and promoting our traditional first food,
    human milk for our youngest members. 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 subcommittee allocate at least $32 million in
    fiscal Year2023 to the Good Health and Wellness in Indian Country.
                   centers for medicare and medicaid services
        Medicare and Medicaid Legislative Initiatives. HHS must work with
    Congress to pass legislation that: expands Part B coverage for services
    furnished by licensed marriage and family therapists, licensed
    professional counselors, peer counselors, and our CHAP behavioral
    health aides; creates the authority for States to extend Medicaid
    eligibility to all AI/AN people with household incomes up to 138
    percent 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
    percent FMAP permanently 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
    subcommittee support legislation to make all Medicare telehealth
    services and flexibilities permanent at the OMB encounter rate at I/T/U
    facilities, authorize Medicare telehealth furnished services by
    federally qualified health centers and rural health clinics be
    reimbursed at the encounter rate, 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.
                  health resources and services administration
        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 subcommittee
    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.
            For fiscal Year2023, we request additional funding to support
            our CHAP education programs including, $4.2 million for the
            Dental therapy education programs with a $1.7 million earmark
            for Portland Area and $2.5 million to support Alaska and $5
            million to build clinical classrooms to train community health
            aide providers throughout the Portland Area.
        Provider Relief Funds. Many Tribal health programs are facing
    significant administrative burdens on reporting their Provider Relief
    Funds. The Tribal health programs need additional time and support to
    compile the necessary information for reporting. We request that the
    subcommittee supports legislation that allows health care providers to
    expend all Provider Relief Funds by at least 90 days after the
    conclusion of the Public Health Emergency and to direct HRSA to
    simplify reporting requirements for Tribal health programs.
                         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
    2023, we recommend increased funding for the NARCH program to $20
    million and request that 30 percent 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
    subcommittee on FY 2023 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. For more information,
    please contact Candice Jimenez, cjimenez@npaihb.org.

        [This statement was submitted by Nickolaus Lewis, Chair, Northwest
    Portland Area Indian Health Board.]
                                     ______

             Prepared Statement of the Nursing Community Coalition
        As the Nation evaluates lessons learned from 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
    investments in nursing education, workforce, and research in Fiscal
    Year (FY) 2023 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), and at least $210 million for the National Institute of Nursing
    Research (NINR), 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 nursing education, research, practice, and regulation.
    Collectively, the NCC represents Registered Nurses (RNs), Advanced
    Practice Registered Nurses (APRNs),\1\ nurse leaders, students,
    faculty, and scientists, as well as other nurses with advanced degrees.
    As the largest segment of the health care profession,\2\ nursing is
    involved at every point of care, which was further exemplified 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\ United States Census Bureau. (2021) Who are our Health Care
    Workers? Retrieved from: https://www.census.gov/library/stories/2021/
    04/who-are-our-health-care-workers.html.
    ---------------------------------------------------------------------------
           through the nursing lens: providing care to all americans
        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. As the largest dedicated
    funding for nursing, Title VIII programs are instrumental in bolstering
    and sustaining the Nation's diverse nursing pipeline by addressing all
    aspects of nursing workforce demand. The Bureau of Labor Statistics
    (BLS) projected that by 2030 demand for RNs would increase 9 percent,
    illustrating an employment change of 276,800 nurses,\3\ and demand for
    most APRNs is expected to grow by 45 percent.\4\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        The need for nurses and APRNs is not only outlined by BLS, but can
    be seen in communities across the Nation, including rural and
    underserved areas. In fact, the American Association of Critical-Care
    Nurses outlined, ``92 percent of nurses surveyed said they believe the
    pandemic has depleted nurses at their hospitals and, as a result, their
    careers will be shorter than they intended.'' \5\ Further, the American
    Nurses Foundation's second COVID-19 impact study noted that 52 percent
    of nurses during the pandemic considered leaving their position, up
    from 40 percent a year earlier! \6\ If that was not enough, ``more than
    one-fifth of all nurses reported they plan to retire from nursing over
    the next 5 years.'' \7\
    ---------------------------------------------------------------------------
        \5\ American Association of Critical-Care Nurses. (2021). Hear Us
    Out Campaign. Retrieved from: https://www.aacn.org/newsroom/hear-us-
    out-campaign-reports-nurses-covid-19-reality.
        \6\ American Nurses Foundation. (2022). Pulse on the Nation's
    Nurses Survey Series: COVID-19 Two-Year Impact Assessment Survey.
    Retrieved from: https://www.nursingworld.org/492857/contentassets/
    872ebb13c63f44f6b11a1bd0c74907c9/covid-19-2-year-impact-assessment-
    written-report-final.pdf.
        \7\ National Council of State Boards of Nursing and the National
    Forum of State Nursing Workforce Centers (2021) The 2020 National
    Nursing Workforce Survey. Retrieved from: https://
    www.journalofnursingregulation.com/article/S2155-8256(21)00027-2/
    fulltext.
    ---------------------------------------------------------------------------
        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. Each program under Title VIII is
    unique and plays an important role in supporting our nursing workforce.
    For example, in Academic Year 2020-2021, the Advanced Nursing Education
    programs, which help APRN students and nurses to practice on the
    frontlines and in rural and underserved areas throughout the country,
    supported more than 8,800 students, many of whom were trained in
    medically underserved areas and primary care settings.\8\
    ---------------------------------------------------------------------------
        \8\ Health Resources and Services Administration. Fiscal Year 2023,
    Pages 164-170. Budget Justification. Retrieved from: https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2023.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. With more than four million nurses
    throughout the country,\9\ we strongly urge historic support for these
    programs in FY 2023.
    ---------------------------------------------------------------------------
        \9\ 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.
    ---------------------------------------------------------------------------
        Therefore, the Nursing Community Coalition respectfully requests at
    least $530 million for the Title VIII Nursing Workforce Development
    programs in FY 2023.
       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. NINR's
    research is aimed at reducing the impact of social determinants of
    health and creating a more equitable health care system by promoting
    patient-centered care across the life continuum. The translational
    research by our Nation's nurses and scientists is essential to
    developing new evidence-based practices to care for all patients. It is
    imperative that we continue to support the necessary scientific
    research, which is why the Nursing Community Coalition respectfully
    requests at least $210 million for NINR in FY 2023.
        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.
    59 Members of the Nursing Community Coalition Submitting this Testimony
        Academy of Medical-Surgical Nurses
        Academy of Neonatal Nursing
        American Academy of Ambulatory Care Nursing
        American Academy of Nursing
        American Association of Colleges of Nursing
        American Association of Critical-Care Nurses
        American Association of Heart Failure Nurses
        American Association of Neuroscience Nurses
        American Association of Nurse Anesthesiology
        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 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
        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 Forum of State Nursing Workforce Centers
        National Hartford Center of Gerontological Nursing Excellence
        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
        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 and Medical Foods Coalition
           summary of fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --Please provide the National Institutes of Health (NIH) with at
            least $49 billion.
        --Please provide proportional funding increases for individual NIH
                Institutes and Centers to advance efforts like those being
                led by the Office of Nutrition Research.
        --Please provide additional, distinct funding for the emerging
                Advanced Research Projects Agency for Health (ARPA-H) at
                NIH, which would facilitate implementation of this
                important program without supplanting ongoing NIH research
                activities.
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least $11 billion.
      --Please enhance support for the Centers for Medicare and Medicaid
            Services (CMS) and work with the administration on innovative
            models to facilitate coverage and access for medical foods.
    _______________________________________________________________________

        Thank you for the opportunity to submit testimony on behalf of the
    Nutrition and Medical Foods Coalition and the diverse community of
    patients that rely on medical foods. Chairwoman Murray, Ranking Member
    Blunt, and distinguished members of the subcommittee, thank you for
    continuing to invest in medical research, public health, and patient
    care through the FY 2022 appropriations process. Please maintain this
    commitment and further enhance support for medical research and public
    health programs as you work with your colleagues on appropriations for
    FY 2023. Please also continue to include committee recommendations
    encouraging ongoing scientific progress and appropriate coverage and
    access for medical foods.
                              about the coalition
        The Nutrition and Medical Foods 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.
                              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.''
                             policy recommendations
        Due to the tireless work of the patient advocacy community, there
    is a growing awareness of the challenges to patient access that impact
    individuals and families in need of medical foods. At this time, we ask
    that you consider the following:
      --Due to advancement in science and the advent of medical foods for a
            variety of conditions, a timely opportunity exists to promote
            and provide access by removing outdated restrictions in
            Medicare Part D.
      --The Centers for Medicare and Medicaid Innovation (CMMI) at CMS are
            interested in evaluating a variety of options to improve proper
            coverage of meritorious medical foods and Congress should
            encourage and collaborate on these efforts.
      --Please promote coverage and access across all forms of coverage by
            supporting legislation that seeks to enhance access to medical
            foods and work with your colleagues to consider options to
            provide a regulatory framework for medical foods that is
            distinct from the drug approval pathway and capable of
            identifying safe and effective products.
      --There exist persistent misperceptions about medical foods that
            often jeopardize coverage, including the mis-categorization of
            medical foods as ``over the counter'' products in contravention
            of FDA guidance, and opportunities exist to identify and
            correct barriers stemming from incorrect information or a lack
            of understanding. HHS through a variety of public health and
            patient care mechanisms can raise awareness of medical foods
            and address current gaps in understanding and care delivery.
                          recommended report language
    Centers for Medicare and Medicaid Services Program Management
        Medical Foods.--The Committee recognizes ongoing scientific
    advancement and innovation in the medical foods space that has
    demonstrated the impact of nutrition and related interventions to a
    variety of patient communities, in addition to digestive and metabolic
    health. The Committee also notes the potential cost-effectiveness of
    many medical foods as part of a physician-directed treatment, including
    with potential applications for non-opioid pain management. CMS is
    encouraged to engage with the medical foods stakeholder community on
    efforts to better understand health and cost effectiveness and approach
    proper coverage paradigms that reflect the growing relevance of medical
    foods within the broader treatment and care landscape.
                                   conclusion
        Please consider NMFC a resource as you work on relevant funding
    issues for FY 2023 and work with your colleagues to advance health
    policy legislation. If you have any questions or if you would like to
    discuss medical foods coverage and access policy further with the
    coalition, please consider us a resource.

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

                       Prepared Statement of PACER Center
        PACER Center would like to thank the subcommittee on Labor, Health
    and Human Services, Education and Related Agencies (LHHS) for
    soliciting the views and recommendations of public witnesses on Fiscal
    Year (FY) 2023 funding.
        PACER is a Statewide and national parent center founded in 1978 and
    based in Minneapolis, Minnesota. PACER's mission is to enhance the
    quality of life and expand opportunities for children, youth, and young
    adults with all disabilities and their families so each person can
    reach his or her highest potential. PACER is staffed primarily by
    parents of children with disabilities. PACER also works to strengthen
    engagement between families and their schools to ensure that parents
    can be fully involved in the education of their children.
        This testimony highlights several critical issues. First, we
    respectfully request that the subcommittee match the President's FY
    2023 request of $45 million for the Parent Information Centers (PIC)
    program, provide $20 million for the Statewide Family Engagement
    Centers program, match the President's FY 2023 request of $2.9 billion
    for Part B of the Individuals with Disabilities Education Act (IDEA)
    and $1.4 million for the Parent Center program funded under the
    demonstration authority of the Rehabilitation Act of 1973. Second, we
    request that the subcommittee maintain bill language that was included
    in the FY 2022 bill that would permit States to subgrant funds under
    Part C of IDEA and report language that ensures that no less than the
    level provided in FY 2022 for the parent center program under
    Rehabilitation Act of 1973 be provided through the FY 2023 bill.
    IDEA Parent Information Centers
        PACER respectfully requests that the subcommittee provide $45
    million for the PIC program at the U.S. Department of Education (ED).
    This level of funding is in line with President Biden's budget request
    for a $15 million increase for the program. The PIC program provides
    crucial assistance to families of children with disabilities, helping
    parents navigate the special education process and ensuring that they
    have the opportunity, knowledge, and skills to help their children with
    disabilities succeed. It also assists parents in navigating the early
    intervention system for infants and toddlers with disabilities and
    developmental delays from birth to age three.
        The PIC program funds Parent Training and Information Centers
    (PTIs), Community Parent Resource Centers (CPRCs), and technical
    assistance for parent centers. Under this program, each State has at
    least one PTI, with a combined total of nearly 100 centers, technical
    assistance centers, and CPRCs targeting underserved populations.
    Centers funded under this program make valuable contributions at the
    State and local level by helping schools improve services and outcomes
    for students with disabilities and providing critical information on
    resolving disputes that may arise between schools and families.
        We appreciate the $2.7 million increase provided for the Parent
    Information Centers program in FY 2022. Prior to FY 2022, the PIC
    program was level funded for a decade. Despite the level funding of
    this program, the number of IDEA-eligible students has increased
    dramatically. In 2010, approximately 6.6 million students were served
    under IDEA. In its most recent Congressional Justification, ED
    estimates that nearly 7.4 million eligible students will be served in
    2023. The PIC program also serves students who are eligible under
    Section 504 of the Rehabilitation Act. Such students numbered 1.4
    million in 2017-2018 and represented 2.7 percent of school enrollment.
    These increased numbers have required the Centers funded under the PIC
    program to try to do more with less. We believe that the rising
    enrollment of students with disabilities warrants the requested
    increase in funding for the institutions such as PACER and other PTIs
    that provide crucial support to the families of students with
    disabilities.
        In addition to the general increase in the number of children with
    disabilities and their families seeking services from centers funded
    under the PIC program, ED has cited rising service demands on centers
    due to the COVID-19 pandemic. In the Administration's FY 2023 budget
    proposal, ED cited that the ``demand for PTI services has increased
    dramatically'' during the COVID-19 pandemic including the need for
    increased virtual trainings. Children with disabilities were also one
    of the hardest hit populations during the pandemic, often having subpar
    access to online learning opportunities and having the most disruption
    to services, supports and accommodations they need to succeed
    academically.
    Statewide Family Engagement Centers
        PACER Center also requests $20 million in funding for the Statewide
    Family Engagement Centers (SFEC) program to help achieve the goal of
    having an SFEC in every State and territory. PACER, in addition to
    serving as a PTI center, also serves as an SFEC and as such provides
    much-needed technical assistance and partnership development to States
    and school districts to foster meaningful engagement with families to
    further their children's academic and developmental progress. As with
    the PTI program, PACER Center appreciates the $2.5 million increase
    included for the SFEC program in the FY 2022 funding bill.
        SFECs provide vital direct services to improve engagement between
    children, parents, teachers, school leaders, counselors,
    administrators, and other school personnel. While SFECs work with all
    parents and schools throughout their state, many, including PACER
    Center, focus on students of color, English learners, and recent
    immigrant children working to integrate into their new communities.
    Research has shown that family engagement in a child's education
    increases student achievement, improves attendance, reduces the dropout
    rate, and advances the emotional and physical well-being of children.
    Students whose families are involved in their children's academic
    success attend school more regularly, earn better grades, enroll in
    more challenging academic programs, and have higher graduation rates.
    The SFEC program harnesses effective practices to help schools and
    districts implement systematic family engagement programs that build
    ties between the community, families, students, and schools.
                                      idea
        We also request a $2.9 billion increase in Part B of the
    Individuals with Disabilities Education Act (IDEA), matching President
    Biden's FY 2023 budget proposal. IDEA funding for Part B is critical in
    our home state of Minnesota and around the country. The Federal
    resources provided to meet the guarantee of a free appropriate public
    education under IDEA are critical as States and local school systems
    construct their annual budgets. This is especially true now as
    educators help children with disabilities recover lost learning time
    resulting from the COVID-19 pandemic. As stated above, the pandemic hit
    children with disabilities among the hardest and States, school
    districts, and schools need this significant increase in Federal
    resources to meet the needs of their children.
        While this focus on pandemic recovery and the need for resources is
    more recent, IDEA's current funding level continues to fall short of a
    path to full funding of Part B of IDEA. The Administration's budget
    estimates that their call for a $2.9 billion increase will raise the
    Federal share to 15 percent. This amount of a funding increase will
    restart the program on a path to full funding.
        With respect to Part C of IDEA, we request that the subcommittee
    maintain bill language that would permit States to subgrant Part C
    funds to organizations to carry out Part C State-level activities. This
    authority has been extremely useful in Minnesota to allow the State to
    reach families eligible for Part C across the State by avoiding the
    need to conduct such activities via a contract.
           rehabilitation act parent training and information centers
        We also support the Administration's request to increase funding by
    $1.4 million under the Demonstration and Training Authority in the
    Rehabilitation Act of 1973 for the National Parent Training and
    Information Center as well as the eight Regional Parent Training and
    Information Centers. The Administration's FY 2023 budget request
    documents how existing funding levels are insufficient to support the
    current workload. The budget request would allow the Regional Parent
    Training and Information Centers to expand collaboration and enhance
    services to consumers in their respective regions.

                                     ______

                     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. I am submitting this testimony to request
    that the Committee include language in the fiscal year 2023 Labor,
    Health and Human Services report expanding NIH research funding and
    awareness efforts on amyloidosis.
        The COVID pandemic has brought about an awareness of the need to
    address health issues through increased investment in research. This
    investment in COVID has resulted in research that is saving lives
    through vaccines, early diagnosis and programs of awareness. It has
    heightened the need to accelerate research and awareness of
    amyloidosis, to prevent deaths, and to help patients with amyloidosis
    related multi-organ dysfunction.
        A further commitment to amyloidosis research, I believe, would
    prove to be a lifesaving investment.
        I want to thank this subcommittee for its efforts to raise
    awareness and funding for issues related to amyloidosis. Progress has
    been made on research into treatment and awareness. 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.
        However, the causes of amyloidosis remain elusive. 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.
        I have endured two stem cell transplants and chemotherapy in order
    to fight the deadly disease amyloidosis and have been one of the lucky
    ones to survive the disease for 19 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.
                              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. Secondary or reactive
    amyloidosis occurs in patients with chronic infections or inflammatory
    diseases.
        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.
        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.
        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.
                          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 transplantation and other
    new drugs have increased the remission rate and long-term survival
    dramatically. However, this treatment can also be life threatening and
    more research needs to be done to provide less risky forms of
    treatment.
                   fiscal year 2023: more research is needed
        The COVID pandemic has illustrated the need to accelerate research
    and treatment on diseases such as amyloidosis. Here are the main points
    for taking action in the fiscal year 2023 bill:
        1. Thousands of people die because they were diagnosed with
    amyloidosis too late to obtain effective treatment. Many people are
    diagnosed after the point that they are physically able to undertake
    treatment.
        2. Thousands of others die never knowing they had amyloidosis.
        3. 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.
        4. Additional funding for amyloidosis research and equipment is
    needed to increase the survival rate and to find safe treatments to
    help more patients.
        5. Although amyloidosis is often fatal, Federal and foundation
    support over the past years has given hope for successful new
    treatments.
        6. More efforts are needed to alert health professionals to
    identify this disease, to accelerate research and awareness of the
    disease, and to help patients with amyloidosis related multi-organ
    dysfunction.
        Amyloidosis is vastly under-diagnosed. 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.
        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. Expanding funding for research and
    treatment of amyloidosis is key to preventing death from amyloidosis.
        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
    this 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) 2023 appropriations and to
    highlight the importance of NIH-funded 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 have come together to support this growing field. We
    appreciate the sustained, robust funding for NIH provided by the
    subcommittee in recent years, which has allowed NIH to continue
    building the foundation of scientific knowledge underpinning
    personalized medicine in the midst of unprecedented challenges.
    Sustaining this momentum will be essential to support further discovery
    of targeted health care interventions for patients with cancer as well
    as rare, common, and infectious diseases. As the subcommittee begins
    work on the FY 2023 Labor, Health and Human Services, Education and
    Related Agencies appropriations bill, we request at least $49.048
    billion for NIH's base program level budget. We also urge you to ensure
    that funds for targeted programs, like those supporting the new
    Advanced Research Projects Agency for Health (ARPA-H) and pandemic
    preparedness, supplement this request for NIH's base program level
    budget.
        Our funding request for FY 2023 amounts to a $4.1 billion (or
    nearly 8 percent) increase to the NIH budget, including funding for
    specific initiatives under the 21st Century Cures Act (Cures Act). This
    request would allow for meaningful growth above inflation in NIH's base
    budget and expand NIH's capacity to support progress in personalized
    medicine.
        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 the government's
    investment in 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
        Decades of NIH-funded biomedical research on the genetic and
    biological underpinnings of disease have contributed to the development
    of personalized treatments that patients are benefitting from today. As
    of 2020, this research has informed the development of more than 286
    personalized treatments \2\ and over 166,703 genetic testing
    products.\3\ These numbers continue to grow, with personalized
    medicines accounting for more than a quarter of all new drugs approved
    by FDA each of the past 7 years and with more than half of new
    personalized treatments being approved for indications outside of
    oncology.\4\ Nearly 20 years since the historic completion of the Human
    Genome Project in 2003, researchers recently finished deciphering the
    final 8 percent of the roughly 3-billion-base human genome sequence
    that was previously impossible to decode.\5\ Having a complete, gap-
    free reference sequence of human DNA will further improve our
    understanding of how genes influence human health. In recent years,
    scientists have also made notable progress in assessing biomarkers
    beyond the genome, such as proteomic and metabolic biomarkers.\6\
    Harnessing the power of personalized medicine to better diagnose,
    treat, and prevent disease will require a continued commitment by
    Congress to fund NIH's basic and translational 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://www.personalizedmedicinecoalition.org/Userfiles/PMC-
    Corporate/file/Personalized_
    Medicine_at_FDA_The_Scope_Significance_of_Progress_in_2021.pdf.
        \5\ https://www.nih.gov/news-events/nih-research-matters/first-
    complete-sequence-human-
    genome.
        \6\ https://www.personalizedmedicinecoalition.org/Userfiles/PMC-
    Corporate/file/PMC_The_
    Personalized_Medicine_Report_Opportunity_Challenges_and_the_Future.pdf.
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       ii. sustaining basic and translational research for personalized
                                    medicine
        NIH is leading much of the 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 NIH are contributing 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), the National Institute of
    Diabetes and Digestive and Kidney Diseases (NIDDK), the National Center
    for Advancing Translational Sciences (NCATS), and the National
    Institute on Minority Health and Health Disparities (NIMHD). A robust
    base budget for NIH in FY 2023 would protect the agency's foundational
    role in the identification and development of treatments, technologies,
    and tools for personalized medicine.
        Cancer care has been and will continue to be profoundly influenced
    by new personalized medicine approaches for detecting and treating
    early- and late-stage cancers. In 2021, for example, FDA approved two
    new chimeric antigen receptor (CAR) T-cell-based immunotherapies for
    patients with refractory large B-cell lymphoma and refractory multiple
    myeloma.\7\ These treatments work by genetically re-engineering a
    patient's own immune cells to combat cancer. Over the past decade,
    personalized treatments harnessing the immune system have also driven
    declines in mortality for lung cancer and melanoma. Recognizing the
    potential of multi-cancer early-detection tests designed to find
    evidence of cancer wherever it occurs in the body from a simple blood
    draw, NCI is also exploring large national trials to evaluate these
    novel tests and is already funding the collection of blood samples to
    serve as controls. These tests may provide less invasive testing
    options that could detect a patient's cancer at early stages when
    treatment may be more effective and less costly.
    ---------------------------------------------------------------------------
        \7\ https://www.personalizedmedicinecoalition.org/Userfiles/PMC-
    Corporate/file/Personalized_
    Medicine_at_FDA_The_Scope_Significance_of_Progress_in_2021.pdf.
    ---------------------------------------------------------------------------
        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. Over the past decade,
    programs at NCATS have helped shift the scientific approach to
    researching rare diseases from one disease at a time to many diseases
    at a time. 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 and diagnostic options.
    Accelerating this research can help shorten the average of 6 years it
    takes for a rare disease patient to find the correct diagnosis and
    lower the nearly $1 trillion annual economic burden of rare
    diseases.\8\
    ---------------------------------------------------------------------------
        \8\ https://everylifefoundation.org/burden-study/.
    ---------------------------------------------------------------------------
        Other patients are living with highly prevalent diseases where
    personalized medicine can offer better treatments or a cure. For
    example, the Alzheimer's Association estimates that 6.2 million
    Americans are living with Alzheimer's disease.\9\ Despite increasing
    numbers of Alzheimer's diagnoses, researchers still need to study 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 (AMP) for Alzheimer's disease, led by NIH, has
    identified over 500 drug targets, and in 2021 the public-private
    partnership launched a second iteration to enable a personalized
    medicine approach to researching new treatments.\10\ Other new and
    ongoing AMP projects aim to facilitate the development of gene
    therapies for rare diseases as well as treatments and diagnostics for
    type 2 diabetes, rheumatoid arthritis, lupus, Parkinson's disease,
    common metabolic diseases like kidney and heart disease, and
    schizophrenia.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        Ensuring that 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 and clinical trials. Multiple initiatives at NIH to
    improve research policies and incorporate diverse perspectives into
    solving complex scientific problems--such as through the UNITE
    initiative, NHGRI's action agenda for a diverse genomics workforce, and
    the forthcoming NIH-Wide Diversity, Equity, Inclusion, and
    Accessibility Strategic Plan--will play a key role in addressing these
    disparities, as will the research led by NIMHD on improving minority
    health and understanding factors contributing to health disparities.
                iii. accelerating personalized medicine research
        Increasing 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 of these initiatives made possible in part by the Cures
    Act, 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 March 2022, over
    475,000 individuals consented to participate, with more than 326,000
    being fully enrolled.\11\ More than 80 percent of the enrolled
    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.
    Extensive efforts are also underway to engage American Indian and
    Alaska Native communities. Reaching a significant milestone, the
    program recently released its first dataset of nearly 100,000 whole
    genome sequences,\13\ and over 1,100 research projects have been
    launched using the program's groundbreaking dataset. Later this year,
    the program also plans to begin sharing results with participants on
    their hereditary disease risk and medication-gene interactions. Pooling
    health care data across large datasets that span populations and
    disease areas will play a key role in advancing research for
    personalized medicine approaches to care.
    ---------------------------------------------------------------------------
        \11\ https://www.joinallofus.org/newsletters/2022/march.
        \12\ https://officeofbudget.od.nih.gov/pdfs/FY23/br/
    Overview%20of%20FY%202023%20Presidents percent20Budget.pdf.
        \13\ https://directorsblog.nih.gov/2022/03/29/nihs-all-of-us-
    research-programs-first-nearly-100000-complete-human-genome-sequences-
    set-stage-for-new-discoveries/.
    ---------------------------------------------------------------------------
        The second initiative spurred by the Cures Act, the Beau Biden
    Cancer Moonshot, aims to transform the way cancer research is conducted
    by fostering collaboration and data sharing. As it enters its seventh
    year, the Cancer Moonshot has grown to support over 240 new research
    projects \14\ and has established a significant infrastructure for
    conducting cancer research and sharing resources.\15\ Collaborations
    formed by the program include the Partnership for Accelerating Cancer
    Therapies (PACT), which consists of 12 pharmaceutical companies, the
    Foundation for NIH, and FDA working together to identify, develop, and
    validate biomarkers advancing the discovery of new immunotherapy
    treatments. This year, President Biden announced a bold new goal for
    the initiative of ending cancer as we know it. Funding provided by the
    Cures Act ends in FY 2023, and additional base budget funding will help
    NCI sustain this progress that has already been made in cancer research
    once the Cures Act funding expires.
    ---------------------------------------------------------------------------
        \14\ https://doi.org/10.1016/j.ccell.2021.04.015.
        \15\ https://www.cancer.gov/research/annual-plan/directors-message.
    ---------------------------------------------------------------------------
                                 iv. conclusion
        PMC appreciates the opportunity to highlight NIH's importance to
    the continued success of personalized medicine. PMC believes that basic
    and translational research at NIH is key to bringing us closer to a
    future in which every patient benefits from an individualized approach
    to health care. Therefore, we urge the subcommittee to appropriate at
    least a $49.048 billion budget to support existing centers and programs
    at NIH, in addition to funding Congress may provide for targeted
    initiatives.

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

      Prepared Statement of the Physician Assistant Education Association
        The Physician Assistant Education Association (PAEA), representing
    the 287 accredited PA programs in the United States that graduate more
    than 10,000 students each year, appreciates the opportunity to submit
    the following testimony on the Association's funding priorities for
    Fiscal Year (FY) 2023. Throughout the COVID-19 pandemic, the issue of
    provider shortages, particularly in historically underserved
    communities, has received renewed attention. As practicing providers
    have experienced unprecedented strain during the past 2 years,
    increasing rates of burnout and attrition has made congressional action
    to support workforce development an urgent imperative. To address these
    challenges and mitigate further projected workforce shortages, it is
    critical that Congress make bold investments in both proven and new
    programs that support the development of a sufficient supply of well-
    trained, diverse providers in the communities where they are needed
    most.
        PAEA joins with the Health Professions and Nursing Education
    Coalition, a national alliance of more than 90 organizations, to
    request a total of $1.51 billion in FY23 for the Title VII health
    professions and Title VIII nursing workforce development programs
    administered by the Health Resources and Services Administration
    (HRSA). This funding level, a significant increase from the $799
    million allocated for Title VII and VIII in FY22, would provide the
    resources necessary to meet workforce demand and promote equitable
    outcomes for all patients.
                background on the pa profession and pa education
        As Congress seeks to bolster the health workforce following the
    pandemic, PAs are uniquely equipped to be a key part of the solution
    given the accelerated training model and wide practice flexibility that
    has characterized the profession since its inception. Following their
    baccalaureate-level education, all PA students complete a rigorous
    graduate-level curriculum based upon the more than 100-year-old model
    of medical student training. The typical PA program curriculum consists
    of approximately 1 year of classroom-based training followed by 1 year
    of clinical rotations under the supervision of practicing preceptors.
    During their clinical year, students complete placements in family
    medicine, emergency medicine, surgery, pediatrics, women's health, and
    behavioral health in a wide array of practice settings. This generalist
    approach to PA education provides graduates with the necessary
    knowledge and experience to switch specialties over the course of their
    careers based upon workforce needs without additional required post-
    graduate training.
        In recognition of the quality of services rendered by PA graduates
    and in response to significant projected physician shortages, the
    number of PA programs has risen significantly in the past decade,
    growing from 149 in 2010 to 287 as of 2022. While the promise of this
    expansion to combat workforce shortages is considerable, its
    sustainability depends upon PA programs having access to the resources
    necessary to provide high-quality training to students. Despite
    widespread vaccine availability and reduced pressure on health systems
    as COVID-19-related hospitalizations have fallen, nearly 85 percent of
    PA programs indicate that their existing clinical training sites
    continue to take fewer students than prior to the pandemic.\1\ This
    reduction in clinical education capacity is the most daunting challenge
    facing PA programs across the Nation and, if left unaddressed,
    threatens the ability of programs to meet demand for graduate services.
    ---------------------------------------------------------------------------
        \1\ Physician Assistant Education Association. (2021). COVID-19
    Rapid Response Report 3. https://paea.edcast.com/insights/ECL-c621408d-
    c82a-43f5-a067-75a03494d8be..
    ---------------------------------------------------------------------------
        In response to this challenge, HRSA has taken steps to expand
    clinical site access but currently has limited resources to address the
    crisis. In September 2021, HRSA released the Primary Care Training and
    Enhancement--Physician Assistant Rural Training funding opportunity,
    explicitly allowing grantees to pay preceptors to train students in
    rural communities in order to expand access to placements. While this
    program is well-aligned with the needs of PA education, current PCTE
    funding levels only allowed 7 PA programs to receive an award through
    this competition. If the program is to meaningfully achieve its
    intended aim, significantly increased funding will be needed to broaden
    the scope of this opportunity.
        Beyond PCTE grants, an additional critical source of support to
    expand clinical education capacity is Area Health Education Centers
    (AHECs), which facilitate clinical placements for PA and other health
    professions students in underserved areas through community
    partnerships. In academic year 2020-2021, AHEC grantees facilitated
    over 27,000 clinical rotations for health professions students with
    approximately 70 percent taking place in medically underserved
    communities and 60 percent occurring in primary care settings.\2\ To
    further expand clinical education capacity and meet workforce demand,
    PAEA urges the subcommittee to support a funding level of $98 million
    for PCTE grants and $86 million for AHECs in FY23.
    ---------------------------------------------------------------------------
        \2\ Health Resources and Services Administration. (2022).
    Justification of Estimates for Appropriations Committees. https://
    www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-
    justification-fy2023.pdf.
    ---------------------------------------------------------------------------
                         promoting workforce diversity
        As Congress works to address the toll that COVID-19 has taken on
    the Nation's health workforce, particular emphasis must be placed on
    reducing barriers that prevent the workforce from reflecting the
    communities that it serves. Across disciplines, students from
    marginalized communities often face daunting socioeconomic challenges
    to successfully entering the health professions and practicing in the
    communities where their services are needed most. In the case of PA
    education, only 3.9 percent of first-year PA students identify as Black
    or African American and 9.1 percent identify as Hispanic or Latino as
    of 2019.3 Representation steadily declines among graduates with 3
    percent identifying as Black or African American and 6.8 percent
    identifying as Hispanic or Latino.\3\
    ---------------------------------------------------------------------------
        \3\ Physician Assistant Education Association. (2020). By the
    Numbers: Student Report 4: Data from the 2019 Matriculating Student and
    End of Program Surveys. https://paeaonline.org/wp-content/uploads/
    imported-files/student-report-4-updated-20201201.pdf.
    ---------------------------------------------------------------------------
        To combat these trends and promote the availability of culturally
    competent care for patients, PAEA believes it is critical to
    significantly increase the scale of HRSA's existing workforce diversity
    programs, which aim to provide support to marginalized students
    throughout the continuum of their education. Specifically, the Health
    Careers Opportunity Program (HCOP) provides targeted K-16 programming
    targeted to marginalized students to expose them to the possibility of
    pursuing a career in the health professions and ensure they have the
    resources necessary to matriculate into a program. In FY20, HCOP
    grantees provided this type of support to 2,452 underrepresented
    minority students interested in pursuing careers in the health
    professions.\2\
        Beyond HCOP, HRSA programs also seek to ensure that students are
    retained in their programs through graduation. The Scholarships for
    Disadvantaged Students (SDS) program provides financial support to meet
    this aim. In FY20, SDS supported more than 2,600 disadvantaged health
    professions students with 65 percent being from underrepresented
    minority communities.\2\ To ensure that these programs are scaled to
    meet patient demand for a diverse health workforce, PAEA urges the
    subcommittee to fund HCOP and SDS at a level of $30 million and $103
    million, respectively, for FY23.
                    combating maternal mortality disparities
        While COVID-19 has been the predominant focus of national public
    health policy since 2020, other long-standing public health challenges
    have persisted throughout the pandemic. Currently, the United States
    has one of the highest maternal mortality rates among industrialized
    nations at a rate of 23.8 deaths per 100,000 live births as of 2020
    with many deaths concentrated in historically underserved areas.\4\
    Black or African American women continue to be disproportionately
    affected by this crisis with a mortality rate of 55.3 deaths per
    100,000 live births--nearly three times the rate of non-Hispanic white
    women.\4\ While the causes of maternal mortality disparities are
    multifactorial, a key concern is limited access to well-trained
    providers with the capacity to provide the culturally competent care
    that patients deserve.
    ---------------------------------------------------------------------------
        \4\ Centers for Disease Control and Prevention. (2022). Maternal
    Mortality Rates in the United States, 2020. https://www.cdc.gov/nchs/
    data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm.
    ---------------------------------------------------------------------------
        Ensuring the availability of a high-quality workforce requires
    investments in clinical training in the communities where care is most
    needed. However, at a time when providers are most needed to address
    this issue, the availability of training opportunities for students is
    significantly declining. Nearly 75 percent of PA programs indicate that
    it is either harder or much harder to secure clinical rotations in
    obstetrics/gynecology/women's health than prior to the COVID-19
    pandemic--a critical threat to the ability of PA education to respond
    to demand for providers.\1\
        Recognizing this challenge, Congress authorized a new Rural
    Maternal and Obstetric Care Training demonstration program in the
    omnibus appropriations legislation enacted for FY22. This program is
    intended to provide funding to PA education and other health
    professions programs to support clinical training opportunities in
    community-based settings with the aim of strengthening the pipeline and
    increasing the supply of providers practicing in these communities.
    PAEA strongly supports this program's authorization and urges the
    subcommittee to provide $5 million for its initiation in FY23.
                        fiscal year 2023 recommendation
        To mitigate the toll that COVID-19 has taken on providers across
    the country, Congress must seize the opportunity to make bold
    investments to strengthen the supply and diversity of the health
    workforce and ensure access to high-quality care for all patients. The
    Association joins the Health Professions and Nursing Education
    Coalition in requesting $1.51 billion in funding for the Title VII
    health professions and Title VIII nursing workforce development
    programs in FY23. PAEA thanks the subcommittee for the opportunity to
    submit testimony and looks forward to the opportunity to serve as a
    resource to members and staff.

        [This statement was submitted by Kara Caruthers, MSPAS, PA-C,
    President, Physician Assistant Education Association.]
                                     ______

    Prepared Statement of the Physicians Committee for Responsible Medicine
        On behalf of the Physicians Committee for Responsible Medicine,
    thank you for the opportunity to submit this written testimony. The
    Physicians Committee is a nonprofit organization with more than 175,000
    members worldwide that works to make medical research more effective
    and ethical. As the subcommittee crafts the FY 2023 Labor, Health and
    Human Services, Education, and Related Agencies Appropriations bill,
    the Physicians Committee asks that you please consider the following
    provision to increase transparency and public accountability regarding
    research funded by the National Institutes of Health (NIH).
                                  the problem
        Research transparency and accountability are vital to ensure that
    the United States remains a global leader in medical research. While
    the governments of other countries-including the United Kingdom,
    Canada, and the entire European Union-collect and publish detailed
    information on the number of animals used in research and testing, the
    United States lags far behind. Estimates of the number of animals used
    each year in U.S. laboratories vary wildly-from 10 million to 110
    million \1\--and the vast majority of those animals are utilized by
    federally funded labs. The drastic difference in estimates demonstrates
    that accurate reporting is needed.
    ---------------------------------------------------------------------------
        \1\ Carbone, L. Estimating mouse and rat use in American
    laboratories by extrapolation from Animal Welfare Act-regulated
    species. Sci Rep 11, 493 (2021). https://doi.org/10.1038/s41598-020-
    79961-0.
    ---------------------------------------------------------------------------
        The U.S. commitment to the ``3Rs'' principles of refinement,
    reduction, and replacement of animals in research is described in the
    Guide for the Care and Use of Laboratory Animals,\2\ the use of which
    is required by the Public Health Service Policy. Integral to this
    commitment are the accurate counting of animals used in experiments and
    the accurate reporting of Federal funding dedicated to projects
    involving animals. It has been the NIH's policy since 1985 to collect
    an ``average daily inventory'' \3\ of vertebrate animals housed in
    research facilities that wish to receive agency funding. This
    ``average'' is highly inaccurate; it is only a crude estimate of how
    many animals are present in the facility on any given day, not an
    annual total, and facilities are only required to file such
    documentation every 4 years as part of an Animal Welfare Assurance.
    Further, copies of these documents are available to the public only
    through Freedom of Information Act requests, making large-scale
    tracking and accountability efforts impossible.
    ---------------------------------------------------------------------------
        \2\ National Research Council. 2011. Guide for the Care and Use of
    Laboratory Animals: Eighth Edition. Washington, DC: The National
    Academies Press. https://doi.org/10.17226/12910.
        \3\ National Institutes of Health, Office of Laboratory Animal
    Welfare. PHS Policy on Humane Care and Use of Laboratory Animals.
    https://olaw.nih.gov/policies-laws/phs-policy.htm.
    ---------------------------------------------------------------------------
                                  the solution
        Congress must improve the accuracy and transparency of animal use
    in federally funded research by instructing the NIH to do two things:
          1. NIH must provide a plan to Congress detailing how the agency
            will annually collect an accounting of vertebrate animals from
            all agency-funded researchers, organized by species and pain
            and distress category. The plan should also require the NIH to
            detail how it will provide public access to this information.
          2. NIH must also provide a plan for tracking and publishing
            information on NIH-funded projects involving the use of
            vertebrate animals. The NIH currently collects such information
            with every grant application using the Research & Related Other
            Project Information form, which asks applicants to answer
            ``Yes'' or ``No'' to the question ``Are Vertebrate Animals
            Used?'' \4\ Making the answer to this question searchable for
            each funded project via the NIH's Research Portfolio Online
            Reporting Tools website \5\ or a similar database is a vital
            step toward greater transparency of Federal research spending.
    ---------------------------------------------------------------------------
        \4\ National Institutes of Health. ``G.220--R&R Other Project
    Information Form.'' Accessed August 20, 2020. https://grants.nih.gov/
    grants/how-to-apply-application-guide/forms-e/general/g.220-r&r-other-
    project-information-form.htm.
        \5\ National Institutes of Health. ``RePORTER.'' Accessed February
    4, 2022. https://reporter.nih.gov/.
    ---------------------------------------------------------------------------
                                 recent history
        A similar requirement was included in the House-passed H. Rpt. 117-
    96 and the Senate draft FY 2022 committee report.\6\ However, the
    finalized text in the omnibus joint explanatory statement (JES) failed
    to include important specifics included in the aforementioned committee
    reports, and detailed in the requested language below, including the
    directives to (1) create plans for collecting and reporting animal
    numbers and species used and (2) identifying which NIH grants involve
    animals. Instead, the omnibus FY 2022 JES language requested a report
    from the NIH outlining a plan to ``increase the accuracy and
    transparency of the data collected'' and to detail ``how NIH will
    address any incomplete reporting of NIH-funded research with animals.''
    To ensure that the forthcoming report meaningfully achieves the goals
    described above, it is crucial that these specifics are restored.
    ---------------------------------------------------------------------------
        \6\ United States Senate Committee on Appropriations, ``Chairman
    Leahy Releases Remaining Nine Senate Appropriations Bills.'' https://
    www.appropriations.senate.gov/imo/media/doc/LHHSREPT_FINAL3.PDF.
    ---------------------------------------------------------------------------
                           requested report language
        ``Collection and Reporting of Animal Research Numbers and Agency
    Funding.--The Committee recognizes that Congress has long expressed an
    interest in reducing the use of nonhuman animals in NIH-funded research
    and replacing animals with valid, reliable alternatives. In the
    National Institutes of Health Revitalization Act of 1993, Congress
    first requested that the agency create a plan for doing so. The
    Committee also recognizes the scientific community's stated commitment
    to the ''three Rs'' of replacement, reduction, and refinement. Integral
    to that commitment are the accurate counting of animals used in
    research and testing and the accurate reporting of NIH funding
    dedicated to projects involving animals. The Committee recognizes that
    it has been NIH's policy since 1985 to collect an ''average daily
    inventory'' of vertebrate animals housed in research facilities that
    wish to receive agency funding. The Committee understands that domestic
    facilities are required to file such documentation every 4 years as
    part of an Animal Welfare Assurance and that copies of the documents
    are available to the public only through Freedom of Information Act
    requests. The Committee anticipates the report requested in the Joint
    Explanatory Statement for the Consolidated Appropriations Act, 2022
    (Public Law 117-103) outlining a plan to improve the accuracy and
    transparency of collected data. However, the Committee directs NIH to
    include in the forthcoming report how the agency plans to annually
    collect from each research facility that receives NIH funding the total
    number of animals bred, housed, and used in the previous year, sorted
    by species and pain and distress categories. Further, the Committee
    directs NIH to include in the report a draft form for collecting this
    information annually. NIH should also include details on how the agency
    will create a publicly accessible online database for dissemination of
    the information collected via the new annual forms. The Committee
    directs NIH to include in its report a plan for implementing a system
    that identifies which agency-funded projects involve the use of animals
    and makes the information publicly accessible. The Committee recognizes
    that NIH currently collects such information with every grant
    application using the Research & Related Other Project Information
    form, which asks applicants to answer ''Yes'' or ''No'' to the question
    ''Are Vertebrate Animals Used?'' NIH's plan should ensure that the
    answer to that question for each funded project is searchable via the
    Expenditures and Results module of NIH's Research Portfolio Online
    Reporting Tools website.''

        [This statement was submitted by Ryan Merkley, Director of Research
    Advocacy, Physicians Committee for Responsible Medicine.]
                                     ______

              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 fiscal year
    2023, we urge the subcommittee to adopt the following funding
    recommendations for agencies under its jurisdiction: $49 billion, NIH;
    $210 million, NCHS; $815 million, IES; and $814 million, BLS. In
    addition, we urge the subcommittee to accept report language,
    previously submitted, regarding population research programs and
    surveys supported by the National Institute on Aging and Eunice Kennedy
    Shriver National Institute on Child Health and Human Development at 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 $49 billion for the NIH, a $4.1 billion increase over the NIH's
    program level funding in fiscal year 2022. In addition, we urge the
    Committee to ensure that any funding for the new Advanced Research
    Project Agency for Health (ARPA-H), supplements the $49 billion
    recommendation for NIH's base budget, rather than supplants the
    essential foundational investment in the NIH. Finally, we urge that NIA
    and NICHD, as components of the NIH, receive commensurate funding
    increases (7.9 percent) in fiscal year 2023.
                          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 fiscal year
    2023, 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 fiscal year 2023, 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 and proceed with plans to
    integrate the population sciences into the Institute's Geroscience
    research agenda.
      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. Population scientists support NICHD exploring
    the use of existing and new mechanisms to enhance research regarding
    the effects of COVID on fertility trends and reproductive health
    overall and developing informed frameworks for conceptualizing and
    measuring social determinants of health, including structural racism.
    With additional funding in fiscal year 2023, the Institute could
    sustain its existing population research activities as well as pursue
    our field's recommendations regarding these additional research
    activities related to COVID and social determinants of health.
                     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 members of the Friends of NCHS,
    recommend the agency receive $210 million in fiscal year 2023, which is
    $30 million above its fiscal year 2022 appropriation, restoring the
    agency to its FY2010 inflation adjusted level. 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). 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. PAA and APC are
    especially supportive of NCHS using additional funding to improve the
    quality of vital statistics data to inform research regarding the
    underlying causes of mortality and health disparities across different
    population and geographies.
                           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 grateful to the subcommittee for providing the agency with steady
    increases since fiscal year 2018-especially after years of flat
    funding. We are also pleased that the subcommittee included language in
    its fiscal year 2022 report expressing support 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 are enthusiastic about the new NLSY cohort
    and urge the subcommittee to sustain its support for its development.
    We urge the subcommittee to provide BLS with $814 million in fiscal
    year 2023 and to adopt, once again, report language urging the agency
    to maintain its plans for a new NLSY cohort.
                     institute of education sciences (ies)
        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 an
    array of topics, such as linkages between educational access/attainment
    to health outcomes of specific populations, economic well-being, and
    incarceration rates. PAA and APC were pleased that Congress enacted a
    substantial, nearly 15 percent increase for IES in fiscal year 2022,
    which, in addition to investments in other priorities, will allow the
    agency to finally address longstanding staffing shortfalls. We were
    disappointed that the President's Budget Request (PBR) would reverse
    that investment by recommending an overall cut of 10 percent at IES.
    Although the National Center for Education Statistics (NCES) was not
    targeted for a cut per the PBR, we assume this is due to NCES not
    receiving an increase in fiscal year 2022. Adoption of the PBR line
    item for NCES would represent three consecutive years of flat funding;
    the last increase, enacted in fiscal year 2021, was less than 1 percent
    over fiscal year 2020. We therefore urge the committee to provide IES
    with at least $815 million in fiscal year 2023, an amount recommended
    by the Friends of IES, and to ensure that NCES receives an increase
    over its fiscal year 2022 level, $291.5 million.
        Thank you for considering our support for these agencies as the
    subcommittee drafts the fiscal year 2023 Labor, Health and Human
    Services and Education Appropriations bill.

        [This statement was submitted by Mary Jo Hoeksema, Director,
    Government and Public Affairs, Population Association of America/
    Association of Population Centers.]
                                     ______

                         Prepared Statement of PrEP4All
        On behalf of PrEP4All, thank you for the opportunity to comment on
    fiscal year (FY) 2023 appropriations for a National PrEP Program.
    Founded in March 2018, PrEP4All is an organization of community
    members, healthcare professionals, lawyers, and academics all dedicated
    to increasing access to lifesaving HIV medications. Every member of
    PrEP4All has been personally affected by the HIV epidemic, and most of
    us rely on HIV treatment and pre-exposure prophylaxis (PrEP)
    medications every day. As patients ourselves, we have all experienced
    the shortcomings in the domestic HIV response first hand.
        We are calling on Congress to allocate $400M for a National PrEP
    Program to the Department of Health and Human Services (HHS) in its
    FY23 budget, a necessary first step to implementing the ambitious
    reforms to PrEP access proposed in President Biden's FY23 budget.
        The nation will not meet the goals of its Ending the HIV Epidemic
    initiative without a new approach to PrEP. In 2019, nearly 37,000
    people in the U.S. were diagnosed with HIV. Black and Latinx/Hispanic
    individuals comprised 42 percent and 29 percent of new diagnoses,
    respectively. Despite the availability of PrEP--antiretroviral
    medication that if taken regularly drastically reduces the risk of
    acquiring HIV--since 2012, relatively few people in the U.S. are able
    to access it. In 2020, only 25 percent of people who could benefit from
    PrEP actually received it, with large and growing disparities by race,
    ethnicity, gender, and geography. Sixty-six percent of White Americans
    recommended for PrEP received a prescription in 2020, compared to only
    16 percent of Latinx/Hispanic Americans and just nine percent of Black
    Americans.
        A National PrEP Program must move away from a patchwork approach to
    access that requires uninsured individuals to navigate a set of
    separate and confusing programs for PrEP medications, labs, and
    necessary ancillary services. A National PrEP program must create
    simple pathways to PrEP access for those who need it most and engage a
    broader network of PrEP providers. Over 20 national HIV organizations
    have signed onto a letter supporting a National PrEP Program and
    calling for a program to be guided by the following core principles:
    accessibility, equity, simplicity, affordability, sustainability, and
    adaptability.
        We urge Congress to recognize the urgency of addressing the
    Nation's broken and inequitable PrEP financing and delivery system and
    allocate $400M for this program in its FY23 budget.
        Please reach out to me if I can be of any assistance; I can be
    reached at 185 Hall Street #105, Brooklyn, NY 11205,
    Jeremiah@PrEP4All.org.
        Sincerely.

        [This statement was submitted by Jeremiah Johnson, PrEP Project
    Manager, PrEP4All.
                                     ______

                    Prepared Statement of Prevent Blindness
        Chairman Murray, Ranking Member Blunt, and Committee Members: I
    appreciate the opportunity to submit testimony to the subcommittee on
    behalf of Prevent Blindness--the Nation's leading nonprofit, voluntary
    organization committed to preventing blindness and preserving sight for
    Americans of all ages, racial and ethnic backgrounds, communities, and
    socioeconomic circumstances. We stand ready to work with the
    subcommittee and Members of Congress to advance policies that seek to
    improve our Nation's vision and eye health.
        Prevent Blindness respectfully requests the following allocations
    in Fiscal Year (FY) 2023 to vision and eye health programs at the
    Centers for Disease Control and Prevention (CDC), National Center for
    Chronic Disease Prevention and Health Promotion:
      --$5,000,000 for Vision and Eye Health to conduct necessary national-
            level surveillance of vision impairment and eye disease, and
            continue state and community partnerships that promote early
            detection and access to eye care treatment; and
      --$4,000,000 for Glaucoma, which will help to achieve a reduction in
            the incidence of glaucoma in high-risk patient populations
            through screening, referral, and treatment.
        We are grateful to and applaud this Committee's recognition of the
    importance of the CDC's Vision and Eye Health program with an
    allocation of a much-needed increase in FY 2022. This new funding level
    of $1.5 million will better inform interventions--particularly around
    the social, economic, and environmental contexts as related to eye
    health care disparities--and allow for stronger integration of vision
    and eye health into current and ongoing community approaches around
    aging, childhood development, mental health services, referral to care
    and care coordination, and chronic disease prevention.
        In order to improve upon existing State- and community-based data,
    to fully capture what is happening at the National-level, and get ahead
    of the most serious consequences of preventable vision loss, Prevent
    Blindness respectfully calls on the Senate to build upon the
    investments made in FY 2022 with a total allocation of $5 million to
    the CDC's Vision and Eye Health program. This funding will serve two
    purposes:
          (1) It will allow the CDC to place ophthalmology examinations and
            visual content on The National Health and Nutrition Examination
            Survey (NHANES) and collect national-level examination-based
            data that will identify those who are unaware of their risk for
            vision loss or eye disease; thus, creating a much more accurate
            and authentic illustration of prevalence, and
          (2) Use this data to improve health equity through State and
            community partnerships by determining the burden of vision loss
            against demographic factors like racial or ethnic background,
            age, socioeconomic circumstances, geography, or health status
            and improving existing interventions to include these
            approaches to preventing vision loss and blindness.
        Currently, the CDC relies on a patchwork of best-available data
    pieced together through claims, registries, and self-reported national-
    level surveys. The 2005-2008 data set is the last collection of
    reliable, national-level prevalence estimates of vision impairment and
    eye diseases; meaning that our best available data on our National
    vision loss and eye disease burden is nearly 15 years old with current
    state and community interventions based on 10 to 14-year-old data. We
    cannot respond to the needs of patients who may not know that they are
    living with blinding eye disease, low vision, or vision loss using data
    that predates such trends as our rapidly aging population, skyrocketing
    rates of chronic disease, our National mental health crisis, new
    stresses to our eye health such as prolonged and frequent use of
    technology, and rising costs of health care. In the long term, not
    having this critical information base will create gaps in our knowledge
    of COVID-19 and other infectious diseases--the consequences of which
    may include gaps in research at the National Institutes of Health.
        Vision is a critical sensory enabler that allows us to live and
    function in our daily lives. From early in life as a part of childhood
    development and enabling readiness to learn in school, for adults who
    seek a sense of well-being through economic independence, pursuit of
    professional and personal interests, and recreational activities, and
    for older Americans to age healthfully and independently with a high
    quality of life and strong social connections, good vision enables all
    aspects of a productive, satisfying, engaging, and healthy life. New
    research published by CDC in 2022 estimates that the annual economic
    burden of vision loss and blindness was $134.2 billion, including over
    $40 billion in excess and potentially avoidable long-term care
    expenses, and $16.2 billion resulting from reduced labor force
    participation.\1\
    ---------------------------------------------------------------------------
        \1\ Rein DB, Wittenborn JS, Zhang P, et al. The Economic Burden of
    Vision Loss and Blindness in the United States. Ophthalmology. Apr
    2022;129(4):369-378. doi:10.1016/j.ophtha.2021.
    09.010.
    ---------------------------------------------------------------------------
        Forthcoming research, using the federally funded American Community
    Survey (ACS), the Behavioral Risk Factor Surveillance System (BRFSS),
    and available data from NHANES, has found that vision loss is strongly
    associated with social determinants of health and regional variation at
    the community level. That research illustrates that presenting vision
    loss is strongly associated with poor economic conditions, and could be
    addressed nationwide with additional support. Those with incomes lower
    incomes, educational attainment, food security were significantly more
    likely to have evaluated presenting vision problems or to self-report
    being blind or having serious difficulty seeing compared to those with
    higher incomes and educational attainment and those with fewer issues
    with food security. People living in rural areas were more likely to
    experience vision problems than their urban counterparts, as were
    unmarried persons (whether they were single, divorced, or widowed).
    Using ACS data, the research found that approximately 20% of the
    variation in self-reported vision problems was explained by community
    level differences beyond those described by economic and demographic
    variables in the ACS. Additional research is required to understand the
    social determinants of vision health at the community level, and to
    design public health programs that help all Americans maintain the
    highest level of vision possible.
        And yet, despite its significance, we tend to accept vision loss as
    inevitable to aging, a consequence of chronic disease, family history,
    personal risk, socioeconomic circumstances, or a result of under-
    development in childhood or adolescence. Vision loss and eye disease
    often come at significant cost to the patient and to our National
    health care system as they contribute to or worsen many conditions like
    diabetes, stroke, hypertension, cardiovascular problems, mental health
    concerns like anxiety, depression, social isolation, cognitive decline,
    and injury related to falls. Incidents of avoidable vision loss each
    represent a missed opportunity when considered that timely diagnosis
    and early treatment could prevent up to 98% \2\ of visual impairment
    and blindness in the U.S.
    ---------------------------------------------------------------------------
        \2\ Centers for Disease Control and Prevention, 2018: https://
    www.cdc.gov/media/releases/2018/a0726-vision-health.html.
    ---------------------------------------------------------------------------
        Unfortunately, vision loss and eye disease are often left on the
    margins of important policy conversations around social determinants of
    health, health equity, access to care including coverage and costs of
    obtaining eye care, and improving health outcomes, which creates a
    significant disadvantage in efforts to improve our National public
    health and lower personal and national health expenditures. Vision loss
    and eye disease are linked to numerous social determinants of health,
    including: lower income levels, lower levels of attained education,
    residence in low-quality housing or an unsafe neighborhood which limits
    physical activity and increases psychological distress, and inability
    to access care due to cost, lack of coverage, transportation issues,
    and refusal of services by providers. Lack of provider availability is
    a major complication in access to eye care as it is estimated that 721
    of 3,006 (roughly 24%) American counties have no ophthalmologist or
    optometrist,\3\ even as approximately one-fifth of the Nation's
    population lives in rural America and only 10% of the country's
    physicians currently practice in rural communities.\4\
    ---------------------------------------------------------------------------
        \3\ https://pubmed.ncbi.nlm.nih.gov/25602911/.
        \4\ https://www.ruralhealthweb.org/.
    ---------------------------------------------------------------------------
        A May 2021 \5\ analysis from the CDC and the NORC at the University
    of Chicago that summarizes these data sources, as well as data from the
    last use of visual content on NHANES from 1999--2008, has found that
    over 7 million in the U.S. are living with vision loss or blindness and
    1.62 million people who live with vision loss or blindness are under
    age 40. This same study determined that vision loss or blindness is 68%
    higher than previous published estimates, with higher prevalence among
    Black and Hispanic populations and women more than men. This data
    analysis is based on best estimates of vision loss only, and its
    authors conclude that examination-based information would create
    stronger national-level and State-based data that can lend better to
    more targeted efforts to prevent and treat vision loss and eye disease.
    ---------------------------------------------------------------------------
        \5\ https://jamanetwork.com/journals/jamaophthalmology/fullarticle/
    2779910?guestAccessKey= fb84d04c-a5f4-4753-a5f8-
    835f528ea50e&utm_source=For_The_Media&utm_medium=
    referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=051321.
    ---------------------------------------------------------------------------
        Our nation needs a strong, public health approach to vision and eye
    health that includes surveillance, evidence-informed early detection
    and interventions, public awareness and community-level education, and
    measures to address and eliminate barriers in access to eye care. will
    create a stronger understanding of how vision loss intersects with
    other chronic health conditions, population demographics, and social
    determinants of health. We urge the Committee to direct $5 million to
    the CDC's Vision and Eye Health program to ensure we are doing
    everything we can to protect Americans' vision and eye health.
                              glaucoma at the cdc
        Glaucoma is known as the ``thief sneak of sight'' due to its
    progressive nature that is often undetectable until changes to vision
    are noticed by the patient-which is often when vision loss has become
    irreversible and permanent. According to the National Eye Institute,\6\
    women account for 61% of glaucoma cases in the U.S. with black
    Americans over the age of 40 at highest risk for developing glaucoma.
    In addition, according to the CDC,\7\ Hispanics and Latinos are the
    largest and fastest-growing minority group in the United States, by
    2050, half of people living with glaucoma will be Hispanic or Latino.
    ---------------------------------------------------------------------------
        \6\ https://www.nei.nih.gov/learn-about-eye-health/outreach-
    campaigns-and-resources/eye-health-data-and-statistics/glaucoma-data-
    and-statistics.
        \7\ https://www.cdc.gov/visionhealth/resources/features/hispanic-
    latino-vision-health.html#::text
    =High%20blood%20pressure%20can%20cause,will%20be%20Hispanic%20or%20Latin
    o.
    ---------------------------------------------------------------------------
        Glaucoma is the second leading cause of blindness worldwide.
    Treatment has been shown to reduce the progression of visual field loss
    from glaucoma, but population-based studies suggest that even in
    developed countries, half of the people with glaucoma do not know that
    they have the disease. Because glaucoma is usually asymptomatic until
    the very late stages, affected individuals may not have a reason to
    seek eye care before the optic nerve is irreversibly damaged.
    Unfortunately, people in whom glaucoma is diagnosed late in the disease
    process are at greatest risk for going blind.
        There are two main pathways for high-risk minority populations to
    result in blindness due to glaucoma. The first is through low community
    resources, which leads to a lack of program funding, lack of
    transportation systems, and low paying jobs that do not provide
    adequate health benefits. Lack of program funding and lack of
    transportation converge directly on a lack of primary health care
    clinic locations, whereas low paying jobs includes the mediators of
    lack of education and lack of adequate healthcare coverage, to lack of
    available eye care providers that can provide treatment in a timely
    manner. A lack of access to health care providers leads directly to
    lower rates of routine screening for glaucoma. These lower screening
    rates cause delayed detection of glaucoma. A lack of eye care providers
    also leads to delayed treatment, even in the absence of lower screening
    rates. Delayed treatment for glaucoma causes higher rates of permanent
    vision impairment or blindness both directly and through a lack of
    treatment options. A lack of treatment options is also affected by a
    lack of healthcare, making it a major compounding factor.
        The second pathway for high-risk minority populations is a lack of
    education. A lack of education refers specifically to a lack of proper
    information of glaucoma risk and maintaining proper vision health. A
    lack of overall education likely compounds the effects of each link of
    the pathway. A lack of subject specific education leads to lower rates
    of routine glaucoma screening, delayed detection of disease during a
    treatable stage, and increased social isolation due to vision
    impairment. Social isolation is a compounding factor in reduced
    capacity to maintain one's health, be a productive member of society,
    and engage in appropriate physical activity.
        The pathways between high-risk minority populations and higher
    rates of vision loss due to glaucoma are complex, and there are many
    opportunities for intervention. The most promising intervention comes
    from a change in the location where glaucoma screening is performed.
    Until recently, the most reliable way to detect and initiate treatment
    of glaucoma was through a comprehensive eye examination performed by
    and optometrist or an ophthalmologist--something which data
    demonstrates is not done in this high-risk population. The advent of
    teleretinal eye screenings in a primary health care and community
    settings provide an increased opportunity to identify glaucoma in high-
    risk populations and properly refer individuals for treatment of this
    eye disease.
        Several research studies funded by the CDC since 2014 have
    initiated and refined the protocols for the addition of teleretinal
    vision screening services in primary health care and community settings
    of minority and underserved populations. As such, we ask the Committee
    to maintain the CDC's glaucoma program at $4 million in FY 2023, which
    will improve glaucoma screening, referral, and treatment particularly
    for populations that face disparity in access to glaucoma care through
    innovative, community-based approaches and models of care that connect
    glaucoma patients to sight-saving glaucoma care.
        Thank you.

        [This statement was submitted by David B. Rein, PhD, MPA, NORC, at
    the
    University of Chicago.]
                                     ______

                      Prepared Statement of ProvenTutoring
        As providers of scalable research-proven tutoring models designed
    to rapidly recover from the negative impact of COVID on student
    learning, we propose the following legislative language to encourage
    application of funds to needed approaches:
    Proposed Language
        High-Quality Tutoring.--The Committee notes that to address
    significant learning loss due to disruptions caused by Covid-19,
    particularly among historically disadvantaged students, many LEAs have
    dedicated Title I and other Federal resources to support academic
    tutoring. It is estimated that more than $3.6 billion in Federal relief
    funds could be spent on tutoring between 2022 and 2024. Research shows
    that using high-quality tutoring programs with evidence of
    effectiveness as defined in the 2015 ESSA law can have a significant
    impact on addressing learning loss. These integrated systems include
    three to five half-hour (or longer) sessions a week, delivered by a
    human tutor to a group of 1 to not more than 4 students at a time, and
    use a well-structured process, high-quality materials designed for
    tutoring during the school day, ongoing professional development and
    coaching for tutors, and assessment tools to benchmark student
    achievement. Proven tutoring models can close the gap and bring
    struggling students up to the level of their peers. The Committee
    encourages the Department to promote and provide technical assistance
    to LEAs to ensure the implementation of tutoring models that have
    evidence of effectiveness.
                                   background
    Introduction
        The educational crisis created by the pandemic and the
    unprecedented Federal funding to address it have generated widespread
    attention toward the most effective tool to accelerate learning:
    research-proven tutoring models. Now is the time to ensure districts
    are making solid investments of Federal dollars by encouraging the
    adoption of tutoring programs that have evidence of increasing student
    achievement. This outside witness testimony outlines the crucial
    features of high quality tutoring models and proposes language for the
    Committee to consider including in the FY 2023 budget to encourage the
    adoption of such tutoring models.
        Research shows that high-quality tutoring programs that have been
    evaluated and proven to improve student achievement can have a strong
    impact on learning loss when they are delivered by a human tutor during
    the school day. Therefore, funding that is available for tutoring
    should be invested in these models to ensure that tutoring is advancing
    an equitable learning recovery.
    Road-Tested Tutoring Models
        There is a critical need at the State and local levels for guidance
    around the characteristics and value of high-quality tutoring models.
    Dozens of State and district tutoring programs launched this year, but
    many lack crucial features: a replicable tutoring system, delivered by
    a human tutor during the school day, that has evidence of improved
    student achievement compared to a control group.
        A replicable tutoring system is essentially a road-tested model
    that possesses several interdependent, essential components:
      --Structured instructional process
      --High dosage format (3-5 times a week)
      --Professional development and ongoing coaching for tutors
      --High-quality materials designed for tutoring
      --A system of assessment and data collection tools for measuring
            student achievement
        Each component supports the other to ensure optimal impact on
    achievement. The professional development and coaching are specific to
    the program's procedures and materials. A system of regularly-scheduled
    assessments and data collection ensures that students are working at
    the appropriate levels and helps to move them through a program
    efficiently. The high dosage format ensures the program is delivered
    consistently, providing students with ongoing support.
        Road-tested models are distinct from other tutoring initiatives
    because they have been shown to make meaningful gains in student
    achievement in studies that meet the evidence standards of the Every
    Student Succeeds Act (ESSA). Tutoring during the school-day with
    proven, integrated models can double the rate of growth in reading
    skills for struggling readers--students tutored for half a year can
    grow a full year more in reading skills than similar students not
    receiving tutoring. Similar growth is possible in secondary math. With
    evidence of effectiveness, these models provide the greatest promise of
    impact.
    A Human Tutor
        Human tutors are a crucial component of effective tutoring
    programs. An invested, trained, and qualified tutor can develop a human
    connection with a student in the way that a technology platform never
    can, can answer questions on the spot, and can adapt instruction to
    address student needs. The human connection can provide students with
    emotional support and bring joy to the process. Successful tutors can
    be paraprofessionals employed by the school or external staff. When
    they are highly trained and guided by an evidence-based program, tutors
    support the classroom teacher in their efforts to accelerate learning
    for struggling students. Online tutoring platforms are tempting for
    many districts because they are affordable and easy to adopt, but a
    large number of students who need the intervention do not engage with
    these platforms. Human tutors provide structure, consistency, and the
    in-person connection that students lost during the pandemic. Of course,
    human tutors can serve in-person, or can connect remotely to students
    in the schools on platforms designed to recreate in-person
    relationship-based tutorials.
    School Day Tutoring
        In order for tutoring to be delivered consistently and reach the
    students who need it the most, it must be conducted during the school
    day. Out-of-school time tutoring contends with issues of attendance and
    students having to ``opt-in'' to the intervention. Embedding tutoring
    during the school day guarantees access to the students who need it,
    particularly those students who have been disproportionately impacted
    by the pandemic.
    Signatories:
        Nancy Madden, Founder of ProvenTutoring, Professor, School of
    Education, Johns Hopkins University
        Alan Safran, CEO and co-founder, Saga Education
        Dr. Claire Hagen Alvarado, Director, Literacy First at UT Austin
        Kate Bauer Jones, Executive Director, Future Forward Literacy
        Julie Wible, Executive Director, Success for All Foundation
                                     ______

          Prepared Statement of the Pulmonary Hypertension Association
          pha's fiscal year 2023 l-hhs appropriations recommendations
    _______________________________________________________________________

      --At least $49 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 FY2023 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 FY 2023.
                         national institutes of health
        Please provide NIH with meaningful increases--including at least
    $49 billion in program funding in FY 2023--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 acces
        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 3-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 percent chance of survival over the next 5
    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 FY 2023 L-HHS Appropriations bill.
                                     ______

            Prepared Statement of Rebuilding America's Middle Class
        On behalf of (RAMC), a coalition of State and individual community
    college systems from across the Nation--representing over 120 colleges
    and 1.5 million students, I appreciate the opportunity to provide
    written comments on the funding in the fiscal year 2023 Labor, Health
    and Human Services, Education and Related Agencies (LHHS)
    appropriations bill that is essential to community colleges and the
    students that we serve.
        Community colleges have an unparalleled commitment to
    accessibility, which encourages traditionally underrepresented
    audiences to pursue a college degree. We serve 45 percent of all first-
    time freshmen, and 40 percent of our students are the first in their
    family to attend college. Forty two percent of all African American
    undergraduates, nearly half of all Hispanic undergraduates, and 56
    percent of Native American undergraduates attend community colleges.
        Community colleges are open access, seek to make higher education
    accessible and affordable for everyone, and matches employers' need for
    a larger, more diverse workforce. Preparing more Americans to enter the
    workforce with the skills necessary to compete for in-demand jobs,
    especially during difficult economic times, is a top priority for all
    RAMC members. With this in mind, we make the following recommendations
    to improve Federal financial aid policies to support community college
    students, particularly those from nontraditional background who
    continue to rely on our schools for access to higher education:
    Increase the Maximum Pell Grant.
        RAMC members believe that the Pell Grant program is the key to
    ensuring low-income students can afford college. Community colleges are
    the most affordable of the many options facing students; yet, even at
    our institutions, low-income community college students overwhelmingly
    rely on this critical Federal student aid program. Even with our low
    tuition institutions, Pell grants allow such students to afford books
    and supplies and help with housing, childcare, food and other basic
    needs. For these reasons we urge the subcommittee to adopt the
    discretionary portion of the Administration's call for a $1,775
    increase in the maximum Pell grant as part of the President's fiscal
    year 2023 budget request.
        We also strongly support the expansion of Pell to cover short-term
    certificates that open pathways to high paying employment options.
    While we are working closely with the House and Senate Conference
    Committee on the United States Innovation and Competition Act to
    maintain House language on this matter, we welcome the opportunity to
    work with that conference Committee or the House and Senate
    appropriations committee to achieve this important policy goal. The
    expansion of Pell to allow short-term credentials will provide an
    immediate boost to a significant number of our students focused on
    obtaining the workforce skills they need to earn middle class incomes.
    Increase Career Technical Education State Grants.
        The Administration's fiscal year 2023 request proposes to decrease
    CTE State Grants by $25 million compared to the fiscal year 2022 level.
    RAMC believes that career and technical education certificates and
    degrees provide essential value to those that earn them. Accordingly,
    RAMC believes that Congress should again provide an increase in funding
    to the CTE grant program as part of the fiscal year 2023 appropriations
    process.
    Support the Title III Strengthening Institutions Program.
        The fiscal year 2023 budget request includes an increase of $98.9
    million for the Strengthening Institutions Program (SIP). RAMC
    institutions utilize SIP funds to increase student retention, provide
    enhanced faculty professional development and expand access to high-
    demand STEM programs through the conversion of high-demand courses. We
    strongly support the Administration's request for an increase and urge
    the subcommittee to include it in the fiscal year 2023 LHHS
    appropriations bill.
    Expand Strengthening Community Colleges Program.
        The Strengthening Community College Training Grant program provides
    vital capacity building resources at community colleges to build
    training programs that partner with industry. Community colleges are
    always at the forefront of developing and supporting education and
    training opportunities that enable individuals to acquire the skills
    they need to obtain jobs for which businesses are hiring. The
    Administration's budget calls for a $55 million increase for this
    initiative. RAMC supports this increase and urges the subcommittee to
    include it in the fiscal year 2023 LHHS appropriation bill.
    Support Apprenticeships and Innovative Partnerships.
        As community college leaders, RAMC members are at the forefront of
    working to expand apprenticeships and create opportunities for students
    to earn while they learn. As such, we applaud the fiscal year 2023
    proposal that includes $303 million for the Apprenticeship Program, an
    increase of $68 million above the fiscal year 2022 funding level. We
    support the President's proposal and would urge the subcommittee to
    consider the $68 million increase for this program in the fiscal
    Year2023 appropriations process.
        Thank you for your consideration of our comments. RAMC members
    stand ready and willing to help you in any way we can as the fiscal
    year 2023 Appropriations process moves forward.

        [This statement was submitted by Dr. Monty Sullivan, President,
    Rebuilding America's Middle Class: A Coalition of Community Colleges.]
                                     ______

                   Prepared Statement of Refugee Council USA
        Chairwoman Murray, Ranking Member Blunt, and members of the
    subcommittee, thank you for this opportunity to submit these funding
    and oversight recommendations for Fiscal Year (FY) 2023 on behalf of
    the 29-member organizations of Refugee Council USA (RCUSA) dedicated to
    refugee protection, welcome, and integration and representing the
    interests of refugees, refugee families, and volunteers and community
    members across the country who support refugees and resettlement. RCUSA
    recommends FY 2023 funding levels of $9,991,000,000 for the Department
    of Health and Human Services' (HHS) Refugee and Entrant Assistance
    (REA) account.
        The REA account funds the Office of Refugee Resettlement (ORR)
    within HHS' Administration of Children and Families (ACF). ORR funding
    provides critical Federal investments in the States and local
    communities that welcome refugees and is a crucial component of
    fostering refugee integration and economic contributions. In addition
    to new refugee arrivals, ORR provides essential services to refugees
    who have arrived in recent years, asylees, Cuban and Haitian Entrants,
    Iraqi and Afghan recipients of Special Immigrant Visas (SIVs),
    trafficking and torture survivors living in the United States, certain
    Amer-Asians, Afghan humanitarian parolees who arrived under Operation
    Allies Welcome, and unaccompanied refugee and immigrant children.
        RCUSA recommends an increase for the Transitional Medical
    Assistance (TAMS) program to $2,530,000,000 to fund critical initial
    assistance to refugees and other new arrivals, programs for vulnerable
    unaccompanied refugee children, and the highly effective Matching Grant
    program, which leverages public funds with private donations,
    empowering refugees to secure employment within 6 months. RCUSA also
    recommends increases for Refugee Support Services (RSS) programs to
    $1,400,000,000; for domestic and foreign-born trafficking survivor
    services to $50,000,000; for torture survivor assistance to
    $28,000,000; and for unaccompanied children to $5,100,000,000. We also
    recommend the creation of an emergency contingency fund for needs
    across ORR-eligible populations appropriated at $100,000,000.
        In addition, we recommend new funding for family reunification for
    separated asylum-seeking families ($533,00,000) and legal
    representation needs for Afghans evacuated to the U.S. under Operation
    Allies Welcome ($250,000,000).
    Robust Appropriations to Support the Rapid Rebuild and Expansion of the
            Resettlement Network
        Throughout the previous administration, the U.S. Refugee Admissions
    Program (USRAP) was steadily dismantled: refugee admissions decreased
    by 80 percent and one-third of all resettlement offices in the U.S.
    closed. From the outset, the Biden administration committed to
    rebuilding a robust and innovative USRAP and set an ambitious refugee
    admissions goal of 125,000 for FY 2022. There were soon new and urgent
    demands on resettlement service providers: following the U.S. military
    withdrawal from Afghanistan, over 75,000 U.S.-affiliated and at-risk
    Afghans have been welcomed into the United States under Operation
    Allies Welcome. The domestic network of resettlement agencies was
    quickly mobilized to receive and support the integration of this newly
    arrived Afghan population. There are currently 271 resettlement offices
    providing Reception & Placement (R&P) services to refugees--an over 35
    percent increase from 199 offices at the beginning of 2021.
        Six of the nine voluntary agency networks are faith-based and
    harness the energy of many faith communities to help welcome newcomers
    to their new communities. These community organizations ensure the
    provision of a core set of services during someone's first months in
    the U.S., including the provision of food, housing, clothing,
    employment services, follow-up medical care, and other necessary
    services. After this initial period, ORR funds integration services
    through both the States and resettlement providers around the country.
        Once refugees arrive in the U.S., they are supported in orienting
    to their new community, learning English, enrolling their children in
    school, and finding employment. With this crucial support, they often
    are not only able to support themselves and their families but also
    become contributors to their new communities, integrating with and
    bringing innovation to our neighborhoods. The following highlights
    critical needs within the REA account but does not include all program
    activities:
    Legal Services for Afghans Arriving Under Operation Allies Welcome
        The needs of newly arrived Afghan evacuees are distinct from other
    groups served by ORR. Unlike immigrant visas or the refugee program,
    humanitarian parole is not a pathway to permanent status; it is a
    temporary allowance to enter and remain in the United States. As such,
    Afghans who have been or will enter the U.S. with humanitarian parole
    under Operation Allies Welcome find themselves under a cloud of legal
    uncertainty and must seek an existing immigration pathway in order to
    remain in lawful status once their parole expires. In all likelihood,
    many will need to pursue asylum. This is a complex legal process for
    any immigrant to navigate, let alone for the many Afghans who arrived
    with little more than the clothes on their backs. It is essential that
    these Afghan neighbors have access to reliable legal counsel to assist
    them in their immigration process.
        While resettlement agencies across the country are practiced at
    assisting refugees in adjusting their immigration status, requiring
    their existing legal service providers to assist with hundreds of
    asylum applications--simultaneously--will overburden available
    resources. Resettlement agencies do not have enough Department of
    Justice accredited representatives and on-staff immigration attorneys
    to meet this need. Indeed, even with legislation to provide a pathway
    to lawful permanent residency, such as an Afghan Adjustment Act, the
    reliance on these providers will be substantial.
        As such, RCUSA is recommending $250,000,000 for legal
    representation needs for Afghans evacuated to the U.S. under Operation
    Allies Welcome.
    Trauma-Informed Care for Unaccompanied Children
        Unaccompanied children (UC) are immigrant children who arrive in
    the U.S. without legal guardians and who require special protections.
    Care for unaccompanied children is mandated by the Trafficking Victims
    Protection Reauthorization Act (TVPRA) and governed by the TVPRA, the
    Homeland Security Act of 2002, and the Flores Settlement Agreement. ORR
    is the legal caretaker of unaccompanied children until they can be
    reunited with family. ORR funds a network of shelters where UC stay
    while reunification happens and ORR's primary goal is the safe and
    secure placement of each child with a sponsoring family.
        In FY 2021, 121,000 unaccompanied children arrived in the United
    States, an all-time high. RCUSA's recommendation of $5,100,000,000 will
    provide for an increased number of beds in licensed facilities. The
    increased arrivals over FY 2021 led to the use of both influx
    facilities and Emergency Intake Sites due to lack of online licensed
    bedspace. While the pandemic took many beds offline, ORR still needs to
    increase licensed placements. This funding will allow the necessary
    network growth in small-scale shelters, which are much better suited to
    meeting the needs of UC.
        This critical funding will also provide universal access to post-
    release services (PRS) for both children and their sponsors. Post-
    release services are bridging services that assist children and
    sponsors adjust to their new lives together after reuniting. We know
    that trauma responses from migration or home-country experiences often
    manifest after the initial ``honeymoon'' period ends, and access to
    social workers and community services is critical in these cases.
    Historically, around 25 percent of UC have received PRS; ORR intends to
    provide these services to 85 percent of UC in FY22 and 100 percent of
    UC by FY23.
        RCUSA does not support an expansion of detention, including through
    large-scale institutional facilities, or efforts to support forced
    family separation.
                                     ______

                     Prepared Statement of Research!America
        On behalf of Research!America's alliance, which advocates for
    science, discovery, and innovation to achieve better health for all,
    thank you for this opportunity to share our views on Fiscal Year 2023
    (FY23) appropriations under the jurisdiction of the subcommittee on
    Labor, Health and Human Services, Education, and Related Agencies.
        And, to all members of the subcommittee, thank you for all your
    work to include strong FY22 funding levels for critically important
    Federal health research agencies, including the National Institutes of
    Health (NIH), the Centers for Disease Control and Prevention (CDC), and
    the Agency for Healthcare Research and Quality (AHRQ); and for
    including funding to get ARPA-H off the ground. We were also so pleased
    that the subcommittee was able to include language naming the Roy Blunt
    Center for Alzheimer's Disease and Related Dementias Research Building
    in the FY22 Omnibus Appropriations Act.
                       the national institutes of health
        We are particularly concerned about funding for the National
    Institutes of Health. While there were many positive provisions in the
    President's FY23 budget proposal, Research!America was deeply
    disappointed by the shockingly low (0.6% percent) funding increase
    included for the NIH. We recommend that the subcommittee allocate at
    least $49.1 billion, an increase of $4.1 billion over FY22, for our
    Nation's flagship research institution. This funding level, inclusive
    of 21st Century Cures funding, would empower NIH to grow the number of
    progress-fueling grants the Institutes can support. The American people
    need and value fast-paced medical progress, which cannot be
    accomplished without funding barrier-breaking, foundational research.
        The NIH is the world's leading funder of basic biomedical research,
    and Americans recognize the value of this research. Since 1992,
    Research!America has commissioned national and State-level surveys to
    assess public sentiment on issues related to research and innovation.
    According to a January 2022 national survey commissioned by
    Research!America, 85% of Americans believe it is important for Congress
    and the President to prioritize achieving faster medical progress.
    Americans want medical progress, and they want the U.S. to drive it.
        NIH awards more than 80% of its funding in the form of 50,000
    competitive grants to more than 300,000 researchers at over 2,500
    universities, medical schools, and other research institutions in every
    State and around the world. Research supported by NIH is directed at
    the early, non-commercial stages of the research pipeline, which
    complements later-stage research funded primarily by the private
    sector. NIH-funded research fuels the entry of new drugs into the
    market, providing an estimated return to public investment of $1.43 for
    every dollar invested. Among its many success stories, the NIH
    supported research which helped create the first kinases-targeted
    category of cancer treatment drugs, launching a new wave of drug
    development targeting similar molecules to treat cancer and other
    diseases. In the case of the COVID-19 pandemic, the NIH had already
    invested in research to develop vaccine platforms, which enabled it to
    jumpstart development of powerful COVID-19 vaccines and treatments once
    the pandemic hit.
        NIH advances our Nation's interests in other important ways. For
    example, the All of Us Research Program at NIH is advancing the largest
    clinical trial in our Nation's history to accelerate precision medicine
    and advance a host of other medical and health research objectives. NIH
    has also prioritized diversity, equity, inclusion, and accessibility
    through its implementation of its NIH Cross-agency DEIA Strategic Plan.
    Its Human Genome Project has produced $1 trillion of economic growth-a
    178-fold return on investment. The Helping to End Addiction Long-term,
    or HEAL, Initiative is conducting interdisciplinary research to end the
    opioid epidemic. The National Institute of Aging supports research on
    the health and well-being of older Americans and, through its
    Alzheimer's Disease Education and Referral Center, provides information
    on age-related cognitive changes and neurodegenerative disease. The
    Accelerating Medicines Partnerships combines contributions from both
    private and public sectors to streamline collaboration between the NIH,
    FDA, life science companies, and non-profit organizations working to
    develop treatments for Alzheimer's, Type 2 diabetes, rheumatoid
    arthritis, lupus, and Parkinson's disease. The NIH also invests in
    educating and training America's future scientists and medical
    innovators by sponsoring training grants and fellowships for
    biomedical- and health-focused graduate and medical students,
    postdoctoral researchers, and young investigators.
                the advanced research projects agency for health
        Research!America is grateful to members on both sides of the aisle
    for providing $1 billion in FY22 to stand up this new agency. We
    support the goal of developing ARPA-H into an entity that supports high
    risk, high reward public-private R&D, and we support an FY23 funding
    allocation of $5 billion for ARPA-H that complements but does not
    supplant funding for the NIH.
        By funding transformative high-risk, high-reward research, ARPA-H
    has the potential to drive biomedical and health breakthroughs-ranging
    from molecular to societal-to revolutionize treatments for all
    patients. This health innovation incubator, modeled after DARPA and
    ARPA-E, will empower the public and private sector to pursue
    transformative, cross-disease R&D advances. We believe ARPA-H can bring
    about progress that saves millions of lives around the globe while
    significantly strengthening U.S. competitiveness in the global economic
    arena.
                 the centers for disease control and prevention
        The threats posed by COVID-19, Ebola, Zika, dengue fever,
    influenza, the opioid epidemic, measles outbreaks, and other emerging
    health threats have demonstrated the critical role the CDC plays in
    protecting Americans. They have also revealed the enormity of
    challenges the agency faces as it works to safeguard American lives. To
    protect our Nation, CDC scientists must be on the ground fighting
    public health challenges wherever and whenever they occur. We recommend
    an allocation of at least $11 billion for the CDC in FY23, an increase
    of $2.6 billion over FY22, to carry out its crucially important
    responsibilities.
        The CDC is tasked with protecting and advancing Americans' health.
    Over the past 70 years it has worked diligently to thwart deadly
    outbreaks, costly pandemics, and debilitating disease. The CDC also
    plays a key role in research that leads to life-saving vaccines,
    bolsters our Nation's response to the opioid crisis, and improves
    health tracking and data analytics.
        The CDC's work has benefited Americans in a myriad of ways. For
    example, the CDC has successfully eliminated the endemic spread of
    rubella within the United States; played a lead role in addressing the
    growing threat of antibiotic resistance; dramatically reduced the
    incidence of child lead poisoning; addressed disparities in health and
    health care; tracked and contained dangerous pandemics and epidemics;
    reduced deaths from motor vehicle accidents; and expanded newborn
    hearing and other screening tests,
                 the agency for healthcare research and quality
        AHRQ is the lead Federal agency responsible for ensuring medical
    progress translates into better patient care. This investment improves
    the care received by patients and saves taxpayer dollars. We recommend
    the subcommittee allocate $500 million for the AHRQ in FY23, a 30%
    increase over FY22.
        AHRQ has a proven track record in using evidence-based approaches
    to improve health care delivery. Using AHRQ's research and how-to
    tools, the U.S. health care system prevented 1.3 million errors, saved
    50,000 lives, and avoided $12 billion in wasteful spending from 2010 to
    2013. For example, AHRQ-funded research has contributed to infection
    control strategies in long-term care facilities by identifying
    methicillin-resistant Staphylococcus aureus (MRSA) in these facilities.
    AHRQ-funded research has played a pivotal role in reducing hospital-
    acquired infections by nearly 1 million from 2014-2017. It has made
    important contributions to patient-centered outcomes research (PCOR) by
    investing in PCOR method training grants, including PCOR application in
    opioid use disorder, and by promoting the implementation of PCOR in
    clinical decision making.
        We appreciate your consideration of our funding requests and thank
    you for your stewardship over these critically important Federal
    spending priorities. Please call on us if we can be of any assistance.
    Contact: Sheila Murphy, Senior Policy and Advocacy Officer,
    Research!America, smurphy@researchamerica.org.
        Sincerely.

        [This statement was submitted by Mary Woolley, President and CEO,
    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) 2023
    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 standard 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 medication; a class of medication used when all other
    drug classes have failed due to augmentation, inadequate efficacy, or
    adverse side-effects. Research and clinical experience indicate 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.
                     fy 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 2023 to bring NIH's budget up to $49
    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 $6,000,000 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, even though 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 opioid therapy 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 72 hour psychiatric hold and sent me to a psychiatric 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 the Rotary Foundation
        Chairwoman Murray, Ranking Member Blunt, and members of the
    subcommittee: Rotary appreciates the opportunity to encourage
    continuation of funding for FY 2023 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),\1\ 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
    $276 million for the polio eradication activities of the CDC to
    capitalize on the historic opportunity of unprecedented low levels of
    endemic polio virus transmission which is simultaneously threatened by
    the diversion of critical resources toward the COVID-19 pandemic. These
    funds will support the GPEI's immediate priority of stopping all form
    of polio virus transmission through procurement of vaccines, including
    the recently introduced novel oral polio vaccine, a new tool that is
    being rolled out to accelerate control of circulating vaccine derived
    polio. These funds will also provide vital support for surveillance
    activities which provide confidence in both the presence and absence of
    polio virus transmission.
    ---------------------------------------------------------------------------
        \1\ The Global Polio Eradication Initiative (GPEI) is a partnership
    led by Rotary International, the Centers for Disease Control and
    Prevention (CDC), the World Health Organization (WHO), the United
    Nations Children's Fund (UNICEF), the Bill and Melinda Gates
    Foundation, and Gavi, the Vaccine Alliance.
    ---------------------------------------------------------------------------
        The 300,000 members of Rotary clubs in the U.S. appreciate the
    United States' generous support and longstanding leadership toward a
    polio free world. Rotary, including matching funds from the Gates
    Foundation, has contributed more than $2.4 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
    U.S. leadership will help achieve a polio free world and ensure the
    continued global health contribution of polio eradication
    infrastructure and resources.
     unprecedented progress presents the best opportunity we have ever had
                             to achieve eradication
        Since the launch of the GPEI in 1988, eradication efforts have led
    to more than a 99.9 percent decrease in cases. Thanks to this
    committee's support, 20 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 2021, for the first time in history, there were no cases of wild
    polio virus in the entire world for more than 7 months. In addition,
    Pakistan didn't record a new case of wild polio virus for over a year.
    Wild poliovirus polio incidence hit an all-time low in 2021 with only
    five cases recorded in the two remaining endemic countries of Pakistan
    and Afghanistan- a 96 percent reduction from 2020.
        Outbreaks of circulating vaccine derived polio virus (CVDPV) which
    affected more than 20 countries in 2020 are being brought under control
    with fewer cases in fewer places in 2021 as compared to 2020 (638 cases
    in 22 countries for 2021 vs 1087 cases in 26 countries in 2020). The
    novel oral polio vaccine type 2 (nOPV2) is also being introduced to
    accelerate progress in bringing these outbreaks under control.
        Despite this progress, the GPEI and countries it supports face
    significant challenges. In February 2022, a 3-year-old girl from Malawi
    was confirmed as having contracted the first case of wild polio in
    Africa since 2016. The virus that infected the child in Malawi was of
    Pakistani origin underscoring the fact that as long as polio exists
    anywhere, it is a threat everywhere. Fortunately, the case in Malawi
    does not change Africa's status as a region certified free from wild
    poliovirus because the virus originated in Pakistan and is considered
    to be an imported case as opposed to locally circulating/endemic virus.
    In April 2022, Pakistan reported its first cases of wild poliovirus
    (WPV1) in nearly 15 months. The ongoing COVID-19 pandemic continues to
    hamper the efforts of countries to sustain high levels of population
    immunity which poses increased risk for outbreaks at a time of
    unprecedented constraints on human and financial resources on the
    ground and from the global community. Conflict and instability also
    jeopardize progress, hampering efforts to organize and conduct polio
    eradication activities. These challenges threaten thirty years of
    progress and the cumulative U.S. investment of U.S. $4.2 billion which
    has brought us to the threshold of a polio free world.
        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.
        Essential technical capacity and program management expertise: CDC
    directly contributes to polio eradication activities and is also used
    to build in-country capacity. This includes the international
    assignment of technical staff on direct 2-year assignments to WHO and
    UNICEF to assist polio-endemic and polio-reinfected priority countries.
    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 2021, STOP has trained
    and deployed more than 2,200 public health professionals to work on
    polio surveillance, data management, campaign planning and
    implementation, program management, and communications in high-risk
    countries. STOP also provided support to 42 countries on responding to
    COVID-19 in 2020-2021.
        Vital Country-level Capacity: In Pakistan, CDC supported 81
    National Stop the Transmission of Polo (NSTOP) officers for the
    Expanded Program on Immunization (EPI), and data usage and risk
    assessment officers distributed in 66 very high, high, and medium risk
    communities in 3 provinces, and 10 managers/officers to support the
    National Ministry of Health.
                        fiscal year 2023 budget request
        Rotary respectfully requests $276 million in FY 2023 for the polio
    eradication activities of CDC. These funds will ensure that CDC
    provides technical and management expertise in polio endemic, outbreak
    and at-risk countries; builds country level capacity to build
    population immunity to prevent future outbreaks as well as capacity to
    quickly identify and respond to outbreaks.
        Increased funding is needed to address three specific areas
    critical to protecting existing progress and capitalizing on the window
    of opportunity to stopping transmission of all polio viruses: Outbreak
    Response, Surveillance and Vaccine Procurement.
    Outbreak Response
        Increased funding is needed to maximize the effectiveness of
    outbreak response campaigns and fully leverage the use of nOPV2 through
    improvements in response planning, execution and monitoring to ensure
    rapid, high-quality activities including those which:
      --utilize and expand existing in country government coordination
            mechanisms to establish polio control rooms, enabling the use
            of real-time data for decision-making and an incident
            management structure to streamline emergency operations;
      --accelerate emergency outbreak response through the establishment of
            incident command structures at global, regional and country
            level to guide and direct outbreak response;
      --digitize the entire outbreak response, from planning to campaign
            monitoring and utilizing an evidence-based approach for clear
            assessments of response coverage and quality, including age-
            and sex disaggregated monitoring data; and
      --ensure a stronger role for women in outbreak response operations
            through increased participation in outbreak response oversight,
            management, supervision and delivery.
    Surveillance
        Additional funding will support the expansion of surveillance
    activities which provide confidence in both the presence and absence of
    polio virus transmission, and specifically to:
      --implement a new direct detection strategy and augment investment in
            lab infrastructure and data information management to increase
            regional and country capacity to detect and respond to
            outbreaks and improve the quality and timeliness of
            surveillance, and
      --expand active surveillance, enhance the use of community-based
            surveillance in hard to reach areas; and expand use of
            environmental surveillance.
    Vaccine Procurement
        Additional funds will support procurement of vaccines, including
    the recently introduced novel oral polio vaccine (nOPV2), a tool that
    is being rolled out to accelerate control of circulating vaccine
    derived polio. Twenty-five countries are already qualified to use this
    vaccine, 12 have already conducted campaigns and up to forty countries
    are preparing for use of this vaccine.
                        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 U.S. $417
    million of the more than U.S. $2.4 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 priorities from the community level to the National
    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. Investing in polio eradication now may
    cumulatively save an estimated $33.1 billion by 2100 in the form of
    reduced costs of surveillance and vaccination. The costs to control
    polio at today's low levels, plus costs to treat the survivors, would
    be over U.S. $1 billion per year for decades to come. Without
    investment now, by 2032 the world would be spending more to control the
    virus. 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 $19 billion already invested in eradication. Success will
    ensure that the investment made by the U.S., Rotary International, and
    many other countries and entities, is protected in perpetuity.
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
        Chairwoman Murray, Ranking Member Blunt, and members of the
    subcommittee, my name is Dr. Jehan Budak and I serve as the Assistant
    Medical Director and as an HIV primary care physician for the Madison
    Clinic at Harborview Medical Center in Seattle, Washington. I am
    pleased to submit testimony on behalf of the Ryan White Medical
    Providers Coalition (RWMPC), for which I serve as a Steering Committee
    member. 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) in the Department
    of Health and Human Services.
        First, I would like to thank the subcommittee for increasing FY22
    funding for several of the Ryan White Program parts that support access
    to HIV care and treatment, as well as increasing funding for the Ending
    the HIV Epidemic (EHE) initiative at both the HIV/AIDS Bureau and the
    Bureau of Primary Health Care at HRSA. These increases will help ensure
    access to effective, comprehensive HIV care and treatment through the
    Ryan White Program nationwide as well as support target EHE initiative
    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. Increasing funding for
    the Ryan White Program parts in FY23 would help jurisdictions
    nationwide continue to deliver comprehensive, effective HIV care and
    treatment as well as engage and retain new patients in a challenging
    environment impacted by rising care and workforce costs. To sustain and
    expand these critical services, I request $231 million (a 12 percent or
    $25.5 million increase) in FY23 for Ryan White Part C, which supports
    approximately 350 HIV medical clinics nationwide.
        RWMPC also requests additional resources for the EHE initiative to
    expand access to HIV prevention, care, and treatment, including $462.3
    million for HRSA's EHE program. This funding would include $290 million
    for the Ryan White Program EHE initiative to provide additional HIV
    care and treatment, as well as $172.3 million for the Bureau of Primary
    Health Care EHE intiative 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 FY23 budget
    request.
        It is important that increases for Ryan White Part C and for the
    EHE initiative be new, additional funding and not a repurposing of
    current resources. The additional pressure on the medical and public
    health infrastructure in the wake of the COVID-19 pandemic, 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 with HIV. Ryan White clinics were critical to responding to
    COVID-19 and many Ryan White medical providers were pulled in as
    leaders of the pandemic response in their jurisdictions. This worked
    well as these providers are infectious diseases experts with
    significant experience caring for vulnerable populations. These same
    providers also have been key to addressing the overdose crisis in their
    regions as well as increasing viral hepatitis and sexually transmitted
    infections, all which intersect with the domestic HIV epidemic.
        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 as
    well as the escalating overdose crisis. Part C clinics have helped
    people living with HIV by sustaining access to health care and
    medication through telehealth and other services, such as case
    management and transportation; by enrolling new patients who have lost
    health insurance as a result of economic disruption; and by providing
    overdose prevention and behaviroal health care to patients living with
    HIV and mental health and/or substance use disorders.
    Madison Clinic at Harborview Medical Center in Washington State 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 over 3,000 individuals
    with HIV, most with complex medical and psychosocial needs.
    Approximately 30 percent of our population is Black or African American
    (Seattle overall has 7 percent Black representation), 15 percent is
    Latinx, and 10 percent is Asian, Pacific Islander, or Native American.
    47 percent 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 percent 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 percent of patients lack permanent
    housing, and many patients were negatively impacted by the intersection
    of housing instability; the opioid and other drug crisis 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 to approximately 500 individuals at risk for
    HIV. 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 provide incentivized,
    drop-in 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 is infectious, so identifying,
    engaging, and retaining individuals with HIV in effective care and
    treatment saves lives and benefits public health by stopping HIV
    transmission when individuals are virally suppressed.
        In 2020, 89.4 percent of Ryan White patients were virally
    suppressed--a 28.6 percent increase in the program-wide viral
    suppression rate since 2010. In 2021, 92.8 percent of Madison Clinic
    patients were virally suppressed in spite of the complex challenges
    presented by the COVID-19 pandemic. The Ryan White Part C program's
    comprehensive services engage and keep people in HIV care and
    treatment. For example, 98 percent of HIV patients are on
    antiretroviral therapy at Madison Clinic. Early, reliable access to HIV
    care and treatment helps patients living with HIV live healthy and
    productive lives and is more cost effective.
    Part C Clinics are on the Frontlines of the Opioid Crisis 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 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 $310 million for CDC to provide surveillance, response,
    and other HIV prevention services as part of the EHE initiative, as
    well as $150 million for CDC to address the infectious diseases
    consequences of the opioid and other drug 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 and other drug epidemics and that informed the treatment and
    prevention of COVID-19.
        Thank you for your time and consideration of these requests, and
    please do not hesitate to contact me or Jenny Collier, Convener of the
    Ryan White Medical Providers Coalition, at
    jcollier@colliercollective.org, if you have any questions or need
    additional information.

        [This statement was submitted by Jehan Budak, MD, Assistant Medical
    Director, Madison HIV Clinic at the Harborview Medical Center in
    Seattle, Washington.]
                                     ______

                     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
    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 $102 million in FY22. 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 $200 million for the REO
    program in FY23.
        Authorized by section 169 of the 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,\1\ 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.
    ---------------------------------------------------------------------------
        \1\ 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.
    ---------------------------------------------------------------------------
        REO is the only Federal program that focuses specifically on
    workforce development and employment for people with records. As the
    economy recovers and workforce needs continue to evolve and change, it
    is essential to ensure that the significant number of people with
    criminal legal histories has the reentry supports and workforce
    training needed to achieve gainful employment and long-term reentry
    success. Developing this pool of trained, talented, and motivated
    workers also will help fill the workforce gaps employers currently
    face, especially in sectors with critical worker shortages. For these
    reasons, Congress should significantly expand the program in FY23 to
    $200 million.
          employment reduces recidivism and improves reentry outcomes
        1 in 3 adults in the United States has a criminal record that
    interferes with their ability to find a job.\2\ 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.\3\ 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.
    ---------------------------------------------------------------------------
        \2\ ``Research Supports Fair-Chance Policies'' (March 2016),
    National Employment Law Project, footnote 1 on p. 7. Available at
    http://www.nelp.org/publication/researchsupports-fair-chance-policies.
        \3\ Visher, C., Debus, S., & Yahner, J. Employment After Prison: A
    Longitudinal Study of Releasees in Three States. Washington, DC: Urban
    Institute (2008).
    ---------------------------------------------------------------------------
    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 both
    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 works closely with employers to identify what types
    of trained employees are needed. In December 2021, the National
    Federation of Independent Business (NFIB) reported that 60 percent of
    businesses overall (and 95 percent 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, 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 FY23 to $200 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 percent of
    participants obtained employment--15 percent higher than the grant's
    employment target. Given the success of this first cohort of
    participants, T2W was expanded to include a second cohort who did even
    better with an employment rate of 78 percent--30 percent 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
    percent recidivism rate, and its second participant cohort had a 9
    percent recidivism rate -75 percent and 80 percent lower respectively
    than the National recidivism rate of 44 percent.\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.
    ---------------------------------------------------------------------------
        Safer's REO grant for their Advancing Careers & Employment program
    also saw great outcomes with 577 enrolled clients. The ACE program
    provided workforce development, education, trauma-informed case
    management, and occupational training to adults (25 and older) who had
    been released from incarceration within 180 days or who were currently
    under supervision. Of the enrolled clients 93 percent developed an
    employment plan and 60 percent completed job training in the areas of
    carpentry, commercial driving, IT, hospitability, and solar panel
    installation.
        Program evaluation has shown that such success is related to the
    comprehensive service model that REO 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 recent study found that in Illinois the average cost
    associated with just one recidivism event is $151,662. Another study
    found that individuals who were employed and earning higher wages after
    release were less likely to return to prison within the first year. 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.
    investments in reo as a reentry and workforce development programs will
                 help ensure a more equitable economic recovery
        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. Reentry and
    workforce development programs, such as REO, are critical to ensuring a
    more equitable economic recovery for people with criminal legal
    histories, especially Black people and people of color who are
    disparately impacted by the criminal legal system.
                                   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 $200 million to the REO program in FY23.
        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 at Kevin.Brown@saferfoundation.org or
    Jenny Collier at colliercollective.org.

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

                    Prepared Statement of Save the Children
        Chairwoman Murray, Ranking Member Blunt, and honorable Members of
    the subcommittee, thank you for the opportunity to provide testimony on
    behalf of Save the Children about the critical investments in the
    Departments of Health and Human Services and Education to ensure robust
    investment in early childhood education programs and to support
    unaccompanied children seeking safety and security in the U.S. In the
    United States and around the world, Save the Children works every day
    to give children a healthy start in life, the opportunity to learn and
    protecting children in crisis. We do whatever it takes for children--
    every day and in times of crisis--transforming their lives and the
    future we share. We urge the subcommittee to support robust
    appropriations for the Department of Health and Human Services,
    specifically the Office of Refugee Resettlement and the programs of
    Head Start/Early Head Start, Child Care and Development Block Grants,
    and Preschool Development Grants, as well as the Department of
    Education programs--21st Century Community Learning Centers and Promise
    Neighborhoods.
                    administration for children and families
    Child Care and Development Block Grant (CCDBG)
                Request: $12.3 billion for the Child Care and Development
                        Block Grant.
        Families continue to struggle to afford child-care and childcare
    providers operate on razor thin margins. Despite significant
    investments in recent years, fewer than 1 in 7 eligible families
    received a subsidy under CCDBG. The much-needed relief provided by the
    American Rescue Plan has been essential to keep the child care sector
    afloat, and these temporary funds must be supplemented with an
    expansion to the base CCDBG budget. States face significant pressures
    on their existing CCDBG and child care relief funds: they must use a
    portion of CCDBG funds for quality improvement, as well as implementing
    new health and safety requirements, increasing payment rates, serving
    more children, and expanding eligibility.
        An additional $6.17 billion is needed--for a total of $12.3
    billion--to avoid damaging funding cliffs, and support States in making
    targeted investments to their child care systems aligned with longer-
    term recovery needs.
    Head Start and Early Head Start
                Request: $15.4 billion for Head Start and Early Head Start.
        Head Start and Early Head Start are key to providing and expanding
    comprehensive early care and education to our poorest children. At the
    current level of funding, Head Start serves less than half of eligible
    preschoolers, and Early Head Start only serves approximately one in 10
    eligible infants and toddlers. During the pandemic the remarkable Head
    Start staff across the country have stepped up in order to maintain
    quality programming by modifying both their in-home and in-person early
    education programs. Without increased funds, the realities of a
    competitive market will require programs to choose between cutting
    access for children or underpaying and risk losing experienced and
    skilled staff.
        An additional investment of $4.4 billion--for a total of $15.4
    billion--is needed for Head Start and Early Head Start in order to
    maintain the high-quality early education opportunities the program
    provides. Specifically, $1 billion is needed for expansion of Early
    Head Start and Early Head Start-Child Care Partnerships, $596 million
    to sustain the workforce through a cost-of-living adjustment, $2.5
    billion for workforce compensation realignment, $262 million to provide
    flexibility to address local quality improvement priorities, including
    facilities, and $10 million to help develop the most effective and
    appropriate staff for American Indian/Alaska Native programs.
    Preschool Development Grants (PDG)
                Request: $500 million for Preschool Development Grants
                        Birth through Five (PDG B-5) program.
        Expanded investments in Preschool Development Grants will enable
    more children to take advantage of early learning opportunities that
    encourage their learning and growth and will support efforts to further
    strengthen the quality of these programs. Research has demonstrated
    that high-quality early education has long-term benefits for children,
    especially low-income children, which far exceed the costs. And yet,
    despite the proven benefits of high-quality early education in general
    and the PDG program in particular, funding constraints mean that only
    28 of the 46 planning grant recipients have received renewal grants.
        An additional $210 million is needed--a total of $500 million--for
    Preschool Development Grants to allow state and territories to increase
    the quality and efficiency of existing early learning programs and
    systems, while thinking strategically about how to optimize Federal and
    State funding streams. Through PDG B-5, Congress has the unique
    opportunity to foster state-led early learning initiatives, which is
    particularly necessary as States continue to recover from the pandemic.
                      office of refugee resettlement (orr)
    Pilot Grant Program for Federally Funded Respite/Welcoming Centers
                Request: $50 million for the Grant Program for the
                        humanitarian reception of individuals and families
                        who have been released from DHS custody.
        In order to create a more humane processing system at our Southern
    border, the department should establish an ORR-administered Non-
    Custodial Migrant Shelter Grant Program to support the establishment
    and operation of shelters by non-profit, non-governmental organizations
    at the border for families and single adults released from DHS custody.
    These welcome centers would be run by local community and faith based
    nonprofit organizations where families and adults can receive legal
    orientations and other services, reducing time in CBP custody. The
    funds for this program shall provide humanitarian assistance to
    individuals and families encountered and released by DHS, including
    basic medical care, psychosocial support, orientation to legal
    responsibilities and rights, referrals to community-based case
    management services at destination cities, and facilitation of onward
    travel.
    Increased Funding for Legal Services, Child Advocates, and Post-Release
            Services
                Request: $400,000,000 for the provision of legal services
                        for all unaccompanied children in the UC program,
                        $12 million for the appointment of a Child
                        Advocates, and $250 million shall remain available
                        to ensure rapid access to and high quality of post-
                        release services.
        Unaccompanied children are uniquely vulnerable and face daunting
    challenges in the immigration system. Many unaccompanied children have
    valid claims for relief from deportation owing to past or feared harm,
    abuse, abandonment, neglect, or human trafficking; and all children
    have a right to a fair hearing in immigration court. Services provided
    by qualified and independent legal counsel to unaccompanied children
    increase the efficiency and effectiveness of immigration proceedings
    and significantly reduce the failure-to-appear rate of children who are
    released from HHS custody. Along these lines, independent Child
    Advocates appointed pursuant to the TVPRA provide a vital resource to
    the most vulnerable unaccompanied and separated children in Federal
    custody and to Federal agencies charged with their care, release and
    safe repatriation. While the additional funding recently appropriated
    for family reunification services has helped, there continue to be
    significant gaps in adequate home study and post-release service
    provision.
    Creation of Ombudsperson Within HHS to Advocate for the Rights of
            Immigrant Children
                Request: $10 for the creation of the Office of Ombudsperson
                        within HHS to provide independent child-welfare
                        focused recommendations to ORR and the Secretary
                        regarding the care of unaccompanied children.
        Save the Children supports the creation of the Office of the
    Ombudsperson for Immigrant Children in Federal Custody to advocate for
    the quick, safe, and efficient release of immigrant children from
    government custody whenever possible, including the right to review
    placement decisions. Additionally, the Ombudsperson shall have access
    to facilities data, reviews, and recommendations of the HHS Office of
    Inspector General, in order to investigate systemic issues or
    improvements of facilities or grantees. Other longstanding problems-
    such as lagging reunifications or inappropriate placements in
    restrictive settings-also merit additional scrutiny and escalation
    mechanisms, as children and sponsors are often left with little to no
    recourse to bring their concerns to bear. The office would support
    Congress' longstanding view that family separation and detention are
    generally not in a child's best interest and, in cases in which
    detention or government custody is required, ensure that immigrant
    children are only detained or held in government custody in the least
    restrictive setting. In particular, this office would help mitigate and
    promptly address conditions that adversely impact children's safety,
    health, and wellbeing.
    Restrictions on Use of Unlicensed Facilities
                Request: None of the funds made available under the heading
                        ``Department of Health and Human Services-
                        Administration for Children and families-Refugee
                        and Entrant Assistance'' may be used to house
                        unaccompanied children in any facility that is not
                        State-licensed or any proposed facility ineligible
                        for state licensure for the care of unaccompanied
                        children.
        State licensing is an essential and irreplaceable guardrail to
    ensure the safety of children in government custody. When the number of
    children arriving at the border increased during 2021, the Biden
    Administration opened new unlicensed facilities called ``emergency
    intake sites'' to quickly transfer children from Customs and Border
    Protection custody. These emergency intake sites were opened and have
    been operating without adherence to legal standards or ORR policies
    regarding services and safeguards, leading multiple whistleblowers to
    speak out against deplorable conditions for children. State actions
    like those taken by Texas and Florida to strip ORR facilities of state
    licenses are concerning, as they leave facilities without an
    independent oversight and monitoring mechanism to ensure the safety and
    well-being of children.\1\ It is critical that ORR continues to
    challenge these state decisions through litigation while also
    proactively working with other States to expand its licensed capacity
    of family- and community-based settings. Congress must ensure that ORR
    is prepared for fluctuating numbers of arrivals at the border by
    expanding its system of State-licensed facilities that are compliant
    with the Flores Settlement and implementing policies that ensure
    children's safe and prompt release from custody; it is never acceptable
    to deprioritize child welfare.
    ---------------------------------------------------------------------------
        \1\ https://www.texastribune.org/2021/08/10/texas-child-migrant-
    facilities-licenses/.
    ---------------------------------------------------------------------------
                     department of education appropriations
    21st Century Community Learning Centers (CCLC)
                Request: $1.789 billion for 21st Century Community Learning
                        Centers.
        Every day 11.3 million children are alone after school and are
    unsupervised for an average of seven hours per week. Parents of more
    than 19.4 million youth say their children would participate in an
    afterschool program if one were available in their community. Programs
    like CCLC help working families, keep young people safe during the
    hours after school when juvenile crime peaks, and improve academic
    achievement. Without funding for afterschool and summer learning
    programs, students will lose out on essential learning opportunities
    that help them prepare for school, college and careers, and can make up
    for time lost during the pandemic. The pandemic has shown how important
    robust afterschool and summer learning programs are to working families
    and our most vulnerable students, and how vital resources are to
    support these programs to ensure they are available and effective for
    the children who need them.
    Promise Neighborhoods
                Request: $118 million for Promise Neighborhoods.
        The Promise Neighborhoods program supports the implementation of
    innovative strategies that improve outcomes for children in the
    Nation's most distressed communities. To do so, communities must build
    a continuum of supports for children, from cradle to career. This
    holistic approach to improving the educational achievement of low-
    income students ensures sustainable, community-driven changes and
    interventions.\2\ Since its creation in 2010, this innovative program
    has proven a to be strategic investment in high-needs communities,
    funding communities with demonstrated success as well as new
    communities who create plans for change. This funding would allow for
    expansion of existing grants and new implementation grants, full
    funding for extension grants, and the creation of new capacity-building
    grants to strengthen communities' ability to deliver critical services
    to children and families while also scaling city and regional
    investment strategies.
    ---------------------------------------------------------------------------
        \2\ https://www.brookings.edu/research/the-harlem-childrens-zone-
    promise-neighborhoods-and-the-broader-bolder-approach-to-education/.
    ---------------------------------------------------------------------------
                                   conclusion
        On behalf of Save the Children, and our advocates across the
    country, I want to thank the subcommittee for its continued leadership
    and bipartisan work on these programs. I ask that you continue to make
    a robust investment in children in FY23, increasing access to
    opportunity, and ensuring a more prosperous America for generations to
    come.

        [This statement was submitted by Christy Gleason, Vice President of
    Policy,
    Advocacy, and Campaigns, Save the Children.]
                                     ______

             Prepared Statement of the Seattle Indian Health Board
        Chair Murray, Ranking 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,
    of Latino descent, and third generation in my family living 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 Organizations (UIO) nationwide. I have had the privilege
    of serving SIHB for 6 years and have been providing congressional
    testimonials for the past 4 years. I am honored to have the opportunity
    to submit my testimony today requesting: the permanent authorization of
    100 percent Federal Medical Assistance Percentage (FMAP) for UIOs;
    encouraging behavioral health parity and integration through workforce
    development initiatives across the U.S. Department of Health and Human
    Services (HHS) and Health Resource and Services Administration (HRSA);
    modifying the Substance Abuse and Mental Health Services Administration
    (SAMHSA) Government Performance and Results Act (GPRA) tool; increasing
    access to traditional health services through the Centers for Medicare
    and Medicaid Services (CMS); and increasing administrative time under
    the Indian Health Service (IHS) Loan Repayment Program. Addressing
    these key issues can advance the health of urban American Indian and
    Alaska Native (AI/AN) population.
        SIHB is an Indian Health Service (IHS)-designated UIO and a HRSA
    330 Federally Qualified Health Center, which serves nearly 5,000 AI/AN
    living in the Greater Seattle Area in Washington state. Nationwide,
    UIOs operate 74 health facilities in 22 States and offer services to
    over 5.4 million AI/AN people in select urban areas. As a culturally
    attuned service provider, we offer direct medical, dental, traditional
    health, behavioral health services, and a variety of social support
    services on issues of gender-based violence, youth development, and
    homelessness. We are part of the Indian healthcare system and honor our
    responsibilities to work with our Tribal partners to serve all Tribal
    people, wherever they may reside.
        We are home to a Tribal public health authority, Urban Indian
    Health Institute (UIHI), 1 of 12 Tribal Epidemiology Centers (TEC) in
    the country and the only TEC with a national purview-serving both rural
    and urban AI/AN's. For over 20 years, UIHI has managed public health
    information systems, managed disease prevention and control programs,
    communicated vital health information and resources, responded to
    public health emergencies, and coordinate these activities with other
    public health authorities and UIO's nationwide. Due to a lack of access
    to disease surveillance data, UIHI released the only AI/AN COVID-19
    Data Dashboard,\1\ providing critical disease surveillance data to the
    45 UIO service areas ensuring AI/AN communities have access to
    culturally informed data collection, research, and evaluation.
    ---------------------------------------------------------------------------
        \1\ Urban Indian Health Institute (April 2022) COVID-1 Data
    Dashboard. Retrieved from: https://www.uihi.org/covid-19-data-
    dashboard/.
    ---------------------------------------------------------------------------
    Extend 100 percent Federal Medical Assistance Percentage (FMAP)
        The American Rescue Plan act of 2021 temporarily extended 100
    percent Federal Medical Assistance Percentage (FMAP) to UIOs. For
    Washington state, the 2-year temporary extension has resulted in $18
    million in Federal cost savings that will be captured in the Indian
    Health Improvement Reinvestment Account. The investment account will be
    able to expand its funding to activities, programming, and initiatives
    that improve the health of AI/AN people across the State of Washington.
        The permanent extension of 100 percent FMAP to UIOs upholds the
    political status of Tribal citizens to ensure Federal dollars provide
    Medicaid-coverage to urban AI/AN Medicaid beneficiaries. Permanent
    extension of 100 percent FMAP reduces State Medicaid expenditures,
    honors Federal trust and treaty responsibility to AI/AN people and
    creates innovative healthcare delivery and systems changes to address
    social determinants of health experienced in AI/AN communities.
    Encourage Behavioral Health Parity and Integration
        We request HHS improve partnerships and invest resources with the
    Indian healthcare system to support recruitment and retention of health
    care professionals to support health integration, consumer demand, and
    identify need. A HRSA report found significant shortages of
    psychiatrists, psychologists, social workers, school counselors, and
    therapists across the country resulting in severe workforce deficits
    for Indian County.\2\ For Washington state, HRSA has identified our
    area as having a Mental Health Professional Shortage Area, with
    only16.8 percent of mental health needs being met.\3\
    ---------------------------------------------------------------------------
        \2\ U.S. Department of Health and Human Services--Health Resources
    and Services Administration. (2016). National Projections of Supply and
    Demand for Selected Behavioral Health Practitioners: 2013-2025.
    Retrieved from: https://bhw.hrsa.gov/sites/default/files/bureau-health-
    workforce/data-research/behavioral-health-2013-2025.pdf.
        \3\ KFF. (2021). Mental Health Care Health Professional Shortage
    Areas (HPSA). Retrieved from: https://www.kff.org/other/state-
    indicator/mental-health-care-health-professional-shortage-areas-hpsas/
    ?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:
    %22asc%22%7D.
    ---------------------------------------------------------------------------
        We ask that HHS encourage behavioral health parity and integration
    by supporting initiatives to dual credential our providers to support
    vacancies. We request HHS mirror the Veterans Benefits Administration
    (VBA) dual certification process to support our providers. As AI/AN
    people are disproportionately represented in poor behavioral health
    outcomes, including higher rates of behavioral health conditions such
    as mental health, substance use, or suicide,\4\ it is necessary for HHS
    to invest in behavioral health parity through workforce developments
    for Indian healthcare clinics.
    ---------------------------------------------------------------------------
        \4\ U.S. Department of Health and Human Services--Office of
    Minority Health. (2021). Mental and Behavioral Health--American
    Indians/Alaska Natives. Retrieved from: https://minorityhealth.hhs.gov/
    omh/browse.aspx?lvl=4&lvlID=39.
    ---------------------------------------------------------------------------
        To address the workforce shortage of the Indian healthcare system
    as a whole, we support the National Tribal Budget Formulation Workgroup
    Recommendations, which includes $1 billion to the Indian healthcare
    workforce development program to recruit and retain health
    professionals to address chronic and pervasive health care provider
    shortages. In addition, we ask that HHS advocate for, prioritize, and
    support workforce development incentives at IHS, SAMHSA, and HRSA.
    Increase Partnerships and Resources to Address Provider Shortages
        As previously mentioned, we recommend HRSA support investments into
    the Indian healthcare system through workforce development and
    supporting dual credentialing of providers to address our workforce
    deficits and meet the needs of Indian Country.
        In order to ameliorate the significant vacancy rates for the Indian
    healthcare system, and address challenges to filling the vacancies in
    our facilities, SIHB has a strong workforce development program which
    includes 6 family medicine residents, 6 public health interns, and 4
    Master of Social Work program students. Of our 6 family residents, 4
    identify as AI/AN and recent graduation rates show 80 percent of our
    previous residents go on to work in communities of color and 50 percent
    go on to work in Native communities. These types of training programs
    increase AI/AN representation in provider positions.
        As we develop the next generation of Indian Health Care Providers,
    we must ensure that barriers for American Indian and Alaska Native
    providers are eliminated, and we must increase leadership and
    management opportunities for all Indian Health Care Providers in the
    LRP program. We recommend that IHS modify LRP program requirements to
    allow providers additional administrative time. Additionally, HRSA
    investments can support vacancies, salary comparison, incentives,
    training programs, and dual credentialing needed to support recruitment
    and retention of AI/AN representation in the healthcare workforce.
    Mandate CMS Reimbursement for Traditional Health Services
        We request CMS support the integration of Traditional health
    services as reimbursable services to improve access to quality health
    services for AI/AN populations. Improved access to Traditional health
    services support equity-based health care initiatives that are outcome-
    oriented, patient-centered, and support primary and preventative
    healthcare services.
        In 2021, SIHB secured a SAMHSA grant to launch a Traditional Indian
    Medicine (TIM) pilot that will code Traditional health services into
    our Electronic Health Records (EHR) system and will replicate
    reimbursable services. UIHI will provide evaluation on the pilot to
    document the health benefits of integrating Traditional Practitioners
    as part of our wraparound services. SIHB has uniquely integrated our
    Traditional Practitioners into our clinical and social services teams
    to provide over 39,000 encounters through assessments, counseling,
    hospital visits, and group services. In March 2023, SIHB will release a
    report documenting our methods to credential Traditional Practitioners,
    code Traditional health services into EHR, replicate reimbursable
    billing, and health outcomes from this pilot.
        The pilot will demonstrate how integrating traditional services in
    relatives' (patients) primary and preventative care can support and
    improve health outcomes of our relatives. Traditional health services
    can complement Western healthcare to support culturally attuned care
    for AI/AN people and BIPOC communities across the Nation. We will
    utilize our success story to advocate for Traditional health services
    being a standard practice across healthcare systems in the Nation to
    advance health equity by supporting outcome-oriented, patient-centered,
    and primary and preventative healthcare services.
    Modify the GPRA Tools for Low-Barrier and Culturally Attuned Services
        The GPRA Modernization Act of 2010 modified the GPRA tool to better
    serve the needs of providers. Twelve years later, we desperately need
    the GPRA tool to be remodified to meet the modern needs of providers.
    The Administration, Congress, and local elected officials have all
    announced their efforts to address rising Substance Use Disorder (SUD)
    rates. However, the GPRA tool continues to be a burden to SUD access
    and treatment for our relatives due to the trauma triggering
    questionnaire. Additionally, the GPRA tool places a strain on our
    providers to meet required quotas. To ensure continued funding for our
    critical services, providers must commit their time and resources to
    fulling the requirements of the GPRA tool despite it not informing
    multidisciplinary teams of local clinics.
        Today, the GPRA performance tool is burdensome to patients and
    providers. From providers in the Indian healthcare system, we have
    heard the GPRA tool is trauma triggering for patients, time intensive
    for patients and providers, and collects data that is solely beneficial
    for the Federal Government. The GPRA tool must be modified to be
    patient-centric, consider the time of our patients and providers, and
    avoid collecting unnecessary data that does not benefit local clinics.
    For example, UIHI and our medical division, are recipients of GRPA
    funds and certain questions related to behavioral health do not benefit
    our clinical team or research division.
        We request HHS and SAMHSA modify the GPRA tool to be culturally
    attuned and low barrier to support the needs of our relatives.
    Additionally, we request HHS and SAMHSA modify the tool with the input
    of providers, patients, and Native experts to shorten the screening
    tool, ensure it is patient-centered, holds validity, administratively
    considerate, and informs providers of the immediate and long-term care
    of relatives.
    Increase Administrative Time under the IHS Loan Repayment Program (LRP)
        IHS has notified me amending the Loan Repayment Program (LRP)
    structure is a legislative fix that must be addressed by Congress. As
    the Indian healthcare system is severely understaffed, we must continue
    to implement unique initiatives to support our providers, which
    includes amending the IHS LPR to increase administrative time.
        Under the current IHS LPR structure, medical providers are limited
    to 20 percent of FTE allocated to administrative time. While direct
    clinical care training is essential to the development of healthcare
    providers, we must acknowledge that administrative time is an
    opportunity to develop skillsets in leadership and operations
    management. I believe this amendment will support providers in the
    Indian healthcare system.

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

               Prepared Statement of the Sex Education Coalition
        Dear Chairwoman Murray and Ranking Member Blunt,
        As we honor Sex Education for All month this May, the undersigned
    55 organizations, committed to supporting the sexual and reproductive
    health and rights of young people, request your support for fiscal year
    (FY) 2023 funding that helps to ensure the health of our Nation's
    youth. We urge you to protect the integrity of the Teen Pregnancy
    Prevention Program (TPPP) and increase support for the Centers for
    Disease Control and Prevention's (CDC) school-based HIV and STI
    prevention efforts. We also encourage the elimination of the
    abstinence-only ``sexual risk avoidance'' competitive grant program.
        In the wake of numerous attacks on a young person's right to
    evidence-based, accurate information and services, young people face
    increased barriers, it is all the more critical that Congress address
    the resulting persistent inequity and health disparities. While a young
    person's health and wellbeing is about more than just the absence of
    disease, or in the case of sexual health, the absence of HIV and other
    STIs, unintended pregnancy, or sexual violence, the adolescent data on
    these points alone, remain largely unchanged and alarming in recent
    years.
        You have likely seen some of these statistics: young people under
    the age of 25 account for more than 1 in 5 new HIV infections; \1\ half
    of the nearly 20 million estimated new STI cases each year in the U.S.
    occur among those aged 15-24; \2\ 75 percent of pregnancies among young
    people ages 15-19 are unintended compared to an overall unintended
    pregnancy rate of 45 percent across all age groups; \3\ and 7 percent
    of high school students reported being sexually assaulted by a
    partner.\4\
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention (CDC), U.S.
    Department of Health and Human Services (HHS), HIV among youth, 2017,
    www.cdc.gov/hiv/group/age/youth/index.html.
        \2\ National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
    Prevention, CDC, HHS, Sexually Transmitted Disease Surveillance 2017:
    STDs in Adolescents and Young Adults, Atlanta: CDC, 2018, https://
    www.cdc.gov/std/stats17/adolescents.htm#ref1.
        \3\ Guttmacher Institute, Adolescent sexual and reproductive health
    in the United States, Fact Sheet, New York: Guttmacher Institute, 2017,
    www.guttmacher.org/fact-sheet/american-teens-sexual-and-reproductive-
    health.
        \4\ Kann L et al., Youth risk behavior surveillance--United States,
    2017, Morbidity and Mortality Weekly Report (MMWR), 2018, Vol. 67, No.
    8, https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/ss6708.pdf.
    ---------------------------------------------------------------------------
        Marginalized young people, such as young people of color, lesbian,
    gay, bisexual, transgender, and queer (LGBTQ+) young people, and young
    people with differing abilities, face disproportionate indicators of a
    lack of systemic support for their sexual health. Lesbian, gay, and
    bisexual high school students, for example, are more than twice as
    likely as their heterosexual peers to experience partner violence, be
    sexually assaulted by a partner, or be forced to have sex.\5\ Further,
    35 percent of transgender students report experiencing bullying at
    school, and the same percentage have attempted suicide.\6\
    ---------------------------------------------------------------------------
        \5\ Kann L, Sexual identity, sex of sexual contacts, and health-
    related behaviors among students in grades 9-12-United States and
    selected States, 2015, MMWR, 2016, Vol. 65, No. 9, www.cdc.gov/mmwr/
    indss_2016.html.\6\ Johns MM et al., Transgender Identity and
    Experiences of Violence Victimization, Substance Use, Suicide Risk, and
    Sexual Risk Behaviors Among High School Students--19 States and Large
    Urban School Districts, 2017, https://www.cdc.gov/mmwr/volumes/68/wr/
    mm6803a3.htm.
        \6\ Johns MM et al., Transgender Identity and Experiences of
    Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk
    Behaviors Among High School Students--19 States and Large Urban School
    Districts, 2017, https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm.
    ---------------------------------------------------------------------------
        This data continues to highlight the importance of additional
    resources to better meet the needs of young people, particularly as the
    availability and quality of sexual health information and sexuality
    education varies drastically across the country. Less than 43 percent
    of all high schools and only 18 percent of middle schools in the U.S.
    provide education on all of the 20 topics the CDC has deemed essential
    to ensuring sexual health.\7\
    ---------------------------------------------------------------------------
        \7\ 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.
        Secura GM et al., Provision of no-cost, long-acting contraception
    and teenage pregnancy, New England Journal of Medicine, 2014.
    ---------------------------------------------------------------------------
        Fortunately, research has shown us how we can better assist young
    people in leading healthy lives. Access to medically accurate programs
    that include sexual health information beyond abstinence works to
    promote adolescent health. These programs help young people determine
    if and when to have sex, teach them how to use condoms and
    contraception when they do so, and reduce unintended pregnancies.\8\
    Programs that are inclusive of LGBTQ+ youth and LGBTQ+-related
    resources ultimately promote academic achievement and overall
    health.\9\ Equipping young people with sexual decision-making and
    relationship skills results in safer sexual behaviors. Additionally,
    promoting gender equity reduces physical aggression between intimate
    partners and improves safer sex practices for all genders.\10\
    ---------------------------------------------------------------------------
        \8\ 371(14):1316-1323; Community Preventive Services Task Force,
    HIV/AIDS, other STIs, and teen pregnancy: group-based comprehensive
    risk reduction interventions for adolescents, 2012,
    www.thecommunityguide.org/hiv/riskreduction.html.
        \9\ Schalet AT et al., Invited commentary: broadening the evidence
    for adolescent sexual and reproductive health and education in the
    United States, Journal of Youth and Adolescence, 2014, 43(10):1595-
    1610, http://link.springer.com/article/10.1007/s10964-014-0178-8.
        \10\ Ibid.
    ---------------------------------------------------------------------------
               support congressional intent and funding for tppp
        Provide $150 million in programmatic funding and $6.8 million in
    evaluation transfer authority to support the continuation of a wide-
    range of evidence-based and informed community approaches to healthy
    youth development and unintended pregnancy prevention. Support bill and
    report language that protects the integrity of the program, which has
    been subject to unlawful attacks by the Trump administration.
        TPPP was established in 2010 to support community-driven, evidence-
    based or informed, medically accurate, and age-appropriate approaches
    to preventing pregnancy among adolescents, involving parents,
    educators, researchers, and providers. In the program's first round of
    grants, TPPP served over 500,000 young people, trained more than 7,000
    professionals, and partnered with more than 3,000 community-based
    organizations. In the second round of grants, 84 organizations in 33
    States, the District of Columbia, and the Marshall Islands were awarded
    funds to replicate evidence-based programs in communities with the most
    need; conduct rigorous evaluation of new and innovative approaches to
    prevent unintended pregnancy among teens; or build capacity to support
    implementation of evidence-based programs.\11\
    ---------------------------------------------------------------------------
        \11\ OAH, HHS, HHS Office of Adolescent Health Fiscal Year 2016
    Annual Report, Rockville, MD: HHS, 2016, www.hhs.gov/ash/oah/sites/
    default/files/2016-annual-report.pdf.
    ---------------------------------------------------------------------------
        Beginning in 2017, The Trump Administration sought to eliminate and
    undermine the integrity of the TPPP Program, including by proposing the
    elimination of the program in the annual President's budget, attempting
    early termination of ongoing projects, and awarding Tier 1 funding to
    organizations implementing abstinence-only ``sexual risk avoidance''
    programs. Prior to the Trump Administration's attacks, the second
    program round was on track to reach 1.2 million young people. Courts
    have ruled that these attacks were unlawful, as was the April 20, 2018,
    Tier 1 Funding Opportunity Announcement, which violated TPPP's
    appropriations language.
        This funding would support the work of trained educators and
    community partnerships, serve young people, and expand the body of
    evidence available to best meet their needs in alignment with the
    program's original intent. Further, funding for the Teen Pregnancy
    Prevention Program and related evidence review and evaluation funding
    will help to restore evidence-based implementation of grants by
    supporting adequate technical assistance and high-quality evaluation,
    reviving the evidence review, allowing grantees to meet the needs of
    young people in the wake of COVID-19, and serving approximately 125,000
    more young people.
        In addition, TPPP evaluation funds have been used to examine the
    efficacy of programs to inform new and innovative adolescent health
    promotion approaches. The findings from evaluations of the first TPPP
    grant cycle contributed to the body of evidence that guides educators
    in making program decisions and highlighted the importance of continued
    investment in new programs and strategies for various settings and
    audiences.\12\ Learning both what works and what doesn't to support
    adolescent health is equally important; in building this evidence base
    and sharing it with communities and educators, TPPP uses a science-
    based approach to the prevention of unintended pregnancy among young
    people.
    ---------------------------------------------------------------------------
        \12\ Margolis AL and Roper YV, Practical experience from the Office
    of Adolescent Health's large scale implementation of an evidence-based
    Teen Pregnancy Prevention Program, Journal of Adolescent Health, 2014,
    54(3):S10-S14, www.jahonline.org/article/S1054-139X(13)00791-X/
    fulltext.
    ---------------------------------------------------------------------------
             support funding for cdc's school based hiv prevention
        Provide $100 million for CDC's school-based HIV and STI prevention
    efforts within the Division of Adolescent and School Health (DASH) to
    enable robust assistance and to States, districts, and schools in their
    efforts to support student health and to lead research on school health
    and a range of adolescent health behaviors.
        The CDC provides a unique source of support for adolescent health
    education in our Nation's schools by seeking to promote education,
    health access, and environments where young people can gain fundamental
    health knowledge and skills and establish healthy behaviors. Currently,
    DASH provides funding to 28 school districts across the country to
    implement school-based HIV and STI prevention programs in schools,
    integrating substance use prevention, violence prevention, and other
    public health approaches. The work within DASH expands the research and
    evidence base of how to best meet the needs of young people, including
    LGBTQ+ youth, youth of color and disabled youth. Currently, DASH
    reaches 2 million young people at less than $10 per student.\13\ With
    $100 million in appropriations, DASH could directly reach 20 percent of
    all 56 million middle and high school students in the Nation, and reach
    the other 80 percent of young people indirectly through widespread
    implementation of safe and supportive environments in schools. This
    funding increase would allow DASH to fund the 100 largest local
    education agencies in the country, as well as all 57 State and
    territorial education agencies.
    ---------------------------------------------------------------------------
        \13\ DASH, Centers for Disease Control and Prevention https://
    www.cdc.gov/healthyyouth/about/cdc-dash-health-program-impact.htm.
    ---------------------------------------------------------------------------
                          end abstinence-only funding
        Eliminate funding for the abstinence-only-until-marriage ``sexual
    risk avoidance'' competitive grant program, putting an end to harmful
    programs, regardless of new packaging, that have been proven
    ineffective at their primary goal of young people delaying sex until
    marriage.
        Despite more than two decades of rigorous research demonstrating
    that programs with the sole aim of promoting abstinence until marriage
    are ineffective at this primary goal, over $2 billion in Federal
    funding alone has been wasted on this stigmatizing approach. In
    addition to violating young people's human rights, federally funded and
    independent analyses alike have found that youth participating in such
    programs were no more likely to abstain from premarital sexual activity
    than those who did not participate in the program.\14\ Moreover,
    regardless of what they are called, abstinence-only programs withhold
    necessary and lifesaving information that allow young people to make
    informed and responsible decisions about their own health. These
    programs have been found to include content that reinforces gender
    stereotypes, ostracizes and denigrates LGBTQ+ youth, stigmatizes
    sexually active young people and pregnant or parenting youth, and fails
    to respect the needs of youth who have experienced sexual abuse or
    assault.\15\ Rather than supporting the needs of young people,
    abstinence-only programs undermine opportunities to empower youth to
    make informed decisions about their health and wellbeing.
        Young people deserve access to the information, education, and
    resources they need to make healthy decisions about their lives.
    Significantly more can, and needs to, be done to support the sexual
    health education of our Nation's youth. Supporting these requests in
    the FY 2023 funding is an essential step in the right direction.
        Thank you for your consideration of our request to support the
    health and wellbeing of young people.
        Sincerely,

        AAUW IL
        Advocates for Youth
        AIDS Alliance for Women, Infants, Children, Youth & Families
        AIDS Foundation Chicago
        AIDS United
        American Academy of HIV Medicine
        American Sexual Health Association
        APLA Health
        Black Women for Wellness
        Caracole
        Catholics for Choice
        Center for Reproductive Rights
        CHLP
        EducateUS
        Equality California
        ETR
        EyesOpenIowa
        Families USA
        Girls Inc.
        Girls Inc. of Omaha
        Healthy Teen Network
        HIV+Hepatitis Policy Institute
        If/When/How: Lawyering for Reproductive Justice
        Ipas Partners for Reproductive Justice
        Jacobs Institute of Women's Health
        Michigan Organization on Adolescent Sexual Health (MOASH)
        NARAL Pro-Choice America
        NASTAD
        National Family Planning & Reproductive Health Association
        National Health Law Program
        National Institute for Reproductive Health
        National Partnership for Women & Families
        National Women's Law Center
        North Carolina AIDS Action Network
        North Dakota Women's Network
        Planned Parenthood Action Fund of New Jersey
        Planned Parenthood Federation of America
        Positive Women's Network-USA
        Power to Decide
        Reproductive Health Access Project
        SIECUS: Sex Ed for Social Change
        Silver State Equality
        The AIDS Institute
                                     ______

                   Prepared Statement of SHEPHERD Foundation
        Thank you for the opportunity to submit this testimony in support
    of increasing funding for rare cancer research and for utilization of
    molecular diagnostics in cancer care. These issues are deeply personal
    for me. While undergoing Navy SEAL selection training at age 27, I
    collapsed, and upon subsequent examination, was diagnosed with a rare
    cancer called adenoid cystic carcinoma (ACC). I quickly discovered that
    the options I had for treatment were extremely limited. While I was
    able to get my tumor surgically removed, my disease is very likely to
    return. I will have no choices for treatment beyond more surgery,
    radiation, chemotherapy that is ineffective in treating ACC, and other
    treatments which have not been proven to work for this cancer.
        I found that I was not alone in facing this dire situation--the
    lack of treatment options is the unfortunate reality for most rare
    cancer patients. Frustrated at these shortcomings in ``modern''
    medicine, I started a rare-cancer focused biotech company called
    SHEPHERD Therapeutics and an associated nonprofit. We may be the only
    pan rare-cancer focused organization in the world. I am extremely proud
    of the work our team has accomplished. SHEPHERD is comprised of
    patients and caregivers, those who have lost loved ones to rare
    cancers, and those who are still fighting. Our mission centers on
    ensuring that cancer patients have the treatments and diagnostics they
    need to survive. To achieve this mission, funding for cancer research
    must be robust and include directed funding streams for rare cancers
    and those cancers currently without therapies. We believe one of the
    best ways to accomplish these goals is the study of commonalities
    across subsets of cancer to bring forth platform solutions that can
    save lives near term. The use of broad-spectrum diagnostics, new
    technologies such as AI, and precision medicine including molecular
    diagnostics will ensure patients have access to the most effective
    treatments, reduce the use of costly and ineffective therapies, and
    enable physicians to select targeted treatments that improve outcomes.
        From our research, we know 380 out of the 400 forms of cancer meet
    the most conservative estimate of what constitutes a rare cancer, the
    American Cancer Society's metric of fewer than six new diagnoses per
    100,000 people per year. Rare cancers account for over 550,000 new
    diagnoses each year--almost 1 in 3 new patients. Not only are all
    pediatric cancers and primary brain cancers rare, but so are the
    majority of cancers experienced by service members. Almost 70 percent
    of the more than 60 forms of cancer that disproportionately affect
    those who have served our country are rare forms, and only 25 of them
    have an FDA approved targeted therapy. Many of those cancers are linked
    to service-related exposures, such as asbestos, burn pits, radiation
    and Agent Orange. Evidence suggests that even children of veterans who
    were exposed to Agent Orange may have an increased risk of certain
    cancers, like acute myeloid leukemia, according to the National Academy
    of Sciences.
        Beyond the pervasive impact of rare cancer, the lack of treatments
    is abominable. Over 100 cancers are not even mentioned in the NCCN
    treatment guidelines. The vast majority of new cancer patients--over 80
    percent--who lack an FDA-approved targeted therapy for their cancer,
    are rare cancer patients. In other words, 182 cancers lacked even one
    FDA-approved targeted therapy, and 181 of them were rare cancers, as of
    February 2019. That means that in 2019 almost 200,000 new rare cancer
    patients faced their diagnosis without a modern treatment. Part of the
    challenge is the lack of development due to insufficient financial
    incentives to develop rare cancer therapies. This is in part is due to
    a dearth of clinical trials that include rare cancer patients.
    SHEPHERD's analysis of all cancer clinical trials between 2012 and 2016
    showed that approximately 75 percent of all trials did not include even
    one rare cancer by name. Only 13 percent of all rare cancers were
    specifically named as a focus of a phase III clinical trial in those 5
    years. More than four times as much money in that time frame was spent
    on non-rare cancer trials than on trials which included a rare cancer.
    Clinical trials are expensive to run, and pharmaceutical companies are
    unlikely to choose to run a clinical trial in a small indication with
    few patients when a drug will work for a large population, even if that
    population already has dozens of drugs available for use, and even if
    that drug is a ``me too'' therapy which provides little benefit over
    the current standard of care. Most companies decide that the cost of
    drug development cannot be justified by the potential market for a rare
    cancer like mine, ACC, which has around 1,200 new patients a year.
        Fortunately, in the last few years, the FDA has encouraged new
    trial designs that allow trials to be run that target the molecular
    drivers of a cancer, allowing all patients whose tumors exhibit that
    genomic trait to potentially be included in the trial, regardless of
    their specific diagnosis. More good news: This approach can reach
    hundreds of thousands of additional patients right now via the
    utilization of molecular diagnostics. These tests can identify the
    presence of specific genomic alterations in a tumor that can be treated
    with an FDA-approved therapy today. Unfortunately, most patients are
    never even offered the option to receive these tests. Though broad
    spectrum molecular diagnostics cost less than a single round of
    chemotherapy, they are not reimbursed by CMS until the cancer has
    metastasized or reoccurred. In the absence of these tests, patients who
    lack a standard of care are most frequently put on generic chemotherapy
    protocols that are highly toxic and have very low odds for success.
        The incorporation of molecular diagnostics into the standard of
    care protocol for cancer patients would improve treatment outcomes,
    reduce the use of costly and ineffective drugs, and increase the
    availability of data related to little-studied cancers like mine.
    Providing molecular diagnostics to patients at the time of cancer
    diagnosis, and especially to rare cancer patients, is the single most
    powerful tool currently available to improve outcomes and advance the
    science of oncology care. Underutilization of these readily available
    technologies due to lack of awareness or lack of insurance coverage
    needlessly puts the lives of cancer patients--including patients with
    my cancer--at risk. Moreover, failure to provide CMS coverage of
    molecular diagnostics is not just an issue of adequate care, it is also
    an issue of equity. The majority of cancer patients are treated in
    community hospitals that are unable to pay for diagnostics out of
    pocket on behalf of patients. Patients treated at large NCI care
    centers and academic hospitals, in contrast, more frequently conduct
    and cover the costs of these tests. Surely, we can all agree that a
    patient's specific diagnosis, geographic location, income level, or
    form of insurance should not dictate the quality of their cancer care
    or their odds of survival.
        I respectfully request that you make the commitment in the FY 2023
    Labor, Health and Human Services, and Education Appropriations bill to
    changing the system to properly address rare cancer and help all cancer
    patients. This would require a substantial increase in Federal spending
    on rare cancers (following the well-established six new diagnoses per
    100,000 people per year definition) and prioritize research, data
    sharing, and translational development for cancers that lack an FDA
    approved targeted therapy. Additionally, these changes must strive to
    greatly increase the utilization of molecular diagnostics at both
    diagnosis and reoccurrence to ensure that patients are receiving
    appropriate therapies. Synergistic efforts to close the rare cancer
    equity gap would also encompass the following: (1) CMS and private
    insurance coverage of molecular diagnostics for all cancer patients at
    the time of diagnosis and when the cancer reoccurs (2) Education on the
    use and interpretation of molecular diagnostics for oncology care
    providers, and (3) Establishment of more clinical trials that
    specifically include rare cancers, either as an indication or via
    mutational target inclusion criteria.
        Behind the statistics there are over half a million Americans who
    at this moment do not know that during the course of this year they
    will be diagnosed with a cancer for which there is frequently no
    treatment beyond what their parents or even their grandparents would
    have been offered. Science sees no second-class citizens, only patients
    in need of help. We ask Congress to do the same and take the necessary
    steps to make cancer a thing of the past. Thank you.

        [This statement was submitted by David Hysong, Founder & Chairman
    of the Board, SHEPHERD Foundation.]
                                     ______

                Prepared Statement of the Sleep Research Society
                fiscal year 2023 appropriations recommendations
    _______________________________________________________________________

      --The sleep community joins the broader research community in
            requesting $49 billion in discretionary funding for the
            National Institutes of Health (NIH), an increase of $3.5
            billion over FY 2022. 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 provide distinct, additional funding to further support
                and implement the new Advanced Research Projects Agency for
                Health (ARPA-H).
      --The sleep community joins the broader public health community in
            requesting $11 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 emerging CDC Chronic Disease Education and
                Awareness (CDEA) program with $6 million, an increase of $3
                million over FY 2022, 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
    2023 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 2022
    appropriations, particularly for increasing funding for the new CDC
    Chronic Disease Education & Awareness Program, which is now supporting
    a 3-year cooperative agreement on obstructive sleep apnea and can
    support additional public health projects related to healthy sleep.
    Please maintain the commitments to NIH, CDC, and the CDEA program and
    increase funding as you and your colleagues work on appropriations for
    FY 2023.
                        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 psychology,
    neuroanatomy, pharmacology, cardiology, immunology, metabolism,
    genomics, 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
        Sleep research activities at NIH and across the government are
    coordinated through the National Center on Sleep Disorders Research
    (NCSDR). Recently, NCSDR released its next 5-year plan for sleep
    research and welcomed a dynamic new Director, Dr. Marishka Brown.
        As a result of sustained investment in NIH and the scientific
    opportunities in the field of sleep research, the research portfolio
    has doubled in size from $233 million in FY 2014 to $470 million today.
    This support has led to significant advancements in basic science,
    including the 2017 Nobel Prize in Medicine. However, research gaps
    remain in individual sleep disorders, such as narcolepsy, restless legs
    syndrome, and Kleine Levin syndrome, and patients lack innovative
    treatments, biomarkers, and new diagnostic tools. Team-based science
    and translational research is now needed to build on the momentum in
    sleep research and secure progress that benefits patients and the
    healthcare system. To effectively and comprehensively move sleep
    research forward in accordance with the goals of the new research plan,
    the community recommends support for a sleep research network at NIH.
    Sleep Research Network
        The sleep/circadian health sciences field requests the
    establishment of a Sleep Research Network that would allow for rapid
    assembly of research investigators and support. This will facilitate a
    prompt response to opportunities for multi-center clinical trials that
    address key unmet public health needs pertaining to sleep health and
    sleep disorders. Our members have the expertise necessary to implement
    a network across key domains including; data informatics, recommended
    measurement survey tools and technologies, site initiation/quality
    control, protocol assessment, and commercial/industry partnerships.
    Research networks like this can encourage development in emerging
    priority areas via conferences, pilots, educational activities,
    diversity/inclusion and public education/community engagement with the
    ultimate goal of accelerating transformative research and intervention
    to reduce risks and improve treatments.
    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.
    NIH Sleep Research Plan
        To recognize NIH for its leadership on sleep research and to ensure
    ongoing support for advancing sleep research activities, the community
    asks for inclusion of the following report language for the National
    Heart, Lung, and Blood Institute at NIH.
        Sleep Research Plan.--The Committee commends the National Center on
    Sleep Disorders Research for the release of the NIH Sleep Research
    Plan. The Committee requests information on the resources and
    assistance NCSDR will need to fully implement the plan and advance
    stated goals. The Committee supports the use of infrastructure capable
    of conducing multi-center sleep network studies and clinical trials
    related to the Sleep Research Plan.
    Sleep Health and Health Equity
        Sleep is a critical component of efforts to promote health equity
    and address health disparities. To raise awareness of ongoing efforts
    and to encourage emerging activities, the community asks for inclusion
    of the following report language for the National Institute of Health,
    National Institute on Minority Health and Health Disparities.
        Sleep Health and Health Disparities.--The Committee applauds
    ongoing and emerging efforts by the NIMHD to advance health equity and
    address health disparities, including cross-institute initiatives and
    the initiatives identified by the recent Minority Health and Health
    Disparities Research Framework. The Committee notes the
    disproportionate impact of sleep deficiencies among populations that
    experience health disparities in the United States, including American
    Indians/Alaska Natives, Asian Americans, Blacks/African Americans,
    Hispanics/Latinos, Native Hawaiians and other Pacific Islanders, sexual
    and gender minorities, the socioeconomically disadvantaged; and those
    living in underserved rural areas. The Committee encourages further
    work in and collaboration with community stakeholders on the issue of
    sleep health disparities.
    CDC Chronic Disease Education & Awareness Program
        Thank you for establishing the CDC CDEA program in FY 2021 by
    providing an initial investment of $1.5 million and then doubling that
    investment to $3 million for FY 2022. With the initial round of
    funding, CDC is now supporting four meritorious 3-year cooperative
    agreements in psoriasis, hearing loss, lymphedema, and sleep apnea.
    With additional funding for FY 2022, there is an expectation that CDC
    will fund another round cooperative agreements in critical public
    health areas. To ensure that there can be another competition to meet
    the growing demand for this important program for the third year,
    please provide $6 million in funding for FY 2023. Further, the
    community asks that report language for this program encourage the
    participation of rare conditions in the CDC process and ensure that
    broader categories, such as sleep health, can be supported along with
    the current project on sleep apnea.
                                 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.
                                brittany's story
        One February afternoon during Brittany Matthews' senior year of
    high school, she awoke on her bedroom floor to her mom frantically
    screaming at her for skipping school for the 20th time that year.
    Brittany hadn't moved from the spot on the floor where she was doing
    her makeup at 7 am when her mom left for work. However, Brittany was
    confused because just a few minutes before this, she had thought she
    actually was at school and this ``hypnopompic hallucination''
    experience felt just as real as now finding herself still at home. When
    the school informed Brittany's parents that she needed to go to court
    for her truancy issues and was not likely to graduate on time, Brittany
    was sent to live with her dad, who thought he could ``straighten her
    out.'' That was one of the last straws in a sequence of events that
    finally led Brittany to receiving a diagnosis of narcolepsy at age 19,
    which was about 12 years after she began experiencing symptoms at the
    young age of 7. Narcolepsy is a misunderstood and under-diagnosed
    chronic neurological disorder affecting the brain's ability to regulate
    the sleep/wake cycle with a prevalence of 1 in 2,000 people worldwide.
    During the 5 years that followed, Brittany struggled in every aspect of
    her life until eventually finding a more effective treatment regimen,
    which allowed her to re-consider her dream of finishing college. Two
    years ago, Brittany graduated with her Bachelor of Science degree at
    the age of 26. Now, she is working full-time and is in the process of
    applying for graduate school programs for speech language pathology.
    Despite the progress she has made, Brittany still grapples daily with
    excessive daytime sleepiness, as well as cataplexy (sudden muscle
    weakness brought on by emotions). Advancements in research, treatments,
    and awareness are critical to improve the lives of those living with
    narcolepsy and other sleep disorders.

        [This statement was submitted by Namni Goel, PhD, President-Elect,
    Sleep
    Research Society, Project Sleep, and the stakeholder community.]
                                     ______

        Prepared Statement of the Society for Human Resource Management
        As the voice of all things work, workers and the workplace, SHRM is
    the foremost expert, convener and thought leader on issues impacting
    today's evolving workplaces. One such issue is employee mental health
    and wellness. This year, Congress has an opportunity to make a modest
    change that will have a significant impact in combating the mental
    health crisis across the Nation.
        To accomplish this, we urge the inclusion of Committee Report
    language that will accompany the FY 2023 Department of Labor, Health
    and Human Services (LHHS) and Related Agencies' Appropriations bill to
    enable grant recipients under the Community Mental Health Block Grant
    (MHBG) program overseen by the Substance Abuse and Mental Health
    Services Administration (SAMHSA) to aid in workplace mental health.
        As the country continues to recover and adapt to new norms in our
    daily lives and how we work, workplaces and employers are a critical
    nexus to improve mental health in America. Congress should take
    meaningful steps to bolster SAMHSA's mission and reduce the impact of
    substance abuse and mental illness should extend into our workplaces.
    Adding explicit language that workplace-based programs are eligible for
    funding through MHBG is a critical first step
        Burnout, exhaustion and hopelessness are more common among workers
    than ever before, and pandemic-related stresses are chipping away at
    productivity. As millions of Americans return to physical worksites or
    adjust to hybrid and fully remote work environments, mental health
    issues will continue to mount. Employers are leading the charge to
    improve mental health in the United States and are poised to do more
    for the workforce with access to the necessary resources. The mental
    health crisis is multi-faceted and requires commitment from Congress
    and the private sector to address this pressing issue.
        The proposed report language will not require additional funding or
    increases to current allocations to SAMHSA, but it will allow for
    programs to address workplace mental health and wellness. Throughout
    the pandemic, organizations have relied heavily on their human
    resources (HR) professionals as the primary function and stakeholder in
    guiding employees and employers. These professionals proved themselves
    invaluable by providing the necessary leadership, empathy and human
    touch to keep workers connected while adapting to the pandemic and
    evolving needs of the workforce. The infrastructure is in place for
    effective workplace mental health programs and resources. The inclusion
    of this report language would ensure that this framework is well-
    utilized to meet the evolving needs of the Nation's workforce. The
    proposed language addition to the Committee Report is provided below:

          The Committee notes that undiagnosed and untreated mental
            illnesses among America's workforce results in increased
            absenteeism, lowered productivity at work, higher turnover, and
            other factors that affect productivity. According to the
            Society for Human Resource Management (SHRM) Foundation, this
            lack of productivity amounts to an estimated loss of $23
            billion every year in the United States. The Committee believes
            that workforce mental health is an important part of ensuring
            the overall mental health of our larger communities. To address
            workforce mental health in the community context, the Committee
            sees value in SAMHSA encouraging the use of Community Mental
            Health Block Grant (MHBG) funds for this purpose. Therefore,
            the Committee directs SAMHSA to issue guidance to State
            agencies receiving MHBG funds to encourage public and nonprofit
            organizations to use a portion of their MHBG funds to implement
            evidence-based programs designed to educate and aid employers
            in providing mental health assistance to their employees to
            reduce the stigma and encourage the treatment of mental health
            illness in the workplace.
        In April 2022, the SHRM Foundation released a report on mental
    health in the workplace. The report found that the extent of America's
    mental health crisis is alarming. Tens of millions of U.S. workers are
    experiencing mental health issues and are less productive because of
    it, inundating organizations with a vast array of new challenges.
    Mental health issues such as burnout and stress are hampering short-
    term productivity and long-term business growth.
        Without mental health resources, employees will keep struggling to
    add value to their organizations. Employers that fail to offer mental
    health benefits to their workers will struggle to stay afloat. Hundreds
    of billions of dollars are at stake. In many ways, the U.S. economy-not
    to mention public health-hangs in the balance.
        We cannot afford to wait, as the following statistics demonstrate:
      --The World Health Organization estimates that the global economy has
            lost $1 trillion due to anxiety and depression alone.
      --41 percent of HR professionals believe their organization does not
            currently offer enough support for employees' mental health
            care.
      --Nearly 78 percent of organizations currently offer workplace mental
            health resources or plan to offer such resources in the next
            year.
      --94 percent of HR professionals believe organizations can improve
            the health of employees by offering mental health programs.
            They point to increased productivity, employee retention and
            attracting new talent as additional reasons to support mental
            health.
        The United States will continue to grapple with the ongoing effects
    of the pandemic for an unknown period. Congress must continue to be
    proactive in supporting its constituent communities, as it has
    throughout the pandemic Granting SAMHSA the ability to issue workplace
    mental health grants is the right place to start. Thank you for
    considering our request.
                                     ______

         Prepared Statement of the Society for Maternal-Fetal Medicine
        The Society for Maternal-Fetal Medicine (SMFM) is pleased to submit
    testimony in support of the pivotal work of the Department of Health
    and Human Services (HHS) to optimize the health of birthing people and
    infants. 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 fiscal year (FY)
    2023. Specifically, SMFM urges the Committee to provide at least the
    following in base program level funding:
      --$49.048 billion for the NIH, with at least $1.816 billion of that
            funding to support the Eunice Kennedy Shriver National
            Institute of Child Health and Human Development (NICHD);
      --$11 billion for the CDC, including $164 million for the Safe
            Motherhood Initiative, $100 million for the Surveillance for
            Emerging Threats to Moms and Babies initiative, and $210
            million for the National Center for Health Statistics (NCHS);
      --$9.8 billion for the HRSA, including $1 billion 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 5,500 individuals, the core of
    SMFM's membership is comprised of maternal-fetal medicine (MFM)
    subspecialists. MFM subspecialists are obstetricians with additional
    training in caring for individuals experiencing high-risk 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 infants.
                                 hhs secretary
        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. 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 HHS Secretary in 2020. Since that time, various
    agencies across HHS have taken steps to implement PRGLAC
    recommendation, but there has been no coordinated effort across HHS.
    This disjointed implementation lends itself to potential duplication
    and missed opportunities. As such, SMFM recommends that Congress
    provide $200,000 in FY 2023 for the creation of an HHS advisory
    committee to monitor and report on implementation of PRGLAC
    recommendations.
        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 mothers have access to necessary
    medications.
                                   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.
        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.
        Maternal Mortality: 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 2020 was 23.8 deaths per 100,000 live births, and
    racial disparities persisted with a maternal mortality rate of 55.3
    deaths per 100,000 live births among non-Hispanic black women compared
    to 19.1 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 meet the President's budget
    request by providing at least $164 million for this work.
    ---------------------------------------------------------------------------
        \2\ Hoyert DL. Maternal mortality rates in the United States, 2020.
    NCHS Health E-Stats. 2022.Available at https://www.cdc.gov/nchs/data/
    hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm.
    ---------------------------------------------------------------------------
        Emerging Threats Initiative: 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 $1 billion 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 2023, Congress will allow AHRQ to expand its maternal health
    portfolio, improving care for nearly 4 million pregnant patients each
    year.
                                   conclusion
        The COVID-19 pandemic has further exposed existing inequities and
    gaps within our healthcare system for people across the country,
    including pregnant people. It is more important than ever to prioritize
    the needs of pregnant people and their infants in Federal programs from
    research, to public health surveillance, to care. We urge HHS to
    prioritize and adequately fund maternal health efforts for that aim to
    reduce maternal mortality and severe morbidity during and after the
    pandemic.
        With your support of vital HHS programs, obstetric researchers,
    clinicians, and patients can address the complex problems of pregnancy
    and truly improve the health and wellbeing of mothers and infants.
    Please direct any inquiries about this testimony to Rebecca Abbott,
    SMFM's Director of Government Relations (rabbott@smfm.org).
                                     ______

               Prepared Statement of the Society for Neuroscience
        Chair Murray, Ranking Member Blunt, and members of the
    subcommittee, on behalf of the Society for Neuroscience (SfN), we are
    honored 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 $49 billion, a $4 billion increase over
    FY22, in funding for the NIH for FY23, including the full release of
    funding for the NIH Innovation Account for 21st Century Cures programs
    and $680 million for the Brain Research through Advancing Innovative
    Neurotechnologies (BRAIN) Initiative. As both a researcher and a
    Professor in the Department of Biology at Brandeis University, I
    understand the critical importance of Federal funding for neuroscience
    research in the United States. My own research identified the ability
    of brain circuits to ``tune themselves'' to maintain the appropriate
    level of excitability, which is critical for healthy brain function.
        My research group, supported by NIH funding, made fundamental
    discoveries in how neurons self-adjust their excitability, making it
    easier or harder to send electrical messages to other neurons. Over the
    past two decades, we have unearthed a family of mechanisms that allow
    for this unique flexibility called ``homeostatic plasticity,'' so
    neurons can change the rate they send messages and protect
    communication in the face of outside disturbances. Our work has many
    wide-reaching implications: We are studying how learning and memory
    suffer when these mechanisms malfunction; We are exploring how being
    awake or asleep affects these mechanisms; and we are investigating how
    States of being too excitable or not excitable enough contribute to
    disorders like epilepsy and autism spectrum disorder. Basic research,
    like my own, is paramount to understanding the brain at a level deep
    enough to develop treatments and interventions for diseases and
    disorders.
        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 6 years.
    Growing the NIH budget over $9 billion in that period is exactly the
    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 the 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 America's research and development
    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. Industry typically does
    not fund research on this important first step given the long-term path
    of basic science and pressure for shorter-term return on investments.
    Congressional investment in basic science is irreplaceable on the
    pathway for development of drugs, biologics, devices, and other
    treatments for brain-related diseases and disorders.
        For example, in January 2022, NIH launched Phase 1 of Neuromod
    Prize to increase the development of neuromodulation therapies.
    Neuromodulation treatments act directly on peripheral nerves to improve
    organ function and have the potential to treat a variety of conditions,
    including heart failure. The Neuromod Prize is part of the SPARC
    (Stimulating Peripheral Activity to Relieve Conditions) NIH initiative.
    With SPARC, NIH will combine early-stage research and clinical
    applications to provide targeted treatments for multiple organ
    functions.
        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 is 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 FY23. Some recent exciting
    advancements in NIH funded neuroscience research include the following:
         covid-19 and its impact on adolescent mental health & drug use
        Since March 2020, Covid-19 has had a profound impact on our lives,
    physically and mentally. Adolescence is a challenging transition
    period, and researchers recognized the need to determine the impact of
    the pandemic on early adolescent's mental health. Using data from the
    Adolescent Brain Cognitive Development (ABCD) study, researchers fitted
    machine learning models that considered factors for adolescent
    psychological distress and emotional wellbeing during the Covid-19
    pandemic. Factors that predicted adolescent psychological distress
    during the pandemic included being female, pre-pandemic internalizing
    symptoms, and sleep problems. They also found healthy habits (exercise,
    better sleep) and social support reduced detrimental effects of the
    pandemic on adolescent mental health. This study stresses the
    importance of mental health in vulnerable populations to complement
    investigations into the physical manifestations of the pandemic.
        While adolescent mental health challenges have increased during the
    pandemic, adolescent drug use significantly decreased in 2021 since the
    start of the Covid-19 pandemic. These results come from the Monitoring
    the Future survey, funded by the National Institute of Drug Abuse.
    Since 1975, the Monitoring the Future has recorded drug and alcohol
    intake of adolescents across the United States at three time periods:
    lifetime, past year, and past month use. Findings from the survey show
    10th and 12th graders alcohol, marijuana, nicotine, and illicit drug
    use decreased significantly from 2020 to 2021. This decrease was the
    largest 1-year decrease recorded in the Monitoring the Future survey
    since 1975. The results taken from the survey demonstrate how the
    pandemic has impacted drug use in adolescents. It will be interesting
    to see how adolescent drug use changes from 2021-2022, with the
    continuation of the pandemic.
    congress & nih must support access to models necessary for neuroscience
                                   discovery
        SfN urges the Committee to appropriate funding for biomedical
    research without restriction on the use of animal models. 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 primates 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 well-regulated research can continue.
                            funding in regular order
        SfN joins the biomedical research community supporting an increase
    in NIH funding to at least $49 billion for existing NIH institutes and
    centers, a $4 billion increase over FY22. 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
    new grants and to fully fund continuation 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 its 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 your strong support of biomedical
    research.

        [This statement was submitted by Gina Turrigiano, PhD, President,
    Society for Neuroscience.]
                                     ______

         Prepared Statement of the Society for Women's Health Research
        The Society for Women's Health Research (SWHR)--a more than 30-
    year-old national nonprofit with a mission of promoting research on
    biological sex differences in disease and improving women's health
    through science, policy, and education--is pleased to submit testimony
    outlining SWHR's funding requests for fiscal year (FY) 2023. While SWHR
    believes that all Federal research is complementary and thus supports
    robust funding across all Federal research and public health agencies,
    we specifically urge appropriators in FY 2023 to support a program
    level of at least $49 billion for the National Institutes of Health
    (NIH), at least $62.5 million for the Office of Research on Women's
    Health (ORWH) and $1.816 billion for the Eunice Kennedy Shriver
    National Institute of Child Health and Human Development (NICHD).
        Biological sex differences influence disease development,
    progression, and response to treatment, while social determinants of
    health, including gender, affect disease risk, health care access, and
    outcomes. Yet, due to years of insufficient research addressing women,
    we have limited knowledge about women's health relative to men's
    health.
        This lack of prioritization, or inattention, to women's health has
    not only affected our understanding about key aspects of women's health
    and overlooked a critical portion of the population, but it has also
    amounted to tremendous money lost for the U.S. economy. Recent research
    conducted by the RAND Corporation revealed that ``even a slight
    increase in capital invested in basic research into women's health
    would unleash staggering returns...'' The study's simulations, which
    examined the potential return on investment if NIH were to double the
    budget for studies specifically assessing the health of women, showed
    the tremendous opportunity that lies in women's health:

          ``By doubling the NIH budget for research on coronary artery
            disease in women from its current $20 million, we could expect
            an ROI of 9,500 percent. Studies focused on rheumatoid
            arthritis in women receive just $6 million a year. Doubling
            that would deliver an ROI of 174,000 percent and add $10.5
            billion to our economy over the 30-year timespan.''--Chloe
            Bird, Fortune

        Robust, sustained funding for Federal research entities that
    prioritize research into diseases, conditions, and life stages that
    differently, disproportionately, or solely affect women across the
    lifespan is critical to achieve health equity for women. The COVID-19
    pandemic served as an important reminder that sex and gender
    differences that exist across diseases (e.g., men are more at risk for
    worse outcomes 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 vaccinations) and
    that health disparities are still widespread, with women
    disproportionately affected by socioeconomic challenges, food
    insecurity, domestic violence, and mental health concerns related to
    COVID-19.
        To continue building on the progress made and to ensure women's
    needs are represented in Federal research, SWHR urges Congress to
    prioritize women's health across the lifespan and women's health
    research by supporting NIH, ORWH, and NICHD in fiscal Year2023 funding
    legislation.
                       the national institutes of health
        The NIH is the premier medical research agency in the United States
    and the largest source of funding for biomedical and behavioral
    research in the world. As such, its mission is vital to promote the
    overall health and well-being of Americans by fostering creative
    discoveries and innovative research; training and supporting the next
    generation of researchers to ensure a diverse, strong research pipeline
    to continue scientific progress; and expanding the scientific and
    medical knowledge base.
        Continued support for the NIH is necessary to drive women's health
    forward. Across NIH, researchers conduct and support basic, clinical,
    and translational research on diseases and conditions that impact women
    across the life stage. Among the NIH initiatives specifically aimed at
    improving women's health is the Trans-NIH Strategic Plan for Women's
    Health Research. Released in 2019, the 5-year Strategic Plan laid out
    broad NIH goals to complement its more targeted women's health
    programs, advancing women's health research, developing a well-trained
    biomedical research workforce, and promoting the role of sex and gender
    influences in research. Initiatives like these--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--will help us achieve consequential progress in making women's
    health mainstream.
        SWHR urges Congress to provide a program level of at least $49
    billion for the NIH, a $3.5 billion increase in the NIH appropriation
    plus funding from the 21st Century Cures Act for specific initiatives,
    in FY 2023. Additionally, SWHR asks that appropriators ensure that any
    funding for the new Advanced Research Projects Agency for Health (ARPA-
    H) or other targeted programs like pandemic preparedness supplement
    this base budget recommendation rather than supplant the foundational
    investment in NIH. This funding level, which is supported across the
    public health and scientific research communities, would allow for
    meaningful growth above inflation in the base budget and would expand
    NIH's capacity to support promising science in all disciplines
    (including women's health research) across the agency, keeping the NIH
    competitive on the world stage.
                    the office of research on women's health
        The biomedical sciences for decades have treated men and women as
    interchangeable subjects. 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. This approach ignored the impact of sex and
    gender on human development and disease progression, overlooking a
    critical slice of the population and leaving untapped important areas
    of scientific opportunity.
        As the NIH hub 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 on
    programs, such as the Specialized Centers of Research Excellence, or
    SCORE, 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.
        SWHR recommends that Congress provides $62.5 million in funding for
    ORWH in FY 2023. This increase will allow ORWH to build upon its
    existing programs, take steps in realizing a vision where sex and
    gender are integrated into research and where women receive
    personalized, evidence-based prevention and treatment, and continue its
    efforts coordinating and elevating women's health research across NIH.
    the eunice kennedy shriver national institute of child health and human
                                  development
        The NICHD, founded to investigate human development throughout the
    life process, also provides a home for women's health research in areas
    across reproductive sciences and maternal health, including
    infertility, pregnancy, and menopause. The Institute's research
    portfolio is critical for addressing pressing public health issues,
    such as pregnancy outcomes, gynecological health issues, such as
    uterine fibroids and endometriosis, and the environmental, behavioral,
    and social factors that shape women's health.
        Among NICHD's myriad contributions to women's health research is
    its work with respect to pregnant and lactating individuals. Nearly 94
    percent of women take at least one medicine during pregnancy, and 50
    percent take at least one medication during the postpartum period. Yet,
    pregnant and lactating women are often excluded from 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.
        As part of its efforts to support these populations is NICHD's
    Maternal and Pediatric Precision in Therapeutics (MPRINT) Hub, which
    will serve as a national resource for expertise in maternal and
    pediatric therapeutics to conduct and foster therapeutics-focused
    research in obstetrics, lactation, and pediatrics while enhancing
    inclusion of people with disabilities. The MPRINT Hub will aggregate,
    present, and expand the available knowledge, tools, and expertise in
    maternal and pediatric therapeutics to the broader research, regulatory
    science, and drug development communities.
        SWHR calls on Congress to provide at least $1.816 billion for NICHD
    in fiscal Year2023 so the Institute can continue driving advancements
    in women's reproductive health and funding research and training
    activities that help address some of the Nation's leading public health
    issues.
                                      ***
        SWHR appreciates the opportunity to submit this testimony and
    thanks the subcommittee of considering our requests of a program level
    of at least $49 billion for NIH, at least $62.5 million for ORWH and
    $1.816 billion for NICHD. We look forward to working with you to ensure
    the highest possible support for Federal research agencies in FY 2023.
    If you have questions or need any additional information, please
    contact SWHR President and CEO Kathryn G. Schubert at kathryn@swhr.org.
                                     ______

           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. Enclosed are our report
    language recommendations to encourage the National Cancer Institute to
    prioritize research activities to address endometrial cancer
    disparities in people of color. 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, who include physicians, nurses, and
    other advanced practice providers, represent the entire 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 to support
    research aimed at improving outcomes for diverse patient populations.
        Endometrial cancer is the most common gynecologic cancer in the
    United States, and the fourth most common malignancy among American
    women, behind breast, lung, and colorectal cancers. According to the
    American Cancer Society, the incidence and mortality rate of uterine
    corpus cancers, over 90 percent of which arise from the endometrium, is
    rising. In 2012, there were an estimated 47,000 cases of uterine cancer
    and 8,000 deaths. This has increased by more than 140 percent over the
    last 10 years, with 65,950 expected new cases and 12,550 expected
    deaths in 2022.\1\ While the majority of other cancers have seen
    improvement in survival rates, survival rates for endometrial cancer
    have worsened annually since 2010. Greater prevalence of key risk
    factors, such as obesity and delayed childbearing may be contributing
    to the increased incidence of endometrial cancer, but do not explain
    the worsening mortality.
    ---------------------------------------------------------------------------
        \1\ American Cancer Society. Cancer Facts & Figures 2022. Atlanta:
    American Cancer Society; 2022. file:///C:/Users/mjc92028/Downloads/
    cancer-facts-and-figures-2012.pdf; American Cancer Society. Cancer
    Facts & Figures 2022. Atlanta: American Cancer Society; 2022. https://
    www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-
    statistics/annual-cancer-facts-and-figures/2022/2022-cancer-facts-and-
    figures.pdf].
    ---------------------------------------------------------------------------
        Endometrial cancer was previously thought to be more common in
    White women, however as of 2007, the incidence of endometrial cancers
    in Black women surpassed that of White women and continues to increase
    each year.\2\ The majority of endometrial cancers are the result of
    obesity, making this one of the only preventable cancers. Additionally,
    some of the distressing disparity between lower survival and outcomes
    for women who have endometrial cancer is missed opportunities at early
    detection. Bleeding, often accompanied by debilitating menstrual pain,
    is a symptom that allows early detection, but is sometimes misdiagnosed
    as fibroids, uterine cysts, or perimenopause. Unfortunately, fewer than
    70 percent of endometrial cancers are now diagnosed while still
    confined to the uterus.\3\ Thirty-eight percent (38 percent) of
    endometrial cancers are diagnosed at advanced stages in Black women
    compared to 25 percent in White women.\4\
    ---------------------------------------------------------------------------
        \2\ National Cancer Institute. Surveillance, Epidemiology, and End
    Results Program. Cancer Stat Facts: Uterine Cancer. Available at:
    https://seer.cancer.gov/statfacts/html/corp.html. Last queried February
    13, 2020.
        \3\ Memorial Sloan-Kettering Cancer Center, Stages of Uterine
    (Endometrial) cancer. https://www.mskcc.org/cancer-care/type/uterine-
    endometrial/diagnosis/stages.
        \4\ American Cancer Society. Cancer Facts & Figures 2022. Atlanta:
    American Cancer Society; 2022. https://www.cancer.org/content/dam/
    cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-
    and-figures/2022/2022-cancer-facts-and-figures.pdf].
    ---------------------------------------------------------------------------
        Additionally, black women are less likely to receive evidenced
    based care. Moreover, disparities exist regarding social determinants
    of health, access to genetic testing, preventive services, and other
    aspects of care for patients with endometrial cancer. These disparities
    are creating enormous inequities in outcomes and survivorship in our
    health care system, particularly for endometrial cancer. Black women
    are more likely to be diagnosed with aggressive subtypes of endometrial
    cancer and the mortality and 5-year survival rates are much worse for
    black women than white women. The five-year survival rate in black
    women is 63 percent compared to an 84 percent 5-year survival rate in
    white women.\5\ Black women are two times more likely to die from this
    disease compared to White women.\6\
    ---------------------------------------------------------------------------
        \5\ American Cancer Society. Cancer Facts & Figures 2022. Atlanta:
    American Cancer Society; 2022. https://www.cancer.org/content/dam/
    cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-
    and-figures/2022/2022-cancer-facts-and-figures.pdf].
        \6\ Giaquinto Obstet & Gynecol Feb 2022.
    ---------------------------------------------------------------------------
        Disparities in endometrial cancer outcomes may be furthered by
    inequities in access to appropriate screening, genetic testing, and
    preventive services. Identifying actionable targets to mitigate
    disparities in early detection and receipt of timely, guideline-
    concordant care remain critical to improving endometrial cancer
    outcomes among underserved populations. Research is critically needed
    to help understand barriers to care; elucidate differences in tumor
    biology; discover new approaches to screening, prevention, and
    treatment; and promote wider implementation of known strategies to
    facilitate optimal treatments to improve survival for all patients with
    endometrial cancer
        Therefore, the SGO urges the subcommittee to adopt the following
    report language on endometrial cancer in the report accompanying the
    Fiscal Year 2023 Labor-HHS-Education appropriations bill.

                           National Cancer Institute

          Endometrial Cancer.--The Committee remains concerned about the
            significant disparities in mortality rates for endometrial
            cancer that adversely impact Black women. The age-adjusted
            mortality rate for Black women with endometrial cancer is much
            worse than it is for White women, which is partly attributed to
            cancer stage at diagnosis. The Committee urges the NCI to
            conduct research activities that will lead to the development
            of targeted interventions to improve early diagnosis among
            Black women with endometrial cancer and improved access to high
            quality care through innovative community-based outreach
            methods to increase the enrollment and participation by Black
            women in clinical trials. The Committee requests an update on
            NCI's activities regarding endometrial cancer in the fiscal
            year 2024 Congressional Justification, including progress made
            in endometrial cancer early diagnosis, survival rates, and
            clinical trial enrollment by ethnicity.

        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
    endometrial cancer outcomes and remove barriers to health equity for
    all underserved women diagnosed with this lethal disease.
                                     ______

      Prepared Statement of the Society of Nuclear Medicine and Molecular
                                    Imaging
        Chair Murray, Ranking Member Blunt, 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 at least $49.048 billion for the National
    Institutes of Health's base appropriation. This figure represents an
    increase of $3.5 billion over FY 2022 plus the release of the 21st
    Century Cures funds. SNMMI also supports a proportional increase to the
    National Institute of Biomedical Imaging and Bioengineering (NIBIB),
    resulting in at least $458.5 million for FY 2023--a $33.6 million
    increase over the FY 2022 enacted level. Further, should the Advanced
    Research Projects Agency for Health (ARPA-H) or pandemic preparedness
    efforts progress, funding should be designated separately from NIH's
    base and should supplement, not supplant, investment in basic research.
    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.
    ---------------------------------------------------------------------------
    Improved Imaging and Therapy for Cancer using Molecularly Targeted
            Radiopharmaceuticals
        Major nuclear medicine advances in the fight against prostate
    cancer have appeared in the news. In the past year, three cancer-
    targeted radioactive imaging agents (Pylarify, Illuccix, and
    Locametz) received FDA approval and have entered commercial
    distribution for greatly improved detection of prostate cancer. These
    radiotracers seek out prostate cancer cells throughout the body,
    allowing the active foci of cancer to 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. The FDA has also recently approved a
    companion targeted radiotherapeutic, Pluvicto\TM\ (\177\Lu-PSMA-617),
    for men with late-stage castrate-resistant prostate cancer that had
    spread. The PSMA part of the drug makes it act like a guided missile or
    geotag 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 accelerated its
    approval time and allow it to reach patients in need faster. None of
    this would have been possible without the early support of 13 NIH
    grants.\2\
    ---------------------------------------------------------------------------
        \2\ Szabo Z, Mena E, Rowe SP, et al. Initial Evaluation of
    [(18)F]DCFPyL for Prostate-Specific Membrane Antigen (PSMA)-Targeted
    PET Imaging of Prostate Cancer. Mol Imaging Biol. 2015;17:565-574.
    ---------------------------------------------------------------------------
        Imaging and therapy molecule pairs, such as those using PSMA
    molecules as targeting agents, are often referred to as theranostics, a
    rapidly developing area of personalized medicine. If the diagnostic
    version of the molecule can find the cancer with a PET scan, then the
    same molecule with a therapeutic isotope can be used to attack the
    cancer. Further advancements in the theranostics space are anticipated.
    This treatment principle is being applied to cancer types for which we
    have no or few treatment options, such as pancreatic cancer. An
    exciting new class of theranostic molecules are those targeting
    fibroblast-activation-protein (FAP).\3\ This protein (FAP) is
    overexpressed in many cancer types including breast, pancreas, lung,
    kidney, and ovarian. The FAP molecule can be labeled as a diagnostic
    agent and then as a therapy. This treatment paradigm gives doctors a
    new tool in the fight against cancer. The NCI is currently supporting a
    phase 1 clinical trial (NCT04457258) on this promising new agent.
    ---------------------------------------------------------------------------
        \3\ Kratochwil C, Flechsig P, Lindner T, Abderrahim L, Altmann A,
    Mier W, Adeberg S, Rathke H, Rohrich M, Winter H, Plinkert PK, Marme F,
    Lang M, Kauczor HU, Jager D, Debus J, Haberkorn U, Giesel FL. 68Ga-FAPI
    PET/CT: Tracer Uptake in 28 Different Kinds of Cancer. J Nucl Med. 2019
    Jun;60(6):801-805. doi: 10.2967/jnumed.119.227967. Epub 2019 Apr 6.
    PMID: 30954939; PMCID: PMC6581228.
    ---------------------------------------------------------------------------
        None of these advances would be possible without the support of
    radiochemistry and isotope production research. The next generation of
    radioisotopes, alpha emitting therapeutic isotopes, which have much
    greater cancer killing power per radioactive decay, are in clinicals
    trials and are expected to provide better patient outcomes. Support of
    that research is critical.
    Quantitative Molecular Imaging
        A PET scanner is often thought of as an imaging tool; however, it
    is inherently a highly specific measuring tool. Recent advances in PET
    technology such as PET/MRI and total-body PET, where the whole body can
    be imaged at once, have opened new research possibilities.\4\ To
    realize the full potential of these advances, quantitative analysis
    will be required to appreciate the sensitivity of the scanner and the
    tracers it measures. The NCI has supported the harmonization of PET/CT
    scanners through numerous grants including NIH R01CA169072, and for the
    last decade, the NCI, through their Cancer Imaging Program has
    developed and supported a consortium of academic sites called the
    Quantitative Imaging Network performing and advancing quantitative
    imaging mostly in support of clinical trials.
    ---------------------------------------------------------------------------
        \4\ Meikle SR, Sossi V, Roncali E, Cherry SR, Banati R, Mankoff D,
    Jones T, James M, Sutcliffe J, Ouyang J, Petibon Y, Ma C, El Fakhri G,
    Surti S, Karp JS, Badawi RD, Yamaya T, Akamatsu G, Schramm G, Rezaei A,
    Nuyts J, Fulton R, Kyme A, Lois C, Sari H, Price J, Boellaard R, Jeraj
    R, Bailey DL, Eslick E, Willowson KP, Dutta J. Quantitative PET in the
    2020s: a roadmap. Phys Med Biol. 2021 Mar 12;66(6):06RM01. doi:
    10.1088/1361-6560/abd4f7. PMID: 33339012.
    ---------------------------------------------------------------------------
    Imaging of the brain in Alzheimer Disease
        About a year ago, 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 U.S.
    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 U.S. President
    Jimmy Carter had a remarkable response to ICI therapy. However, they do
    not work in all patients; indeed over half of patients treated with
    these agents die of their disease. New radiotracers are in development
    to image the immune system in conjunction with a PET or SPECT camera.
    Clinical trials with these tools have demonstrated the ability to
    predict response to ICI therapy after just one cycle of therapy. Future
    studies will aim to pre-select, with imaging, patients who are likely
    to respond to immune checkpoint inhibitors thus enabling effective
    therapy earlier and eliminating side effects of futile treatments. The
    ability to select patients likely to respond to therapy will also save
    billions in healthcare dollars.
    ---------------------------------------------------------------------------
        \5\ https://www.whatisbiotechnology.org/index.php/timeline/science/
    immunotherapy/80.
    ---------------------------------------------------------------------------
    Data Science and Workforce
        The field of nuclear medicine and molecular imaging is rapidly
    expanding with new diagnostic imaging tracers, radiopharmaceutical
    therapies (RPT), and technologies. With new diagnostic tracers comes a
    need to properly interpret the innovative scans. Artificial
    intelligence (AI) algorithms can assist with the tedious components of
    image interpretation and even help with quality report generation.
    Development of well-credentialed registries of studies to train and
    validate such AI algorithms, reflecting diverse sets of patients will
    help advance this field. Radiopharmaceuticals therapies (RPTs), like
    other oncology therapies, are often studied in and approved for
    patients with late-stage disease, for example, after all other
    treatments have failed. To harness the full potential of RPTs, use
    earlier in the disease course may be advisable. Image and clinical data
    registries are needed to capture post-approval information on the use
    of RPTs and the patient outcomes to further guide their use. Recent
    imaging and therapy FDA approvals in prostate cancer and Alzheimer's
    disease, two highly prevalent conditions, require that the highly
    specialized field of nuclear medicine and molecular imaging train a
    cadre of qualified individuals to diagnose and treat these patients. It
    is critical for the NIH to fund and expand training grants so that our
    brightest scientists have the skills to develop a sustainable career
    pathway. Funding for AI technologies and registries will improve
    patient care and outcomes.
                             summary and conclusion
        Robust NIH funding is crucial to advancing our efforts to detect
    and treat serious medical conditions. NIH investments help to sustain
    both our local and national research institutions across every State in
    the Nation. China is advancing rapidly in the high technology medical
    space notably in AI. Funding NIH's base program with at least $49.048
    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 Spina Bifida Association of America
    Shoshana Siegel of Hollywood, Florida
        My name is Shoshana Siegel and I'm a 17-year-old, and I was born
    with Spina Bifida. I have had seven major surgeries in my life
    beginning at the age of 3 months. These surgeries include neurosurgery
    to detether my spine and brain surgery due to a related condition
    called Chiari Malformation. I am hospitalized 4-6 times a year for on-
    going foot infections that are a result of lack of feeling in my legs.
    Sometimes children with Spina Bifida are called million-dollar babies;
    by the time I was 6 months old my medical costs were half a million
    dollars. At the age of 17, between my surgeries, medications and
    hospitalizations, we estimate my medical costs are about $3 million. I
    am fortunate to have always had private medical insurance through my
    mom's employers. I am on-track to graduate high school early and want
    to go into medical science as my career. I would like to be a forensic
    medical examiner or forensic psychologist. There are instances of
    people with Spina Bifida suddenly dying in their 40s with no
    explanation. I want to find out why and help us all live longer.
        I'm here today to talk about the importance of funding for the
    CDC's National Spina Bifida program which funds research and clinics
    around the country. At the age that I'm at, I have around seven doctors
    who talk to each other openly through our local children's hospital
    system. My doctors include wound care specialists, two different
    neurologists, a neurosurgeon, an orthopedic surgeon, urologist and a
    primary doctor. Also, I see two mental health specialists to help me
    navigate life. If all goes well, I can go to these experienced doctors
    who know about my condition until I'm 20 years old. After I'm 20, I
    will no longer be able to receive care from these experts or be
    entitled to this quality care from my experienced and personalized
    medical team when I have an infection and need to be hospitalized. At
    17 one of my doctors is already starting to transition me to an adult
    doctor for my next surgery which will take place before I am 18. This
    is not usually how it is done. Typically, a 20-year-old would be solely
    responsible for seeking doctors who may have experience with my
    condition and needs and it could take years to find the right fit for
    my type of Spina Bifida. It is not as easy as googling ``spina bifida
    doctor''. Spina Bifida is referred to as a snowflake condition because
    no two cases are alike. So for me it would be finding doctors who can
    specifically understand my body, my conditions and work with my other
    doctors. This is hard to do outside of a medical clinic situation. And
    there are not many Spina Bifida medical clinics at adult hospitals.
        No one with Spina Bifida should have to fight to have basic medical
    care or be penalized because a condition which was once pediatric is
    now witnessing its first generation of adults. The medical system must
    figure out how to keep pace with a growing, aging and surviving Spina
    Bifida population.
        Funding the National Spina Bifida Program at $11 million would help
    prevent individuals like myself from falling over the care cliff that
    happens when a child with Spina Bifida makes the move from a
    coordinated pediatric system of care into a fragmented and fractured
    system for adult care. Establishing more adult care clinics would help
    individuals transition and provide for coordination among doctors so we
    could secure employment and enrich our lives.
        With the support of my family, I have had excellent medical care my
    whole life. This care has allowed me to thrive and excel in life. I
    would like to keep my life on track for success without being consumed
    by healthcare stress. Thank you for listening to my story and for your
    support.
    Charlotte Mountz of Harpers Ferry, West Virginia
        My name is Charlotte Mountz, and I am 18 years old and I have Spina
    Bifida. I am just like any other young woman, with hopes, dreams, and
    fears. I love animals and would like to be a zookeeper. Like most other
    siblings. My younger brother and I will argue about petty things. But
    one of my greatest concerns is the lack of healthcare for adults with
    Spina Bifida.
        I have grown up going to fantastic pediatric doctors, who know how
    to treat people with Spina Bifida. However, Spina Bifida used to be
    thought of as a pediatric condition because kids would not live until
    adulthood, happily that has changed and we are seeing adults living
    into their senior years. Unfortunately, the adult healthcare system
    hasn't caught up. That is why I am writing to you today.
        The Spina Bifida community experiences what is called a care cliff,
    meaning that when a child becomes an adult, they lose their care, and
    because of the lack of education about care for adults with Spina
    Bifida, there are a lack of providers, both PCPs, and specialist
    including, but not limited to, Urologists, Nephrologists, Neurologists,
    Neurosurgeons, Orthopedics, and more. Access to these providers is
    necessary for people with Spina Bifida to live happy and healthy.
        I would like you to support an increase to $11 million dollars for
    the National Spina Bifida Program at the CDC. This increase will allow
    the NSBP to find more research into care for adults with Spina Bifida
    so that we can better educate doctors and lessen the care cliff.
                                     ______

       Prepared Statement of theAmerican Association of Neuromuscular &
                           Electrodiagnostic Medicine
                        fiscal year 2023 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 $49
            billion in discretionary funding, an increase of $3.5 billion
            over FY 2022. 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).
      --Please provide distinct, additional funding to support and further
            implement 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.
      --Please provide the Centers for Disease Control and Prevention (CDC)
            with $11 billion to bolster support for public health programs
            that support patient communities, such as the National
            Neurologic Conditions Surveillance System.
    _______________________________________________________________________

        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 2023 L-HHS
    appropriations. First and foremost, thank you for the ongoing
    investment in medical research, patient care, and healthcare fraud
    prevention programs. Please maintain this investment and provide
    further support for FY 2023.
        Concerning 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 nearly 6,700 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
    impulses 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 2023 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
    percent 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).
        A case in Alabama earlier this year recently led to a guilty plea.
    According to the Justice Department, the provider conspired with... a
    Huntsville-based testing company, to bill insurers millions of dollars
    for electro-diagnostic testing that its technicians performed,
    regardless of whether there was a medical need for them. Insurers were
    then billed using the providers National Provider Identifier (NPI)
    number, even where they did not conduct the tests, supervise the tests,
    interpret the test results, or have anything to do with the tests
    beyond allowing the NPI number to be used for billing purposes. The
    fraud identified by the FBI for this case alone is $28 million.
        https://www.justice.gov/usao-ndal/pr/huntsville-doctor-charged-
    health-care-fraud-conspiracy.

        [This statement was submitted by Peter A. Grant, MD, EDX Fraud and
    Abuse Consultant for FBI and OIG, AANEM Past-President.]
                                     ______

                Prepared Statement of Today's Student Coalition
        Dear Chairwoman Murray, Ranking Member Blunt, Chairwoman DeLauro,
    and Ranking Member Cole:
        The Today's Student Coalition (TSC) respectfully requests the
    following funding levels within the Fiscal Year (FY) 2023 Labor, Health
    and Human Services, Education, and Related Agencies (LHHS)
    appropriations bill. The TSC--a collective of 34 cross-cutting higher
    education policy, advocacy, and membership organizations--appreciates
    the steps that Federal policymakers have taken to support students
    through the pandemic. Yet, as our Nation looks to turn the corner and
    begin the process of rebuilding our economy for a post-pandemic world,
    Federal investments must continue to enhance the capacities of
    postsecondary institutions while ensuring student access to the support
    necessary for success in higher education.
        As you begin to work on FY 2023 appropriations legislation, the TSC
    would like to express our support for investments in the key child
    care, financial aid/support, and campus mental health programs outlined
    below. As our coalition strives to create a system of higher education
    that better reflects and supports the needs of today's students, we
    believe that investments in these programs represent a chance to not
    merely repair the damage caused by the pandemic, but to provide real
    educational and economic opportunity to all.
      --Emergency Aid Grants: Create a permanent Emergency Aid Grant
            program to provide grants to institutions with the explicit
            purpose of providing direct student emergency financial aid.
            This funding would allow institutions to provide direct
            financial assistance to ensure an emergency cost does not
            derail a student's ability to complete college, similar to the
            assistance provided to students through the Higher Education
            Emergency Relief Fund (HEERF).
        An emergency financial aid grant can help students cover any
    unexpected expenses so these emergencies do not suspend or halt their
    education. The Coronavirus Aid, Relief, and Economic Security Act and
    the two other subsequent COVID-19 aid packages provided resources for
    institutions of higher education to provide financial support in the
    form of emergency aid grants for students related to the pandemic. This
    aid enabled millions of students to stay in school despite the
    increased costs of living through the pandemic in a postsecondary
    environment. This authority proved that even a relatively small amount
    of financial aid can ensure students have a chance to stay in school.
      --Pell Grants: Pell Grants have served as the cornerstone of Federal
            financial aid for students from low-income backgrounds,
            providing crucial support for roughly 7 million students each
            year. We urge Congress to consider a significant increase in
            the maximum Pell Grant award in both discretionary and
            mandatory funding--continuing the trajectory towards a full
            doubling of the maximum award amount in the coming years.
      --Child Care Access Means Parents in School: Increase funding to $500
            million for the Child Care Access Means Parents in Schools
            (CCAMPIS)--the amount needed to provide child care support to
            about six percent of Pell-eligible student parents of children
            ages 0-5. The CCAMPIS program provides vital support for the
            participation and success of low-income parents in
            postsecondary education through the provision of campus-based
            child care, widely recognized as one of the most important
            supports for parenting college students. Increasing CCAMPIS
            funding to $500 million would ensure that roughly 100,000 more
            parenting college students receive the child care assistance
            they need to continue their educational journeys.
      --Garrett Lee Smith Memorial Act Campus Suicide Prevention Grant:
            Finally, increase the Garrett Lee Smith Campus Suicide
            Prevention Grant (GLS CSPG) to $15 million, as this funding did
            not receive an increase in the FY 22 package.
        In June 2020, data from the CDC showed that more than half of
    adults aged 18-24 had at least one adverse mental or behavioral health
    symptom, with more than a quarter considering suicide in the past 30
    days. The GLS CSPG provides vital funding in colleges' efforts to not
    only address the unique needs of students experiencing mental health
    challenges or contemplating suicide, but support them in reaching their
    academic goals. As the mental health challenges on college campuses
    have grown, funding for this important program has become even more
    critical.
        As you consider programmatic funding levels for FY 2023
    appropriations, we urge you to reaffirm Congress's historic, bipartisan
    commitment to postsecondary education and to today's students. Thank
    you for the consideration of important requests. We look forward to
    continued work with you to advance programmatic funding that meets the
    needs of our students and the Nation as a whole.
        Sincerely.
                         the today's students coalition
    Higher Learning Advocates
    Achieving the Dream
    Advance Vermont
    America Forward
    Association of Young Americans
    Center for First-generation Student Success
    Coalition on Adult Basic Education
    Cornell University Student Assembly
    Institute for Higher Education Policy
    The Jed Foundation
    Jobs for the Future
    Let's Get Ready
    National Association of Student Personnel Administrators
    National College Attainment Network
    National Skills Coalition
    New America Higher Education Program
    Student Veterans of America
    Swipe Out Hunger
    uAspire
    University of California Student Association
    University Professional and Continuing Education Association
    Veterans Education Success
    Young Invincibles

                                     ______

                    Prepared Statement of TRIO Talent Search
        ``You're so smart. It's too bad you can't go to college,'' my dad
    sighed, a sad look on his face. I was a freshman in high school when he
    said that to me after reviewing my first report card. Up until that
    point, I hadn't really thought about college. I had assumed I would
    probably go because that's what people did after high school. I felt
    shocked by my dad's words; why wouldn't I go? His answer was ``money,''
    of course. There was no money for college.
        I would soon come to learn that it wasn't just about money. Well-
    meaning though they were, my parents, who themselves struggled to
    complete high school and worked blue collar jobs, didn't have any idea
    of how to help prepare me for college. When it came to grades, it was
    simply ``do your best.'' If homework was challenging, my mom jokingly
    reminded me she flunked out of algebra. There would be no SAT prep
    courses, no private education, no unpaid internships ``for the
    experience.'' The time I had for extracurricular activities was shared
    with the 25 hours per week I worked at a pizza shop. I was smart, yes,
    but that was about all I had in my favor.
        While I was in high school, I was informed that I was eligible to
    participate in a program called TRIO Talent Search (TTS). My ETS
    advisor, Carolyn, provided me with critical guidance I didn't get
    anywhere else. I'd had no idea that college applications cost money,
    but Carolyn helped me get fee waivers and meet application deadlines,
    schedule campus tours, and jump through all the hoops I had never known
    existed, and certainly couldn't have figured out on my own. With her
    help, I was accepted to the University of New Hampshire Honors Program
    with a partial scholarship.
        In my first year of college, my dad experienced a significant
    mental health crisis that would ultimately lead to his becoming
    permanently psychiatrically institutionalized. His illness also
    resulted in a loss of income that ultimately led to foreclosure on our
    family home during my sophomore year. I took out extra loans to help
    with the mortgage, but it simply wasn't enough. These family stressors,
    coupled with my socioeconomic background, often made me feel ``other''
    than my peers, who seemed so carefree by comparison.
        As in high school, I worked through college and was fortunate to
    complete my work-study in TTS's administrative office. During that
    time, I became familiar with the many services provided by other TRIO
    programs. My TRIO supervisors and mentors encouraged me to apply for a
    tutor-counselor position at Upward Bound, another TRIO program that
    helped low-income, first generation, and ethnic minority students
    become competitive for college, in part through their intensive summer
    college preparatory program. I spent the summer before my junior year
    working as a teaching assistant for classes and providing mentorship,
    leadership, and individual tutoring to a fantastically bright and funny
    group of high school students. It was the first meaningful job I could
    put on my resume--a dramatic departure from Papa Gino's, Subway, and
    the Getty gas station off of exit 14.
        That wasn't the end of what TRIO had to offer. Right before my
    senior year, an TTS mentor asked me if I had applied for TRIO's McNair
    Postbaccalaureate Achievement Program. I hadn't because I had never
    heard of it. Learning about the program, it seemed too good to be true:
    a summer spent living and conducting funded research on campus, a free
    GRE prep course, attending research conferences and college tours,
    personalized mentorship, graduate school application fee waivers, and
    peer support. I could barely contain my excitement. When I was accepted
    into the McNair Program, I felt like I had won the lottery, and in a
    sense, I really had. The summer I spent with McNair was among the most
    memorable of my life. I am certain that without that experience, their
    guidance, and the financial assistance, I would not have been
    competitive in graduate school application pools saturated with high-
    pedigree students with stunning CVs. Good grades and a passion for
    learning are simply not enough for success. With their help, I was
    accepted to The New School's clinical psychology program with a 75
    percent tuition scholarship. I graduated with my BA in psychology summa
    cum laude, first in my class, with the honor of being designated a
    Dean's Fellow and Class Marshal. I had the privilege of carrying my
    college banner in our graduation march, which was one of the proudest
    moments of my life.
        I went on to earn my MA and PhD in Clinical Psychology. While at
    the New School, I served as lab manager for a psychology lab that
    studied the psychophysiology of complex trauma. In short, we worked to
    understand how people with a lifetime of traumatic exposure (such as
    abuse and neglect) experience and manage their emotions. By also
    including measures of psychobiology, we were able to better understand
    the biological mechanisms underlying their emotional processes. A
    highlight of my time in the lab was when I was able to serve as project
    coordinator for a 5-year, multi-site NIMH-funded grant study on the
    common factors underlying various mental health issues, with a focus on
    the role of trauma in diagnosis and emotional processing. In
    understanding how people with various mental health concerns process
    emotional information, we can develop better, more sensitive treatment
    interventions. My dissertation research, which focused on how people
    with trauma histories use physical pain to manage emotional distress,
    has clinical implications in helping patients reduce self-harming
    behavior while still coping with intense negative emotions. My research
    also served to de-stigmatize those who engage in self-harm by showing
    that many people use benign forms of pain to cope with stress. The main
    findings from this research have been presented at the Society for
    Affective Science conference, where I won an award for my talk. My
    results have since been published in Emotion, a highly regarded
    psychology research journal, and have been picked up by two psychology
    research digests.
        During my graduate school years, I also completed 3 years of
    predoctoral training at the Manhattan VA hospital, where I provided
    therapy for veterans, including those with PTSD and traumatic brain
    injuries. After graduating with my PhD summa cum laude, I completed 2-
    year postdoctoral fellowship at NYU Langone's World Trade Center Health
    Program for first responders to the 9/11 attacks. During my time there,
    I provided therapy and assessment for first responders, and founded a
    therapy group for responders with 9/11-related cancers. I also had the
    opportunity to co-author an integrative mental health treatment manual
    to help providers meet the unique needs of this population.
        After completing this training, I accepted a full-time position at
    Bellevue Hospital's World Trade Center Health Program for survivors of
    the 9/11 attacks, where for 2 years I provided psychotherapy to
    survivors with trauma-related disorders and co-morbid medical
    conditions, such as cancer. I was given my first faculty appointment as
    a Clinical Instructor at NYU School of Medicine and continued to pursue
    and publish my own research. My time in both the responder and survivor
    World Trade Center Health Programs was humbling and deeply meaningful,
    fueling my passion to continue helping people thrive in the wake of
    trauma.
        In October 2021, I accepted an Associate Clinical Director position
    at the Center for Stress, Resilience, and Personal Growth (CSRPG) at
    Mount Sinai's Icahn School of Medicine. This also came with a promotion
    to Assistant Professor of Psychiatry at the School of Medicine. CSRPG
    conducts resilience-building outreach and provides immediately
    accessible mental health care to front-line healthcare workers at Mount
    Sinai. In my role, I coordinate all day-to-day clinical operations,
    conduct outcome research, engage in outreach, provide clinical
    supervision, and provide individual psychotherapy and resilience-
    building workshops to healthcare workers. It has been an immense
    privilege to provide care to those impacted by these chronic traumatic
    stressors.
        As someone who benefited immensely from the mentorship and guidance
    of others, I feel strongly about carving out time away from therapy and
    research to give back to students. During my college years, I served as
    a youth mentor to a troubled middle school student. During my years as
    lab manager, I helped masters- and doctoral-level students develop and
    hone their research interests and skills, while also working to build a
    sense of community within the lab. As a teaching assistant, I provided
    both group and individualized support to master's students working on
    their theses. During my time as a postdoctoral fellow, I began
    supervising psychology trainees on their clinical cases. At Bellevue, I
    continued to stay active the training program, providing supervision
    and mentorship to pre-doctoral psychologists in training on both
    trauma-related and general outpatient cases. I also led several
    didactics and seminars throughout the year on how to understand and
    treat complex trauma cases. Now, I supervise a group of 10 social
    workers in their clinical work.
        The McNair program's naming after an astronaut is apt, because
    reaching the exit velocity required to ascend out of the working class
    requires force akin to a rocket engine and jet fuel. Obtaining my PhD
    (the first in my family) was of course the result of my own hard work--
    my ``engine'', so to speak. But TRIO programs provided the jet fuel and
    mapped my course, without which I would certainly not be where I am
    today. I am privileged now to be doing a meaningful job that I love,
    with only a continued upward ascent ahead of me.
        In addition to what TRIO has helped me accomplish, I am also
    immensely grateful to know that my future children, and their children
    in turn, will grow up with the knowledge and resources required to
    pursue their own educations and build fulfilling careers. TRIO helps
    individuals, yes--and I am one of those lucky ones. But TRIO's impact
    goes far beyond the individual, radiating outward to the patients I can
    now treat as a result of their assistance, and far into the future. I
    am so incredibly grateful for all TRIO has done for me; I would not be
    where I am today without these programs.

        [This statement was submitted by Ashley Doukas, PhD, Alumna, TRIO
    Talent Search and Ronald E. McNair Postbaccalaureate Achievement.]
                                     ______

            Prepared Statement of TRIO Upward Bound, Math & Science
        As a native Missourian, TRIO Upward Bound Math and Science alumna,
    former Obama Administration staffer, current TRIO Student Support
    Services (SSS) Director at Washington University in St. Louis, and
    Jennings City Council Member in St. Louis, MO, I am a true testament to
    how #TRIOWorks and shapes lives. I have been and educator and public
    servant for over two decades because of my wonderful TRIO experience.
        As a high school student in Upward Bound Math and Science, the TRIO
    program helped me think about why I wanted to attend college; my
    advisor assisted me as I navigated college applications and figuring
    out which path to take. Being in the TRIO family, I was encouraged to
    not only receive an undergraduate degree from the University of Central
    Missouri, but also get a master's degree in Teaching, Social Science
    from Webster University, and to pursue a PhD in Educational Management-
    Higher Education from Hampton University.
        While in the Upward Bound Math and Science program, I was able to
    cultivate meaningful friendships and met my best friends at the
    University of Northern Iowa where we attended summer classes through
    the program. Thanks to Upward Bound Math and Science, most of us
    attended college and graduated, and some of us went on to attain
    graduate degrees. Four of us from my TRIO cohort became Obama staffers.
    One friend who did not immediately attend college, went to and taught
    at cosmetology school. Because of that persistent spirit that TRIO
    programs instill in students, I am proud to have witnessed this very
    friend graduate from the only HBCU in St. Louis this past May 2022. She
    had the foundation of TRIO Upward Bound Math & Science. My TRIO cohort
    friend group is full of successful career paths: we have an urban
    farmer and food justice advocate, a healthcare worker, a CEO of a tech
    company, an education advocate, and a defense attorney. We all
    attribute our success to the support of the TRIO program and its
    advisors along our journeys.
        Having the support during my high school years prepared me to
    attend college. Without the TRIO program, there would not be a Dr.
    Kimberly Morton or the countless other successful TRIO alumni who have
    benefited from this wonderful program. As a staffer in the Obama
    Administration working at the U.S. Department of Education in the
    office of post-secondary in the TRIO department and then as a current
    TRIO SSS director, I understand the impact of TRIO on all sides.
        From a TRIO Director's lens, how we advise and advocate for our
    students throughout their college experience, especially during COVID,
    has been difficult because of mental health challenges among our first-
    generation, low-income students, and student with disabilities. We are
    slowly getting back to a new normal, but I think the long-lasting
    impacts of COVID, physically and mentally, will remain for years to
    come. We have also provided programming and three courses to assist
    students with resources on how to navigate WashU, we collaborate with
    campus partners, corporations, non-profits, and researchers to assist
    students with thinking about life post-graduation: whether they plan to
    go to medical school, law school, pursue other graduate degrees, or if
    they plan to join the workforce. We are setting students up with
    mentors and internships while providing them with professional
    development opportunities so that they can be the best versions of
    themselves when they graduate from the institution.
        TRIO needs more funding to provide academic resources and increase
    staffing so that we can also serve as students' 4-year advisors. My
    team takes a holistic approach to advising. As 4-year advisors, we know
    that the students are getting the critical support that they need from
    first-year to graduation, and beyond. I would like to ask for support
    for an increase of $170 million dollars for the FY23 budget because it
    is essential that we increase programming and provide academic
    resources and services to match student needs.
        It has been a true honor for me to understand the TRIO program, on
    all levels. Knowing how many lives the program impacts across the
    country, it would be great if every institution across the country had
    a TRIO program. We must continue and expand this important work of
    ensuring that students who are first-generation, low-income, or have
    disabilities are seen and heard, have the academic support and
    programming, and advocacy to navigate to graduation and beyond. Our
    mission is to develop students who go on to have successful careers and
    become productive citizens who give back to their communities.

        [This statement was submitted by Kimberly Morton, PhD, Alumna, TRIO
    Upward Bound, Math & Science.]
                                     ______

                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) 2023 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. We are funded by philanthropic
    organizations and do not accept government funding and support
    evidence-based investments that strengthen public health, disease
    prevention, and health equity. The pandemic has demonstrated the impact
    of chronic underfunding of public health and prevention. Communities
    across the country have responded to the 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.
    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 familiar but inefficient pattern of underfunding
    core public health and then providing significant infusions of
    emergency funding when a disaster hits. This short-term funding cannot
    build cross-cutting capacity or strengthen the underlying
    infrastructure and workforce needed for effective program
    implementation and emergency response. Now is the time to fix an
    underfunded system so we can ensure every community has the chance for
    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 $11 billion for the FY 2023 budget,
    including investing in these effective public health programs:
        Emergency Preparedness: The COVID-19 response was hindered in part
    because the CDC's emergency preparedness funding had been repeatedly
    cut, reducing essential training and expert personnel. The Public
    Health Emergency Preparedness (PHEP) cooperative agreement has enabled
    great strides in our Nation's all-hazards preparedness, but the
    pandemic has renewed the urgency in expanded investment in domestic
    health security. Yet, PHEP appropriations has been cut significantly
    from $918 million in FY2002 to $715 million in FY 2022, or 51 percent
    when accounting for inflation. The PHEP cooperative agreement supports
    62 State, local, and territorial recipients to develop and strengthen
    core public health preparedness capabilities. TFAH recommends at least
    $824 million for the PHEP, the level authorized in 2006, to rebuild
    capacity to respond to an escalating number of emergencies.
        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
    at HHS, supports the readiness of the healthcare delivery system for
    emergencies. HPP provides critical funding and technical assistance to
    health care coalitions (HCCs) across the country to meet the disaster
    healthcare needs of communities, but funding has been cut drastically
    from $515 million in FY2003 to $296 million in FY 2022. TFAH recommends
    at least $474 million for HPP (PHSSEF), the level authorized in 2006,
    to build capacity for the healthcare system to save lives during
    disasters.
        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. A February 2022 study found that these programs resulted in
    significant decreases in sexual risk behaviors, violent experiences,
    and substance use, as well as improvements in mental health and
    reductions in suicidal thoughts and attempts.\1\ During the COVID-19
    pandemic, DASH has also leveraged its programs to improve student
    connections to mental health services during virtual learning. TFAH
    recommends at least $100 million for DASH to expand its work to around
    25 percent of all U.S. students and enable them to become healthy
    adults.
    ---------------------------------------------------------------------------
        \1\ Robin L, Timpe Z, Suarez NA, et al. ``Local Education Agency
    Impact on School Environments to Reduce Health Risk Behaviors and
    Experiences Among High School Students.'' Journal of Adolescent Health,
    February 2022. https://www.sciencedirect.com/science/article/abs/pii/
    S1054139X21004006. https://www.liebertpub.com/doi/10.1089/
    lgbt.2021.0133.
    ---------------------------------------------------------------------------
        Suicide Prevention: The COVID-19 pandemic appears to have
    heightened the risk for suicide among certain groups, including girls
    aged 12-17 years,\2\ Black youth,\3\ and Latino males.\4\ Concerningly,
    the recent CDC Adolescent Behaviors and Experiences Survey also found
    that almost 20 percent of youth respondents had seriously considered
    attempting suicide, and 9 percent actually attempted suicide.\5\ The
    complex nature of suicide requires a comprehensive program that focuses
    on disproportionately affected 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 risk. CDC programs consist of multisector
    partnerships, using data to identify populations of focus and risk and
    protective factors, rigorous evaluation efforts, and filling gaps
    through complementary strategies and effective communications. TFAH
    recommends at least $40 million to expand innovative prevention
    activities to at least 25 sites and support State health departments as
    they expand comprehensive suicide prevention and syndromic
    surveillance.
    ---------------------------------------------------------------------------
        \2\ Yard E, Radhakrishnan L, Ballesteros, M, et al. ``Emergency
    Department Visits for Suspected Suicide Attempts Among Persons Aged 12-
    25 Years Before and During the COVID-19 Pandemic--United States,
    January 2019-May 2021.'' Morbidity and Mortality Weekly Report,
    70(24);888-894, June 18, 2021. https://www.cdc.gov/mmwr/volumes/70/wr/
    mm7024e1.htm.
        \3\ Protecting Youth Mental Health: The U.S. Surgeon General's
    Advisory. U.S. Surgeon General, December 7, 2021. https://www.hhs.gov/
    sites/default/files/surgeon-general-youth-mental-healthadvisory.pdf.
        \4\ Ehlman D, Yard E, et al. ``Changes in Suicide Rates--United
    States, 2019 and 2020.'' Morbidity and Mortality Weekly Report,
    71(8);306-312, February 25, 2022. https://www.cdc.gov/mmwr/volumes/71/
    wr/mm7108a5.htm.
        \5\ Everett Jones S, Ethier K, et al. ``Mental Health, Suicidality,
    and Connectedness Among High School Students During the COVID-19
    Pandemic--Adolescent Behaviors and Experiences Survey, United States,
    January-June 2021.'' Morbidity and Mortality Weekly Report, 71(3);16-
    21, April 1, 2022. https://www.cdc.gov/mmwr/volumes/71/su/
    su7103a3.htm?s_cid=su7103a3_w.
    ---------------------------------------------------------------------------
        Adverse Childhood Experiences: As the number of adverse childhood
    experiences (ACEs) an individual experiences increases, so does the
    risk for negative health outcomes such as asthma, diabetes, cancer,
    substance use, and suicide in adulthood. CDC estimates that 61 percent
    of adults report having experienced at least one ACE in their lifetime,
    and the prevention of ACEs could reduce cases of depression in adults
    by 44 percent and avoid 1.9 million cases of heart disease.\6\ To help
    address these issues, CDC has worked to build the evidence base by
    supporting innovative research and evaluation, support surveillance and
    data innovation, and identify strategies and build capacity and
    awareness to prevent ACEs across the country.\7\ CDC currently supports
    six State-level offices, institutes, or departments that are
    implementing two or more strategies from its Preventing ACEs guidance
    document, including economic assistance to families, efforts to connect
    youth to care, and short-term and long-term interventions to reduce
    harms.\8\ TFAH recommends at least $15 million to expand surveillance
    and innovative ACEs prevention activities to additional States.
    ---------------------------------------------------------------------------
        \6\ Justification of Estimates for Appropriations Committees.
    Centers for Disease Control and Prevention, 2022. https://www.cdc.gov/
    budget/documents/fy2023/FY-2023-CDC-congressional-justification.pdf.
        \7\ Adverse Childhood Experiences Prevention Strategy FY2021-
    FY2024. In Centers for Disease Control and Prevention, September 2020.
    https://www.cdc.gov/injury/pdfs/priority/ACEs-Strategic-
    Plan_Final_508.pdf
        \8\ Preventing Adverse Childhood Experiences: Data to Action. In
    Centers for Disease Control and Prevention, updated August 19, 2021.
    https://www.cdc.gov/violenceprevention/aces/
    preventingacedatatoaction.html.
    ---------------------------------------------------------------------------
        Obesity and Chronic Disease Prevention: The COVID-19 pandemic has
    been exacerbated by preventable, chronic health conditions, including
    obesity. In 2018, 42.4 percent of adults had obesity.\9\ 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.\10\ This Division
    funds State health departments to protect the health of all Americans
    by promoting healthy eating, active living, and obesity prevention in
    early care and education facilities, hospitals, schools, 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
    expand SPAN to all 50 States and territories and build State-level
    capacity.
    ---------------------------------------------------------------------------
        \9\ State of Obesity 2021. Trust for America's Health. Sept 2021.
    https://www.tfah.org/report-details/state-of-obesity-2021/.
        \10\ 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, inequities in social and economic conditions facing
    people of color and Tribal Nations continue to negatively impact health
    outcomes. Among the programs that are effective in reducing racial and
    ethnic health disparities are Racial and Ethnic Approaches to Community
    Health (REACH) program and Healthy Tribes (previously referred to as
    Good Health and Wellness in Indian Country). CDC's REACH program,
    within DNPAO, works in 40 communities across the country by supporting
    innovative, community-centered approaches to develop and implement
    evidence-based and culturally tailored programs that reduce health
    disparities. The REACH program will be going through a re-compete in
    FY23, and increased funding is needed to meet the overwhelming need for
    the program, with over 260 approved but unfunded applications. The
    Healthy Tribes program represents CDC's largest investment in American
    Indian/Alaska Native health by coordinating three separate programs:
    the Good Health and Wellness in Indian Country (GHWIC), Tribal
    Epidemiology Centers for Public Health Infrastructure (TECPHI), and
    Tribal Practices for Wellness in Indian Country (TPWIC). Healthy Tribes
    supports holistic approaches to chronic disease prevention while also
    allowing Tribal leaders to direct public health interventions most
    effective for their communities. TFAH recommends at least $102.5
    million for the total REACH funding line (CDC), with $75.5 million
    directed to REACH and $27 million for Healthy Tribes.
        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,\11\ contributing to an
    estimated 80-90 percent of a person's health outcomes.\12\ Public
    health agencies are uniquely situated to build collaborations across
    sectors, identify SDOH priorities in communities, and promote cost-
    saving interventions that prevent chronic health conditions. Currently
    most public health departments lack funding and tools to support such
    cross-sector efforts and are limited by disease-specific Federal
    funding. 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 all States and territories. CDC is
    also building out the evidence-base for these interventions. In a
    review of existing multi-sector partnerships addressing SDOH, 29
    organizations projected a savings of $566 million over 20 years from
    saved medical costs and increased productivity levels.\13\
    ---------------------------------------------------------------------------
        \11\ 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.
        \12\ S. Magnan. Social Determinants of Health 101 for Health Care:
    Five Plus Five. National Academy of Medicine, Oct 9, 2017. https://
    nam.edu/social-determinants-of-health-101-for-health-care-five-plus-
    five/.
        \13\ CDC, SDOH Evaluation. https://www.cdc.gov/chronicdisease/
    programs-impact/sdoh/pdf/GFF-eval-brief-508.pdf.
    ---------------------------------------------------------------------------
        Environmental Health: Not all emergencies are caused by infectious
    disease. Many occur due to environmental factors. 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,\14\ the
    Tracking Network is a cost-effective program that examines and combats
    harmful environmental factors. Yet only half the States receive
    funding. TFAH recommends at least $54 million for National
    Environmental Public Health Tracking Network (CDC), which would enable
    15 additional States to join the network.
    ---------------------------------------------------------------------------
        \14\ Return on Investment of Nationwide Health Tracking,
    Washington, DC: Public Health Foundation, 2001.
    ---------------------------------------------------------------------------
        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 public health approaches to healthy aging. 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.

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

                 Prepared Statement of Tuberculosis Roundtable
        Tuberculosis Roundtable (TBR) 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 2023 (FY23)
    appropriations. As organizations tasked with protecting the country
    from tuberculosis (TB), TBR members are gravely concerned about the
    long-term impacts of the COVID-19 pandemic on future TB incidence.
    These impacts include significant delays in diagnosis with increasingly
    complicated cases, increases in co-morbidities, the suspension of
    targeted testing and treatment of latent TB infection, and the
    diversion of economic and human resources to the COVID-19 response. We
    respectfully urge you to fund the domestic TB program at CDC at $225
    million for FY23. This funding is vital to recoup lost staff time and
    resources due to the pandemic, focus on identifying and treating latent
    TB, respond to emerging outbreaks and challenges, and strengthen
    national, State, and local efforts to detect, treat, and prevent all
    forms of TB, including drug-resistant TB.
        TB is the world's second most deadly infectious disease, still
    ranking ahead of HIV/AIDS, killing 1.5 million people annually.\1\ In
    the United States, TB remains a serious problem with all 50 States
    continuing to report cases every year. According to CDC, there were an
    estimated 7,860 new cases of TB reported in the United States during
    2021, with many States reporting increases over 2020 case counts.\2\
    The pandemic severely impacted TB case notifications due to TB program
    staff being reassigned to work on COVID-19 and patients being unable or
    unwilling to seek testing and care under stay-at-home orders and
    similar policies. Many of these delayed diagnoses have resulted in a
    rebound increase of TB cases nationally, but many remain undiagnosed.
    As a direct result, staff and clinicians are seeing much more advanced
    and difficult-to-treat TB, and jurisdictions are seeing increases in TB
    deaths.
    ---------------------------------------------------------------------------
        \1\ World Health Organization. Global tuberculosis report 2021.
    https://www.who.int/publications/i/item/9789240037021.
        \2\ U.S. Centers for Disease Control and Prevention. U.S. TB
    Statistics. Division of TB Elimination. https://www.cdc.gov/tb/
    statistics/default.htm.
    ---------------------------------------------------------------------------
        Tuberculosis often starts out as a latent, or asymptomatic,
    infection which progresses to active and contagious TB disease when the
    immune system is challenged. Right now in the U.S., there are up to 13
    million individuals with an asymptomatic latent TB infection.\3\ The
    diagnosis and treatment of individuals with latent TB, who are at high
    risk of progression to active and contagious TB disease, could prevent
    an estimated 650,000 to 1,300,000 new cases of active TB as people are
    treated before they risk transmitting the disease to their families and
    communities.
    ---------------------------------------------------------------------------
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Antibiotic resistant bacteria are an immense threat to the health
    of the world, and drug resistant tuberculosis counts for one-third of
    all deaths related to antimicrobial resistance globally. Multidrug-
    resistant TB (MDR-TB) cases are more difficult and expensive to treat
    and threaten to overwhelm underfunded state TB programs.\4\ Between
    2005 and 2020, there were 1,664 cases of MDR-TB and 40 cases of
    extensively drug-resistant TB (XDR-TB) reported in the United
    States.\5\ MDR-TB regimens are longer, often with more expensive
    medications that include more extensive side effects and require more
    oversight and assistance from healthcare workers. In 2020, CDC
    estimated that the cost of treating a single patient with MDR-TB in the
    United States averaged $182,000, and the average cost of treating a
    patient with XDR-TB was even higher at $568,000, compared with $20,000
    to treat a patient with drug-susceptible TB. CDC also estimated that
    the costs resulting from all forms of TB in the US totaled over $503
    million in 2020. This doesn't begin to address the costs patients and
    communities face in the form of lost wages and opportunities during
    their treatment.\6\
    ---------------------------------------------------------------------------
        \4\ The Economist. A call to action: It's time to end drug-
    resistant tuberculosis. Economist Intelligence Unit. https://
    pages.eiu.com/jj-healthcare---2019-healthcare_landing-page-report.html.
        \5\ U.S. Centers for Disease Control and Prevention. U.S. TB
    Statistics. Division of TB Elimination. https://www.cdc.gov/tb/
    statistics/default.htm.
        \6\ vi Ibid.
    ---------------------------------------------------------------------------
        Global crises are also heavily impacting TB in the U.S. as we
    welcome new arrivals from Ukraine, which has one of the highest rates
    of MDR-TB in the world.\7\ Testing and treatment is largely falling
    upon State and local health departments to complete, even while they
    grapple with budget cuts and increasingly overstretched capacity in the
    wake of COVID-19. TB program staff have expressed their desire to help
    during this humanitarian crisis, but fear that an upcoming wave of
    delayed diagnoses from the pandemic coupled with a new population to
    care for could prove impossible for them to adequately handle.
    ---------------------------------------------------------------------------
        \7\ World Health Organization. Global tuberculosis report 2021.
    https://www.who.int/publications/i/item/9789240037021.
    ---------------------------------------------------------------------------
        CDC's Division of TB Elimination (DTBE) also contains a research
    arm that houses the TB Trials Consortium (TBTC). Recent TBTC studies
    have led to monumental breakthroughs in shortening and improving
    treatment for latent TB and drug-susceptible TB disease, and other
    studies focus on such priorities as pediatric safety and dosage.\8\
    Despite TBTC's tremendous value and the dire need for the benefits of
    its work, funding constraints risk limiting this vital research.
    ---------------------------------------------------------------------------
        \8\ 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.
    ---------------------------------------------------------------------------
        We recognize your commitment to careful consideration of the many
    domestic, health, labor, and education programs that require assistance
    in FY23, and thank you for your continued leadership. We urge you to
    make eliminating TB in the U.S. a top priority for your FY23
    appropriations bill by funding CDC's domestic TB program at $225
    million to recover from the COVID-19 pandemic, focus on addressing
    latent TB, and strengthen national, State and local efforts to
    identify, treat, and prevent TB.
                                     ______

           Prepared Statement of the Tuskegee University College of
                              Veterinary Medicine
                  summary of fiscal year 2023 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).
    Centers for Disease Control and Prevention
      --$74 million for the Racial and Ethnic Approaches to Community
            Health (REACH) Program
    National Institutes of Health
      --$49 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
        --$50 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.
    Community Project Funding/Congressional Directed Spending Request
            (HRSA)
      --$10 million for the Development of a Center for Food Animal Health,
            Food Safety, and Food Defense in TUCVM
    _______________________________________________________________________

        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. Ruby Perry, Dean and Professor of Veterinary
    Radiology at the College of Veterinary Medicine at Tuskegee University.
    Since its inception in 1945, Tuskegee University College of Veterinary
    Medicine (TUCVM) has educated more than 70 percent of the Nation's
    African American veterinarians, and is recognized as the most diverse
    of all veterinary schools and colleges in the U.S. The College is the
    only veterinary medical professional program located on the campus of a
    historically black college or university (HBCU) in the U.S.
        The pandemic has pulled back the curtain on what TUCVM and other
    Historically Black Graduate Institutions (HBGIs) and HBCUs 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.
        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.
      --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 U.S. are
    disproportionately suffering from 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 TUCVM
    and other HBGI 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).
        President Biden recently signed the John Lewis NIMHD Research
    Endowment Revitalization Act to revitalize this important initiative,
    and it is our expectation that NIMHD will act swiftly to reinvigorate
    the research endowment program so minority-serving institutions can
    participate in this competitive opportunity to build their research
    endowments in a manner consistent with the statutory goal of assisting
    them in achieving a research endowment that is comparable to the
    endowments of other schools in their health professions discipline. The
    NIMHD Research Endowment Program (REP) allows academic institutions to
    build research infrastructure and recruit, train, and maintain a
    diverse faculty and student body. Robust funding would allow active and
    former NIMHD Centers of Excellence to continue their historic focus on
    research to close the gap between the burden of illness and premature
    mortality experienced more commonly by communities of color, as well as
    other medically underserved populations. It would also help improve
    access to grants to fund research projects, as well as hire staff and
    provide scholarships for students who come from underserved
    communities. To ensure successful implementation, we are asking for the
    Committee to allocate robust funding to NIMHD for this program.
        In addition to the recommendations referenced above, TUCVM has
    submitted a community project funding/congressionally directed spending
    request for Development of a Center for Food Animal Health, Food
    Safety, and Food Defense in TUCVM. We are working with key members of
    Congress to advance this request and ensure its success. Development of
    a Center for Food Animal Health, Food Safety, and Food Defense in the
    TUCVM will position Tuskegee University to play a more vital role in
    supporting Alabama`s Agriculture, and to serve its students and farmers
    in the black-belt region of the State of Alabama more effectively and
    efficiently. The center would enhance TUCVM's ability to facilitate
    teaching, research, and service to benefit students, researchers, and
    the local community, play a pivotal role in assisting the State of
    Alabama`s poultry and fish farmers in adopting modern herd health
    practices to not only increase production and profits but also to
    ensure safety of poultry and fish products, and initiate new strategies
    to encourage DVM students to consider careers in Food Animal
    Production, Food Animal practice and research to combat the current
    shortage of food animal veterinarians.
        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, veterinarians,
    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 College of Veterinary Medicine at Tuskegee University.

        [This statement was submitted by Ruby L. Perry, DVM, PhD,
    Diplomate-ACVR, Dean & Professor of Veterinary Radiology, College of
    Veterinary Medicine, Tuskegee University.]
                                     ______

        Prepared Statement of the U.S. Hereditary Angioedema Association
                  summary of fiscal year 2023 recommendations
    _______________________________________________________________________

      --Provide the National Institutes of Health (NIH) with at least a
            $3.5 billion increase in discretionary funding for FY 2023 to
            bring overall agency funding up to a minimum of $49 billion
            annually.
        --Continue to support committee recommendations that encourage
                advancement and expansion of the hereditary angioedema
                research portfolio at NIH, as well as research efforts
                focused on rare conditions more broadly, through timely.
        --Please provide proportional funding increases for NIH's various
                Institutes and Centers, most notably given the research
                portfolio; the National Institute of Allergy and Infectious
                Diseases (NIAID), the National Centers for Advancing
                Translational Sciences (NCATS, which houses the Office of
                Rare Diseases Research), and the National Heart, Lung, and
                Blood Institute (NHLBI)
      --Provide the Centers for Disease Control and Prevention (CDC) with
            at least a $2.55 billion increase in discretionary funding for
            FY23 to bring overall agency funding up to a minimum of $11
            billion annually.
      --Encourage the Centers for Medicare and Medicaid Services (CMS) to
            prevent discrimination in health coverage by ensuring rare
            disease patients do not face arbitrary restrictions when
            seeking charitable assistance to maintain access to life-
            sustaining care and therapy when they have no other options,
            and to prevent from being steered into Federal need-based or
            illness-based programs that they would not otherwise qualify
            for while properly managing their illness (building on
            committee recommendations included in previous fiscal years).
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to present the views
    of the U.S. Hereditary Angioedema Association (U.S. HAEA) on funding
    and related policy items for NIH, CDC, and CMS during consideration of
    appropriations for FY 2023. First and foremost, thank you for
    supporting these programs in FY 2022. It is our hope that this invest
    will continue for FY 2023 to ensure that meaningful progress can
    continue in specific, promising areas.
                                about u.s. haea
        U.S. HAEA is a patient-driven organization comprised of affected
    individuals and their families. In this regard, we would primarily like
    to recognize this subcommittee for its leadership and commitment to
    providing medical research and public health programs with notable
    funding increases for FY 2020. This investment will have a tangible
    positive impact for patients by significantly improving scientific
    inquiry and public health activities.
        U.S. HAEA is a non-profit patient advocacy organization dedicated
    to serving the estimated 6,000 HAE sufferers in the U.S. We provide a
    support network and a wide range of personalized services for patients
    and their families. We are also committed to advancing clinical
    research designed to improve the lives of HAE patients and ultimately
    find a cure.
                          about hereditary angioedema
        Hereditary angioedema (HAE) is a painful, disfiguring,
    debilitating, and potentially fatal genetic disease that occurs in
    about 1 in 30,000 people. Symptoms include episodes of swelling in
    various body parts including the hands, feet, face and airway. Patients
    often have bouts of excruciating abdominal pain, nausea and vomiting
    that is caused by swelling in the intestinal wall. The majority of HAE
    patients experience their first attack during childhood or adolescence.
    Approximately one-third of undiagnosed HAE patients are subject to
    unnecessary exploratory abdominal surgery. About 50 percent of patients
    with HAE will experience laryngeal edema at some point in their life.
    This swelling is exceedingly dangerous because it can lead to death by
    asphyxiation. The historical mortality rate due to laryngeal swelling
    is 30 percent.
                            a research success story
        There was a time not long ago that HAE was a debilitating, and
    often life-ending, chronic disease. In addition to the serious health
    impacts, affected individuals suffered with trauma, anxiety, and PTSD
    stemming from torturous attacks (and the uncertainty of when the next
    attack might occur). Due to advancements in medical research, HAE
    patients now have access to life-altering and life-sustaining
    medications. Properly medically managing the disease now allows many
    the freedom to work productively, live independently, and thrive.
        While we are appreciative of the scientific progress, much more can
    be done. There is no cure of HAE and treatment is highly
    individualized. More needs to be learned about the underlying disease
    mechanisms and successful treatment often involves personalized care
    and a customized treatment regimen prepared (using trial and error) by
    a leading physician expert.
        NIH has a modest, but meaningful HAE research portfolio. Recent
    annual investments will facilitate growth in this portfolio and have
    led to important new scientific projects. The ongoing research at NIH
    will lead to a time when HAE patients can move beyond their disease.
    However, a key question that remains is how much of this investment is
    going to rare and ultra-rare disease research programs, particularly
    in-light of the ``big ticket'' items that are often now the focus of
    annual research appropriations.
        For FY 2023, please include committee recommendations thanking
    NCATS and NIAID for their leadership on HAE research and asking that
    they continue to prioritize emerging activities to advance our
    scientific understanding in this area moving forward.
              the importance of proper health coverage and access
        The HAE community first became aware of the fact that the Centers
    for Medicare and Medicaid Services (CMS) had allowed private insurers
    offering marketplace plans to deny coverage to individuals receiving
    charitable assistance in 2015 when more than a dozen HAE patients in
    Louisiana received notices that their coverage was being cancelled due
    to the fact someone else had helped them pay their premiums. Since that
    time, the practice has become pervasive and HAE patients are regularly
    informed that they will lose coverage if they receive any charitable
    assistance, that they may be committing fraud, and that they may face
    legal action if they accept assistance. This dynamic has effectively
    become a back door to pre-existing condition discrimination that is
    implemented to steer HAE patients into tax-payer funded healthcare.
    Moreover, the threat now stretches beyond just marketplace plans (to
    Medigap plans and COBRA) due to the inability to address this issue
    when it first began jeopardizing health for patients with no
    alternatives.
        Many HAE patients properly manage their illness when they have
    proper access to healthcare and treatment. HAE patients would typically
    not qualify for need-based or health-based government programs due to
    the life-sustaining nature of their treatment. If, however, proper
    coverage is lost, an HAE patient may have to endure a life-threatening
    experience of waiting while they spend down to qualify for Medicaid or
    become sick enough to apply for disability.
        US HAEA has joined with other patient-driven organizations
    experiencing the harm of current pre-existing condition discrimination
    facilitated by barriers to charitable assistance and the related
    practice of a restrictive co-pay accumulator to form the ad hoc group,
    United for Charitable Assistance (UCA). We join with UCA and all
    stakeholders in asking this subcommittee to once again highlight these
    rare-disease challenges for CMS and request the current barriers are
    resolved to protect patients that have no other reasonable options to
    maintain coverage.
        We thank the subcommittee for including meaningful language in
    previous fiscal years and recommend language similar to the draft
    committee recommendations below for FY 2023.
                          recommended report language
                   centers for medicare and medicaid services
                               program management
        Third-Party Charitable Assistance.--The Committee continues to have
    concerns about proliferation of policies that block patient to access
    to premium and copay assistance from qualified independent charities,
    civic groups, and houses of worship. The continued growth of these
    restrictions are expanding beyond marketplace plans and into other
    forms of coverage. These policies can be arbitrarily enforced and too
    easily leveraged against high-cost rare disease patients with the
    greatest need for third-party healthcare safety net programs and
    requirements for continued access to therapies to disrupt or delay
    essential care. We recognize the administration's stated commitment to
    expanding coverage and protecting access for those with complex
    healthcare needs and direct CMS to provide its current position on the
    third-party payer rule, any potential or planned actions to address
    insurance restrictions jeopardizing care for rare disease patients that
    utilize charitable assistance, and how these plans align with
    overarching CMS efforts to improve coverage and access for the patient
    community within 180 days of the enactment of this act.

        [This statement was submitted by Anthony J. Castaldo, President and
    CEO, U.S. Hereditary Angioedema Association.]
                                     ______

             Prepared Statement of United for Charitable Assistance
           summary of fiscal year 2023 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 continue to support investment in medical research through
            the National Institutes of Health and public health through the
            Centers for Disease Control and Prevention to further improve
            care and health outcomes for patients facing complex illnesses,
            including providing $49 billion for NIH (with distinct and
            additional funding for the Advanced Research Projects Agency
            for Health) and $11 billion for CDC.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished member
    of the subcommittee, thank you for your leadership on health funding
    and patient care issues. On behalf of the dozens of patient
    organizations comprising United for Charitable Assistance (UCA), we
    extend our gratitude and appreciation for the opportunity to provide a
    critical, patient-centered perspective as you consider FY 2023
    appropriations issues that impact healthcare coverage and patient
    access. Most notably, we urge you to continue to support committee
    recommendations that feature and emphasize the value and importance of
    charitable assistance programs that serve patients with no other
    options, while working with your colleagues to maintain and enhance
    access to this critical part of the health safety net. Thank you again
    for this important opportunity. Please consider UCA a resource on these
    issues moving forward.
                     about united for charitable assistance
        We are an 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). Most
    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.
        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.
        From our experience, there appears to be dangerous misconceptions
    that alternatives to charitable assistance exist, that manufacturers
    can bridge gaps by voluntarily offering free product as needed, and
    that Medicare Part A and hospital emergency rooms can provide a base
    solution for those in extreme circumstances. The reality is that no
    alternatives exist, there is no comparable or cost-effective substitute
    for properly managing an illness, and charitable assistance programs
    will need to be an integral part of the healthcare safety net for the
    foreseeable future.
        When charitable assistance was started decades ago, it was a
    benevolent response to real and immediate needs facing the seriously
    ill. This assistance was intended to protect those with pre-existing
    conditions, prevent medical bankruptcy, and stop involuntary divorce.
    These were the same goals shared by the core patient protections
    advanced by the Affordable Care Act and supported on a bipartisan basis
    in Congress. These patient protections have been an improvement, but
    they have not supplanted the need for charitable assistance programs.
           contemporary examples of charitable assistance challenges
                               (patient stories)
        Collen.--Colleen is a working mother with two young children from
    Connecticut. Her family has health insurance through her husband's
    employer. Colleen's family has, relied on a combination of a
    manufacture co-pay coupon and non-profit assistance to make ends meet.
    Now, the non-profit they relied on no longer offers support, leaving
    them with a financial shortfall. To make things worse, their health
    insurance plan now refuses to apply their co-pay assistance to their
    deductible and out-of-pocket maximum.
        Colleen says, ``It is double dipping on the part of the insurance
    giants, and it is unconscionable. These co-pay cards are meant to take
    the pressure off very sick, very expensive patients. And instead we're
    getting hit just as hard, even when we have a co-pay card. We are
    seriously considering pulling my daughter from her preschool for next
    year because we just can't absorb all these extra health care costs.''
        Edith.--Edith is in her 70s and a Medicare recipient from Florida
    who was diagnosed with a rare, chronic, and life-threatening illness
    about 5 years ago. She takes two targeted therapies to manage her
    condition. Recently, the non-profit charity she had relied on stopped
    offering co-pay assistance.
        Edith says, ``after [I stopped getting copay assistance], every
    number that I tried either didn't help with my condition or was out of
    funds. It was scary there for a while because I don't have that kind of
    money to be able to pay that every month. If I didn't have the
    medication I wouldn't be around. I would have passed away.'' Edith's
    husband adds, ``without her medications she cannot breathe. Without
    these drugs I would lose my wife in a day.''
        Irene.--Irene is in her 60s and a former building supervisor from
    Virginia. She now receives Medicare due to disability. Irene's cost
    sharing requirements outpace her fixed income.
        The non-profit organization that had been assisting Irene with her
    co-pay recently stopped offering funds. Irene said, ``I was a single
    mom and over the years worked very hard to support myself and my son,
    but there was never enough to save or put away. My [financial
    assistance] grant runs out... in 21 days. I don't have a clue as to
    what to do...Basically, I have exhausted all means of other resources
    and am mentally preparing myself to die.''
                        fiscal year 2023 recommendations
        Please support committee recommendations like the language outlined
    below. Thank you for your time and for your consideration of UCA's
    input.
                          recommended report language
                   centers for medicare and medicaid services
                               program management
        Third-Party Charitable Assistance.--The Committee continues to have
    concerns about proliferation of policies that block patient to access
    to premium and copay assistance from qualified independent charities,
    civic groups, and houses of worship. The continued growth of these
    restrictions are expanding beyond marketplace plans and into other
    forms of coverage. These policies can be arbitrarily enforced and too
    easily leveraged against high-cost rare disease patients with the
    greatest need for third-party healthcare safety net programs and
    requirements for continued access to therapies to disrupt or delay
    essential care. We recognize the administration's stated commitment to
    expanding coverage and protecting access for those with complex
    healthcare needs and direct CMS to provide its current position on the
    third-party payer rule, any potential or planned actions to address
    insurance restrictions jeopardizing care for rare disease patients that
    utilize charitable assistance, and how these plans align with
    overarching CMS efforts to improve coverage and access for the patient
    community within 180 days of the enactment of this act.
                                     ______

            Prepared Statement of the Urban Indian Health Institute
        Members of the Senate Committee on Appropriations--Subcommittee on
    Commerce, Labor, Health and Human Services, Education, and Related
    Agencies, my name is Abigail Echo-Hawk, and I am an enrolled citizen of
    the Pawnee Nation of Oklahoma, currently living in an urban Indian
    community in Seattle, Washington. I am Executive Vice President of the
    Seattle Indian Health Board (SIHB) and the Director of the Urban Indian
    Health Institute (UIHI) where I oversee policy, research, data, and
    evaluation initiatives. I request the subcommittee support efforts with
    the U.S. Department of Health and Human Services (HHS) to: immediately
    transfer the Healthy Native Babies Program (HNBP) to the CDC; advocate
    for improved access and reimbursement of doula services; expand grant
    edibility from the Administration for Children and Families (ACL) to
    Urban Indian Organizations (UIO) to address the Missing and Murdered
    Indigenous Women and People (MMIWP) crisis, and; uphold Tribal health
    authority status of Tribal Epidemiology Centers (TEC). Targeted
    investments are critical for improving the health of American Indian
    and Alaska Native (AI/AN) people.
        I am an American Indian health researcher with more than 20 years
    of experience in both academic and non-profit settings. I participate
    in numerous local, State, and Federal efforts to support AI/AN
    communities in research, including serving on the Tribal Collaborations
    Workgroup for the National Institutes of Health (NIH) All of Us
    precision medicine initiative. I serve as the only Native
    representative for the NIH Office of AIDs Research Advisory Council. I
    am a co-author to four groundbreaking research studies on sexual
    violence and Missing and Murdered Indigenous Women and Girls (MMIWG)
    where I have called national attention to the institutional barriers in
    data collection, reporting, and analysis of demographic data that
    perpetuate violence against AI/AN people. I am a member of the National
    Academies of Sciences, Engineering, and Medicine (NASEM) Standing
    Committee for the Centers for Disease Control and Prevention (CDC)
    Center for Preparedness and Response (SCPR). Additionally, I was a
    committee member for the NASEM: Framework for Equitable Allocation of
    COVID-19 Vaccine.\1\
    ---------------------------------------------------------------------------
        \1\ The White House. 2021. Biden-Harris Administration Announces
    Initial Actions to Address the Black and Indigenous Maternal Health
    Crisis. Retrieved from: https://www.whitehouse.gov/briefing-room/
    statements-releases/2021/04/13/fact-sheet-biden-harris-administration-
    announces-initial-actions-to-address-the-black-maternal-health-crisis/.
    ---------------------------------------------------------------------------
            address barriers to accessing maternal and infant health
        In alignment with the Administration's Initial Actions to Address
    the Indigenous Maternal Health Crisis \1\ and E.O. 13985: Advancing
    Racial Equity and Support for Underserved Communities Through the
    Federal Government and the HHS--Equity Action Plan, we request HHS
    immediately transfer HNBP to the CDC to respond to the disproportionate
    maternal and infant mortality in AI/AN populations.
        Since 2003, NIH has operated the HNBP to provide culturally attuned
    programming and trainings to address AI/AN infant health disparities.
    However, the HNBP's contract expired May 5, 2022. NIH is offering to
    support the transition of HNBP to another Federal agency. As the only
    public health campaign for AI/AN maternal and infant health, HNBP
    aligns with the mission and initiatives of the CDC to reduce rates of
    sudden unexplained infant death (SUID) in marginalized communities.
    Currently the budget for HNBP is $217,000, under 3-year agreements, and
    funds two full-time employees which will have minimal fiscal impact on
    the CDC. The HNBP must be moved to the CDC to continue supporting
    generations of Native families.
        In 2018, SUID rates for AI/ANs were the highest among any racial or
    ethnic population with a rate of 212.1 per 100,000 live births for AI/
    AN infants which is more than twice the rate for non-Hispanic white
    infants of 84.9 per 100,000 live births.\2\ In 2020, non-Hispanic AI/AN
    mothers were nearly three times as likely to receive late or no
    prenatal care compared to non-Hispanic white mothers \3\ and the
    highest rate of infant mortality were among non-Hispanic AI/AN infants
    born preterm or low birthweight.\4\ HNBP aims to address the high rates
    of SUID through culturally attuned educational materials, training,
    outreach events, and stipends awarded to Tribes and Native-led
    organizations.
    ---------------------------------------------------------------------------
        \2\ CDC. (2021). Sudden Unexpected Infant Death and Sudden Infant
    Death Syndrome. Data and Statistics. https://www.cdc.gov/sids/data.htm.
        \3\ CDC. (2022). Births: Final Data for 2020. National Vital
    Statistics Reports, 70(17). Table 13. https://www.cdc.gov/nchs/data/
    nvsr/nvsr70/nvsr70-17.pdf.
        \4\ CDC 2020. Infant Mortality Statistics from the 2018 Period
    Linked Birth/Infant Death Data Set. National Vital Statistics Reports.
    Table 2.
        https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-7-508.pdf.
    ---------------------------------------------------------------------------
                   transfer the healthy native babies program
        To support maternal and infant health, I also request HHS evaluate
    and consider reimbursement services for doulas. The Centers for
    Medicaid and Medicare Services (CMS) must increase grant flexibility,
    provide enhanced technical assistance, and ensure more States fully
    reimburse doulas and midwives at financially sustainable levels. For
    Native women, doulas decrease negative childbirth experiences, and
    support their access to health care providers who understand the unique
    cultural, social, and economic burden mothers face. In the 2022
    Legislative session, Washington state passed legislation to credential
    doulas and midwives. A competent credentialing system for doulas allows
    us to continue practicing traditional ways of knowing with their care
    and expertise being vital to improve health outcomes of our people.
        These trends illuminate the need for greater investments and
    targeted approaches for addressing maternal and infant health for AI/AN
    populations. UIOs and Native-led organizations must be included in
    grant eligibility by HHS agencies to continue providing maternal and
    infant health services related to disease prevention, health promotion,
    screen for maternal depression, service delivery, research, and
    healthcare professional education for providers interacting with AI/AN
    communities.
      support public safety for missing and murdered indigenous women and
                                     people
        In support of Executive Order (E.O)14053: Improving Public Safety
    and Criminal Justice for Native Americans and Addressing the Crisis of
    Missing or Murdered Indigenous People and the U.S. Government
    Accountability Office (GAO) report titled Missing or Murdered
    Indigenous Women: New Efforts are Underway but Opportunities Exist to
    Improve the Federal Response,\5\ we urge HHS and ACF to expand grant
    eligibility of the Family Violence Prevention and Services (FVPS) to
    include UIOs. UIOs are on the front lines of responding to violence,
    sexual abuse, and human trafficking experienced by urban AI/AN
    populations. UIOs must be included in FVPS grant eligibility to support
    our programs, services, and initiatives to support AI/AN individuals,
    families, and communities affected by violence.
    ---------------------------------------------------------------------------
        \5\ U.S. Government Accountability Office (November 2021). Missing
    or Murdered Indigenous Women:
        New Efforts Are Underway but Opportunities Exist to Improve the
    Federal Response Retrieved from: https://www.gao.gov/products/gao-22-
    104045.
    ---------------------------------------------------------------------------
        I am grateful for the HHS recently holding a joint consultation in
    partnership with the Department of Justice and Department of Interior
    related to the GAO report on MMIWG. I request HHS utilize a multi-
    pronged approach from all HHS agencies including NIH, Indian Health
    Service (IHS), and CDC to support research and gender-based violence
    services to serve survivors, victims, community-based organizations,
    and families affected MMIWP.
        To inform HHS' MMIWP efforts, UIHI has released several recent
    reports identifying gaps in data collection methods and developing
    culturally attuned frameworks for gender-based violence programming. In
    2021, UIHI released Sacred: Womxn of Resilience,\6\ the report
    documented the COVID-19 impact on Native femme-identifying survivors of
    sexual violence. The report also highlighted the critical need to build
    relationships between law enforcement, providers, and survivors to
    provide culturally responsive intervention and prevention services. The
    report also stresses that gender-based violence prevention,
    programming, and evaluation be led by experts from the Native community
    to adequately offer culturally responsive services to individuals
    impacted by MMIWP.
    ---------------------------------------------------------------------------
        \6\ Urban Indian Health Institute. (September 2020). Sacred: Womxn
    of Resilience. www.uihi.org/download/supporting-the-sacred-womxn-of-
    resilience/?wpdmdl=18261&refresh=6217b40a4ce3e1645720586.
    ---------------------------------------------------------------------------
        In 2022, UIHI released Service as Ceremony: A Journey Toward
    Healing \7\ a national study interviewing gender-based violence direct
    service providers. The report reveals offering culturally attuned
    holistic programming to address physical, psychological, and spiritual
    impacts for clients were essential to building resiliency and
    responding to the spectrum of gender-based violence experienced by
    individuals impacted by MMIWP. This report makes recommendations to
    fund TECs conducting research, assure gender-based violence grant
    funding is non-competitive, multi-year, flexible, and include UIO in
    grant carve outs.
    ---------------------------------------------------------------------------
        \7\ Urban Indian Health Institute. (February 17, 2022). Service as
    Ceremony: A Journey Toward Healing. www.uihi.org/download/service-as-
    ceremony-a-journey-toward-healing/?wpdmdl=19563
    &refresh=621d39d2458ae1646082514XX.
    ---------------------------------------------------------------------------
        To support gender-based violence services offered to AI/AN
    survivors, victims, and families, UIHI provides several encompassing
    recommendations HHS can implement including providing flexible grants
    to community-based organizations, investing in research conducted by
    TECs, investing in educational campaigns related to violence
    intervention and prevention, and investing in human services to support
    social determinants of health impacting an individual's safety
    including housing, education, and access to health services.
      honor public health authority status of tribal epidemiology centers
        I recently provided feedback for the GAO report Tribal Epidemiology
    Centers: HHS Actions Needed to Enhance Data Access \8\ highlighting
    necessary actions to be taken by HHS to improve TEC's access to Federal
    public health data. Despite HHS being required to share public health
    data with TECs, TECs continue to experience barriers to accessing data,
    thus limiting available information on AI/AN populations. The report
    recommends HHS: develop a policy clarifying HHS data available to TECs
    as required by Federal law; encourage the CDC Director develop written
    guidance for TECs on how to request data as well as document agency
    procedures on reviewing TECs data requests; encourage the IHS Director
    to develop written guidance for TECs on how to request data, and;
    encourage the IHS Director to develop and document agency procedures on
    reviewing TEC data requests.
    ---------------------------------------------------------------------------
        \8\ U.S. Government Accountability (March 2022). Tribal
    Epidemiology Centers: HHS Actions Needed to Enhance Data Access.
    Retrieved from: https://www.gao.gov/products/gao-22-
    104698#::text=Also%2C%20
    GAO%20was%20asked%20to,documentation%20of%20TECs'%20data
    %20requests.
    ---------------------------------------------------------------------------
        Additionally, several HHS agencies, including the CDC and IHS, have
    failed to recognize the public health authority of TECs and thereby
    ignore or reject data requests by TECs. UIHI has been denied access to
    national and regional data, data collected through the National
    Notifiable Disease Surveillance System (NNDSS), National Violent Death
    Reporting System (NVDRS), and other COVID-19 surveillance data. Failure
    to grant TECs data access perpetuates systemic health inequities in AI/
    AN communities by limiting the public health surveillance and
    epidemiological data collected by governmental agencies.
        All HHS agencies must ensure data sharing requirements with TECs
    uphold Congressional intent and recommendations by the GAO report. TECs
    inform decision-making by Tribes, Tribal organizations, UIOs,
    government agencies, and public health agencies to ensure equitable
    distribution of resources and to inform robust policies, planning, and
    programming to address social determinants of health experienced in
    Indian Country.

        [This statement was submitted by Abigail Echo-Hawk, MA,Director,
    Urban Indian Health Institute.]
                                     ______

                       Prepared Statement of VentureWell
        On behalf of VentureWell, we thank the subcommittee for its support
    of the National Institutes of Health (NIH). VentureWell strongly
    believes that robust investments in scientific research are crucial for
    sustained economic growth and technological innovation. VentureWell
    encourages the subcommittee to provide at least $49 billion for the NIH
    base budget in FY 2023, with any additional funding for the new
    Advanced Research Projects Agency for Health (ARPA-H) to supplement,
    not supplant, core investments in the NIH base budget. VentureWell also
    asks the subcommittee to encourage increased support at NIH for
    programs like the Rapid Acceleration of Diagnostics (RADx) initiative
    that focus on commercialization and innovation.
                               about venturewell
        VentureWell is a global nonprofit organization with more than two
    decades of experience supporting early-stage science and technology
    innovators, helping them to bring inventions or discoveries from lab to
    market in order to offer innovative technological solutions to pressing
    challenges. VentureWell's training programs are distinguished by the
    quality of instruction and mentorship provided by our staff and large
    network of experts in areas such as technology commercialization,
    intellectual property, global supply chains, and financing. VentureWell
    is an active partner in the U.S. innovation ecosystem, providing
    grants, training, and support to early-stage science and technology
    innovators, startups, and entrepreneurship educators. Our programming
    has helped bring groundbreaking technological advancements to millions
    of people across the U.S. and in more than 90 countries, in fields
    including biotechnology, healthcare, information and communications
    technology, sustainable energy and materials, and other sectors
    critical to people and the planet.
        Since our founding more than 26 years ago, VentureWell has
    supported over 12,000 innovators, resulting in more than 2,700 ventures
    that have raised over $2.2 billion in follow on investment. Ongoing
    programs include entrepreneurship grants and training programs focused
    on innovation and commercialization; faculty grants to researchers and
    instructors focused on integrating innovation and entrepreneurship
    teaching in higher education; and competitive national award
    competitions focused on innovation, design, and commercialization. A
    core component of our work is partnering with Federal agencies to
    accelerate the impact and scale of innovation programs and initiatives.
    Among other NIH collaborations, VentureWell has notably worked to
    launch the agency's I-Corps program since 2014, the Design by
    Biomedical Undergraduate Teams (DEBUT) competition with the National
    Institute of Biomedical Imaging and Bioengineering (NIBIB) since 2016,
    the NIH Technology Accelerator Challenge (NTAC) for sickle cell
    diagnostics (2019) and maternal health (2022), and the Rapid
    Acceleration of Diagnostics (RADx) initiative to speed innovation in
    the development, commercialization, and implementation of technologies
    for COVID-19 testing starting in 2020.
           from invention to product: the commercialization ecosystem
        Innovation and entrepreneurship in science and technology is a key
    driver of economic development in the United States. Our country's
    ability to transform breakthroughs from basic research into consumer
    products and scalable businesses has led to enormous benefits for
    society, including new cures for diseases, better communication and
    information sharing technology, and safer food and transportation. In
    recent years, U.S. leadership in science and technology on the world
    stage--and by extension our National security and global economic
    leadership--has been threatened as other countries increase their own
    investments in this area. Our country can address this challenge by
    increasing Federal investments in agencies like NIH and programs that
    close key gaps in the pipeline for developing and commercializing new
    technologies. The U.S. commercialization ecosystem would benefit from
    comprehensive support for early-stage researchers to translate their
    ideas into products, to grow the pipeline of entrepreneurial talent in
    the U.S., and from the reduction of barriers that block the progress of
    individuals or organizations to commercializing innovations.\1\
    VentureWell partners with Federal agencies to address these needs by
    supporting the ventures, individuals, and ecosystems that drive
    American innovation.
    ---------------------------------------------------------------------------
        \1\ https://www.dayoneproject.org/ideas/closing-critical-gaps.
    ---------------------------------------------------------------------------
       opportunities for innovation at the national institutes of health
        Biological sciences and clinical medicine are key areas of research
    and development linked to entrepreneurial activity. New therapeutics,
    medical devices, and other health-related technologies have enormously
    high potential benefits yet relatively long and complex development
    timelines, making support for venture development in this sector a
    crucial component of bringing products to market quickly and
    efficiently. Given its position as the top funder for biomedical
    research in the U.S., NIH plays a major role in fostering more
    effective and efficient translation of basic scientific discoveries
    into treatments and therapeutics. Not only does NIH support the
    fundamental research that underpins most clinical and commercial
    advances in biomedical research, the agency also funds a portfolio of
    venture acceleration programs specifically aimed at encouraging
    entrepreneurship and innovation at all career stages. Our organization
    has played a key role in NIH's I-Corps program, an intensive start-up
    training program for academic researchers and students that teaches
    participants how to evaluate commercialization potential and develop a
    business model. Our organization also administers the Design by
    Biomedical Undergraduate Teams (DEBUT) challenge in partnership with
    the National Institute of Biomedical Imaging and Bioengineering
    (NIBIB). This competition challenges teams of undergraduate students to
    solve real-world problems in health care by applying their analytical
    and design skills towards the development of a new product. VentureWell
    also partners with the National Institute of Biomedical Imaging and
    Bioengineering (NIBIB) to help improve maternal health around the world
    through the NIH Technology Accelerator Challenge for Maternal Health
    (NTAC: Maternal Health). This challenge seeks to spur and reward the
    development of prototypes for low-cost, point-of-care molecular,
    cellular, and/or metabolic sensing and diagnostic technologies to guide
    rapid clinical decision-making, improve patient outcomes, and
    ultimately prevent maternal morbidity and mortality. VentureWell thanks
    the subcommittee for its ongoing support for these programs and
    encourages continued strong funding for these initiatives at NIH in FY
    2023.
        To truly capitalize on all the talent and potential in the U.S.
    entrepreneurial workforce, we believe that diversity, equity, and
    inclusion must be reflected throughout all Federal efforts in this
    area. We must remove systemic barriers that limit the participation of
    underrepresented groups in innovation and entrepreneurial activities
    and ensure that pathways for commercialization are open to all
    innovators regardless of their racial, ethnic, gender, or socioeconomic
    background. VentureWell is committed to supporting a diverse workforce
    of researchers, faculty, entrepreneurs, and innovators whose voices and
    ventures have been underestimated and under-resourced, and encourages
    the subcommittee to ensure that equity is reflected throughout all
    innovation programs funded by NIH.
       diversity, equity, and inclusion in innovation & entrepreneurship
        In 2019, VentureWell ccommissioned a national study around
    broadening participation in the higher education innovation and
    entrepreneurship ecosystem. Informed by this study, our Advancing
    Equity: Dynamic Strategies for Authentic Engagement in Innovation and
    Entrepreneurship report presents a blueprint for university-based
    entrepreneurship centers that strive to increase diversity, equity, and
    inclusion (DEI) practices. We co-developed with researchers, faculty,
    and center directors, a series of resources for advancing the DEI tools
    and best practices specific to science and technology commercialization
    and training, and our report Advancing Equity: Navigating New Terrain,
    demonstrates ways to apply this blueprint at higher education
    institutions around the country. We continue to provide resources to
    academic, industry, and network partners as part of our Advancing
    Equity webinar series. VentureWell fully supports NIH's efforts to
    broadening participation in biomedical research supports the NIH UNITE
    initiative to address structural racism and promote racial equity and
    inclusion at NIH and within the larger biomedical research enterprise.
                        the radx model: covid and beyond
        The RADx Initiative was officially launched in April 2020 with a
    $500 million investment through emergency appropriations from Congress
    to speed innovation in the development, commercialization, and
    implementation of technologies for COVID-19 testing. RADx leveraged the
    infrastructure developed through NIBIB's Point-of-Care Technologies
    Research Network (POCTRN)--created by NIH in 2007--to quickly bring
    COVID-19 testing technologies to market. Previous investments made by
    Congress in this innovation infrastructure at NIH were critical to
    RADx's ability to bring new diagnostic technologies to the American
    people in record time.
        VentureWell has worked alongside NIH on the RADx program since its
    inception, providing infrastructure support and coordination services,
    clinical evaluation services through contract research organizations,
    and performing important administrative roles including government
    compliance, security testing on platforms, payment processing, sub-
    contracting to third parties, and procurement standards. In 2 years,
    VentureWell engaged 869 experts, contracted with 337 vendors/companies/
    service providers, issued 201 software licenses, funded 140 RADx
    projects, and have received 44 FDA authorizations. RADx-supported
    companies have increased COVID-19 testing capacity across the United
    States by 1.9 billion tests and condensed the typical multi-year tech
    commercialization process into approximately 6 months. Tests developed
    through RADx, with support from VentureWell, have enabled the U.S. to
    begin to recover from the public health and economic devastation
    brought on by COVID-19. VentureWell has continued to support NIH
    through the RADx initiative by providing online educational tools like
    the whentotest.org Covid-19 calculator, supporting the analysis of test
    performance through variant modeling and analytical testing, and
    working in close collaboration with the Food and Drug Administration
    (FDA) to establish the Independent Test Assessment Program (ITAP) in
    order to accelerate regulatory review and availability of high-quality,
    accurate, and reliable over-the-counter COVID-19 tests.
        We believe that the RADx approach--a nimble and systematic but
    aggressive strategy--should be applied in the development and
    evaluation of diagnostic tools in other therapeutic areas where
    innovative diagnostics and surveillance technologies are much needed.
    This includes applications ranging from HIV to maternal health. To
    prepare for future pandemics and diseases that threaten the public
    health of the population, we must continue to promote the use of
    innovative methods with a proven record of success to accelerate the
    development, commercialization, and implementation of point of care
    tests for COVID-19, new pathogens, and more. VentureWell encourages the
    subcommittee to direct NIH to continue support for the RADx program in
    FY 2023. Sustained investments in RADx will enable NIH--and our country
    as a whole--to be prepared for future public health threats and will
    help the United States to maintain its historic role as a global leader
    in biomedical science and technology.
        VentureWell thanks the subcommittee for its ongoing work in
    advancing biomedical research in the United States and ensuring that
    our country remains a world leader in science and technology. We urge
    the subcommittee to continue its commitment to research and development
    by providing strong funding for NIH in FY 2023, including increased
    support for programs like RADx that focus on commercialization and
    innovation. Thank you for your consideration of VentureWell's
    testimony. For more information about our organization, please see
    https://venturewell.org/.

        [This statement was submitted by Phil Weilerstein, President and
    Chief Executive Officer, VentureWell.]
                                     ______

                    Prepared Statement of the wAIHA Warriors
                  summary of fiscal year 2023 recommendations
    _______________________________________________________________________

      --Please provide the National Institutes of Health (NIH) with $49
            billion to facilitate continued growth in rare disease research
            activities.
        --Please provide proportional increases for the National Institute
                of Allergy and Infectious Diseases (NIAID), the National
                Heart, Lung, and Blood Institute (NHLBI), and the National
                Center for Advancing Translational Sciences (NCATS) to
                facilitate establishment and advancement of a wAIHA
                portfolio.
        --Please provide a separate, meaningful increase to advance and
                adequately support the emerging Advanced Research Projects
                Agency for Health (ARPA-H).
      --Please provide the Centers for Disease Control and Prevention (CDC)
            with $11 billion to support public health efforts.
        --Please systematically increase funding for the Chronic Disease
                Center at CDC to bring the agencies funding up to $3.75
                billion annually, and please support $6 million in funding
                for the line-item CDC Chronic Disease Education and
                Awareness (CDEA) program to ensure additional cooperative
                agreements are available for stakeholders.
    _______________________________________________________________________

        Chairwoman Murray, Ranking Member Blunt, and distinguished members
    of the subcommittee, thank you for the opportunity to present the views
    of the wAIHA Warriors and the community of individuals impacted by Warm
    Autoimmune Hemolytic Anemia (wAIHA). First, thank you for the
    meaningful investment in medical research and public health programs
    through the FY 2022 omnibus appropriations package. For FY 2023, we
    join other rare disease organizations and the broader patient community
    in asking for a sustained and meaningful investment in NIIH, CDC, and
    related Federal programs. We also deeply appreciate this opportunity to
    raise awareness of wAIHA and share the patient experience. Please
    consider us a resource moving forward. Thank you again.
                 about warm autoimmune hemolytic anemia (waiha)
        wAIHA is a rare autoimmune disorder in which the immune system
    creates antibodies that destroy healthy red blood cells. The condition
    is progressive, potentially fatal, and difficult to address at later
    stages. It can be idiopathic or occur secondary to another condition.
    wAIHA can impact anyone and affects men and women equally, though it
    most commonly affects individuals over 50. Research has led to
    scientific advancements and potential therapies, but at this time
    treatment options are extremely limited and consist of (1) steroids and
    transfusions, (2) immunosuppression and chimeric anti CD20 antibodies,
    and (3) removal of the spleen. The condition is associated with
    significant morbidity and mortality, and less than 50 percent of
    patients remain in remission following front-line treatment.
                            about the waiha warriors
        The wAIHA Warriors are a patient-driven grassroots organization
    focused on supporting the community of individuals impacted by wAIHA.
    Collectively, we use our stories and experiences to raise awareness,
    advance research, and improve healthcare. We also promote fellowship
    and engagement among community members to overcome the isolation of
    wAIHA and work to educate and mobilize healthcare providers to better
    address this rare disease experience.
                       patient experience; eric, new york
        In February 2011 I had a bad flu just before Super Bowl weekend. I
    was well enough to attend a Super Bowl party but remember not feeling
    myself. A few weeks later I had my regular annual physical with my
    internist. We were away celebrating a friend's 50th birthday, sitting
    at the pool, when my internist called and told me that my blood work
    was totally out of kilter (he used the term ``pancytopenia''). My wife,
    Liz, who is a pediatrician, was nervous and just like when our kids
    were little, I only got nervous when she got nervous. I was very lucky
    that one of my closest friends is a Hematologist/Oncologist. The next
    day I went to see him, he set me up for all sorts of scans and bone
    marrow biopsies and we were off trying to figure out what it was and
    was not.
        Over the next few months he became confident that I did not have
    any sort of acute blood cancer. I still did not feel myself (I was
    tired, not hungry, not sleeping well, and not in a good mood). Most the
    blood tests became normal except for the hemaglobin/hematocrit. My
    spleen was very large. My friend thought I had AIHA (but my Coombs
    tests, which are typically what seal the AIHA diagnosis) were negative.
    Over the summer, I had one Coombs that was barely positive. In August
    2011, my hemoglobin was going down and I had a blood transfusion.
        In September 2011, my friend/hematologist wanted me to get another
    opinion, so he referred me to another hematologist who is more of a
    ``benign hematologist'' as they are known--don't typically treat blood
    cancers. She confirmed the diagnosis of AIHA. She began me on
    prednisone and I felt a little better.
        My friend/hematologist thought that if I had a splenectomy (which
    was thought to be the primary treatment option back then) I might be
    ``cured'' and I would not have to be on chronic prednisone the rest of
    my life. I had the surgery In February 2012. It was a very difficult
    few days in the hospital followed by about 3 weeks of recovery at home.
    But after that, I felt pretty good. I was on very very low dose of
    prednisone (less than 5mg per day) and that lasted for a few years.
        In June 2015, I got sick again (tired, peeing a lot, not sleeping,
    could feel my pulse in my temples).The goal then became to find
    something that was not as harmful as prednisone that could control the
    hemolysis and my hemaglobin levels. Over the next couple of years, I
    had a couple of courses of Rituximab, and also tried courses of
    Azathioprine and Danazol. When I was hemolyzing and my hemaglobin was
    dropping, I needed to increase the prednisone.
        I made an appointment to see a leading physician, Dr. Kuter, in
    December 2017. He gave me (and my hematologist) the ``state of the
    art'' on the treatments available. The next time I had a deep crash of
    my hemaglobin, in June 2018, we tried one. Shots of Procrit. Those
    worked quickly and my hemaglobin went as high as it had been since all
    this started in 2011.
        By the middle of 2019, I had another crash and it was time to see
    what else was out there. I connected with Dr. Irina Murackhovskaya at
    Einstein/Montefiore who was doing some clinical trials for AIHA drugs.
    I had to get my hemaglobin below 10 to participate and I needed a
    positive Coombs test, and we managed that closely. In October 2019 I
    started the trial and I chose this trial because it was open and I
    would definitely get the drug (not a placebo).
        In early December 2020, I did not feel well. My legs felt like lead
    weights. Over the next few weeks my prednisone started dropping pretty
    quickly. By Christmas week, I was feeling as sick as I had felt in a
    long time. My Hgb dropped below 8, I had a blood transfusion and I
    increased my prednisone to 60mg per day (the same as the highest I ever
    had in the past).
        During 2021, I felt well. Still working at home. Things started
    opening up. We started to get out more. That helped a lot. I continued
    to wean down the prednisone and by the late Fall was on about 7.5 mg
    per day. My Hgb was pretty stable. My other hemolysis markers were
    better and stable too.
        In early March, my Hgb was 14.2 (highest I can remember and
    ``normal'' range on some ranges). All my other hemolysis markers were
    as good as they had ever been. Had to have another round of primary
    Evusheld as the CDC changed the recommendation on how much to get for
    primary round.
        I feel good now. Started back to work 3 days a week towards end of
    March. Did a quick 3 weeks of Breakthrough M2 diet program and went
    from about 193 lbs. to about 178 lbs. (15 lbs.) in 3 weeks. Things are
    starting to get back to (post COVID) normal. In April, my Hgb went back
    down to low 13s but still holding strong as are the other hemolysis
    markers. Fingers crossed that they will stay good. With Passover,
    gained back about 5 lbs. but still feeling pretty good.

        [This statement was submitted by Karen Jones, Executive Director,
    wAIHA
    Warriors.]
                                     ______

         Prepared Statement of the West Virginia Head Start Association
        Dear Chairman Murray, Ranking Member Blunt, and Members of the
    subcommittee,
        On behalf of the Head Start community nationwide, thank you for
    this opportunity to share views and perspectives on Fiscal Year 2023
    (FY23) funding for Head Start. For 5 years, I have had the distinct
    pleasure of serving as the executive director of the West Virginia Head
    Start Association representing 21 programs from the Cheat River to the
    coal fields. Every day, we diligently work to build early learners and
    support West Virginia families facing financial hardships and
    generational poverty who are too often stung by addiction, depression,
    and economic uncertainty.
        While I am extremely proud of how our programs in the Mountain
    State have weathered a global pandemic, COVID-19 has laid bare a crisis
    that Head Start program managers had previously been able to sweep
    under the rug or gloss over: our neglected and underinvested workforce.
    In the shadow of conflicting and confusing COVID-19 protocols and the
    rising impact of inflation, Head Start staff are struggling to meet the
    needs of West Virginia's most vulnerable children and their families
    and we need your help. We urge you to take immediate action to help
    address the spiraling labor situation crippling Head Start and Early
    Head Start.
        At the present time, we have 143 staff openings in West Virginia--
    significantly higher than normal for this point in the program year.
    Most of those openings are due to the staffs' ability to easily find
    higher wages elsewhere. Local boards of education, which pay more, are
    regularly recruiting our staff for other positions--bus drivers,
    teachers' aides, and lead teachers--in the state pre-K or K-12 public
    school system. Private sector employers are also drawing away both
    potential and current employees. For example, Sheetz currently pays $15
    per hour with a $3,000 sign-on bonus and Wal-Mart's starting wage is
    also $15 per hour.
        In West Virginia, the minimum wage is $8.75. That is the typical
    starting wage for Head Start staff. Full-time employment at $8.75 per
    hour is well below the Federal poverty line, which means many Head
    Start staff are earning an income so low that their children qualify
    for Head Start services. With this in mind, it is not surprising
    workers are choosing other options that better support the wellbeing of
    their own families.
        What is true for West Virginia is also true for Head Start programs
    nationwide. At a recent National Head Start Association conference,
    more than 900 staff were surveyed on current workforce conditions. The
    results were startling: an average of 35 percent of classrooms have
    been closed this school year and 90 percent of programs had to close a
    classroom permanently or temporarily due to staffing considerations. Of
    the programs surveyed, 30 percent was the average number of open and
    unfilled job slots at local Head Start programs. Closures translate to
    thousands of children left at home with an older sibling, a relative,
    or a neighbor while a mom or dad goes to work or school. For wage-based
    employees, missing one day can be a huge setback-often only a day's pay
    away from homelessness or the ability to purchase groceries. For
    children, closed or suspended Head Start classrooms translate into
    critical learning loss in educational basics and missed critical social
    skills-skills that COVID-19 has already weakened for so many young
    children.
        Conditions are dire. In the survey comments, one respondent wrote:
    ``We are struggling because we can't get people to apply for teacher
    positions. We can't compete with pay with our local school districts.
    Children's behaviors have escalated so much and we need so much
    behavioral support. Staff are getting punched, bit, and kicked by
    students on a daily basis. We NEED to take care of our staff. Staff are
    doing two and three jobs to cover for being so short staffed. We need
    help!!!"
        We need help. We need your help.
        Head Start programs need dedicated assistance in paying staff a
    living wage and competing in an increasingly challenging job market.
    Adequate compensation reduces turnover and stabilizes programs.
        But the impact is far greater, given ``turnover disrupts child-
    teacher relationships, which are crucial to children's developmental
    outcomes,'' according to a recent report from the Federal Reserve Bank
    of Minneapolis. The report notes: ``Head Start participants found that
    kids who experienced higher teacher turnover during the school year had
    smaller gains in vocabulary and literacy and higher levels of parent-
    reported behavior problems than peers who had more continuity with
    their caregivers (Markowitz 2019).
        With that in mind, the National Head Start Association (NHSA) is
    recommending an FY23 LHHS-Education Appropriations funding level of
    $14.4 billion for Head Start to help do just that. This includes three
    sizable, but necessary increases to rescue this critical federal-local
    program.
        (1) $596 million cost-of-living adjustment (COLA) increase: Rising
    inflation is an additional stress point on our workforce and the
    families we serve. Head Start's cost of living adjustment for FY22 was
    2.3 percent or approximately one-third the rate of inflation. This is
    not an aberration; historically, salary increases have either been just
    at inflation (when it is low) or below it (when inflation is high, like
    this year) resulting in a cumulative and chronic underpayment that
    leaves the Head Start workforce further behind private sector employers
    of every kind. The FY23 recommended COLA at a 5.4 percent increase
    would be an honest, responsible increase even though it is well-below
    year-over-year inflationary levels.
        (2) $2.5 billion in annual workforce compensation: Under current
    pay constraints, Head Start and Early Head Start can't compete.
    Notably, the five West Virginia Head Start grantees that are school
    boards report no vacant positions likely due to the higher wages they
    are able to pay. In other words, the workforce crisis facing early
    childhood education is clearly a solvable problem. Research has clearly
    shown experienced, well-trained staff are key to achieving the positive
    outcomes which Head Start has demonstrated over the decades; however,
    the constant churn of teachers and staff due to low wages-in addition
    to the significant vacancy rate-threatens Head Start's record of
    success. We urge you to take the necessary action to press for passage
    of $2.5 billion per year in Head Start workforce compensation
    realignment. This is a critical first step to addressing the chronic
    issues that stand in the way of parents' ability to fully participate
    in the workforce and children from being prepared for success in
    school.
        (3) $262 million for quality improvement funding (QIF) trauma-
    informed care: In the aforementioned survey, 56 percent of respondents
    indicated pay was the leading cause of employee loss. The second
    highest was work conditions, with 26 percent of respondents indicating
    both pandemic-related stress and burnout, combined with children
    presenting complex behavioral and social challenges, create an
    overwhelming work environment. We agree. Head Start staff need
    additional resources, training, and counseling support to lead
    classrooms and children through this incredibly difficult season. We
    are thankful that Congress has recognized and funded QIF trauma-
    informed care and welcome this support. Much more needs to be done to
    support the wholeness and wellness to the children and families we
    serve as well as the Head Start workforce.
        In the weeks ahead, the Head Start community would appreciate
    Congress's full embrace of the NHSA FY23 Recommendation of $14.4
    billion and joining in on a singular focus of addressing Head Start
    workforce issues too long brushed aside. Our teachers, classroom aides,
    bus drivers, and support staff deserve to earn a living wage. Please
    take time this month to talk with local Head Start leaders in your
    community. I am quite sure you will immediately hear the daily struggle
    to keep and retain quality staff and the desperate need for change.
    Thank you for your consideration.

        [This statement was submitted by Lori Milam, Executive Director,
    West Virginia Head Start Association.]
                                     ______

            Prepared Statement of the Western Governors' Association
        Chair Murray, Ranking Member Blunt, and Members of the
    subcommittee, the Western Governors' Association (WGA) appreciates the
    opportunity to provide written testimony on the appropriations and
    activities of the Federal agencies under the subcommittee's
    jurisdiction, including the Departments of Labor (DOL), Health and
    Human Services (HHS), and Education (ED). WGA is an independent
    organization representing the Governors of the 22 westernmost States
    and territories. The Association is an instrument of the Governors for
    bipartisan policy development, information sharing and collective
    action on issues of critical importance to the western United States.
        The COVID-19 pandemic has had widespread effects on the labor
    market and the health care system in the United States. As the recovery
    continues, it is critical to align policies, performance metrics,
    regulations and reporting requirements across Federal workforce, human
    services, housing and education agencies in order to achieve the best
    outcomes for program participants.
        DOL funding for workforce development through the Workforce
    Innovation and Opportunity Act (WIOA) supports economic growth and job
    creation in the States. Western Governors request that the 15 percent
    reserve for statewide activities be maintained in appropriations under
    WIOA. This funding allows Governors to be flexible and innovative in
    addressing state needs. More flexibility under the current WIOA streams
    is needed to better anticipate coming labor market disruptions and
    workers who are not traditionally eligible for assistance or as at-risk
    incumbent workers prepare for displacement. That flexibility should
    include allowing Governors to fund outreach and marketing of services
    in an effort to reach more people. Short term and competitive funding
    for innovative programs is inefficient and creates unintended obstacles
    for small States with limited grant writing resources.
        Western Governors support the expansion of registered
    apprenticeship programs and encourage Congress to support and
    incentivize State, local, and industry-led partnerships to create and
    scale apprenticeship programs through increased appropriations. New
    Federal investments in apprenticeships should be provided through line-
    item formula funding and aligned with existing efforts to foster a
    coherent system with minimal duplication at the Federal, State and
    local levels.
        Western Governors support efforts to increase student access to
    short-term education and skills training, including through expanding
    the Pell Grant program to include high-quality short-term training
    programs leading to industry-recognized credentials. Western Governors
    support funding high-quality career and technical education (CTE)
    programs through the Career and Technical Education for the 21st
    Century Act (Perkins V). Adequate funding of Perkins State Grants is
    essential to ensure that CTE programs align with statewide visions for
    education and workforce development. Governors and States are in the
    best position to determine how to use Federal CTE funding to meet the
    needs of their economies.
        Better linkages between K-12, higher education and the workforce
    system are needed. Western Governors call for a carveout of Perkins
    funding directed to the workforce system to support stronger linkages
    to K-12 and higher education. Further, to address the crisis in youth
    employment, Western Governors urge an expanded WIOA funding stream for
    youth, targeted toward youth who are disconnected from school and work,
    as well as the establishment of a Youth Employment Taskforce to make
    further recommendations on effective workforce strategies to address
    the crisis in youth employment. Finally, to ensure that workforce
    development programs are inclusive of people with disabilities,
    Congress should provide additional funding and training for States to
    conduct outreach and education on equal opportunity and
    nondiscrimination and to link workforce programs with K-12 special
    education services.
        Improvements in state data infrastructure are needed to better
    support State education and workforce development, including responding
    to changing labor market demand, improving the effectiveness of
    policies and programs, and improving the delivery of services. The
    subcommittee should provide adequate funding to support state Labor
    Market Information shops and the U.S. Bureau of Labor Statistics.
    States should receive a greater share of funds under the state-federal
    cooperative statistics programs. Western Governors also call for
    significantly greater ongoing funding through the Workforce Information
    Grants to States to enhance state capacity evidence-based decision
    making and the production of locally relevant labor market
    intelligence. Finally, Western Governors recommend that Congress invest
    long-term in multi-State data collaboratives and in more voluntary
    state participation in collaboratives to enable a truly national data
    infrastructure to emerge.
        Building a sufficient cybersecurity workforce is especially
    important to Western Governors. A skilled cyber workforce is imperative
    to the protection of critical infrastructure, which includes a vast
    array of potential targets. These include: the Nation's electric grid;
    energy resource supply and delivery chains; finance, communications,
    and election systems; and a panoply of public, private, military and
    industrial systems. Western Governors request sufficient appropriations
    for high-quality cybersecurity education and workforce development
    programs to grow and sustain the cybersecurity workforce, including
    those that target underrepresented populations, those that include
    rotational components to retain personnel, and work-based learning
    opportunities such as apprenticeships. The Governors support increased
    funding for the CyberCorps: Scholarship for Service program and
    educational initiatives, including the National Institute of Standards
    and Technology's Initiative for Cybersecurity Education and the
    National Centers of Academic Excellence in Cyber Defense. Civilian
    cybersecurity reserves can also help augment cybersecurity workforce
    capacity.
        Despite efforts by Western Governors to address the shortage of
    qualified health care workers in our States, significant challenges
    remain. Governors urge the Federal Government to examine and implement
    programs to ensure States have an adequate health care workforce--
    including positions in primary care, behavioral and oral health as well
    as other in-demand specialties--prepared to serve diverse populations
    in urban, suburban and rural communities. Understanding that
    significant disparities remain in access and treatment for many
    populations, Governors support efforts to increase the diversity and
    representation in the health care workforce to improve health outcomes
    for all. Western Governors recognize efforts to support the health care
    workforce in the American Rescue Plan Act (ARPA, Pub. L. 117-2) and
    request a continued focus on this important topic. They also encourage
    the subcommittee to fund new types of personnel, such as community
    health workers or promotores, in order to further extend the health
    care team and ensure that patients are connected to resources, and
    innovation within the behavioral health care workforce to address gaps
    in the continuum of care professionals.
        Americans are facing an alarming increase in adverse mental health
    conditions, substance misuse, and suicidal ideation, trends that have
    been exacerbated by the COVID-19 pandemic. Western Governors appreciate
    the substantial investment in mental and behavioral health services in
    ARPA and support continued efforts to improve the quality and quantity
    of these services. They are essential to reducing suicide rates and
    treating a range of behavioral health conditions, including substance
    use disorder. The top 10 States with the highest suicide rates are in
    the West. Western States are also among those with the highest overall
    rates of substance use disorder, especially for youth between the ages
    of 12 to17. Western Governors recognize and support efforts at the
    Federal, State and local levels to promote the integration of physical
    and behavioral health services. The Governors encourage Congress and
    the Administration to support States' integration efforts and encourage
    health care providers to better incorporate behavioral and physical
    medicine into their practice of care. The expansion of early
    intervention, diversion, and community reentry programs aid in such
    efforts.
        COVID-19 has also laid bare the importance of investing in our
    Nation's public health system. Congress should examine the lessons
    learned from COVID-19 in collaboration with States, and based on these
    findings, they request that the subcommittee ensure that States and the
    Nation have the capability and necessary public health infrastructure
    investment to effectively confront future public health challenges. The
    expansion and support of international health surveillance and public
    health threat detection mechanisms is of critical importance to these
    efforts as well.
        In addition, Western Governors are committed to identifying risks
    facing high utilizers of health care services and addressing social
    determinants of health. They encourage the continued support of
    services and programs, especially those that empower States and local
    governments to solve persistent economic and social conditions that
    often hinder health outcomes.
        Western Governors recognize that it is an enormous challenge to
    judiciously balance competing funding needs throughout the Federal
    Government, and appreciate the difficulty of the decisions this
    subcommittee must make. The foregoing recommendations are offered in a
    spirit of cooperation and respect. WGA is prepared to assist you as the
    subcommittee discharges its critical and challenging responsibilities.

        [This statement was submitted by James D. Ogsbury, Executive
    Director, Western Governors' Association.]
                                     ______

            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) 2023 LHHS appropriations bill. As you begin work on FY 2023
    appropriations, we respectfully request that you provide at least
    $49.048 billion for the National Institutes of Health (NIH). We also
    request that you consider including our report language on a ``Women's
    Health Research Study'' and a ``Menopause RCDC'' in the report that
    accompanies the final FY 2023 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, including polycystic ovary
    syndrome (which affects up to 20 percent of women), endometriosis
    (which affects up to 12 percent of women), uterine fibroids (which
    affect up to 40 percent of women), menopause (which affects all women)
    and cancers of the cervix, uterus and ovary.. As Congress appropriates
    funding for FY 2023, the WFRC is requesting that Congress provide
    $49.048 billion, an increase of $4.1 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. Almost all of
    NIH's institutes and centers fund research on women's health;
    therefore, 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.
          support for the advanced research projects agency for health
        The WFRC supports the creation of an Advanced Research Projects
    Agency for Health (ARPA-H), which would provide an important
    opportunity to advance research in women's health if done in a manner
    that protects and complements the research already being done by NIH.
    Any funding appropriated to ARPA-H should be in addition to the $49.048
    billion requested for the NIH. Despite the fact NIH has implemented
    policies related to sex as a biological variable and taken steps to
    identify women's health topics where additional research is needed,
    significant gaps remain in our understanding of health conditions
    unique to or occurring predominantly in women and in the translation of
    the research conducted on these topics, despite women accounting for
    over half of the United States population. Unfortunately, the
    implications of these gaps are clear: our country is currently in the
    midst of a maternal mortality and severe morbidity crisis; increasing
    rates of preterm birth; cervical cancer survival rates have stagnated
    since the mid-1970s; vaginal mesh procedures that were not studied in
    clinical trials require regulatory action from the FDA;\1\ and there
    are significant gaps in our understanding of women's fertility and
    hormonal functions.\2,3\
    ---------------------------------------------------------------------------
        \1\ https://www.fda.gov/medical-devices/implants-and-prosthetics/
    urogynecologic-surgical-mesh-implants.
        \2\ MacDorman MF, Declercq E, Cabral H, Morton C. Recent Increases
    in the U.S. Maternal Mortality Rate: Disentangling Trends From
    Measurement Issues. Obstet Gynecol. 2016;128(3):447-55.
        \3\ Jemal A, Ward EM, Johnson CJ, et al. Annual report to the
    Nation on the status of cancer, 284 1975-2014, featuring survival. J
    Natl Cancer Inst. 2017;109.
    ---------------------------------------------------------------------------
        There is a strong need for a greater investment in research of
    these conditions and many others that occur in women's health before,
    during, and after pregnancy. Often, women's health is not looked at
    across the lifespan and we fail to appreciate the very long-term
    consequences of adverse pregnancy progression and outcomes. We believe
    ARPA-H has the potential to transform women's health research by
    investing in a more comprehensive approach to translating basic science
    into cures.
        The existing NIH Institutes and Centers play a critical role in
    improving human health as evidenced by the work done by the agency in
    the development of effective COVID-19 treatments and vaccines and this
    work must continue to receive robust, sustained support. As such,
    funding for ARPA-H must supplement, not substitute, for the research
    funded by the existing Institutes and Centers. The basic science
    supported by the agency are the foundation for the transformational
    work envisioned for ARPA-H. Therefore, WFRC recommends that the same
    proportional increases in funding provided to the existing NIH
    institutes and centers be provided to ARPA-H once established. We also
    support housing ARPA-H outside of the NIH, in order to prevent funding
    cuts to existing Institutes and Centers.
                   support a study on women's health research
        While the National Institutes of Health (NIH) has taken steps to
    better track and evaluate the funds being spent on women's health
    research, we remain concerned about the research gaps, what is being
    funded and what NIH classifies as women's health research as detailed
    above. To address these concerns, we request the inclusion of report
    language directing the NIH Director to contract with the National
    Academy of Science, Engineering, and Medicine (NASEM) to conduct a
    study on gaps in women's health research, and to provide $2 million to
    support this work.
        Specifically, we envision the study would be designed to explore
    the proportion of research on conditions that are more common or unique
    to women, establish how these conditions are defined, evaluate sex and
    gender differences and racial health disparities, and determine the
    appropriate level of funding that is needed to address gaps in women's
    health research. Historically, there has been an inadequate
    representation of minority women as both researchers and research
    participants. There are clear health disparities among conditions that
    are more common or unique to women, and the NASEM is well suited to
    conduct this study to explore these gaps, by looking at women's health
    more comprehensively, across the lifespan.
        Accordingly, the WFRC requests the inclusion of the following
    language in the report accompanying the FY 2023 LHHS Appropriations
    bill with regards to the NIH Office of the Director:

          Women's Health Research Study.--The Committee recognizes
            persistent gaps remain in the knowledge of women's health. To
            address these gaps and improve women's health, the Committee
            includes $2 million within the National Institutes of Health to
            contract with the National Academy of Sciences, Engineering,
            and Medicine (NASEM) to conduct a study on the gaps present in
            women's health research across all institutes and centers at
            the NIH. Specifically, the study should be designed to explore
            the proportion of research on conditions that are more common
            or unique to women, establish how these conditions are defined
            and ensure that it captures conditions across the lifespan,
            evaluate sex and gender differences and racial health
            disparities, and determine the appropriate level of funding
            that is needed to address gaps in women's health research at
            the NIH. The Committee requests the Academies to, not later
            than 18 months after the date on which the agreement is
            entered, to submit to Congress a report containing the findings
            of the study and the recommendations to address research gaps
            in women's health research, including measurable metrics to
            ensure that this research is accurately tracked to meet the
            continuing health needs of women.
                        support for an rcdc on menopause
        The RCDC system is a computer-based process that sorts NIH-funded
    projects into categories of research area, disease, or condition. There
    is currently no RCDC category for menopause, which is a condition that
    will impact all women during their lifespan and remains understudied in
    research. Since menopause is critical to understanding women's health,
    the WFRC believes NIH should create a RCDC category for this condition
    so that this research can be tracked and analyzed over time.
    Furthermore, the creation of an RCDC for menopause will allow for
    increased access to information and greater transparency of funded
    research projects related to the study and treatment of menopause.
        Therefore, the WFRC respectfully requests that you include the
    following report language in the report that accompanies the FY 2023
    LHHS appropriations bill under the NIH Office of the Director:

          Menopause.--The Committee is concerned about the lack of a
            Research Condition, Disease Categorization (RCDC) category for
            menopause, which limits the ability to analyze current and
            future biomedical research being done on menopause. As
            menopause is a condition that will impact all women and is an
            important component of understanding women's health across the
            lifespan, it is critical that the NIH report on and be able to
            track the intramural and extramural research being done. The
            Committee requests that the NIH create a RCDC code for
            menopause.
                                   conclusion
        Thank you again for the opportunity to submit testimony to the
    Committee as you begin your work on the FY 2023 appropriations bills.
    We look forward to working with you to ensure that there is appropriate
    funding for women's health research at the NIH, to address gaps in
    women's health research and to improve health across the lifespan for
    women.
                                     ______

         Prepared Statement of the Women's Health Innovation Coalition
        Thank you for the opportunity to comment on the National Institutes
    of Health (NIH) budget priorities for FY 2023. We provide this
    testimony in support of increased funding for research grants focused
    on addressing health diseases and conditions that solely,
    disproportionately and/or differently impact women within the FY 2023
    Labor, Health and Human Services, and Education Appropriations bill.
        The Women's Health Innovation Coalition (WHIC) is a group of
    innovators, investors, clinicians, analysts, and executives with the
    shared goal of advancing innovation in women's health. We source
    innovative solutions to address unmet needs in diseases, conditions,
    and indications that impact the health of women and minorities. Through
    collaborative advocacy and policy efforts, we are working to drive
    initiatives that demonstrate women's health is not a niche market and
    to promote greater gender--relevant data transparency and increased
    investment in R&D to bring innovations to market that address gaps in
    care that harm women and minorities and result costly medical
    expenditures.
        We have identified eight areas of health that solely,
    disproportionately, or differently impact women, requiring further
    government research investment and better education and awareness among
    patients and clinicians in order to advance scientific understanding
    and medical innovations:
                             cardiovascular health
        Cardiovascular disease affects one in 16 women over the age of 20,
    is responsible for nearly one in five deaths annually for women, and
    women 55 and under are twice as likely to die from a heart attack than
    men.\1\ Furthermore, women are seven times more likely to be
    misdiagnosed and discharged in the middle of a heart attack than men,
    as men and women present with different symptoms during cardiovascular
    distress and too many physicians continue to be trained to only see
    signs in white men.\2\ Women with cardiovascular disease are also more
    likely to report poorer patient experience, lower health-related
    quality of life, and poorer perception of their health when compared
    with men.\3\ This translates to unnecessary costs across the United
    States healthcare system, as unrecognized and inadequate treatment of
    cardiovascular diseases will surpass $1 trillion by 2035.\4\
    ---------------------------------------------------------------------------
        \1\ Mayo Clinic, October 4, 2019: https://www.mayoclinic.org/
    diseases-conditions/heart-disease/in-depth/heart-disease/art-20046167.
        \2\ Coya Partners, 2020: https://www.coyapartners.com/blog.
        \3\ Victor Okunrintemi, Javier Valero-Elizondo, Benjamin Patrick,
    et. al, ``Gender Differences in Patient-Reported Outcomes Among Adults
    with Atherosclerotic Cardiovascular Disease'', December 10, 2018,
    https://www.ahajournals.org/doi/10.1161/JAHA.118.010498.
        \4\ RTI International, ``Cardiovascular Disease Costs will exceed
    $1 Trillion by 2035'', February 14, 2017: https://www.rti.org/news/
    cardiovascular-disease-costs-will-exceed-1-trillion-2035.
    ---------------------------------------------------------------------------
                     autoimmune and immunological diseases
        With 80 percent of all patients diagnosed with autoimmune diseases
    being women and 100 types of them predominantly affecting women, this
    area of health must be addressed.\5\ Part of this disparity can be
    attributed to many autoimmune disorders' tendency to affect women
    during periods of extreme stress, such as pregnancy, or during period
    of hormonal change.\6\ There are few treatments available for many
    autoimmune diseases, which can be uncomfortable, painful and impact a
    woman's ability to work and care for her family. Autoimmune diseases
    are also extremely costly, as the National Institutes of Allergy and
    Infectious Diseases has estimated that the cost of treating autoimmune
    disease in the U.S. is greater than $100 billion annually.
    ---------------------------------------------------------------------------
        \5\ The Prevalence of Autoimmune Disorders in Women: A Narrative
    Review, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292717/.
        \6\ Angum, Fariha et al. ``The Prevalence of Autoimmune Disorders
    in Women: A Narrative Review.'' Cureus vol. 12,5 e8094. 13 May. 2020,
    doi:10.7759/cureus.8094.
    ---------------------------------------------------------------------------
                                    oncology
        Women bear the burden of inequitable oncological treatment options
    as well as disparities in specific cancers. For example, one in five
    people who are diagnosed with lung cancer have never smoked, yet non-
    smoking women are three times more likely to have the disease.\7\
    Gender disparities are also pervasive in terms of treatment options, as
    a recent study showed that the odds of receiving radiation were 60
    percent for women and 70 percent for men, and the odds for receiving
    intensive chemotherapy were 35 percent for women versus 46 percent for
    men.\8\ In terms of mortality, the ratio of cancer deaths versus non-
    cancer deaths was 1.92 times higher for women than for men.\9\ Cancers
    also disproportionately impact minorities and populations with social,
    environmental, and economic disadvantages that hinder access to
    healthcare. African American and Caucasian women have similar rates of
    breast cancer, yet African American women are more likely to die from
    the disease. Hispanic and African American women also have higher rates
    of cervical cancer than women of other ethnic groups, with African
    American women having the highest rates of death from cervical
    cancer.\10\ In addition, ovarian cancer is the only gender-specific
    cancer with greater than 50 percent mortality rate, and accounts for
    more deaths than any other cancer of the female reproductive system
    with Black women having a much higher 5-year mortality rate (62
    percent) vs. Caucasian women (54 percent).\11\
    ---------------------------------------------------------------------------
        \7\ Brigham and Women's Hospital, ``Why Women's Health Can't
    Wait'', 2014, https://www.brighamandwomens.org/assets/bwh/womens-
    health/pdfs/connorsreportfinal.pdf.
        \8\ Ibid.
        \9\ Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA: A
    Cancer Journal for Clinicians 2017; 67(1):7-30.
        \10\ National Cancer Institute, ``Cancer Disparities,'' https://
    www.cancer.gov/about-cancer/understanding/disparities.
        \11\ American Cancer Society, https://www.cancer.org/content/dam/
    cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-
    figures-for-african-americans/cancer-facts-and-figures-for-african-
    americans-2019-2021.pdf.
    ---------------------------------------------------------------------------
                             aging and bone health
        A women's risk of bone fracture is equal to her combined risk of
    breast, uterine, and ovarian cancer, which is four times the rate of
    men. Of the 10 million Americans with osteoporosis, approximately 80
    percent are women and a proximately one in two women over age 50 will
    break a bone because of osteoporosis.\12\ Studies have shown that there
    are multiple reasons why women are more likely to get osteoporosis than
    men. Women tend to have smaller and thinner bones, and women's
    estrogen, a hormone that protects bones, decreases when women reach
    menopause.\13\ This prevalence of bone diseases is not only dangerous
    for women but is also extremely costly. The annual cost of
    osteoporosis-related bone breaks is $19 billion for patients, their
    families, and the healthcare system, and is expected to continue to
    rise.
    ---------------------------------------------------------------------------
        \12\ https://www.nof.org/preventing-fractures/general-facts/what-
    women-need-to-know/.
        \13\ National Osteoporosis Foundation ``What Women Need to Know''
    https://www.nof.org/preventing-fractures/general-facts/what-women-need-
    to-know/.
    ---------------------------------------------------------------------------
                        gynecological and sexual health
        Several gynecological conditions women face throughout their lives
    and especially as they age are often ignored with insufficient
    diagnostics and treatments. For example, the annual gynecological exam
    does not screen for ovarian cancer and 1 in 5 women have masses, yet
    few diagnostics can catch the cancerous tumors during the critical
    early stages, especially among women of color who are most often
    diagnosed too late and die sooner. In addition, more than 4,000 women
    enter menopause every day in the U.S., but only one in five OB/GYN
    residency programs provide menopause training to support them and
    nearly 80 percent of medical residents admit that they feel ``barely
    comfortable'' discussing or treating menopause.\14\ Also, 84 percent of
    women experience menopause symptoms, and more than one in 10 (12
    percent) say their symptoms can be severe or debilitating. Yet
    menopause is understudied and misunderstood by physicians and
    researchers alike with few treatments available for the impact on women
    that is so severe, many stay home or retire early when they are
    otherwise in the prime of their career. Most do not understand when
    symptoms are ignored or misdiagnosed during menopause years, they can
    lead to severe complications, preventable death, and avoidable and
    costly medical expenditures. These conditions cost the U.S. healthcare
    system four times the costs of their non-symptomatic peers. Globally,
    menopause-related productivity losses can amount to more than $150
    billion a year and if costs to the healthcare system are included, the
    total price tag of menopause could be higher than $810 billion.\15\
    ---------------------------------------------------------------------------
        \14\ https://www.aarp.org, Note this study also found 84 percent of
    women say that their menopausal symptoms interfere with their lives,
    including at work.
        \15\ Reenita Das, a partner and senior vice president for
    healthcare and life sciences at consulting firm, Frost & Sullivan,
    https://apple.news/AkFLvCBgGST6IKWENlXbf_w.
    ---------------------------------------------------------------------------
                              reproductive health
        Disparities in maternal and reproductive health are also a major
    concern in the U.S. Studies document decades-long racial and ethnic
    disparities in several areas of reproductive health, including
    contraceptive use, care for sexually transmitted infections and the
    human papillomavirus (HPV) vaccination among younger women aged 18 to
    25 years, as well as reproductive cancers, preterm deliveries, and
    maternal morbidity and mortality in all age groups.\16\ Most women lack
    sufficient resources, information and access to care related to
    perinatal mood and anxiety disorders (PMADs), the number one
    complication resulting from pregnancy and childbirth. Half of perinatal
    women with a diagnosis of depression do not get the medical treatment
    that they need, resulting in poor patient outcomes and increased
    societal costs. The total annual societal costs incurred by PMADs,
    including maternal productivity loss (such as loss of work productivity
    and missing work), greater use of public sector services (such as
    welfare and Medicaid), and higher health care costs due to worsened
    maternal and child health, was $14.2 billion in 2017. This equates to
    $4.7 billion in productivity losses, $2.9 billion in maternal health
    expenditures, $3.3 billion in preterm births, and $1.6 billion in child
    behavioral and developmental disorder spending.\17\ These staggering
    costs and the devastating effects for mothers who suffer from PMADs
    must be discussed and addressed.
    ---------------------------------------------------------------------------
        \16\ Obstetrics & Gynecology: February 2021--Volume 137--Issue 2--p
    225-233, doi: 10.1097/AOG.0000000000004224.
        \17\ Mathematica Policy Research, ``Societal Costs of Untreated
    Perinatal Mood and Anxiety Disorders in the United States'', April 29,
    2019, https://www.mathematica.org/download-media?MediaItemId=(E24EE558-
    B67B-4BF6-80D0-3BC75DB12EB6).
    ---------------------------------------------------------------------------
                           cognitive and brain health
        Cognitive and brain function is another health area in which
    significant disparities exist between men and women. Two-thirds of
    Alzheimer's patients over 65 are women and two--thirds of caregivers
    are women.\18\ Moreover, despite clear biological differences in
    cognitive function, women are not proportionately represented
    throughout the research process, and female-specific cognitive diseases
    are not proportionately funded. In medical research for anxiety
    disorders, 90 percent of animal subjects are male, though women are
    twice as likely to be diagnosed with anxiety in their lifetime.\19\
    Although two-thirds of Alzheimer's patients are women 66 percent of
    animals used in Alzheimer's research are male or of an ``unspecified
    gender,'' which are mostly male. There is also a stark disparity in
    funding allocation, as just 12 percent of the National Institutes of
    Health (NIH)'s 2019 budget of $2.4 billion for Alzheimer's disease
    research went toward projects specifically focused on women. Not only
    does this hinder innovation, understanding, and treatment of
    Alzheimer's disease, it also results in severe economic consequences.
    If $300 million had been shifted to the NIH's Alzheimer's budget to
    focus on women's brain health in that same year, it would have produced
    over $930 million in economic benefits, including quality of life
    improvements, and reduced medical costs.\20\
    ---------------------------------------------------------------------------
        \18\ Centers for Disease Control and Prevention, https://
    www.cdc.gov/aging/caregiving/alzheimer.htm.
        \19\ Gender Differences in Anxiety Disorders: Prevalence, Course of
    Illness, Comorbidity and Burden of Illness, https://
    www.ncbi.nlm.nih.gov/pmc/articles/PMC3135672/.
        \20\ Women's Health Access Matters, ``Societal Impact of Research
    Funding for Women's Health in Alzheimer's Disease and Alzheimer's
    Disease Related Dementias,'' April 2021, https://thewhamreport.org/wp-
    content/uploads/2021/04/TheWHAMReport_ADRD.pdf.
    ---------------------------------------------------------------------------
                              adverse drug events
        While recent clinical studies have included more women, for
    decades, the patients who participated in clinical trials for new drugs
    skewed heavily male. As a result, many drugs commonly prescribed to
    this day do not account for gender differences making them ineffective
    or causing patient harm. Today, most pre-clinical trials continue to
    exclusively use male mice and male animals even though sex differences
    are found at the cellular level. Few pre-clinical trials use both sexes
    to inform the next phase of studies in humans, and even if experiments
    do include female animals, the subgroup analyses by sex are not
    reported.\21\ During the next phase of research when the clinical trial
    includes women, often for the first time, and always at a level far
    below the actual representation of women in prevalence rates for the
    disease for which the drug is being developed to treat, this
    underrepresentation is magnified with greater room for error and ADE
    occurrence.
    ---------------------------------------------------------------------------
        \21\ It is time to integrate sex as a variable in preclinical and
    clinical studies, https://www.ncbi.nlm.nih.gov/pmc/articles/
    PMC6056479/.
    ---------------------------------------------------------------------------
                                recommendations
        With the continued failure to address so many women's health
    issues, we must increase NIH investment in advancing research in these
    areas. An analysis of NIH funding patterns found that in nearly three-
    quarters of the cases where a disease afflicts primarily one gender,
    the funding pattern favors males, in that either the disease affects
    more women and is underfunded, or the disease affects more men and is
    overfunded. Furthermore, the disparity between actual funding and that
    which is commensurate with burden is nearly twice as large for diseases
    that favor males versus those that favor females.\22\ Finally, just 11
    percent of NIH research dollars are dedicated to women's health.
    ---------------------------------------------------------------------------
        \22\ Arthur A Mirin, ``Gender Disparity in the Funding of Diseases
    by the U.S. National Institutes of Health'' July 30, 2021, https://
    pubmed.ncbi.nlm.nih.gov/33232627/.
    ---------------------------------------------------------------------------
        Therefore, we ask that Congress increase funding and programmatic
    investments for the NIH to prioritize all health conditions that
    solely, disproportionately or differently impact women and minorities.
    We must improve scientific understanding, investment, research,
    treatments, diagnostics and awareness for these populations that
    represent over half the population. We are eager to work with you in
    this endeavor, find ways to match government funding by incentivizing
    private investment in this research, and work in a concerted effort to
    advance the health of women and minorities. Thank you for your
    consideration.
                                     ______

       Prepared Statement of the Workforce Innovation and Opportunity Act
        The May 21, 2014 Statement of Managers to Accompany the Workforce
    Innovation and Opportunity Act \1\ (WIOA) provides broad intentions to
    modernize the Nation's workforce development, adult education, and
    vocational rehabilitation systems through a focus on sector strategies,
    career pathways, and strategic alignment. WIOA required disaggregated
    reporting of outcomes by special population as well as participation
    and performance on key indicators by age, race, ethnicity, and gender.
    Even though Congress' statement does not once use the word 'equity,'
    clearly equitable outcomes for community members most in need was at
    the heart of its intent then and what is needed now.
    ---------------------------------------------------------------------------
        \1\ https://www.help.senate.gov/imo/media/doc/
    WIOA%20Statement%20of%20Managers.pdf.
    ---------------------------------------------------------------------------
        Our 2022 policy comments are guided by principles of equity,
    efficiency and quality for youth and adults, responsiveness to
    providers, and collaboration across all WIOA and relevant other
    partners. The comments are distilled from quantitative and qualitative
    research activities undertaken in a comprehensive WIOA landscape
    analysis project conducted by World Education, Inc., as well as decades
    of experience in local, State, and Federal adult education and
    workforce development systems.
    2022 WIOA Reauthorization Opportunities
        Many of the innovative service designs such as career pathway and
    apprenticeship programs and equity levers that WIOA codified have yet
    to be fully utilized, and reauthorization should double-down on
    implementation of those key levers. In addition to increasing the
    potential impact of the existing policy, a number of substantive
    changes would make it easier for WIOA practitioners to partner and
    provide quality education, training, and other services to their
    communities.
        WIOA's implicit purpose is equity, and we respectfully submit these
    recommendations to strengthen the joint purpose of an equitable
    economic recovery and a prosperous future for all America.
    Include a Separate Title for Funding America's Job Centers (AJCs),
            Including Virtual Services
        Fund an Equitable Network. A separate title or section within Title
    I in WIOA should be included to provide for the funding of the AJC
    network, including brick and mortar as well as virtual infrastructure
    and certain shared service delivery costs. This direct additional
    infrastructure funding would solve a longstanding issue and could
    potentially free up more resources for services. The recommended
    separate title would describe allowable uses of funding and specify
    what constitutes fair and reasonable infrastructure costs. These funds
    would be distributed through the local allocation formula used for
    Title I and would be administered under a MOU (Memorandum of
    Understanding) negotiated between the local board and governor. Under
    this model, the WIOA core programs would have a shared presence in the
    physical and virtual AJCs, and other partners could opt to co-locate or
    to provide remote access to services, depending on local needs and
    available resources.
    Amend Deficit-Based Language That Creates Deficit-Based Programming and
            Leverage Community Stakeholders to Design Strategies
        Address the Barrier and Recognize Assets and Experience. WIOA
    reauthorization needs to address this deficit-based language while
    maintaining critical reporting on who receives what services and to
    what impact. One way to do this would be to reframe 'individuals with
    barriers' to 'individuals CONFRONTING barriers' and to clearly
    articulate that the public workforce system's role is to support that
    confrontation with resources needed to overcome barriers. Another way
    is to rethink eligibility and shift the mindset of fixing individuals
    with barriers to a system supporting economic opportunity and mobility
    for those that can benefit from it.
        The deficit-based language is also problematic in how it affects
    the process of designing effective services. Reauthorization should
    involve a stakeholder consultative process, much like that included in
    Strengthening Career & Technical Education for the 21st Century Act
    (Perkins V) in which people confronting the barriers detailed in WIOA
    priority populations should be involved in designing the services for
    their communities. Adults in our communities have skills and
    experiences that can be a powerful starting point for building toward
    their career aspirations. WIOA needs to leverage job seekers' assets in
    order to design more effective solutions.
        In this process of designing effective services, consideration
    should be given to ``lift up alternatives and approaches to workforce
    development beyond those focused on jobs, skills, training, and
    individual worker assets and deficits. Specifically, consider strategy
    and policy approaches that expand access to our Nation's safety net;
    address 'digital redlining' and invest in digital access and learning;
    and support access to high quality jobs and benefits.'' \2\
    ---------------------------------------------------------------------------
        \2\ https://workforce-matters.org/a-racial-equity-framework-for-
    workforce-development-funders/.
    ---------------------------------------------------------------------------
    Optimize Alignment of Services, Systems, Resources, and Reporting
            Across WIOA Core Programs and WIOA Partner Programs
        Provide Flexibility. Incorporate authority that would allow Tribal,
    municipal, county and State governments to request flexibility and
    grant waivers to pool resources from various WIOA Titles and WIOA
    Partner Programs to build career pathway systems and programs toward
    the goal of improved outcomes for low-income youth and adults in the
    domains of education, training, employment, earnings, health and
    wellbeing.
    Invest in Evidence-Based Program AEFLA Models
        IET is Evidence-Based and a Racial Equity Strategy--Create an
    Integrated Education & Training Funding Stream. The Institute for
    Education Science (IES) What Works Clearinghouse (WWC) holds the
    highest standard for rigor in independent education research, seeking
    to drive education policy less by 'professional wisdom' and more by
    evidence-based practice. In September, 2020, the National Center for
    Education Evaluation at IES released an Intervention Report on I-BEST.
    This gold-standard research identified three randomized control trial
    studies that meet the WWC criteria, documenting impacts on 45,413
    learners in nine States and demonstrating statistically significant
    positive impacts for the career pathway participants versus the control
    group:
      --+18 positive effects on industry-recognized credential, certificate
            or license completion;
      --+10 potentially positive effects on short-term employment; and
      --Potentially positive effects on short-term earnings.\3\
    ---------------------------------------------------------------------------
        \3\ (2020, September). Integrated Basic Education Skills and
    Training (I-BEST). Retrieved from https://ies.ed.gov/ncee/wwc/
    InterventionReport/706.
    ---------------------------------------------------------------------------
        Ability to Benefit to Support Adult Dual Enrollment in IET. The
    Ability to Benefit (ATB) student financial aid provision in the Higher
    Education Act (HEA) provides underserved students access to accelerated
    and integrated high school and college credentials through adult dual
    enrollment. When creating IET with HEA Title IV-eligible student
    financial aid, Ability to Benefit (ATB) is the obvious choice. However,
    ATB is poorly understood and massively underutilized, in no small part
    due to the fluctuation of legislative approval.
        Integrated Education and Training works and it works to motivate
    persistence with individuals WIOA is meant to serve. A reauthorized
    WIOA Title II AEFLA needs to directly invest in Integrated Education &
    Training with dedicated funds for this evidence-based strategy and
    clear guidance on utilizing the Ability to Benefit provision of the
    Higher Education Act within an adult dual enrollment strategy. Pell
    grants are critical for adults both for immediate tuition needs and to
    offset the opportunity costs of being an adult student with living
    expense funding.
        Fund Remote and Blended Programs and Make Digital Skill Development
    an Allowable Activity and Fund Use. Remote learning programs require
    additional funds to purchase, maintain and replace devices, software
    licenses, technology navigators, and remote classroom aides. Emerging
    COVID-19 based research suggests that those costs are 12 percent-22
    percent higher than straightforward in-person delivery. This is the
    time to invest in them and take adult education fully into the 21st
    century and beyond. There is a strong foundation to build on and scale
    up. World Education's EdTech Center has been documenting these models
    and specific best practices and providing free professional development
    to providers.
        In addition, amend WIOA to make digital capability/literacy an
    allowable activity and fund use in the same way ABE, ASE, ESOL, and
    Integrated English Language and Citizenship services are. Amend the
    definition of Measurable Skill Gain to include documented digital
    skills.
    Fund Career Navigators
        Fund A Navigation System. Provide direct funding through WIOA for
    career navigators including 2.5 percent of that funding for navigator
    preparation, professional development, and support. Provide
    approximately $4 billion annually in new Federal funding to make
    coaching available to 20 million unemployed and low-wage workers within
    the workforce system, community colleges, and community-based
    organizations. This could be done via the following mechanisms:
      --Additional funding for Wagner-Peyser (WIOA Title III) to expand
            access to career coaching for the newly-unemployed;
      --Increased funding for WIOA Titles I, II, and IV to create coaching
            positions at the AJCs and other workforce service providers;
      --Ensure career navigation is articulated as an AEFLA service and
            make the use of funds for this purpose allowable;
      --Update the Reemployment Services and Eligibility Assessment program
            to encourage more access to high-quality career navigators for
            unemployment insurance recipients; and
      --Funding delivered through WIOA for States to provide career and
            digital navigator funding to community-based organizations,
            labor-management partnerships and for eligible institutions in
            partnership with employers and labor unions to offer career
            navigation/coaching supports at places of work and community
            colleges, with a focus on underserved communities. Clarify that
            some of this funding can go to providers of direct online
            navigation services, as well as to non-profit providers of
            navigator professional development and supports.
        Improve data collection on career navigation services across all
    WIOA titles, and evaluate the provision of career navigation services
    through the AJC network, including assessing the extent to which these
    services can help reduce equity gaps in employment and earnings
    results.
        Additionally, Digital Navigator initiatives \4\ are providing
    valuable just-in-time digital skill building to adults for career and
    wider community needs, but these efforts would benefit from direct
    connection to and investment from the public workforce system.
    ---------------------------------------------------------------------------
        \4\ https://digitalus.org/digital-navigators/.
    ---------------------------------------------------------------------------
        Respectfully.

        [This statement was submitted by Priyanka Sharma, Vice President,
    priyanka_sharma@worlded.org and Judy Mortrude, Senior Technical
    Advisor, judy_mortrude@worlded.org.]

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    America's Public Television Stations and the Public Broadcasting
      Service, Prepared Statement of.................................   431
    Academy for Radiology & Biomedical Imaging Research, Prepared
      Statement of the...............................................   437
    Accessia Health, Prepared Statement of...........................   439
    Ad Hoc Group for Medical Research, Prepared Statement of the.....   440
    Afterschool Alliance, Prepared Statement of the..................   442
    AIDS:
        Institute, Prepared Statement of The.........................   445
        United, Prepared Statement of................................   448
    Alliance to End Slavery and Trafficking, Prepared Statement of
      the............................................................   450
    Alpha-1 Foundation, Prepared Statement of the....................   456
    Alzheimer's Association and Alzheimer's Impact Movement ,
      Prepared Statement of the......................................   458
    American Academy of Pediatrics, Prepared Statement of the........   460
    American Association for:
        the Study of Liver Diseases, Prepared Statement of the.......   463
        Cancer Research, Prepared Statement of the...................   466
        Dental, Oral, and Craniofacial Research, Prepared Statement
          of the.....................................................   467
        the Study of Liver Diseases, Prepared Statement of the.......   469
    American Association of:
        Colleges of Nursing, Prepared Statement of the...............   471
        Colleges of Osteopathic Medicine, Prepared Statement of the..   474
        Immunologists, Prepared Statement of.........................   475
        Neuromuscular & Electrodiagnostic Medicine, Prepared
          Statement of the...........................................   844
    American College of:
        Obstetricians and Gynecologists, Prepared Statement of the...   478
        Physicians, Prepared Statement of the........................   481
        Surgeons, Prepared Statement of the..........................   483
    American Dental Education Association, Prepared Statement of the.   484
    American Educational Research Association, Prepared Statement of
      the............................................................   486
    American Geriatrics Society, Prepared Statement of the...........   489
    American Heart Association, Prepared Statement of the............   491
    American Indian Higher Education Consortium, Prepared Statement
      of the.........................................................   493
    American Library Association, Prepared Statement of the..........   495
    American Liver Foundation, Prepared Statement of the.............   497
    American Lung Association, Prepared Statement of the.............   499
    American Massage Therapy Association, Prepared Statement of the..   502
    American Physiological:
        Association, Prepared Statement of the.......................   507
        Association Services, Prepared Statement of the..............   504
        Society, Prepared Statement of the...........................   503
    American Public Health Association, Prepared Statement of the....   509
    American Red Cross and the United Nations Foundation, Prepared
      Statement of the...............................................   512
    American Society for:
        Engineering Education, Prepared Statement of the.............   514
        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...................   523
        Nephrology, Prepared Statement of the........................   525
        Plant Biologists, Prepared Statement of the..................   527
    American Speech-Language-Hearing Association, Prepared Statement
      of the.........................................................   529
    American Thoracic Society, Prepared Statement of the.............   531
    American Urogynecologic Society, Prepared Statement of the.......   534
    Animal Welfare Institute, Prepared Statement of the..............   536
    Arthritis Foundation, Prepared Statement of the..................   538
    Aspira Women's, Prepared Statement of the........................   539
    Association for:
        Career and Technical Education and Advance CTE, Prepared
          Statement of the...........................................   541
        Clinical Oncology, Prepared Statement of the.................   544
        Professionals in Infection Control and Epidemiology, Prepared
          Statement of the...........................................   547
        Professionals in Infection Control and Epidemiology and the
          Society for Healthcare Epidemiology of America, Prepared
          Statement of the...........................................   550
        Psychological Science, Prepared Statement of the.............   552
    Association of:
        American Cancer Institutes, Prepared Statement of the........   554
        American Medical Colleges , Prepared Statement of the........   555
        Farmworker Opportunity Programs, Prepared Statement of the...   558
        Independent Research Institutes, Prepared Statement of the...   559
        Minority Health Professions Schools, Prepared Statement of
          the........................................................   560
        Schools and Programs of Public Health, Prepared Statement of
          the........................................................   563
        Science and Technology Centers, the Association of Children's
          Museums, and the Association of Science Museum Directors,
          Prepared Statement of the..................................   565
        State and Territorial Health Officials, Prepared Statement of
          the........................................................   567
        University Centers on Disabilities, Prepared Statement of the   570
        University Programs in Occupational Health and Safety,
          Prepared Statement of the..................................   572
    Autism Speaks, Prepared Statement of.............................   574

    Becerra, Hon. Xavier, Office of the Secretary, Department of
      Health and Human Services......................................     1
        Prepared Statement of........................................    10
        Questions Submitted to.......................................    40
        Summary Statement of.........................................     8
    Blunt, Senator Roy, U.S. Senator From Missouri:
        Prepared Statements of

        Questions Submitted by

        Statements of

    Big Cities Health Coalition, Prepared Statement of the...........   576
    Bipartisan Policy Center , Prepared Statement of the.............   579
    Blue Mountain Heart to Heart, Prepared Statement of..............   581
    Brain Injury Association of America, Prepared Statement of the...   583
    Braun, Senator Mike, U.S. Senator From Indiana, Questions
      Submitted by

    Bridgercare, Prepared Statement of...............................   585

    Capito, Senator Shelley Moore, U.S. Senator From West Virginia,
      Questions Submitted by

    Cardona, Hon. Miguel, Office of the Secretary, Department of
      Education......................................................   147
        Questions Submitted to.......................................   180
        Summary Statement of.........................................   155
    CAST, Prepared Statement of......................................   586
    CDC Coalition, Prepared Statement of the.........................   589
    Centers for Disease Control and Prevention, Prepared Statement of
      the............................................................   591
    Choose Healthy Life, Prepared Statement of.......................   593
    Chronic Disease Alliance, Prepared Statement of the..............   594
    Coalition:
        for Clinical and Translational Science, Prepared Statement of
          the........................................................   595
        for Health Funding, Prepared Statement of the................   598
        on Adult Basic Education, Prepared Statement of the..........   599
    Congressional Fire Services Institute, Prepared Statement of the.   600
    Consortium of Social Science Associations, Prepared Statement of
      the............................................................   601
    Council:
        of Academic Family Medicine, Prepared Statement of the.......   603
        of State and Territorial Epidemiologists, Prepared Statement
          of the.....................................................   606
        on Social Work Education, Prepared Statement of the..........   608
    Creutzfeldt-Jakob Disease Foundation, Prepared Statement of the..   610
    Cure Alzheimer's Fund, Prepared Statement of.....................   612

    Dave Purchase Project, Prepared Statement of.....................   615
    Duke Health, Prepared Statement of...............................   617
    Durbin, Senator Richard J., U.S. Senator From Illinois, Questions
      Submitted by

    Dystonia Medical Research Foundation, Prepared Statement of the..   620

    Education Trust, Prepared Statement of The.......................   622
    Endocrine Society, Prepared Statement of the.....................   625
    Entomological Society of America, Prepared Statement of the......   628
    Epilepsy Foundation, Prepared Statement of the...................   630
    Essential Access Health, Prepared Statement of...................   633
    Every Hour Counts Coalition, Prepared Statement of...............   634

    FASD United, Prepared Statement of...............................   636
    Fauci, Anthony, M.D., Director, National Institute of Allergy and
      Infectious Diseases............................................    85
        Questions Submitted to.......................................   131
    Federation of:
        American Societies for Experimental Biology, Prepared
          Statement of the...........................................   638
        Associations in Behavioral and Brain Sciences, Prepared
          Statement of the...........................................   640
    Florida:
        A&M University, Prepared Statement of........................   642
        Agricultural and Mechanical University, Prepared Statement of   644
    Focused Ultrasound Foundation, Prepared Statement of the.........   647
    Fred Hutchinson Cancer Center, Prepared Statement of the.........   648
    Friends of:
        HRSA, Prepared Statement of the..............................   650
        the Institute of Education Sciences, Prepared Statement of
          the........................................................   651
        the National Institute on Aging, Prepared Statement of the...   653
        the National Institute on Drug Abuse, Prepared Statement of
          the........................................................   654
        NICHD, Prepared Statement of the.............................   656
    FSHD Society, Prepared Statement of the..........................   659

    GBS|CIDP Foundation International, Prepared Statement of the.....   664
    Gibbons, Gary, M.D., Director, National Heart, Lung, and Blood
      Institute......................................................    85
        Questions Submitted to.......................................   133
    Gordon, Joshua, M.D., Ph.D., Director, National Institute of
      Mental Health..................................................    85
        Questions Submitted to.......................................   136
    Graham, Senator Lindsey, U.S. Senator From South Carolina,
      Questions Submitted by.........................................   368

    Helen Keller International, Prepared Statement of................   666
    Hepatitis B Foundation, Prepared Statement of the................   668
    Hispanic Association of Colleges and Universities, Prepared
      Statement of the...............................................   670
    HIV:
        Medicine Association, Prepared Statement of the..............   672
        +Hepatitis Policy Institute, Prepared Statement of the.......   675
    Hodes, Richard, M.D., Director, National Institute on Aging......    85
        Questions Submitted to.......................................   138
    Hope Charities, Prepared Statement of............................   678
    Human Factors and Ergonomics Society, Prepared Statement of the..   679
    Hyde-Smith, Senator Cindy, U.S. Senator From Mississippi,
      Questions Submitted by

    Infectious Diseases:
        and the Opioid Epidemic Program, Prepared Statement of the...   680
        Society of America , Prepared Statement of the...............   681
    Integrative Health Policy Consortium, Prepared Statement of the..   684
    Interstitial Cystitis Association, Prepared Statement of the.....   686

    Jamestown S'Klallam Tribe, Prepared Statement of the.............   688
    Johnson & Johnson, Prepared Statement of.........................   690

    Kennedy, Senator John, U.S. Senator From Louisiana, Questions
      Submitted by...................................................    75
    Knowledge Alliance, Prepared Statement of........................   691

    Leahy, Senator Patrick, U.S. Senator From Vermont, Questions
      Submitted by

    Learning and Education Academic Research Network, Prepared
      Statement of the...............................................   694
    Low Income Home Energy Assistance Program, Prepared Statement of
      the............................................................   696
    Lymphatic Education & Research Network, Prepared Statement of the   699

    Manchin, Senator Joe, III, U.S. Senator From West Virginia,
      Questions Submitted by

    March of Dimes, Prepared Statement of............................   701
    Meals on Wheels America, Prepared Statement of...................   703
    Merkley, Senator Jeff, U.S. Senator From Oregon, Questions
      Submitted by...................................................   358
    METAvivor, Prepared Statement of.................................   706
    Michelson Center for Public Policy, Prepared Statement of........   708
    Moran, Senator Jerry, U.S. Senator From Kansas, Questions
      Submitted by...................................................    74
    Morehouse School of Medicine, Prepared Statement of the..........   710
    Murray, Senator Patty, U.S. Senator From Washington:
        Opening Statements of

        Questions Submitted by

    NAF, Prepared Statement of.......................................   712
    National Alliance:
        for Eye and Vision Research, Prepared Statement of the.......   714
        for PANS/PANDAS Action, Prepared Statement of the............   716
        of Public Charter Schools, Prepared Statement of the.........   718
    National Alopecia Areata Foundation, Prepared Statement of the...   721
    National Area Health Education Centers Organization, Prepared
      Statement of the...............................................   723
    National Association of:
        Councils on Developmental Disabilities, Prepared Statement of
          the........................................................   725
        County and City Health Officials, Prepared Statement of the..   726
        Federally Impacted Schools, Prepared Statement of the........   728
        Drug Court Professionals, Prepared Statement of the..........   730
        Free and Charitable Clinics, Prepared Statement of the.......   731
        State Head Injury Administrators, Prepared Statement of......   733
    National Coalition for Homeless Veterans, Prepared Statement of
      the............................................................   735
    National College Attainment Network, Prepared Statement of the...   737
    National Congress of American Indians, Prepared Statement of the.   739
    National Council:
        for Community and Education Partnerships, Prepared Statement
          of the.....................................................   742
        for Diversity in Health Professions, Prepared Statement of
          the........................................................   743
        of Urban Indian Health, Prepared Statement of the............   744
    National Eczema Association, Prepared Statement of the...........   747
    National Family Planning & Reproductive Health Association,
      Prepared Statement of the......................................   750
    National Institute:
        of Diabetes and Digestive and Kidney Diseases, Prepared
          Statement of the...........................................   751
        of Environmental Health Sciences, Prepared Statement of the..   754
        on Drug Abuse, Prepared Statement of the.....................   755
    National Kidney Foundation, Prepared Statement of the............   758
    National Marrow Donor Program/Be The Match, Prepared Statement of
      the............................................................   760
    National Pancreas Foundation, Prepared Statement of the..........   762
    National Scleroderma Foundation, Prepared Statement of the.......   765
    National Technical Institute for the Deaf, Prepared Statement of
      the............................................................   766
    Nature Conservancy, Prepared Statement of The....................   769
    NephCure Kidney International, Prepared Statement of.............   770
    Neurofibromatosis Network, Prepared Statement of the.............   772
    New Leaders, Prepared Statement of...............................   774
    Northwest Portland Area Indian Health Board, Prepared Statement
      of the.........................................................   776
    Nursing Community Coalition, Prepared Statement of the...........   778
    Nutrition and Medical Foods Coalition, Prepared Statement of the.   781

    PACER Center, Prepared Statement of..............................   782
    Pell, Ann D., Prepared Statement of..............................   784
    Personalized Medicine Coalition, Prepared Statement of the.......   786
    Physician Assistant Education Association, Prepared Statement of
      the............................................................   789
    Physicians Committee for Responsible Medicine, Prepared Statement
      of the.........................................................   791
    Population Association of America/Association of Population
      Centers, Prepared Statement of the.............................   793
    PrEP4All, Prepared Statement of..................................   795
    Prevent Blindness, Prepared Statement of.........................   796
    ProvenTutoring, Prepared Statement of............................   799
    Pulmonary Hypertension Association, Prepared Statement of the....   800

    Rebuilding America's Middle Class, Prepared Statement of.........   802
    Refugee Council USA, Prepared Statement of.......................   804
    Research!America, Prepared Statement of..........................   805
    Restless Legs Syndrome Foundation, Prepared Statement of the.....   807
    Rotary Foundation, Prepared Statement of the.....................   809
    Ryan White Medical Providers Coalition, Prepared Statement of the   812

    Safer Foundation, Prepared Statement of..........................   814
    Save the Children, Prepared Statement of.........................   817
    Seattle Indian Health Board, Prepared Statement of the...........   820
    Sex Education Coalition, Prepared Statement of the...............   822
    Schatz, Senator Brian, U.S. Senator From Hawaii, Questions
      Submitted by...................................................    51
    Shelby, Senator Richard C., U.S. Senator From Alabama, Questions
      Submitted by

    SHEPHERD Foundation, Prepared Statement of.......................   826
    Sleep Research Society, Prepared Statement of the................   827
    Society for:
        Human Resource Management, Prepared Statement of the.........   830
        Maternal-Fetal Medicine, Prepared Statement of the...........   831
        Neuroscience, Prepared Statement of the......................   834
        Women's Health Research, Prepared Statement of the...........   836
    Society of:
        Gynecologic Oncology, Prepared Statement of the..............   838
        Nuclear Medicine and Molecular Imaging, Prepared Statement of
          the........................................................   840
    Spina Bifida Association of America, Prepared Statement of the...   843

    Tabak, Lawrence, D.D.S., Ph.D., Acting Director, National
      Institutes of Health...........................................    85
        Prepared Statement of........................................    92
        Questions Submitted to.......................................   117
        Summary Statement of.........................................    90
    Today's Student Coalition, Prepared Statement of.................   846
    TRIO:
        Talent Search, Prepared Statement of.........................   848
        Upward Bound, Math & Science, Prepared Statement of..........   850
    Trust for America's Health, Prepared Statement of................   851
    Tuberculosis Roundtable, Prepared Statement of...................   854
    Tuskegee University College of Veterinary Medicine, Prepared
      Statement of the...............................................   855

    U.S. Hereditary Angioedema Association, Prepared Statement of the   857
    United for Charitable Assistance, Prepared Statement of..........   860
    Urban Indian Health Institute , Prepared Statement of the........   862

    VentureWell, Prepared Statement of...............................   864
    Volkow, Nora, M.D., Director, National Institute on Drug Abuse...    85
        Questions Submitted to.......................................   141

    wAIHA Warriors, Prepared Statement of the........................   867
    Walsh, Hon. Martin J., Office of the Secretary, Department of
      Labor..........................................................   371
        Prepared Statement of........................................   380
        Questions Submitted to.......................................   405
        Summary Statement of.........................................   378
    West Virginia Head Start Association, Prepared Statement of the..   869
    Western Governors' Association, Prepared Statement of the........   871
    Women First Research Coalition, Prepared Statement of the........   873
    Women's Health Innovation Coalition, Prepared Statement of the...   875
    Workforce Innovation and Opportunity Act, Prepared Statement of
      the............................................................   878

                                 SUBJECT INDEX

                                  ----------

       AMERICA'S PUBLIC TELEVISION STATIONS AND THE PUBLIC BROADCASTING
                                    SERVICE

                                                                       Page

    Corporation for Public Broadcasting..............................   431
                                   __________

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    Access to Free Public Education..................................   150
    Additional Committee Questions...................................   179
    Adult Education..................................................   166
    Arming Teachers..................................................   171
    Boldly Addressing Opportunity and Achievement Gaps...............   159
    Building Pathways Through Postsecondary Education that Lead to
      Successful Careers.............................................   161
    Career and Technical Education

    Challenges to Education..........................................   148
    Childcare Access Means Parents in School Program.................   178
    Cost of Postsecondary Education..................................   170
    Department of Education Funding Levels...........................   158
    Enforcement of Civil Rights Laws.................................   161
    Fiscal Year 2022 Congressional Action............................   157
    Free Application for Federal Student Aid Data Release............   164
    Learning Loss....................................................   177
    Making Higher Education Inclusive and Affordable.................   160
    Meeting the Basic Needs of Postsecondary Students................   178
    Mental Health

        Professionals................................................   174
    Miguel Cardona, Prepared Statement of............................   157
    Native Hawaiian Education Program................................   172
    Office for Civil Rights Staffing.................................   162
    Online and Blended Learning......................................   171
    Parental Involvement and Support for Families....................   150
    Parents' Role in Education.......................................   169
    Pell Grants and Educational Opportunity..........................   166
    President's Budget Request, The

    Recent Major Investments.........................................   148
    School:
        Choice and Dollars Following the Student.....................   169
        Desegregation and Educational Equity.........................   176
        Facilities...................................................   165
        Safety

    Second Chance Pell...............................................   171
    Student Loans....................................................   161
        Collection Agreements........................................   179
        Predatory Behavior and Scams.................................   175
        Repayment Moratorium.........................................   173
    Supporting:
        a Talented and Diverse Educator Workforce....................   159
        Students through Pandemic Response and Recovery..............   158
    Teachers with a History of Assault or Absuse.....................   168
    Upward Bound

                                   __________

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    Additional Committee Questions...................................   117
    Aduhelm..........................................................   111
    Advanced Research Projects Agency for Health.....................    92
    Alzheimer's Disease..............................................    97
        Treatments...................................................   114
    ARPA-H Priorities................................................   114
    Autoimmune Disease Research......................................   115
    Cancer Moonshot..................................................    92
    Childhood Cancer STAR Act........................................   101
    COVID:
        Related School Closures......................................   102
        Travel Restrictions..........................................   108
    Drug Overdose....................................................    96
    Early Stage Investigators........................................   115
    Future COVID Lockdowns...........................................   105
    Gender Transforming Care.........................................   107
    Health Disparities...............................................    93
    Interagency Work with BARDA......................................   110
    Investment in Research...........................................   104
    Long Haul COVID..................................................   100
    Maternal Morbidity and Mortality.................................    94
    Mental Health....................................................    93
        Diagnosis Issues.............................................   110
    NCI Budget Reduction.............................................   114
    NIH Buildings and Facilities.....................................    95
    Nutrition Research...............................................    95
    Opioids and Pain Research........................................    94
    Overdose Prevention..............................................    97
    RADx.............................................................    99
    Substance Abuse Epidemic.........................................   103
    Suicide..........................................................   100
    Title 42 Recission...............................................   113
    Undiagnosed Disease Network......................................    98
    Universal COVID Vaccine..........................................   109
    Vaccine:
        and Therapeutic Development..................................   112
        Mandates.....................................................   106

                            Office of the Secretary

    Additional Committee Questions...................................    40
    Advancing Science and Research...................................    12
    Affordable Care Act Premium Relief...............................    35
    ARPA-H...........................................................    20
    Countermeasures Injury Compensation Program......................    25
    COVID-19

    Funding Core Program Operations..................................    18
    Gender Affirming Care............................................    32
    Improving Safety and Oversight Nursing Homes.....................    18
    Insurance Plans..................................................    29
    LIHEAP

    National:
        Strategic Stockpile, The.....................................    28
        Suicide Prevention Lifeline

    Opioid Crisis....................................................    38
    Organ Sharing....................................................    27
    Personal Protective Equipment....................................    32
    Provider Relief Fund.............................................    28
    Providing Oversight and Program Integrity........................    18
    Reducing Health Care Costs and Expanding Access to Care..........    12
    Refugees and Unaccompanied Children..............................    17
    State Opioid Response Grants.....................................    35
    Strengthening Behavioral Health..................................    15
    Supply Chain.....................................................    22
    Supporting Children, Families, and Seniors.......................    17
    Tackling:
        COVID-19 and Preparing for the Next Biological Threat........    11
        Health and Human Services Disparities........................    14
    Title X

    Women's Healthcare...............................................    34
                                   __________

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Additional Committee Questions...................................   405
    American Rescue Plan Funding.....................................   404
    Benefits of Pre-apprenticeship Programs..........................   389
    Black Lung Disability Benefits...................................   424
    BLS Youth Cohort Development.....................................   411
    Budget Priorities Impacting Workers..............................   374
    Business Owners Within the Gig Economy...........................   398
    Career Pathways Funding Levels...................................   388
    Challenges for Small Businesses..................................   394
    Child Care Industry Challenges...................................   388
    Coastwide Labor Contract Negotiations............................   426
    Commitment to Equity.............................................   381
    Confronting Inflationary Pressures...............................   380
    Creating Jobs Through Modernizing High Turnover Industries.......   395
    Defining Independent Contractors.................................   398
    Department of Labor Rulemaking Timelines.........................   386
    Diversity of Supported Apprenticeship Programs...................   399
    DOL Accomplishments..............................................   381
    Employer Injury and Illness Data.................................   428
    Ensuring an Equitable Economic Recovery..........................   386
    Evaluation of OFCCP Contractor Selection.........................   408
    Evidence Capacity Investment Survey..............................   416
    Expanding Apprenticeship Programs................................   387
    FECA Efforts to Combat Fraud.....................................   420
    Fiscal Year 2023 Budget Request..................................   383
    Good Jobs Initiative.............................................   379
    Impacts of Russia's War on Ukraine...............................   394
    Improving:
        Employment Prospects.........................................   394
        Safety in the American Mining Industry.......................   400
    Increased Targeting of the H-2B Visa Program.....................   390
    Independent Contractor:
        Proposed Rule................................................   425
        Rulemaking Feedback..........................................   422
    Industry Participation in Registered Apprenticeships.............   389
    Infectious Disease Notice of Proposed Rulemaking.................   406
    International Labor Enforcement..................................   414
    Investing in:
        Educational and Child Care Training Programs.................   395
        Worker Protection............................................   379
    Investment in Workers is Long Overdue............................   382
    Job Corps Outreach Potential.....................................   403
    Joint Employer Standard, The.....................................   427
    Linking Individuals to Employment Resources......................   392
    Mainstreet and Gig Economy Workforce Challenges..................   397
    Mental Health Parity:
        Law Compliance...............................................   418
        Mental Health Parity Requirement Enforcement.................   429
    Monitoring H-2B Visas............................................   390
    Nature and Impacts of Inflation on Employment, The...............   393
    Office of the Solicitor Operations Funding.......................   412
    OLMS Union Protections...........................................   410
    Online Presence of Departmental Training Resources...............   392
    Permanent Covid Safety Standard..................................   374
    Proposed Prohibited Transaction Exemption Changes................   426
    Protecting Agricultural Sector Workers...........................   406
    Racial Disparities in State Unemployment Programs................   397
    Rescinding Job Corps Exemption from the Service Contract Act.....   391
    Rulemaking for Determining Independent Contractors...............   427
    Specialization of Job Corps Center Curriculums...................   417
    Status of Workplace Violence Rule................................   396
    Strengthening:
        the American Workforce.......................................   378
        Youth Outreach and Engagement................................   402
    Timeline for Silica Standard Rulemaking..........................   422
    Transparency of Employers' Anti-Union Spending...................   405
    Tree Care Industry OSHA Standards................................   430
    Unemployment Insurance Reform....................................   380
    Veterans' Programs Structure and Investment Level................   404
    White Collar Overtime Salary Threshold...........................   428
    Women's Bureau Accomplishments...................................   393
    Worker Protection Oversight and Enforcement......................   401
    Workforce:
        Development Initiatives......................................   379
        Opportunity for Rural Communities Grants.....................   424
    Workplace Safety.................................................   373
    Youthbuild Grant Program Dependability...........................   401

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