[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:
---------------------------------------------------------------------------
    \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: [email protected] 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.
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    \1\ 1 https://www.nih.gov/arpa-h.
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    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.
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    \2\ https://www.darpa.mil/work-with-us/heilmeier-catechism.
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                            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.
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    \3\ https://www.cancer.gov/research/key-initiatives/moonshot-
cancer-initiative.
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    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.
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    \4\ https://www.nih.gov/ending-structural-racism/unite.
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    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\
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    \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\
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    \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.
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    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.
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    \10\ https://covid19.nih.gov/news-and-stories/covid19-ripple-
effects.
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                    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.
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                       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/.
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    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.
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    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/.
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    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.
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                      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.
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    \33\ www.whitehouse.gov/ostp/news-updates/2022/03/17/fact-sheet-
white-house-announces-initial-steps-for-reignited-cancer-moonshot/.
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    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\
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    \34\ gis.cancer.gov/ncicatchment/.
    \35\ ctep.cancer.gov/initiativesPrograms/etctn_catch-up2020.htm.
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    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.
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    \36\ ncorp.cancer.gov/news/2019-08-19.html.
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    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.
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    \37\ clinicaltrials.gov/ct2/
results?cond=cancer&term=&cntry=US&state=US%3AVT&city=&dist=
&Search=Search&recrs=a&type=Intr&fund=0.
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    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.
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    \38\ doi.org/10.1001/jama.2020.0572.
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    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.
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    \39\ grants.nih.gov/grants/guide/pa-files/PAR-14-303.html.
    \40\ reporter.nih.gov/project-details/10205083.
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    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.
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    \41\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-19-064.html.
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    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.
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    \42\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-20-051.html.
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    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.
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    \43\ grants.nih.gov/grants/guide/pa-files/PAR-22-150.html.
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    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.
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    \44\ https://recovercovid.org/.
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    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\
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    \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.
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    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.
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    \47\ recovercovid.org.
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    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.
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    \48\ www.thelancet.com/journals/landig/article/PIIS2589-
7500(22)00048-6/fulltext.
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    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.
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    \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.
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    \50\ recovercovid.org/.
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    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.
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    \51\ https://reporter.nih.gov/project-details/10491027.
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    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\
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    \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.
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    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.
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    \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.
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    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.
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    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/.
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    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.
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    \71\ https://www.nia.nih.gov/news/unique-case-disease-resistance-
reveals-possible-alzheimers-treatment.
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    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.
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    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.
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    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.
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    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.
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    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/.
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    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\
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    \80\ www.alzrisk.org/cohort.aspx?cohortid=15.
    \81\ www.alzrisk.org/cohort.aspx?cohortid=60.
    \82\ pubmed.ncbi.nlm.nih.gov/32554763/.
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    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.
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                                 ______
                                 
                 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.
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    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.
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    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\
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    \100\ https://peartherapeutics.com/products/reset-reset-o/.
    \101\ https://reporter.nih.gov/project-details/10153370.
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    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.
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    \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).
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


    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.
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    \4\ https://www.dol.gov/sites/dolgov/files/OASP/evaluation/pdf/
NHE%20Opioid%20Final%20Report.pdf.
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    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\
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    \5\ https://www.dol.gov/agencies/eta/dislocated-workers/grants/
workforce-opportunity.
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    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\
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    \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.
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    \1\ https://www.acadrad.org/about-the-academy/.
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    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.
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    \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.
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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.
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    \4\ https://unitedformedicalresearch.org/wp-content/uploads/2022/
03/UMR_NIHs-Role-in-Sustaining-the-U.S.-Economy-FY21.pdf.
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    Thank you for your strong, continued support of NIH, NIBIB, and all 
the Institutes and Centers working to advance our biomedical research 
efforts and to improve the lives of patients worldwide. On behalf of 
the Academy, I urge you to continue your strong support of our Nation's 
research and innovation enterprise.

    [This statement was submitted by Mitchell Schnall, M.D., Ph.D., 
President, 
Academy for Radiology & Biomedical Imaging Research.]
                                 ______
                                 
                 Prepared Statement of 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\
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    \1\ America After 3PM, 2020 http://www.afterschoolalliance.org/
AA3PM/.
    \2\ Afterschool in the time of Covid-19 tinyurl.com/362ff68f.
    \3\ Ibid.
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    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 [email protected].

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 [email protected] or 
Frank Hood at [email protected].

    [This statement was submitted by Rachel Klein, Deputy Executive 
Director, The AIDS Institute.]
                                 ______
                                 
                   Prepared Statement of AIDS United
    Dear 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 [email protected].
    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 
([email protected]).

    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 [email protected]. 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.
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    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.
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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\
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    \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.
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    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.
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    \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.
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                               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\
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    \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.
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    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/.
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                    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\
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    \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.
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    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.
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    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\
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    \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.
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    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\
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    \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.
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    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\
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    \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/.
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            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\
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    \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.
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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/.
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    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 
[email protected], 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.
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    To ensure that our Nation is prepared to meet the unique healthcare 
needs of this rapidly growing population, we request that Congress 
provide additional investments necessary to expand and enhance the 
geriatrics workforce, which is an integral component of the primary 
care workforce, and to foster groundbreaking medical research.
         programs to train geriatrics healthcare professionals
Geriatrics Workforce Enhancement Program and Geriatrics Academic Career 
        Award Program (at least $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.
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    \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.
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    The GWEP is currently the only Federal program designed to increase 
the number of providers, in a variety of disciplines, with the skills 
and training to care for older adults. The GWEP awardees educate and 
engage the broader frontline workforce, including 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.
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    \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.
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                      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.
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    \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.
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    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.
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    \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.
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    \1\ https://www.cdc.gov/nchs/products/databriefs/db427.htm.
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    Investment in biomedical research generates new knowledge, improved 
health, and leads to innovation and long-term economic growth. ASN 
recommends at least $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, [email protected].
    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 
[email protected], 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.
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    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.
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    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.
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      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 [email protected].
                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 
[email protected].
                                 ______
                                 
          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 [email protected], 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 
([email protected]) or Advance CTE's Policy Advisor, Steve Voytek 
([email protected]).
                                 ______
                                 
      Prepared Statement of the Association for Clinical Oncology
    The Association for Clinical Oncology (ASCO), the world's leading 
professional organization representing nearly 45,000 physicians and 
other professionals who treat people with cancer, thanks this 
subcommittee for its long-standing commitment to support federally 
funded research at the National Institute of Health (NIH) and National 
Cancer Institute (NCI). ASCO is extremely grateful for the $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 [email protected] with any questions.

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

    [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 
([email protected]) or Jeffrey Ekoma ([email protected]).

    [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.
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                             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.
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                         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 
[email protected].

    [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.
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    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 
[email protected].
    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, [email protected], 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, 
        [email protected].
                                 ______
                                 
     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 
[email protected], or Bill McColl at 
[email protected] if you have questions or need additional 
information.

    [This statement was submitted by Paul LaKosky, Ph.D., Executive 
Director, Dave Purchase Project, the North American Syringe Exchange 
Network, 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.
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  --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/.
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  --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.
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  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 [email protected] 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\
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    \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.
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    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/.
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    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 
[email protected].
    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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---------------------------------------------------------------------------
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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.
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    \1\ https://www.hacu.net/NewsBot.asp?MODE=VIEW&ID=3424.
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    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\
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    \2\ https://www.census.gov/content/dam/Census/library/publications/
2015/demo/p25-1143.pdf.
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    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\
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    \3\ https://nces.ed.gov/pubs2020/2020024abbrev.pdf.
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    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.
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    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.
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    \5\ https://www.bls.gov/opub/mlr/2012/10/art1full.pdf.
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    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 [email protected] 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 [email protected] 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 
[email protected].

    [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 [email protected] 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\
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    \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).
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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.
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    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.
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    \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/.
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    MCPP thanks the subcommittee for its important work dedicated to 
ensuring the health and security of the Nation, and we appreciate this 
opportunity to urge the subcommittee to continue the success of NIH by 
providing $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.
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    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.
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                                 ______
                                 
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 [email protected]. 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 [email protected], 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, [email protected] or Zaida Ricker, NASHIA 
Government Relations, [email protected].
                                 ______
                                 
   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.
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    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\
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    \1\ https://files.constantcontact.com/a3c45cb9201/562eb81b-dee4-
48b8-8519-69bcbebb0ff2.pdf?rdr
=true.
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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\
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    \2\ https://www.usatoday.com/story/news/politics/2022/03/07/
opioids-native-americans-funding/9380063002/?gnt-cfr=1.
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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 
[email protected].
    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 [email protected]; Zach 
Kribs with the American Society of Nephrology at [email protected]; 
or Lauren Drew with the National Kidney Foundation (NKF) at 
[email protected].
                about the american society of nephrology
    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.
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    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\
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    \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).
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    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.
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    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 
[email protected].

    [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, [email protected].

    [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.
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       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.
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    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\
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    \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.
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    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.
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    \7\ https://www.personalizedmedicinecoalition.org/Userfiles/PMC-
Corporate/file/Personalized_
Medicine_at_FDA_The_Scope_Significance_of_Progress_in_2021.pdf.
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    Basic and translational research also offers opportunities for 
personalized medicine beyond oncology, especially for rare diseases. 
Although individually rare, rare diseases collectively affect an 
estimated 25 to 30 million Americans. With advances in genomics, the 
molecular causes of 6,500 rare diseases have been identified--but only 
about 5 percent have an FDA-approved treatment. 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\
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    \8\ https://everylifefoundation.org/burden-study/.
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    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.
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    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.
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    \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/.
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    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.
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    \14\ https://doi.org/10.1016/j.ccell.2021.04.015.
    \15\ https://www.cancer.gov/research/annual-plan/directors-message.
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                             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.
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    \1\ Physician Assistant Education Association. (2021). COVID-19 
Rapid Response Report 3. https://paea.edcast.com/insights/ECL-c621408d-
c82a-43f5-a067-75a03494d8be..
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    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.
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    \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.
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                     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\
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    \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.
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    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.
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    \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.
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    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.
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    \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.
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    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.
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    \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.
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                              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.
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    \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/.
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                             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.
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    \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.
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                       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, 
[email protected].
    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\
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    \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.
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    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.
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    \2\ Centers for Disease Control and Prevention, 2018: https://
www.cdc.gov/media/releases/2018/a0726-vision-health.html.
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    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\
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    \3\ https://pubmed.ncbi.nlm.nih.gov/25602911/.
    \4\ https://www.ruralhealthweb.org/.
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    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.
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    \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.
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    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.
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    \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.
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    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, [email protected].
    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 
[email protected], 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.
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    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).
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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.
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    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 [email protected] 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/.
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                 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/.
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                               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/.
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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.
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    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\
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    \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.
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    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\
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    \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.
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           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.
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         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.
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                      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.
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                                  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 ([email protected]).
                                 ______
                                 
           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 [email protected].
                                 ______
                                 
       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].
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    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].
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    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.
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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.
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    None of these advances would be possible without the support of 
radiochemistry and isotope production research. The next generation of 
radioisotopes, alpha emitting therapeutic isotopes, which have much 
greater cancer killing power per radioactive decay, are in clinicals 
trials and are expected to provide better patient outcomes. Support of 
that research is critical.
Quantitative Molecular Imaging
    A PET scanner is often thought of as an imaging tool; however, it 
is inherently a highly specific measuring tool. Recent advances in PET 
technology such as PET/MRI and total-body PET, where the whole body can 
be imaged at once, have opened new research possibilities.\4\ To 
realize the full potential of these advances, quantitative analysis 
will be required to appreciate the sensitivity of the scanner and the 
tracers it measures. The NCI has supported the harmonization of PET/CT 
scanners through numerous grants including NIH R01CA169072, and for the 
last decade, the NCI, through their Cancer Imaging Program has 
developed and supported a consortium of academic sites called the 
Quantitative Imaging Network performing and advancing quantitative 
imaging mostly in support of clinical trials.
---------------------------------------------------------------------------
    \4\ Meikle SR, Sossi V, Roncali E, Cherry SR, Banati R, Mankoff D, 
Jones T, James M, Sutcliffe J, Ouyang J, Petibon Y, Ma C, El Fakhri G, 
Surti S, Karp JS, Badawi RD, Yamaya T, Akamatsu G, Schramm G, Rezaei A, 
Nuyts J, Fulton R, Kyme A, Lois C, Sari H, Price J, Boellaard R, Jeraj 
R, Bailey DL, Eslick E, Willowson KP, Dutta J. Quantitative PET in the 
2020s: a roadmap. Phys Med Biol. 2021 Mar 12;66(6):06RM01. doi: 
10.1088/1361-6560/abd4f7. PMID: 33339012.
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Imaging of the brain in Alzheimer Disease
    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.
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Data Science and Workforce
    The field of nuclear medicine and molecular imaging is rapidly 
expanding with new diagnostic imaging tracers, radiopharmaceutical 
therapies (RPT), and technologies. With new diagnostic tracers comes a 
need to properly interpret the innovative scans. Artificial 
intelligence (AI) algorithms can assist with the tedious components of 
image interpretation and even help with quality report generation. 
Development of well-credentialed registries of studies to train and 
validate such AI algorithms, reflecting diverse sets of patients will 
help advance this field. Radiopharmaceuticals therapies (RPTs), like 
other oncology therapies, are often studied in and approved for 
patients with late-stage disease, for example, after all other 
treatments have failed. To harness the full potential of RPTs, use 
earlier in the disease course may be advisable. Image and clinical data 
registries are needed to capture post-approval information on the use 
of RPTs and the patient outcomes to further guide their use. Recent 
imaging and therapy FDA approvals in prostate cancer and Alzheimer's 
disease, two highly prevalent conditions, require that the highly 
specialized field of nuclear medicine and molecular imaging train a 
cadre of qualified individuals to diagnose and treat these patients. It 
is critical for the NIH to fund and expand training grants so that our 
brightest scientists have the skills to develop a sustainable career 
pathway. Funding for AI technologies and registries will improve 
patient care and outcomes.
                         summary and conclusion
    Robust NIH funding is crucial to advancing our efforts to detect 
and treat serious medical conditions. NIH investments help to sustain 
both our local and national research institutions across every State in 
the Nation. China is advancing rapidly in the high technology medical 
space notably in AI. Funding NIH's base program with at least $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.
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    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/.
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        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.
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               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.
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    \1\ https://www.dayoneproject.org/ideas/closing-critical-gaps.
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   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\
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    \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.
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    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.
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                 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.
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                                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\
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    \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.
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                         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.
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    \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/.
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                    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.
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                          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).
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                       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, 
[email protected] and Judy Mortrude, Senior Technical 
Advisor, [email protected].]



       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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